Exploring Clinical Lessons Learned by Experienced Hospitalists from Diagnostic Errors and Successes.

BACKGROUND: Diagnostic errors cause significant patient harm. The clinician's ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care. OBJECTIVE: To identify and characterize clinical lessons learned by experienced hospitalists from diagnostic errors and successes. DESIGN: A semi-structured interview guide was used to collect qualitative data from hospitalists at five independently administered hospitals in the Mid-Atlantic area from February to June 2022. PARTICIPANTS: 12 academic and 12 community-based hospitalists with ≥ 5 years of clinical experience. APPROACH: A constructivist qualitative approach was used and "reflexive thematic analysis" of interview transcripts was conducted to identify themes and patterns of meaning across the dataset. RESULTS: Five themes were generated from the data based on clinical lessons learned by hospitalists from diagnostic errors and successes. The ideas included appreciating excellence in clinical reasoning as a core skill, connecting with patients and other members of the health care team to be able to tap into their insights, reflecting on the diagnostic process, committing to growth, and prioritizing self-care. CONCLUSIONS: The study identifies key lessons learned from the errors and successes encountered in patient care by clinically experienced hospitalists. These findings may prove helpful for individuals and groups that are authentically committed to moving along the continuum from diagnostic competence towards excellence.

Factors Influencing Primary Care Career Choice: A Multi-Institutional Cross-sectional Survey of Internal Medicine Primary Care Residency Graduates.

BACKGROUND: Although primary care is associated with population health benefits, the supply of primary care physicians continues to decline. Internal medicine (IM) primary care residency programs have produced graduates that pursue primary care; however, it is uncertain what characteristics and training factors most affect primary care career choice. OBJECTIVE: To assess factors that influenced IM primary care residents to pursue a career in primary care versus a non-primary care career. DESIGN: Multi-institutional cross-sectional study. PARTICIPANTS: IM primary care residency graduates from seven residency programs from 2014 to 2019. MAIN MEASURES: Descriptive analyses of respondent characteristics, residency training experiences, and graduate outcomes were performed. Bivariate logistic regression analyses were used to assess associations between primary care career choice with both graduate characteristics and training experiences. KEY RESULTS: There were 256/314 (82%) residents completing the survey. Sixty-six percent of respondents (n = 169) practiced primary care or primary care with a specialized focus such as geriatrics, HIV primary care, or women's health. Respondents who pursued a primary care career were more likely to report the following as positive influences on their career choice: resident continuity clinic experience, nature of the PCP-patient relationship, ability to care for a broad spectrum of patient pathology, breadth of knowledge and skills, relationship with primary care mentors during residency training, relationship with fellow primary care residents during training, and lifestyle/work hours (all p < 0.05). Respondents who did not pursue a primary care career were more likely to agree that the following factors detracted them from a primary care career: excessive administrative burden, demanding clinical work, and concern about burnout in a primary care career (all p < 0.05). CONCLUSIONS: Efforts to optimize the outpatient continuity clinic experience for residents, cultivate a supportive learning community of primary care mentors and residents, and decrease administrative burden in primary care may promote primary care career choice.

Group concept mapping for health professions education scholarship.

While explicit conceptual models help to inform research, they are left out of much of the health professions education (HPE) literature. One reason may be the limited understanding about how to develop conceptual models with intention and rigor. Group concept mapping (GCM) is a mixed methods conceptualization approach that has been used to develop frameworks for planning and evaluation, but GCM has not been common in HPE. The purpose of this article is to describe GCM in order to make it more accessible for HPE scholars. We recount the origins and evolution of GCM and summarize its core features: GCM can combine multiple stakeholder perspectives in a systematic and inclusive manner to generate explicit conceptual models. Based on the literature and prior experience using GCM, we detail seven steps in GCM: (1) brainstorming ideas to a specific "focus prompt," (2) preparing ideas by removing duplicates and editing for consistency, (3) sorting ideas according to conceptual similarity, (4) generating the point map through quantitative analysis, (5) interpreting cluster map options, (6) summarizing the final concept map, and (7) reporting and using the map. We provide illustrative examples from HPE studies and compare GCM to other conceptualization methods. GCM has great potential to add to the myriad of methodologies open to HPE researchers. Its alignment with principles of diversity and inclusivity, as well as the need to be systematic in applying theoretical and conceptual frameworks to practice, make it a method well suited for the complexities of contemporary HPE scholarship.

Seeing with greater clarity: Stakeholder ratings of blind spots in U.S. medical education.

BACKGROUND: Although medical education is affected by numerous blind spots, there is limited evidence to determine which blind spots to prioritize. METHODS: In summer 2022, we surveyed stakeholders from U.S. medical education who had identified 9 domains and 72 subdomains of blind spots. Respondents used 4-point Likert-type scales to rate the extent and magnitude of problems caused for each domain and subdomain. Respondents also provided comments for which we did content analysis. RESULTS: A total of 23/27 (85%) stakeholders responded. The majority of respondents rated each blind spot domain as moderate-major in both extent and problems they cause. Patient perspectives and voices that are not heard, valued, or understood was the domain with the most stakeholders rating extent (n = 20, 87%) and problems caused (n = 23, 100%) as moderate or major. Admitting and selecting learners likely to practice in settings of highest need was the subdomain with the most stakeholders rating extent (n = 21, 91%) and problems caused (n = 22, 96%) as moderate or major. Respondents' comments suggested blind spots may depend on context and persist because of hierarchies and tradition. DISCUSSION: We found blind spots differed in relative importance. These data may inform further research and direct interventions to improve medical education.

Blind spots in medical education - International perspectives.

BACKGROUND: All individuals and groups have blind spots that can create problems if unaddressed. The goal of this study was to examine blind spots in medical education from international perspectives. METHODS: From December 2022 to March 2023, we distributed an electronic survey through international networks of medical students, postgraduate trainees, and medical educators. Respondents named blind spots affecting their medical education system and then rated nine blind spot domains from a study of U.S. medical education along five-point Likert-type scales (1 = much less attention needed; 5 = much more attention needed). We tested for differences between blind spot ratings by respondent groups. We also analyzed the blind spots that respondents identified to determine those not previously described and performed content analysis on open-ended responses about blind spot domains. RESULTS: There were 356 respondents from 88 countries, including 127 (44%) educators, 80 (28%) medical students, and 33 (11%) postgraduate trainees. At least 80% of respondents rated each blind spot domain as needing 'more' or 'much more' attention; the highest was 88% for 'Patient perspectives and voices that are not heard, valued, or understood.' In analyses by gender, role in medical education, World Bank country income level, and region, a mean difference of 0.5 was seen in only five of the possible 279 statistical comparisons. Of 885 blind spots documented, new blind spot areas related to issues that crossed national boundaries (e.g. international standards) and the sufficiency of resources to support medical education. Comments about the nine blind spot domains illustrated that cultural, health system, and governmental elements influenced how blind spots are manifested across different settings. DISCUSSION: There may be general agreement throughout the world about blind spots in medical education that deserve more attention. This could establish a basis for coordinated international effort to allocate resources and tailor interventions that advance medical education.

What makes an article a must read in medical education?

BACKGROUND: The dissemination of published scholarship is intended to bring new evidence and ideas to a wide audience. However, the increasing number of articles makes it challenging to determine where to focus one's attention. This study describes factors that may influence decisions to read and recommend a medical education article. METHODS: Authors analyzed data collected from March 2021 through September 2022 during a monthly process to identify "Must Read" articles in medical education. An international team of health sciences educators, learners, and researchers voted on titles and abstracts to advance articles to full text review. Full texts were rated using five criteria: relevance, methodology, readability, originality, and whether it addressed a critical issue in medical education. At an end-of-month meeting, 3-4 articles were chosen by consensus as "Must Read" articles. Analyses were used to explore the associations of article characteristics and ratings with Must Read selection. RESULTS: Over a period of 19 months, 7487 articles from 856 journals were screened, 207 (2.8%) full texts were evaluated, and 62 (0.8%) were chosen as Must Reads. During screening, 3976 articles (53.1%) received no votes. BMC Medical Education had the largest number of articles at screening (n = 1181, 15.8%). Academic Medicine had the largest number as Must Reads (n = 22, 35.5%). In logistic regressions adjusting for the effect of individual reviewers, all rating criteria were independently associated with selection as a Must Read (p < 0.05), with methodology (OR 1.44 (95%CI = 1.23-1.69) and relevance (OR 1.43 (95%CI = 1.20-1.70)) having the highest odds ratios. CONCLUSIONS: Over half of the published medical education articles did not appeal to a diverse group of potential readers; this represents a missed opportunity to make an impact and potentially wasted effort. Our findings suggest opportunities to enhance value in the production and dissemination of medical education scholarship.

Gender differences in bullying among internal medicine residents.

PURPOSE: To describe gender differences in experienced types of bullying, and resulting personal consequences, among internal medicine (IM) residents. METHODS: Participants in this cross-sectional study included 21 212 IM trainees who completed a voluntary survey with their 2016 in-training exam that assessed bullying during residency training. The 2875 (13.6% of) trainees who reported experiencing bullying on a screening question were asked for additional details about types of bullying experienced and resulting personal consequences. RESULTS: Female and male trainees experienced bullying at similar rates (47% versus 53%, P = .08). Gender differences were seen in both the type of bullying experienced and the resulting personal consequences. Female trainees were more likely than their male counterparts to report bullying characterized as verbal (83% versus 77%, P < .001) and sexual (5% versus 2%, P < .001), whereas male trainees were more likely to experience physical (6% versus 4%, P = .03) and "other" bullying types (27% versus 22%, P < .001). Female trainees were more likely to report negative personal consequences than male trainees, and the most common resultant sequela reported was feeling burned out (63% versus 51%, P < .001). CONCLUSION: Gender differences exist in both the types and consequences of bullying experienced among this national sample of IM residents. These results should be considered by programs and institutions that are hoping to optimize the culture of their workplace and enhance safety in the learning environment.

Using Group Concept Mapping to Explore Medical Education's Blind Spots.

PHENOMENON: All individuals and groups have blind spots that can lead to mistakes, perpetuate biases, and limit innovations. The goal of this study was to better understand how blind spots manifest in medical education by seeking them out in the U.S. APPROACH: We conducted group concept mapping (GCM), a research method that involves brainstorming ideas, sorting them according to conceptual similarity, generating a point map that represents consensus among sorters, and interpreting the cluster maps to arrive at a final concept map. Participants in this study were stakeholders from the U.S. medical education system (i.e., learners, educators, administrators, regulators, researchers, and commercial resource producers) and those from the broader U.S. health system (i.e., patients, nurses, public health professionals, and health system administrators). All participants brainstormed ideas to the focus prompt: "To educate physicians who can meet the health needs of patients in the U.S. health system, medical education should become less blind to (or pay more attention to) …" Responses to this prompt were reviewed and synthesized by our study team to prepare them for sorting, which was done by a subset of participants from the medical education system. GCM software combined sorting solutions using a multidimensional scaling analysis to produce a point map and performed cluster analyses to generate cluster solution options. Our study team reviewed and interpreted all cluster solutions from five to 25 clusters to decide upon the final concept map. FINDINGS: Twenty-seven stakeholders shared 298 blind spots during brainstorming. To decrease redundancy, we reduced these to 208 in preparation for sorting. Ten stakeholders independently sorted the blind spots, and the final concept map included 9 domains and 72 subdomains of blind spots that related to (1) admissions processes; (2) teaching practices; (3) assessment and curricular designs; (4) inequities in education and health; (5) professional growth and identity formation; (6) patient perspectives; (7) teamwork and leadership; (8) health systems care models and financial practices; and (9) government and business policies. INSIGHTS: Soliciting perspectives from diverse stakeholders to identify blind spots in medical education uncovered a wide array of issues that deserve more attention. The concept map may also be used to help prioritize resources and direct interventions that can stimulate change and bring medical education into better alignment with the health needs of patients and communities.

"I never should have been a doctor": a qualitative study of imposter phenomenon among internal medicine residents.

INTRODUCTION: Imposter phenomenon is common among medical trainees and may influence learning and professional development. The authors sought to describe imposter phenomenon among internal medicine residents. METHODS: In 2020, using emailed invites we recruited a convenience sample of 28 internal medicine residents from a teaching hospital in Baltimore, Maryland to participate in an exploratory qualitative study. In one-on-one interviews, informants described experiences of imposter phenomenon during residency training. Using thematic analysis to identify meaningful segments of text, the authors developed a coding framework and iteratively identified and refined themes. Informants completed the Clance Imposter Phenomenon Scale. RESULTS: Informants described feelings and thoughts related to imposter phenomenon, the contexts in which they developed and the impact on learning. Imposter phenomenon has profound effects on residents including: powerful and persistent feelings of inadequacy and habitual comparisons with others. Distinct contexts shaping imposter phenomenon included: changing roles with increasing responsibilities; constant scrutiny; and rigid medical hierarchy. Learning was impacted by inappropriate expectations, difficulty processing feedback, and mental energy diverted to impression management. DISCUSSION: Internal medicine residents routinely experience imposter phenomenon; these feelings distort residents' sense of self confidence and competence and may impact learning. Modifiable aspects of the clinical learning environment exacerbate imposter phenomenon and thus can be acted upon to mitigate imposter phenomenon and promote learning among medical trainees.

The selection of chief residents across residency programs at a large academic medical center.

BACKGROUND: Chief residents have a unique role in graduate medical education (GME). They not only connect residents with program and hospital leadership, but also advocate for the wellbeing and educational priorities of trainees. Previous studies have focused on describing the characteristics of chief residents (CRs), however little is known about how CRs are selected across GME programs. METHODS: One-on-one semi-structured interviews with all (n = 21) GME program directors at the Johns Hopkins University School of Medicine were conducted from January to March 2022. Investigators independently coded the transcripts using an inductive approach to categorize meaningful segments of text; this culminated in the identification of explanatory themes. RESULTS: From discussions with 21 program directors, four themes were identified: (1) identifying candidates: timing, recruitment, nominations, as well as desirable attributes and data considered; (2) applications: expression of intent and participation in interviews; (3) selections: voting, discussions leading to consensus, and program director intimately involved in the choice(s); and (4) confidence in processes and outcomes. CONCLUSIONS: Our results provide a deeper understanding of the nuances associated with the selection of CRs. It is hoped that the descriptions of the similarities and differences across GME programs will prompt reflection about what is done at one institution such that all programs can consider what are the best practices to serve their individual goals and needs.

Clinical excellence in child and adolescent psychiatry: examples from the published literature.

There has been growing interest in the past century in improving understanding of the development and treatment of psychopathology of children, with increasing government funding of research in the past two decades. However, child and adolescent psychiatry excellence in clinical care has not been well-documented in the existing literature. This article provides examples of clinical excellence in paediatric mental health to supplement existing guidelines for the clinical practice of paediatric psychiatry. A review of the literature identified 204 unique peer-reviewed articles that were then further evaluated for applicability and relevance to the definition of clinical excellence as outlined by the Miller-Coulson Academy of Clinical Excellence (MCACE). Cases were then identified and selected for each domain of clinical excellence as they apply to child and adolescent psychiatry and to provide a model for patient care. KeypointsClinical excellence in child and adolescent psychiatry has not previously been defined or extensively documented.The Miller-Coulson Academy of Clinical Excellence (MCACE) has developed a systematic method to measuring excellence in clinical care and created a definition of clinical excellence.The MCACE defined the domains of clinical excellence as communication and interpersonal skills, professionalism and humanism, diagnostic acumen, skilful negotiation of the healthcare system, knowledge, scholarly approach to clinical practice, exhibiting a passion for patient care and modelling clinical excellence, and collaborating with investigators to advance science and discovery.There are numerous case examples in the literature that represent mastery in paediatric psychiatry in these areas.Clinicians in paediatric mental health will likely benefit from future research on evidence-based approaches to training and education in these domains of clinical excellence.

Elements Influencing Recruitment and Retention of Millennial Hospitalists Born in or after 1982: a Survey-Based Study.

BACKGROUND: Hospitalist turnover is exceedingly high, placing financial burdens on hospital medicine groups (HMGs). Following training, many begin their employment in medicine as early-career hospitalists, the majority being millennials. OBJECTIVE: To understand what elements influence millennial hospitalists' recruitment and retention. DESIGN: We developed a survey that asked participants to rate the level of importance of 18 elements (4-point Likert scale) in their decision to choose or remain at an HMG. PARTICIPANTS: The survey was electronically distributed to hospitalists born in or after 1982 across 7 HMGs in the USA. MAIN MEASURES: Elements were grouped into four major categories: culture of practice, work-life balance, financial considerations, and career advancement. We calculated the means for all 18 elements reported as important across the sample. We then calculated means by averaging elements within each category. We used unpaired t-tests to compare differences in means for categories for choosing vs. remaining at an HMG. KEY RESULTS: One hundred forty-four of 235 hospitalists (61%) responded to the survey. 49.6% were females. Culture of practice category was the most frequently rated as important for choosing (mean 96%, SD 12%) and remaining (mean 96%, SD 13%) at an HMG. The category least frequently rated as important for both choosing (mean 69%, SD 35%) and remaining (mean 76%, SD 32%) at an HMG was career advancement. There were no significant differences between respondent gender, race, or parental status and ratings of elements for choosing or remaining with HMGs. CONCLUSION: Culture of practice at an HMG may be highly important in influencing millennial hospitalists' decision to choose and stay at an HMG. HMGs can implement strategies to create a millennial-friendly culture which may help improve recruitment and retention.

Early administration of COVID-19 convalescent plasma with high titer antibody content by live viral neutralization assay is associated with modest clinical efficacy.

The efficacy of COVID-19 convalescent plasma (CCP) as a treatment for hospitalized patients with COVID-19 remains somewhat controversial; however, many studies have not evaluated CCP documented to have high neutralizing antibody titer by a highly accurate assay. To evaluate the correlation of the administration of CCP with titer determined by a live viral neutralization assay with 7- and 28-day death rates during hospitalization, a total of 23 118 patients receiving a single unit of CCP were stratified into two groups: those receiving high titer CCP (>250 50% inhibitory dilution, ID50; n = 13 636) or low titer CCP (≤250 ID50; n = 9482). Multivariable Cox regression was performed to assess risk factors. Non-intubated patients who were transfused with high titer CCP showed 1.1% and 1.7% absolute reductions in overall 7- and 28-day death rates, respectively, compared to those non-intubated patients receiving low titer CCP. No benefit of CCP was observed in intubated patients. The relative benefit of high titer CCP was confirmed in multivariable Cox regression. Administration of CCP with high titer antibody content determined by live viral neutralization assay to non-intubated patients is associated with modest clinical efficacy. Although shown to be only of modest clinical benefit, CCP may play a role in the future should viral variants develop that are not neutralized by other available therapeutics.

Internal Medicine-Paediatrics residents' application of life design principles to career decisions.

BACKGROUND: Residency is an important time for career planning. Little is known about how trainees make career decisions during this formative period. OBJECTIVE: The objective of this study was to understand whether 'design thinking' activities help to inform Internal Medicine-Paediatrics (Med-Peds) residents' career decisions. METHODS: We performed a cross-sectional survey of a national sample of fourth-year Med-Peds residents in May-July 2019 covering intended career, helpfulness of 'life design' strategies used to inform career decision and confidence with intended career plans. Bivariate analyses were performed to evaluate associations between used strategies and confidence with career plans. RESULTS: A total of 86/145 (59%) of residents responded to the survey. The most helpful activities for clarifying career decisions were immersive exposure to the career during residency, and reflecting on compatibility of careers with their views of life and work. Finding the right mentor was associated with higher confidence in one's intended career path (p<0.05). There were no significant differences with confidence in intended career plan by gender or career path. Career decisions made during the first 2 years of residency were associated with higher confidence than those made prior to or in the second half of residency (p=0.01 and p=0.004). CONCLUSION: This national survey of graduating Med-Peds residents reveals that proactive life design strategies were helpful in bringing clarity to their decision and were associated with higher confidence in intended career plans. These data should be of interest to residency training programmes in their efforts to support trainees with their career decisions.

Healthcare distrust among hospitalised black patients during the COVID-19 pandemic.

STUDY PURPOSE: Distrust of the healthcare system is longstanding in the black community. This may especially threaten the health of the population when a highly contagious infection strikes. This study aims to compare COVID-19-related perspectives and behaviours between hospitalised black patients who trust versus distrust doctors and healthcare systems. STUDY DESIGN: Cross-sectional study at a tertiary care academic hospital in Baltimore, Maryland. Hospitalised adult black patients without a history of COVID-19 infection were surveyed between November 2020 and March 2021 using an instrument that assessed COVID-19-related matters. Analyses compared those who trusted versus mistrusted doctors and healthcare systems. RESULTS: 37 distrusting hospitalised black patients were compared with 103 black patients who trusted doctors and healthcare systems. Groups had similar sociodemographics (all p>0.05). Distrustful patients were less likely to think that they were at high risk of contracting COVID-19 (54.0% vs 75.7%; p=0.05), less likely to believe that people with underlying medical conditions were at higher risk of dying from the virus (86.4% vs 98.0%; p=0.01) and less likely to be willing to accept COVID-19 vaccination (when available) (51.3% vs 77.6%; p<0.01) compared with those who were trusting. CONCLUSION: Healthcare distrustful hospitalised black patients were doubtful of COVID-19 risk and hesitant about vaccination. Hospitalisations are concentrated exposures to the people and processes within healthcare systems; at these times, seizing the opportunity to establish meaningful relationships with patients may serve to gain their trust.

Review of the published literature to characterise clinical excellence in COVID-19 care.

COVID-19 continues to be a major source of global morbidity and mortality. It abruptly stressed healthcare systems early in 2020 and the pressures continue. Devastating hardships have been endured by individuals, families and communities; the losses will be felt for years to come. As healthcare professionals and organisations stepped up to respond to the overwhelming number of cases, it is understandable that the focus has been primarily on coping with the quantity of the demand. During a pandemic, it is not surprising that few papers have drawn attention to the quality of the care delivered to those afflicted with illness. Despite the challenges, clinicians caring for patients with COVID-19 have risen to the occasion. This manuscript highlights aspirational examples from the published literature of thoughtful and superb care of patients with COVID-19 using an established framework for clinical excellence (formulated by the Miller-Coulson Academy of Clinical Excellence).

The Current State of Journal Clubs in Psychiatry Residency Programs: Results from a National Survey of Program Directors.

OBJECTIVE: This study aimed to investigate journal club prevalence, implementation, and perceived effectiveness among psychiatry residency program directors in order to highlight best practices. METHODS: The authors distributed a 44-item thoughtfully designed and peer-reviewed questionnaire electronically via Qualtrics to 235 accredited U.S. psychiatry residency program directors identified using the American Medical Association database. RESULTS: Eighty-nine programs (38%) responded. Of these, 83 (93%) had a journal club. Journal clubs were mandatory in 80 programs (96%), met biweekly or monthly in 62 programs (75%), and lasted 46-60 min in 66 programs (80%). Twenty-three programs (28%) offered a list of articles to choose from, and 22 programs (27%) provided a critical appraisal tool. Only 7 programs (8%) measured learner outcomes from journal clubs. Respondents believed that promoting lifelong learning and practicing evidence-based psychiatry were the most relevant educational goals of journal club (2.57 and 2.51 on a Likert scale of 0 to 3). Journal club's effectiveness in achieving those goals was believed to be lower (2.16 and 2.09). CONCLUSIONS: Journal clubs are common in U.S. psychiatry residency programs and tend to follow a traditional format. In order to boost journal club's effectiveness in achieving the desired educational goals, more programs might elect to infuse elements known to augment learning.

Severe vision impairment and blindness in hospitalized patients: a retrospective nationwide study.

BACKGROUND: Outcomes among hospitalized patients with severe vision impairment or blindness have not been extensively explored. This study sought to determine clinical and resource utilization outcomes in patients with severe vision impairment/blindness (SVI/B). Because obesity is very common among those who are hospitalized, we also sought to understand its impact among patients with SVI/B. METHODS: We conducted a retrospective study using the National Inpatient Sample for the year 2017; hospitalized adults with and without SVI/B were compared. In addition, for all patients with SVI/B, we compared those with and without obesity. Multiple logistic regression and linear analysis were used to evaluate mortality, disposition, length of stay, and hospital charges; the analyses were adjusted for multiple variables including age, sex, and race. RESULTS: 30,420,907 adults were hospitalized, of whom 37,200 had SVI/B. Patients with SVI/B were older (mean age ± SEM: 66.4 ± 0.24 vs. 57.9 ± 0.09 years, p < 0.01), less likely to be female (50 % vs. 57.7 %, p < 0.01), more frequently insured by Medicare (75.7 % vs. 49.2 %, p < 0.01), and had more comorbidities (Charlson comorbidity score ≥ 3: 53.2 % vs. 27.8 %, p < 0.01). Patients with SVI/B had a higher in-hospital mortality rate (3.9 % vs. 2.2 %; p < 0.01), and had lower odds to be discharged home after hospital discharge (adjusted Odds Ratio {aOR} =0.54, [Confidence Interval (CI) 0.51-0.58]; p < 0.01) compared to those without SVI/B. Hospital charges were not significantly different (adjusted Mean Difference {aMD} = $247 CI [-$2,474-2,929]; p = 0.85) but length of stay was longer (aMD = 0.5 days CI [0.3-0.7]; p < 0.01) for those with SVI/B. Patients with vision impariment who were also obese had higher total hospital charges compared to those without obesity (mean difference: $9,821 [CI $1,375-$18,268]; p = 0.02). CONCLUSIONS: Patients admitted to American hospitals in 2017 who had SVI/B had worse clinical outcomes and greater resources utilization than those without SVI/B. Hospital-based healthcare providers who understand that those with SVI/B may be at risk for worse outcomes may be optimally positioned to help them to receive the best possible care.

Association of Obesity on Outcomes of Hospitalized Patients with Cerebral Palsy.

OBJECTIVE: Among hospitalized adults with cerebral palsy (CP), it is unknown whether obesity is associated with clinical and resource utilization outcomes. We sought to identify the association of obesity on clinical and resource utilization outcomes in this population. METHODS: This retrospective cohort study analyzed years 2016 and 2017 of the Nationwide Inpatient Sample database and examined hospitalized adults with CP. Regression analyses were used to evaluate mortality and resource utilization. RESULTS: In total, 154,219 adults with CP were hospitalized. Among them, 13,475 (8.7%) had a secondary diagnosis for obesity. Patients with obesity were older (mean age ± standard error of the mean: 49.9 ± 0.18 versus 44.7 ± 0.18 years, P < 0.01), a greater proportion were female (60.7% vs 43.2%, P < 0.01), and were more likely to be insured by Medicare (65.2% vs 56.2%, P < 0.01). Patients with obesity had higher comorbidity burdens (Charlson comorbidity score ≥ 3: 22.3% vs 9.8%, P < 0.01). Those with obesity had lower mortality rates (1.6% vs 2.4%; P < 0.01). After adjustment for confounders, mortality for patients with obesity remained lower (adjusted odds ratio 0.5, 95% confidence interval [CI] 0.4-0.7, P < 0.01). Hospital charges (adjusted mean difference $2499, 95% CI $6202-$1202, P = 0.18) and length of stay (adjusted mean difference 0.01 days; 95% CI -0.28 to 0.31, P = 0.93) were not significantly different between the groups. CONCLUSIONS: Obesity was associated with reduced mortality among adult patients in the hospital who had CP. This finding is consistent with the obesity paradox that has been observed repeatedly in patients with other chronic diseases. Further studies investigating hospitalized patients with CP are needed to corroborate these findings.

Public Attitudes Regarding Hospitals and Physicians Encouraging Donations From Grateful Patients.

Importance: Philanthropy is an increasingly important source of support for health care institutions. There is little empirical evidence to inform ethical guidelines. Objective: To assess public attitudes regarding specific practices used by health care institutions to encourage philanthropic donations from grateful patients. Design, Setting, and Participants: Using the Ipsos KnowledgePanel, a probability-based sample representative of the US population, a survey solicited opinions from a primary cohort representing the general population and 3 supplemental cohorts (with high income, cancer, and with heart disease, respectively). Exposures: Web-based questionnaire. Main Outcomes and Measures: Descriptive analyses (with percentages weighted to make the sample demographically representative of the US population) evaluated respondents' attitudes regarding the acceptability of strategies hospitals may use to identify, solicit, and thank donors; perceptions of the effect of physicians discussing donations with their patients; and opinions regarding gift use and stewardship. Results: Of 831 individuals targeted for the general population sample, 513 (62%) completed surveys, of whom 246 (48.0%) were women and 345 (67.3%) non-Hispanic white. In the weighted sample, 47.0% (95% CI, 42.3%-51.7%) responded that physicians giving patient names to hospital fundraising staff after asking patients' permission was definitely or probably acceptable; 8.5% (95% CI, 5.7%-11.2%) endorsed referring without asking permission. Of the participants, 79.5% (95% CI, 75.6%-83.4%) reported it acceptable for physicians to talk to patients about donating if patients have brought it up; 14.2% (95% CI, 10.9%-17.6%) reported it acceptable when patients have not brought it up; 9.9% (95% CI, 7.1%-12.8%) accepted hospital development staff performing wealth screening using publicly available data to identify patients capable of large donations. Of the participants, 83.2% (95% CI, 79.5%-86.9%) agreed that physicians talking with their patients about donating may interfere with the patient-physician relationship. For a hypothetical patient who donated $1 million, 50.1% (95% CI, 45.4%-54.7%) indicated it would be acceptable for the hospital to show thanks by providing nicer hospital rooms, 26.0% (95% CI, 21.9%-30.1%) by providing expedited appointments, and 19.8% (95% CI, 16.1%-23.5%) by providing physicians' cell phone numbers. Conclusions and Relevance: In this survey study of participants drawn from the general US population, a substantial proportion did not endorse legally allowable approaches for identifying, engaging, and thanking patient-donors.