Age-Stratified 30-day Rehospitalization and Mortality and Predictors of Rehospitalization Among Patients With Systemic Lupus Erythematosus: A Medicare Cohort Study.

OBJECTIVE: Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age. METHODS: In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors. RESULTS: Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE-40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions. CONCLUSION: Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.

Development of a Pharmacist-Led Opt-Out Cessation Treatment Protocol for Combustible Tobacco Smoking Within Inpatient Settings.

Background: Although people who smoke cigarettes are overrepresented among hospital inpatients, few are connected with smoking cessation treatment during their hospitalization. Training, accountability for medication use, and monitoring of all patients position pharmacists well to deliver cessation interventions to all hospitalized patients who smoke. Methods: A large Midwestern University hospital implemented a pharmacist-led smoking cessation intervention. A delegation protocol for hospital pharmacy inpatients who smoked cigarettes gave hospital pharmacists the authority to order nicotine replacement therapy (NRT) during hospitalization and upon discharge, and for referral to the Wisconsin Tobacco Quit Line (WTQL) at discharge. Eligible patients received the smoking cessation intervention unless they actively refused (ie, "opt-out"). The program was pilot tested in phases, with pharmacist feedback between phases, and then implemented hospital-wide. Interviews, surveys, and informal mechanisms identified ways to improve implementation and workflows. Results: Feedback from pharmacists led to changes that improved workflow, training and patient education materials, and enhanced adoption and reach. Refining implementation strategies across pilot phases increased the percentage of eligible smokers offered pharmacist-delivered cessation support from 37% to 76%, prescribed NRT from 2% to 44%, and referred to the WTQL from 3% to 32%. Conclusion: Hospitalizations provide an ideal opportunity for patients to make a tobacco quit attempt, and pharmacists can capitalize on this opportunity by integrating smoking cessation treatment into existing inpatient medication reconciliation workflows. Pharmacist-led implementation strategies developed in this study may be applicable in other inpatient settings.

The increasing impact of length of stay "outliers" on length of stay at an urban academic hospital.

BACKGROUND: As healthcare systems strive for efficiency, hospital "length of stay outliers" have the potential to significantly impact a hospital's overall utilization. There is a tendency to exclude such "outlier" stays in local quality improvement and data reporting due to their assumed rare occurrence and disproportionate ability to skew mean and other summary data. This study sought to assess the influence of length of stay (LOS) outliers on inpatient length of stay and hospital capacity over a 5-year period at a large urban academic medical center. METHODS: From January 2014 through December 2019, 169,645 consecutive inpatient cases were analyzed and assigned an expected LOS based on national academic center benchmarks. Cases in the top 1% of national sample LOS by diagnosis were flagged as length of stay outliers. RESULTS: From 2014 to 2019, mean outlier LOS increased (40.98 to 45.11 days), as did inpatient LOS with outliers excluded (5.63 to 6.19 days). Outlier cases increased both in number (from 297 to 412) and as a percent of total discharges (0.98 to 1.56%), and outlier patient days increased from 6.7 to 9.8% of total inpatient plus observation days over the study period. CONCLUSIONS: Outlier cases utilize a disproportionate and increasing share of hospital resources and available beds. The current tendency to exclude such outlier stays in data reporting due to assumed rare occurrence may need to be revisited. Outlier stays require distinct and targeted interventions to appropriately reduce length of stay to both improve patient care and maintain hospital capacity.

Identification of a novel HIV-1 inhibitor targeting Vif-dependent degradation of human APOBEC3G protein.

APOBEC3G (A3G) is a cellular cytidine deaminase that restricts HIV-1 replication by inducing G-to-A hypermutation in viral DNA and by deamination-independent mechanisms. HIV-1 Vif binds to A3G, resulting in its degradation via the 26 S proteasome. Therefore, this interaction represents a potential therapeutic target. To identify compounds that inhibit interaction between A3G and HIV-1 Vif in a high throughput format, we developed a homogeneous time-resolved fluorescence resonance energy transfer assay. A 307,520 compound library from the NIH Molecular Libraries Small Molecule Repository was screened. Secondary screens to evaluate dose-response performance and off-target effects, cell-based assays to identify compounds that attenuate Vif-dependent degradation of A3G, and assays testing antiviral activity in peripheral blood mononuclear cells and T cells were employed. One compound, N.41, showed potent antiviral activity in A3G(+) but not in A3G(-) T cells and had an IC50 as low as 8.4 µM and a TC50 of >100 µM when tested against HIV-1Ba-L replication in peripheral blood mononuclear cells. N.41 inhibited the Vif-A3G interaction and increased cellular A3G levels and incorporation of A3G into virions, thereby attenuating virus infectivity in a Vif-dependent manner. N.41 activity was also species- and Vif-dependent. Preliminary structure-activity relationship studies suggest that a hydroxyl moiety located at a phenylamino group is critical for N.41 anti-HIV activity and identified N.41 analogs with better potency (IC50 as low as 4.2 µM). These findings identify a new lead compound that attenuates HIV replication by liberating A3G from Vif regulation and increasing its innate antiviral activity.

Antihypertensive medication initiation among young adults with regular primary care use.

BACKGROUND: Young adults with hypertension have the lowest prevalence of controlled blood pressure compared to middle-aged and older adults. Uncontrolled hypertension, even among young adults, increases future cardiovascular event risk. However, antihypertensive medication initiation is poorly understood among young adults and may be an important intervention point for this group. OBJECTIVE: The purpose of this study was to compare rates and predictors of antihypertensive medication initiation between young adults and middle-aged and older adults with incident hypertension and regular primary care contact. DESIGN: A retrospective analysis PARTICIPANTS: Adults ≥ 18 years old (n = 10,022) with incident hypertension and no prior antihypertensive prescription, who received primary care at a large, Midwestern, academic practice from 2008-2011. MAIN MEASURES: The primary outcome was time from date of meeting hypertension criteria to antihypertensive medication initiation, or blood pressure normalization without medication. Kaplan-Meier analysis was used to estimate the probability of antihypertensive medication initiation over time. Cox proportional-hazard models (HR; 95% CI) were fit to identify predictors of delays in medication initiation, with a subsequent subpopulation analysis for young adults (18-39 years old). KEY RESULTS: After a mean follow-up of 20 (±13) months, 34% of 18-39 year-olds with hypertension met the endpoint, compared to 44% of 40-59 year-olds and 56% of ≥ 60 year-olds. Adjusting for patient and provider factors, 18-39 year-olds had a 44% slower rate of medication initiation (HR 0.56; 0.47-0.67) than ≥ 60 year-olds. Among young adults, males, patients with mild hypertension, and White patients had a slower rate of medication initiation. Young adults with Medicaid and more clinic visits had faster rates. CONCLUSIONS: Even with regular primary care contact and continued elevated blood pressure, young adults had slower rates of antihypertensive medication initiation than middle-aged and older adults. Interventions are needed to address multifactorial barriers contributing to poor hypertension control among young adults.

Gender differences in COVID-19-related manuscript authorship by hospitalists during the pandemic: A bibliometric analysis.

BACKGROUND: Hospital medicine (HM) has a well-described gender disparity related to academic work and promotion. During the COVID-19 pandemic, female authorship across medicine fell further behind historical averages. OBJECTIVE: Examine how COVID-19 affected the publication gender gap for hospitalists. DESIGN, SETTINGS, AND PARTICIPANTS: Bibliometric analysis to determine gender and specialty of US-based physician first and last authors of COVID-19 articles published March 1, 2020 to February 28, 2021 in the four highest impact general medical journals and two highest impact HM-specific journals. MAIN OUTCOME AND MEASURES: We characterized the percentage of all physician authors that were women, the percentage of physician authors that were hospitalists, and the percentage of HM authors that were women. We compared author gender between general medical and HM-specific journals. RESULTS: During the study period, 853 manuscripts with US-based first or last authors were published in eligible journals. Included manuscripts contained 1124 US-based physician first or last author credits, of which 34.2% (384) were women and 8.8% (99) were hospitalists. Among hospitalist author credits, 43.4% (n = 43/99) were occupied by women. The relative gender equity for hospitalist authors was driven by the two HM journals where, compared to the four general medical journals, hospitalist authors (54.1% [33/61] vs. 26.3% [10/38] women, respectively, p = .002) and hospitalist last authors (51.9% [14/27] vs. 20% [4/20], p = .03) were more likely to be women. CONCLUSIONS: Across COVID-19-related manuscripts, disparities by gender were driven by the high-impact general medical journals. HM-specific journals had more equitable inclusion of women authors, demonstrating the potential impact of proactive editorial policies on diversity.

Associations of Postdischarge Follow-Up With Acute Care and Mortality in Lupus: A Medicare Cohort Study.

OBJECTIVE: Patients with systemic lupus erythematosus experience the sixth highest rate of 30-day readmissions among chronic diseases. Timely postdischarge follow-up is a marker of ambulatory care quality that can reduce readmissions in other chronic conditions. Our objective was to test the hypotheses that 1) beneficiaries from populations experiencing health disparities, including patients from disadvantaged neighborhoods, will have lower odds of completed follow-up, and that 2) follow-up will predict longer time without acute care use (readmission, observation stay, or emergency department visit) or mortality. METHODS: This observational cohort study included hospitalizations in January-November 2014 from a 20% random sample of Medicare adults. Included hospitalizations had a lupus code, discharge to home without hospice, and continuous Medicare A/B coverage for 1 year before and 1 month after hospitalization. Timely follow-up included visits with primary care or rheumatology within 30 days. Thirty-day survival outcomes were acute care use and mortality adjusted for sociodemographic information and comorbidities. RESULTS: Over one-third (35%) of lupus hospitalizations lacked 30-day follow-up. Younger age, living in disadvantaged neighborhoods, and rurality were associated with lower odds of follow-up. Follow-up was not associated with subsequent acute care or mortality in beneficiaries age <65 years. In contrast, follow-up was associated with a 27% higher hazard for acute care use (adjusted hazard ratio [HR] 1.27 [95% confidence interval (95% CI) 1.09-1.47]) and 65% lower mortality (adjusted HR 0.35 [95% CI 0.19-0.67]) among beneficiaries age ≥65 years. CONCLUSION: One-third of lupus hospitalizations lacked follow-up, with significant disparities in rural and disadvantaged neighborhoods. Follow-up was associated with increased acute care, but 65% lower mortality in older systemic lupus erythematosus patients. Further development of lupus-specific postdischarge strategies is needed.

Disparities in 30-day readmission rates among Medicare enrollees with dementia.

BACKGROUND: Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses. METHODS: This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds. RESULTS: Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts. CONCLUSIONS: There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.

COVID-19-Related Publications by Hospitalists in the United States.

Objective To determine the degree to which hospitalists published academic manuscripts related to COVID-19 during the first year of the pandemic. Patients and methods The study was a cross-sectional analysis of the author's specialty, defined by byline or professional online biography, from articles related to COVID-19 published between March 1, 2020, and February 28, 2021. It included the top four internal medicine journals by impact factor: New England Journal of Medicine, Journal of the American Medical Association, Journal of the American Medical Association Internal Medicine, and Annals of Internal Medicine. Participants were all United States (US)-based physician authors contributing to COVID-19 publications. Our primary outcome was the percentage of US-based physician authors of COVID-19 articles who were hospitalists. Subgroup analyses characterized author specialty by authorship position (first, middle, last) and article type (research vs. non-research). Results Between March 1, 2020, and February 28, 2021, the top four US-based medical journals published 870 articles related to COVID-19 of which 712 articles with 1940 US-based physician authors were included. Hospitalists accounted for 4.2% (82) of authorship positions including 4.7% (49/1038) of authorship positions in research articles and 3.7% (33/902) of authorship positions in non-research articles. First, middle, and last authorship positions were held by hospitalists at 3.7% (18/485), 4.4% (45/1034), and 4.5% (19/421) of the time, respectively. Conclusions Despite caring for a large number of patients with COVID-19, hospitalists were rarely involved in disseminating COVID-19 knowledge. Limited authorship by hospitalists could constrain the dissemination of inpatient medicine knowledge, impact patient outcomes, and affect the academic promotion of early-career hospitalists.

NFAT and IRF proteins regulate transcription of the anti-HIV gene, APOBEC3G.

The human cytidine deaminase APOBEC3G (A3G) is an innate restriction factor that inhibits human immunodeficiency virus, type 1 (HIV-1) replication. Regulation of A3G gene expression plays an important role in this suppression. Currently, an understanding of the mechanism of this gene regulation is largely unknown. Here, we have identified and characterized a TATA-less core promoter with an NFAT/IRF-4 composite binding site that confers cell type-specific transcriptional regulation. We found that A3G expression is critically dependent on NFATc1/NFATc2 and IRF-4. When either NFATc1 or NFATc2 and IRF-4 were co-expressed, A3G promoter activity was observed in cells that normally lack A3G expression and expression was not detected in the presence of the individual factors. This induced A3G expression allowed normally permissive CEMss cells to adopt a nonpermissive state, able to resist an HIV-1Δvif challenge. This represents the first reporting of manipulating the restrictive state of a cell type via gene regulation. Identification of NFAT and IRF family members as critical regulators of A3G expression offers important insight into the transcriptional control mechanisms that regulate innate immune responses and identifies specific targets for therapeutic intervention aimed at effectively boosting our natural immunity, in the form of a host defensive factor, against HIV-1.

Race, Sex, and Neighborhood Socioeconomic Disparities in Ablation of Ventricular Tachycardia Within a National Medicare Cohort.

Background Ventricular tachycardia (VT) ablation significantly improves our ability to control VT, yet little is known about whether disparities exist in delivery of this technology. Methods and Results Using a national 100% Medicare inpatient data set of beneficiaries admitted with VT from January 1, 2014, through November 30, 2014, multivariable logistic regression techniques were used to examine the sociodemographic and clinical characteristics associated with receiving ablation. Census block group-level neighborhood socioeconomic disadvantage was measured for each patient by the Area Deprivation Index, a composite measure of socioeconomic disadvantage consisting of education, income, housing, and employment factors. Among 131 645 patients admitted with VT, 2190 (1.66%) received ablation. After adjustment for comorbidities, hospital characteristics, and sociodemographics, female sex (odds ratio [OR], 0.75 [95% CI, 0.67-0.84]), identifying as Black race (OR, 0.75 [95% CI, 0.62-0.90] compared with identifying as White race), and living in a highly socioeconomically disadvantaged neighborhood (national Area Deprivation Index percentile of >85%) (OR, 0.81 [95% CI, 0.69-0.95] versus Area Deprivation Index ≤85%) were associated with significantly lower odds of receiving ablation. Conclusions Female patients, patients identifying as Black race, and patients living in the most disadvantaged neighborhoods are 19% to 25% less likely to receive ablation during hospitalization with VT. The cause of and solutions for these disparities require further investigation.

Can inpatient pharmacists move the needle on smoking cessation? Evaluating reach and representativeness of a pharmacist-led opt-out smoking cessation intervention protocol for hospital settings.

PURPOSE: Hospitalization affords an opportunity to reduce smoking, but fewer than half of patients who smoke receive evidence-based cessation treatment during inpatient stays. This study evaluated a pharmacist-led, electronic health record (EHR)-facilitated opt-out smoking cessation intervention designed to address this need. METHODS: Analyses of EHR records for adult patients who smoked in the past 30 days admitted to an academic medical center in the upper Midwest were conducted using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. The reach of a pharmacist-led, EHR-facilitated protocol for smoking cessation treatment was assessed by comparing patients' receipt of nicotine replacement therapy (NRT) and tobacco quitline referral before and after implementation. χ2 tests, t tests, and multiple logistic regression models were used to compare reach across patient demographic groups to assess treatment disparities and the representativeness of reach. Adoption of the program by hospital services was also assessed. RESULTS: Of the 70 hospital services invited to implement the program, 88.6% adopted it and 78.6% had eligible admissions. Treatment reach increased as rates of delivering NRT rose from 43.6% of eligible patients before implementation to 50.4% after implementation (P < 0.0001) and quitline referral rates rose from 0.9% to 11.9% (P < 0.0001). Representativeness of reach by sex and ethnicity improved after implementation, although disparities by race and age persisted after adjustment for demographics, insurance, and primary diagnosis. Pharmacists addressed tobacco use for eligible patients in 62.5% of cases after protocol implementation. CONCLUSION: Smoking cessation treatment reach and representativeness of reach improved after implementation of a proactive, pharmacist-led, EHR-facilitated opt-out smoking cessation treatment protocol in adult inpatient services.

The antiretroviral enzyme APOBEC3G is degraded by the proteasome in response to HIV-1 Vif.

The human protein apolipoprotein B mRNA-editing enzyme-catalytic polypeptide-like-3G (APOBEC3G), also known as CEM-15, mediates a newly described form of innate resistance to retroviral infection by catalyzing the deamination of deoxycytidine to deoxyuridine in viral cDNA replication intermediates. Because DNA deamination takes place after virus entry into target cells, APOBEC3G function is dependent on its association with the viral nucleoprotein complexes that synthesize cDNA and must therefore be incorporated into virions as they assemble in infected cells. Here we show that the HIV-1 virion infectivity factor (Vif) protein protects the virus from APOBEC3G-mediated inactivation by preventing its incorporation into progeny virions, thus allowing the ensuing infection to proceed without DNA deamination. In addition to helping exclude APOBEC3G from nascent virions, Vif also removes APOBEC3G from virus-producing cells by inducing its ubiquitination and subsequent degradation by the proteasome. Our findings indicate that pharmacologic strategies aimed at stabilizing APOBEC3G in HIV-1 infected cells should be explored as potential HIV/AIDS therapeutics.

Health Policy Advocacy Engagement: A Physician Survey.

PURPOSE: Physicians can play an important role in shaping health policy. The purpose of this study was to determine characteristics of physicians participating in health policy and barriers and facilitators to their advocacy. METHODS: A modified previously validated survey instrument was mailed to physicians affiliated with the University of Wisconsin on October 12, 2018. Three follow-up emails were sent, and the response period closed January 30, 2019. Twenty-eight items were included in the survey tool. Respondents were considered highly engaged if they: (a) reported involvement in predetermined high impact areas, (b) had self-reported weekly or monthly advocacy involvement, or (c) had more than 10% dedicated work time for advocacy. RESULTS: Eight hundred eighty-six of 1,432 physicians responded (61.9%), of which 133 (15.0%) were highly engaged. Highly engaged respondents were more commonly male (57.1%), White (90.2%), of nonsurgical specialties (80.5%), and Democrat (55.6%) or Independent (27.1%). Those not highly engaged were more likely to report "I don't know how to get involved." Less than half of all respondents received any advocacy education, with professional organizations providing the majority of education through conferences and distribution of materials. Only 2.5% of respondents had more than 10% of work time dedicated to health policy. CONCLUSIONS: Engagement in health policy exists on a spectrum, but only a small percent of physicians are highly engaged, and very few have dedicated work time for advocacy. Certain demographics predominate the advocacy voice, and health policy training opportunities are lacking.

Assessing Perspectives on Systemic Racism in an Academic Hospital Medical Group: The ARCH Project.

BACKGROUND: Wisconsin residents experience significant racial inequities in health outcomes. OBJECTIVES: The University of Wisconsin School of Medicine and Public Health Division of Hospital Medicine wanted to assess providers' perspectives on systemic racism and gauge their receptiveness to participating in anti-racism training, in conjunction with development and implementation of anti-racism curriculum. METHODS: Existing anti-racism curriculum was adapted to be delivered remotely. Division providers were asked to complete a 9-question survey at the beginning of the curriculum. RESULTS: At baseline, a majority of respondents believed that racial health disparities exist and should be discussed through employer-sponsored training. Respondents generally did not feel confident in their abilities to address racism. CONCLUSIONS: Providers were supportive of anti-racism training in the workplace and feel it is congruent with the public health mission of hospital medicine physicians.

The Hospital Readmissions Reduction Program and Observation Hospitalizations.

The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) penalizes hospitals having excess inpatient rehospitalizations within 30 days of index inpatient stays for targeted conditions. Observation hospitalizations are increasing in frequency and may clinically resemble inpatient hospitalizations, yet HRRP excludes observation in index and 30-day rehospitalization counts. Using 100% 2014 Medicare fee-for-service claims and CMS's 30-day rehospitalization methodology, we modeled how observation hospitalizations impact HRRP metrics when counted as index (denominator) and 30-day (numerator) rehospitalizations. Of 3,806,772 index hospitalizations for HRRP conditions, 418,923 (11%) were observation; 18% (155,553/876,033) of rehospitalizations were invisible to HRRP due to observation hospitalization as index (34%; 63,740/188,430), 30-day outcome (53%; 100,343/188,430), or both (13%; 24,347/188,430). By ignoring observation hospitalizations as index and 30-day events, nearly one of five HRRP rehospitalizations is missed. Policymakers might consider this an opportunity to address broad challenges of the two-tiered observation and inpatient hospital billing distinction.

Antibiotic utilization variability among training services at an academic medical center: An observational study.

OBJECTIVE: Evaluate the difference in antibiotic prescribing between various levels of resident training or attending types. DESIGN: Observational, retrospective study. SETTING: Tertiary-care, academic medical center in Madison, Wisconsin. METHODS: We measured antibiotic utilization from January 1, 2016, through December 31, 2018, in our general medicine (GM) and hospitalist services. The GM1 service is staffed by outpatient internal medicine physicians, the GM2 service is staffed by geriatricians and hospitalists, and the GM3 service is staffed by only hospitalists. The GMA service is led by junior resident physicians, and the GMB service is led by senior resident physicians. We measured utilization using days of therapy (DOT) per 1,000 patient days (PD). In a secondary analysis based on antibiotic spectrum, we used average DOT per 1,000 PD. RESULTS: Teaching services prescribed more antibiotics than nonteaching services (671.6 vs 575.2 DOT per 1,000 PD; P < .0001). Junior resident-led services used more antibiotics than senior resident-led services (740.9 vs 510.0 DOT per 1,000 PD; P < .0001). Overall, antibiotic prescribing was numerically similar between various attending physician backgrounds. A secondary analysis showed that GM services prescribed more broad-spectrum, anti-MRSA, and anti-pseudomonal antibiotics than the hospitalist services. GM junior resident-led services prescribed more broad-spectrum, anti-MRSA, and antipseudomonal therapy compared to their senior counterparts. CONCLUSIONS: Antibiotics were prescribed at a significantly higher rate in services associated with trainees than those without. Services led by a junior resident physician prescribed antibiotics at a significantly higher rate than services led by a senior resident. Interventions to reduce unnecessary antibiotic exposure should be targeted toward resident physicians, especially junior trainees.

One Quarter of Medicare Hospitalizations in Patients with Systemic Lupus Erythematosus Readmitted within Thirty Days.

OBJECTIVE: Thirty-day hospital readmissions in systemic lupus erythematosus (SLE) approach proportions in Medicare-reported conditions including heart failure (HF). We compared adjusted 30-day readmission and mortality among SLE, HF, and general Medicare to assess predictors informing readmission prevention. METHODS: This database study used a 20% sample of all US Medicare 2014 adult hospitalizations to compare risk of 30-day readmission and mortality among admissions with SLE, HF, and neither per discharge diagnoses (if both SLE and HF, classified as SLE). Inclusion required live discharge and ≥12 months of Medicare A/B before admission to assess baseline covariates including patient, geographic, and hospital factors. Analysis used observed and predicted probabilities, and multivariable GEE models clustered by patient to report adjusted risk ratios (ARRs) of 30-day readmission and mortality. RESULTS: SLE admissions (n=10,868) were younger, predominantly female, more likely to be Black, disabled, and have Medicaid or end-stage renal disease (ESRD). Observed 30-day readmissions of 24% were identical for SLE and HF (p = 0.6), and higher than other Medicare (16%, p < 0.001). Both SLE and HF had elevated readmission risk (ARR 1.08, (95% CI (1.04, 1.13)); 1.11, (1.09, 1.13)). SLE readmissions were higher for Black (30%) versus White (21%) populations, and highest in ages 18-33 (39%) and ESRD (37%). Admissions of Black patients with SLE from least disadvantaged neighborhoods had highest 30-day mortality (9% versus 3% White). CONCLUSION: Thirty-day SLE readmissions rivaled HF at 24%. Readmission prevention programs should engage young, ESRD patients with SLE and examine potential causal gaps in SLE care and transitions.

Critical illness-induced dysglycaemia: diabetes and beyond.

Type 2 diabetes has reached epidemic proportions in many parts of the world. The disease is projected to continue to increase and double within the foreseeable future. Dysglycaemia develops in the form of hyperglycaemia, hypoglycaemia and marked glucose variability in critically ill adults whether they are known to have premorbid diabetes or not. Patients with such glucose dysregulation have increased morbidity and mortality. Whether this is secondary to cause and effect from dysglycaemia or is just related to critical illness remains under intense investigation. Identification of intensive care unit (ICU) patients with unrecognised diabetes remains a challenge. Further, there are few data regarding the development of type 2 diabetes in survivors after hospital discharge. This commentary introduces the concept of critical illness-induced dysglycaemia as an umbrella term that includes the spectrum of abnormal glucose homeostasis in the ICU. We outline the need for further studies in the area of glucose regulation and for follow-up of the natural history of abnormal glucose control during ICU admission and beyond.