Delirium Among Hospitalized Older Adults With Acute Heart Failure Exacerbation.

BACKGROUND: Delirium among older adults hospitalized with acute heart failure is associated with increased mortality. However, studies concomitantly assessing the association of delirium with both clinical and economic outcomes in this population, such as mortality, hospital cost, or length of stay, are lacking. METHODS AND RESULTS: We conducted a retrospective observational study using National Inpatient Sample data from 2011 to 2014. Using multivariable logistic regression, we assessed the association of delirium with in-hospital mortality, then estimated the incremental hospital cost and excessive length of stay adjusting for demographic and clinical factors using multivariable generalized linear regression. The association of other medical complications on clinical and economic outcomes was also assessed. A total of 568,565 (weighted N = 2,826,131) hospitalizations of patients 65 years or older with acute heart failure from 2011 to 2014 were included in the final analysis. The reported prevalence of delirium was 4.53%. After multivariable adjustment, delirium was associated with a 2.35-fold increase in the odds of in-hospital mortality (95% confidence interval [CI] 2.23-2.47), which was lower than the odds ratio for sepsis/septicemia (5.36; 95% CI, 5.02-5.72) or respiratory failure (4.53; 95% CI, 4.38-4.69), but similar to that for acute kidney injury (2.39; 95% CI, 2.31-2.48) and higher than for non-ST elevation myocardial infarct (1.57; 95% CI, 1.46-1.68). Delirium increased the total hospital cost by $4,262 (95% CI, $4,002-4,521) and the length of stay by 1.73 days (95% CI, 1.68-1.78), which was slightly lower than, but similar to, acute kidney injury ($4,771; 95% CI, $4,644-4,897) and 1.82 days (95% CI, 1.79-1.84), and higher than non-ST elevation myocardial infarct ($1,907; 95% CI, $1,629-2,185) and 0.31 days (95% CI, 0.25-0.37). CONCLUSIONS: Delirium was associated with increased in-hospital mortality, total hospital cost, and length of stay, and the magnitude of the effect was similar to that for acute kidney injury. Enhanced efforts to prevent delirium are needed to decrease its adverse impact on clinical and economic outcomes for hospitalized older adults with acute heart failure.

The 50/50 Block Schedule: Impact on Residents' and Preceptors' Perceptions, Patient Outcomes, and Continuity of Care.

PROBLEM: Traditionally, internal medicine continuity clinic consists of a half day per week, regardless of rotation, which may create conflict with ongoing inpatient responsibilities. A 50/50 block schedule, which alternates inpatient and outpatient rotations and concentrates continuity clinic during outpatient rotations, minimizes conflicting responsibilities. However, its impact on patient care has not been widely studied. Continuity is a concern, and intervisit continuity in particular has not been evaluated. INTERVENTION: We implemented a 50/50 block model with "clinic buddy" system to optimize continuity and assessed outcomes pre- and postintervention. Residents alternated inpatient and elective blocks, with clinic 1 full day per week on elective blocks only. Resident and preceptor perceptions were measured using 5-point Likert surveys to evaluate impact on clinic experience and workload. The authors calculated visit and intervisit continuity using a Usual Provider of Care index and measured blood pressure and hemoglobin A1c as quality markers to evaluate the impact on continuity and quality of care. CONTEXT: Participants were 208 medicine residents and 39 core faculty members at 3 University of Pittsburgh Medical Center clinics. The intervention was implemented in June 2014. OUTCOME: In the 50/50 system, inpatient distractions decreased (3.59 vs. 1.71, p < .001). Residents more strongly agreed that there was adequate time for conferences (3.33 vs. 4.05), they worked well within the system to achieve best patient care (3.13 vs. 3.61), and multidisciplinary teams worked well together (3.51 vs. 4.08) (all p < .001). Intervisit continuity was unchanged (73%, both models, p = .79). Visit continuity decreased (67.2% vs. 63.7%, p < .001). Blood pressure and hemoglobin A1c were unchanged. LESSONS LEARNED: This 50/50 model minimized inpatient distractions in clinic and increased perceived time for learning. Residents reported improved sense of patient ownership, relations within the multidisciplinary team, and integration into the clinic system. Intervisit continuity was preserved, visit continuity was slightly decreased, and patient outcomes were not impacted in this model.