Lack of racial and ethnic disparities in mortality in minority patients hospitalised with COVID-19 in a mid-Atlantic healthcare system.

INTRODUCTION: In the USA, minoritised communities (racial and ethnic) have suffered disproportionately from COVID-19 compared with non-Hispanic white communities. In a large cohort of patients hospitalised for COVID-19 in a healthcare system spanning five adult hospitals, we analysed outcomes of patients based on race and ethnicity. METHODS: This was a retrospective cohort analysis of patients 18 years or older admitted to five hospitals in the mid-Atlantic area between 4 March 2020 and 27 May 2022 with confirmed COVID-19. Participants were divided into four groups based on their race/ethnicity: non-Hispanic black, non-Hispanic white, Latinx and other. Propensity score weighted generalised linear models were used to assess the association between race/ethnicity and the primary outcome of in-hospital mortality. RESULTS: Of the 9651 participants in the cohort, more than half were aged 18-64 years old (56%) and 51% of the cohort were females. Non-Hispanic white patients had higher mortality (p<0.001) and longer hospital length-of-stay (p<0.001) than Latinx and non-Hispanic black patients. DISCUSSION: In this large multihospital cohort of patients admitted with COVID-19, non-Hispanic black and Hispanic patients did not have worse outcomes than white patients. Such findings likely reflect how the complex range of factors that resulted in a life-threatening and disproportionate impact of incidence on certain vulnerable populations by COVID-19 in the community was offset through admission at well-resourced hospitals and healthcare systems. However, there continues to remain a need for efforts to address the significant pre-existing race and ethnicity inequities highlighted by the COVID-19 pandemic to be better prepared for future public health emergencies.

Self-administered versus clinician-performed BinaxNOW COVID rapid test: a comparison of accuracy.

We conducted a single-center study at a free community testing site in Baltimore City to assess the accuracy of self-performed rapid antigen tests (RATs) for COVID-19. Self-administered BinaxNOW RATs were compared with clinician-performed RATs and against a reference lab molecular testing as the gold standard. Of the 953 participants, 14.9% were positive for SARS- CoV-2 as determined by RT-PCR. The sensitivity and specificity were similar for both self- and clinician-performed RATs (sensitivity: 83.9% vs 88.2%, P = 0.40; specificity: 99.8% vs 99.6%, P = 0.6). Subgroup comparisons based on age and race yielded similar results. Notably, 5.2% (95% CI: 1.5% to 9.5%) of positive results were potentially missed due to participant misinterpretation of the self-test card. However, the false-positive rate for RATs was reassuringly comparable in accuracy to clinician-administered tests. These findings hold significant implications for physicians prescribing treatment based on patient-reported, self-administered positive test results. Our study provides robust evidence supporting the reliability and utility of patient-performed RATs, underscoring their comparable accuracy to clinician-performed RATs, and endorsing their continued use in managing COVID-19. Further studies using other rapid antigen test brands are warranted.IMPORTANCEAccurate and accessible COVID-19 testing is crucial for effective disease control and management. A recent single-center study conducted in Baltimore City examined the reliability of self-performed rapid antigen tests (RATs) for COVID-19. The study found that self-administered RATs yielded similar sensitivity and specificity to clinician-performed tests, demonstrating their comparable accuracy. These findings hold significant implications for physicians relying on patient-reported positive test results for treatment decisions. The study provides robust evidence supporting the reliability and utility of patient-performed RATs, endorsing their continued use in managing COVID-19. Furthermore, the study highlights the need for further research using different rapid antigen test brands to enhance generalizability. Ensuring affordable and widespread access to self-tests is crucial, particularly in preparation for future respiratory virus seasons and potential waves of reinfection of SARS-CoV-2 variants such as the Omicron variant.

Feasibility of and Experience with Free State Funded Telehealth Based Patient Self-referral for COVID-19 Monoclonal Antibody Therapy.

BACKGROUND: Monoclonal antibody (mAb) treatment for COVID-19 has been underutilized due to logistical challenges, lack of access and variable treatment awareness among patients and healthcare professionals. The use of telehealth during the pandemic provides an opportunity to increase access to COVID-19 care. METHODS: This is a single-center descriptive study of telehealth-based patient self-referral for mAb therapy between March 1, 2021, to October 31, 2021 at Baltimore Convention Center Field Hospital (BCCFH). RESULTS: Among the 1001 self-referral patients, the mean age was 47, and most were female (57%) white (66%), and had a primary care provider (62%). During the study period, self-referrals increased from 14 per month in March to 427 in October resulting in a 30-fold increase. About 57% of self-referred patients received a telehealth visit, and of those 82% of patients received mAb infusion therapy. The median time from self-referral to onsite infusion was 2 days (1-3 IQR). DISCUSSION: Our study shows the integration of telehealth with a self-referral process improved access to mAb infusion. A high proportion of self-referrals were appropriate and led to timely treatment. This approach helped those without traditional avenues for care and avoided potential delay for patients seeking referral from their PCPs.

Comparison of hospitalist morale in a COVID-19 alternate care site (ACS) to hospitalist morale in conventional hospitals in Maryland.

BACKGROUND: Morale and burnout were concerns for hospitalists prior to the COVID-19 pandemic; these concerns were amplified as COVID-19 spread and hospitals experienced unprecedented stress. In contrast to prior literature, our study assesses both satisfaction and the importance of various factors. This study examines morale of hospitalists early in the COVID-19 pandemic in two settings: conventional hospitals and a COVID-19 Alternate Care site (ACS) in the same geographic region in Maryland. Multiple studies published early in the pandemic show low morale in COVID-19 hospitals. METHODS: In a cross-sectional survey study, we analyze data from the Hospitalist Morale Index (HMI) administered between September 2020 and March 2021 to determine the pandemic's impact on hospitalist morale. RESULTS: Surprisingly, our study found morale in the ACS was better than morale at the conventional hospitals. ACS hospitalists and conventional hospitalists were demographically similar. Our results show that a significantly higher proportion of conventional hospitalists reported burnout compared to the ACS hospitalists. General quality of life was rated significantly higher in the ACS group than the conventional group. Significantly more ACS hospitalists were invested in making their group outstanding. Five main HMI domains were examined with questions on a 5-point rating scale: Clinical Factors, Workload, Material Rewards, Leadership, and Appreciation/Acknowledgement. ACS hospitalists rated most measures higher than conventional hospitalists; largest differences were observed in Clinical Factors and Appreciation/Acknowledgement domains. Narrative comments from ACS hospitalists revealed strong identification with the mission of the ACS and pride in contributing during a crisis. One key difference between the two groups explains these findings: provider autonomy. The ACS staff chose the position and the assignment, while conventional hospitalists caring for COVID-19 patients could not readily opt out of this work. CONCLUSION: Our data suggest that autonomy in assignments with risk has implications for morale and burnout.

An Educational Needs Assessment of Telehealth in Primary Care Among US Internal Medicine Residents.

OBJECTIVES: As a result of the coronavirus disease 2019 pandemic, many Internal Medicine (IM) residency programs converted to telehealth for primary care. Our objectives in this study were to better understand resident past and present telehealth education, their perceived barriers to telehealth practice, and their perceived solutions to improving telehealth use and education. METHODS: We performed a cross-sectional needs assessment survey between November 2020 and February 2021 among residents at 10 IM residency programs across the United States. Our primary measures were telehealth use in resident continuity clinics before and during the coronavirus disease 2019 pandemic, telehealth training, and confidence and barriers in using telehealth. RESULTS: Of 857 residents contacted, 314 (36.6%) responded. Residents reported low rates of education in telehealth prepandemic with significant improvements after the start of the pandemic across all visit domains (range of 10.7%-19.6% prepandemic compared with 25.6%-55.7% postpandemic, all P < 0.001). Resident confidence levels were significantly lower (P < 0.001) for video visits and telephone visits compared with in-person visiting across domains of communication, history taking, using an interpreter, making a diagnosis, counseling patients, providing psychosocial support, performing medical management, and coordinating after-visit care. Reported barriers included patient resources, clinic resources, lack of preceptor feedback, and lack of observation. Reported resources for improvement included tutorials on physical examination techniques, clinical space for telehealth, and patient resources for telehealth. CONCLUSIONS: To effectively address the educational needs for telehealth practice by IM residents, educators must consider not only curricular needs but also clinical, preceptor, and patient barriers to the high-quality use of telehealth for primary care.

State of research in adult Hospital Medicine: Updated results of a national survey and longitudinal analysis of national data.

We sought to understand the current state of research in adult Hospital Medicine by repeating a 2018 survey of leaders in Hospital Medicine with changes to improve the response rate of surveyed programs. We also analyzed the public sources of federal research funding and MEDLINE-indexed publications from 2010 through 2019 among members of the Society of Hospital Medicine (SHM). Of the 102 contacted leaders of Hospital Medicine groups across the country, 49 responded, for a total response rate of 48%. Among the 3397 faculty members represented in responding programs, 72 (2%) of faculty were identified as conducting research for more than 50% of their time. Respondents noted difficulties at every stage of the research development pipeline, from a lack of mentors to running a fellowship program to a lack of applicants seeking further research training. Improvements to our research training pipeline will be essential to the long-term improvement of our profession.

Racial/Ethnic Disparities in Healthcare Worker Experiences During the COVID-19 Pandemic: An Analysis of the HERO Registry.

Background: The extent to which healthcare worker (HCWs) experiences during the COVID-19 pandemic vary by race or ethnicity after adjustment for confounding factors is not currently known. Methods: We performed an observational prospective cohort study of 24,769 healthcare workers from 50 U.S. states and the District of Columbia, enrolled between April 10, 2020 and June 30, 2021, and evaluated participant experiences during the COVID-19 pandemic, including testing, diagnosis with COVID-19, emotional experiences, burnout, and interest in vaccines and vaccine clinical trials. Findings: After adjustment for professional role, medical history, and community characteristics, Black and Asian participants were less likely to receive SARS-CoV-2 viral testing (adjusted odds ratio (aOR) 0·82 [0·70, 0·96], p=0·012 and aOR 0·77 [0·67, 0·89], p<0·001 respectively) than White participants. Hispanic participants were more likely to have evidence of COVID-19 infection (aOR 1·23 (1·00, 1·50, p=0·048). Black and Asian participants were less likely to report interest in a COVID-19 vaccine (aOR 0·11 [0·05, 0·25], p<0·001 and aOR 0·48 [0·27, 0·85] p=0·012). Black participants were less likely to report interest in participating in a COVID-19 vaccine trial (aOR = 0·39 [0·28, 0·54], p<0·001). Black participants were also less likely to report 3 or more daily emotional impacts of COVID-19 (aOR = 0·66 [0·53, 0·82], p=<0·001). Black participants were additionally less likely to report burnout (aOR = 0·66 ([0·49, 0·95], p=0·025). Interpretation: In a large, national study of healthcare workers, after adjustment for individual and community characteristics, race/ethnicity disparities in COVID-19 outcomes persist. Future work is urgently needed to understand precise mechanisms behind these disparities and to develop and implement targeted interventions to improve health equity for healthcare workers. Funding: This work was funded by the Patient-Centered Outcomes Research Institute (PCORI), Contract # COVID-19-2020-001.

Healthcare Worker Mental Health After the Initial Peak of the COVID-19 Pandemic: a US Medical Center Cross-Sectional Survey.

BACKGROUND: There is a paucity of data on the mental health impact of the Coronavirus disease 2019 (COVID-19) pandemic on United States (US) healthcare workers (HCWs) after the first surge in the spring of 2020. OBJECTIVE: To determine the impact of the pandemic on HCWs, and the relationship between HCW mental health and demographics, occupational factors, and COVID-19 concerns. DESIGN: Cross-sectional survey in an urban medical center (September-November 2020) in Baltimore, MD, in the United States. PARTICIPANTS: A total of 605 HCWs (physicians, nurse practitioners, nurses, physician assistants, patient care technicians, respiratory therapists, social workers, mental health therapists, and case managers). MAIN MEASURES: Measures of mental health (Patient Health Questionnaire-2, Generalized Anxiety Disorder-7, PROMIS Sleep Disturbance 4a, Impact of Event Scale-Revised, Maslach Burnout Inventory-2 item, Connor-Davidson Resilience Scale-2 item), demographics, occupational factors, and COVID-19 related concerns. KEY RESULTS: Fifty-two percent of 1198 HCWs responded to the survey and 14.2% reported depression, 43.1% mild or higher anxiety, 31.6% sleep disturbance, 22.3% posttraumatic stress symptoms, 21.6% depersonalization, 46.0% emotional exhaustion, and 23.1% lower resilience. Relative to HCWs providing in-person care to COVID-19 infected patients none of their working days, those doing so all or most days were more likely to experience worse depression (adjusted odds ratio, 3.9; 95% CI, 1.3-11.7), anxiety (aOR, 3.0; 95% CI, 1.4-6.3), possible PTSD symptoms (aOR, 2.6; 95% CI, 1.1-5.8), and higher burnout (aOR, 2.6; 95% CI, 1.1-6.0). Worse mental health in several domains was associated with higher health fear (aORs ranged from 2.2 to 5.0), job stressors (aORs ranged from 1.9 to 4.0), perceived social stigma/avoidance (aORs ranged from 1.8 to 2.9), and workplace safety concerns (aORs ranged from 1.8 to 2.8). CONCLUSIONS: US HCWs experienced significant mental health symptoms eight months into the pandemic. More time spent providing in-person care to COVID-19-infected patients and greater COVID-19-related concerns were consistently associated with worse mental health.

Depressive Symptoms and Burnout Among Medical Students: a Prospective Study.

BACKGROUND: Depressive symptoms and burnout are common among medical students. However, few studies have investigated their trajectory over the course of medical school. OBJECTIVE: Evaluate year-by-year changes in depressive and burnout symptoms over the course of medical school training. DESIGN: Prospective study. PARTICIPANTS: Medical students who matriculated at a private medical school in Maryland from 2010 to 2016 (n=758). MAIN MEASURES: Clinically significant depressive symptoms were defined as a score of ≥10 on the 9-item Patient Health Questionnaire (PHQ-9), and burnout was measured using the Maslach Burnout Inventory (MBI). High emotional exhaustion, high depersonalization, and low personal accomplishment were defined as scores of ≥ 27, ≥10, and ≤33 on the respective MBI subscales. KEY RESULTS: At matriculation, the prevalences of significant depressive symptoms, high emotional exhaustion, high depersonalization, and low personal accomplishment were 4.3%, 9.4%, 8.6%, and 37.7%, respectively. After adjustment for age, sex, race/ethnicity, marital status, and cohort, compared with year 1, the odds of significant depressive symptoms was significantly higher at the beginning of the 2nd, 3rd, and 4th years of study (ORs=2.63, 2.85, and 3.77, respectively; all ps<0.001). Compared with the 1st year, the odds of high emotional exhaustion also increased during the 2nd, 3rd, and 4th years of study, (ORs=3.46, 4.79, 8.20, respectively; all ps<0.001), as did the odds of high depersonalization (ORs=3.55, 6.14, 12.53, respectively; all ps<0.001). The odds of low personal accomplishment did not significantly differ across years of study. CONCLUSIONS: The results of this study suggest that symptoms of depression and burnout may increase during medical school. Because of the high prevalence of depressive symptoms and burnout in medical students, interventions earlier in the medical career pathway that aim to prevent, detect, and treat these symptoms may be of benefit to the physician community.

Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department.

BACKGROUND: Emergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time. METHODS: After initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric 'bed downtime'-the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre. INTERVENTIONS: Interventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures. RESULTS: This package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit. CONCLUSION: Use of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.

A Method for Attributing Patient-Level Metrics to Rotating Providers in an Inpatient Setting.

BACKGROUND: Individual provider performance drives group metrics, and increasingly, individual providers are held accountable for these metrics. However, appropriate attribution can be challenging, particularly when multiple providers care for a single patient. OBJECTIVE: We sought to develop and operationalize individual provider scorecards that fairly attribute patient-level metrics, such as length of stay and patient satisfaction, to individual hospitalists involved in each patient's care. DESIGN: Using patients cared for by hospitalists from July 2010 through June 2014, we linked billing data across each hospitalization to assign "ownership" of patient care based on the type, timing, and number of charges associated with each hospitalization (referred to as "provider day weighted "). These metrics were presented to providers via a dashboard that was updated quarterly with their performance (relative to their peers). For the purposes of this article, we compared the method we used to the traditional method of attribution, in which an entire hospitalization is attributed to 1 provider, based on the attending of record as labeled in the administrative data. RESULTS: Provider performance in the 2 methods was concordant 56% to 75% of the time for top half versus bottom half performance (which would be expected to occur by chance 50% of the time). While provider percentile differences between the 2 methods were modest for most providers, there were some providers for whom the methods yielded dramatically different results for 1 or more metrics. CONCLUSION: We found potentially meaningful discrepancies in how well providers scored (relative to their peers) based on the method used for attribution. We demonstrate that it is possible to generate meaningful provider-level metrics from administrative data by using billing data even when multiple providers care for 1 patient over the course of a hospitalization.

Predictors of response to cardiac resynchronization therapy: A systematic review.

BACKGROUND: Multiple studies have sought to determine variables associated with improved "response" to cardiac resynchronization therapy(CRT). Such variables, however, are often derived from inadequately controlled, single center cohort studies calling external validity into question. We sought to determine predictors of response to CRT-D and CRT-P utilizing the methods of systematic review. METHODS: We searched MEDLINE, Embase®, and the Cochrane Central Register of Controlled Trials (CENTRAL) from January 1, 1995, as this is the date of first article reporting use of CRT through October 20, 2014. Paired investigators independently screened search results to assess eligibility. For inclusion, investigators abstracted data sequentially and assessed risk of bias independently. Investigators graded the strength of evidence as a group. RESULTS: We identified 13,015 unique citations of which 11,897 were excluded during the abstract screen. During the full-text screening, we excluded 1118 citations. 12 studies reported in 15 articles were included in this review. A left bundle branch (LBBB) morphology, non-ischemic cardiomyopathy (NICM), and female gender were generally associated with improved outcomes following CRT-D. Sinus rhythm (as compared to atrial fibrillation) and a wider QRS duration were associated with improved outcomes following CRT-D albeit with a lower strength of evidence. There was insufficient evidence to determine predictors of outcomes in patients undergoing CRT-P. CONCLUSIONS: A native LBBB, NICM, female gender, sinus rhythm, and a wider QRS duration are associated with improved outcomes following CRT-D implant.

Screening Accuracy for Aspiration Using Bedside Water Swallow Tests: A Systematic Review and Meta-Analysis.

BACKGROUND: Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration. METHODS: Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines. RESULTS: Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration. CONCLUSIONS: Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.

Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis.

BACKGROUND: Despite safe and cost-effective venous thromboembolism (VTE) prevention measures, VTE prophylaxis rates are often suboptimal. Healthcare reform efforts emphasize transparency through programs to report performance and payment incentives through pay-for-performance programs. OBJECTIVE: To sequentially examine an individualized physician dashboard and pay-for-performance program to improve VTE prophylaxis rates among hospitalists. DESIGN: Retrospective analysis of 3144 inpatient admissions. After a baseline observation period, VTE prophylaxis compliance was compared during both interventions. SETTING: A 1060-bed tertiary care medical center. PARTICIPANTS: Thirty-eight part-time and full-time academic hospitalists. INTERVENTIONS: A Web-based hospitalist dashboard provided VTE prophylaxis feedback. After 6 months of feedback only, a pay-for-performance program was incorporated, with graduated payouts for compliance rates of 80% to 100%. MEASUREMENTS: Prescription of American College of Chest Physicians' guideline-compliant VTE prophylaxis and subsequent pay-for-performance payments. RESULTS: Monthly VTE prophylaxis compliance rates were 86% (95% confidence interval [CI]: 85-88), 90% (95% CI: 88-93), and 94% (95% CI: 93-96) during the baseline, dashboard, and combined dashboard/pay-for-performance periods, respectively. Compliance significantly improved with the use of the dashboard (P = 0.01) and addition of the pay-for-performance program (P = 0.01). The highest rate of improvement occurred with the dashboard (1.58%/month; P = 0.01). Annual individual physician performance payments ranged from $53 to $1244 (mean $633; standard deviation ±$350). CONCLUSIONS: Direct feedback using dashboards was associated with significantly improved compliance, with further improvement after incorporating an individual physician pay-for-performance program. Real-time dashboards and physician-level incentives may assist hospitals in achieving higher safety and quality benchmarks.