Initiative to deprescribe high-risk drugs for older adults presenting to the emergency department after falls.

BACKGROUND: Over 35 million falls occur in older adults annually and are associated with increased emergency department (ED) revisits and 1-year mortality. Despite associations between medications and falls, the prevalence of fall risk-increasing drugs remains high. Our objective was to implement an ED-based medication reconciliation for patients presenting after falls and determine whether an intervention targeting high-risk medications was related to decreased future falls. METHODS: This was an observational prospective cohort study at a single site in the United States. Adults 65 years and older presenting to the ED after falls had a pharmacist review their medicines. Pharmacists made recommendations to taper, stop, or discuss medications with the primary clinician. At 3, 6, and 12 months, we recorded the number of fall-related return ED visits and determined if recommended medication changes had been implemented. We compared the rate of return visits of patients who had followed the medication change recommendations and those who received recommendations but had no change in their medications using chi-square tests. RESULTS: A total of 577 patients (mean age 81 years, 63.6% female) were enrolled of 1509 potentially eligible patients. High-risk medications were identified in 310 patients (53.7%) who received medication recommendations. High-risk medications were associated with repeat fall-related visits at 12 months (risk difference 8.1% [95% confidence interval 0.97-15.0]). A total of 134 (43%) patients on high-risk medications had evidence of medication modification. At 12 months, there was no statistically significant difference in return fall visits between patients who had modifications to medications compared with those who had not implemented changes (p = 0.551). CONCLUSIONS: Our findings identified opportunities for medication optimization in over half of emergency visits for falls and demonstrated that medication counseling in the ED is feasible. However, evaluation of the effect on future falls was limited.

Accuracy of the electronic health record's problem list in describing multimorbidity in patients with heart failure in the emergency department.

Patients with heart failure (HF) often suffer from multimorbidity. Rapid assessment of multimorbidity is important for minimizing the risk of harmful drug-disease and drug-drug interactions. We assessed the accuracy of using the electronic health record (EHR) problem list to identify comorbid conditions among patients with chronic HF in the emergency department (ED). A retrospective chart review study was performed on a random sample of 200 patients age ≥65 years with a diagnosis of HF presenting to an academic ED in 2019. We assessed participant chronic conditions using: (1) structured chart review (gold standard) and (2) an EHR-based algorithm using the problem list. Chronic conditions were classified into 37 disease domains using the Agency for Healthcare Research Quality's Elixhauser Comorbidity Software. For each disease domain, we report the sensitivity, specificity, positive predictive value, and negative predictive of using an EHR-based algorithm. We calculated the intra-class correlation coefficient (ICC) to assess overall agreement on Elixhauser domain count between chart review and problem list. Patients with HF had a mean of 5.4 chronic conditions (SD 2.1) in the chart review and a mean of 4.1 chronic conditions (SD 2.1) in the EHR-based problem list. The five most prevalent domains were uncomplicated hypertension (90%), obesity (42%), chronic pulmonary disease (38%), deficiency anemias (33%), and diabetes with chronic complications (30.5%). The positive predictive value and negative predictive value of using the EHR-based problem list was greater than 90% for 24/37 and 32/37 disease domains, respectively. The EHR-based problem list correctly identified 3.7 domains per patient and misclassified 2.0 domains per patient. Overall, the ICC in comparing Elixhauser domain count was 0.77 (95% CI: 0.71-0.82). The EHR-based problem list captures multimorbidity with moderate-to-good accuracy in patient with HF in the ED.

Cost variation and revisit rate for adult patients with asthma presenting to the emergency department.

BACKGROUND: Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care. STUDY OBJECTIVE: We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation. METHODS: We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering. RESULTS: In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371-980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18-1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00-1.00). CONCLUSION: Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial.

OBJECTIVE: To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN: Pragmatic cluster randomized controlled trial (EMBED). SETTING: 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS: 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION: A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES: Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS: 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS: User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov NCT03658642.

Advance Care Planning for Emergency Department Patients With COVID-19 Infection: An Assessment of a Physician Training Program.

OBJECTIVE: Coronavirus Disease 2019 (COVID-19) has heightened the importance of advance care planning (ACP), particularly in the emergency department (ED). The objective of this study was to determine the effect of an educational program for emergency physicians on ACP conversations in the ED during the COVID-19 pandemic. DESIGN: This was an observational pre-/post-interventional study. SETTING: This study was conducted at a Southeastern U.S. academic ED. PARTICIPANTS: 143 patients with confirmed COVID-19 infection in the 2 weeks up to and including the ED encounter of interest (between March 26 and May 25, 2020) were included. INTERVENTIONS: The primary intervention was an ACP training toolkit with three components: (1) an evidence-based guide to COVID-19 risk stratification, (2) education on language to initiate ACP conversations, and (3) modification of the electronic health record (EHR) to facilitate ACP documentation. Palliative care physicians also delivered a 60-minute ACP educational session for emergency medicine physicians. OUTCOME MEASURES: The primary outcome was a composite of ACP activities including: (1) identification of a healthcare decision-maker (HCDM), (2) an order for a code status, or (3) a documented goals of care conversation. RESULTS: There was a 25.4% (95% CI: 7.0-43.9) increase in the composite outcome of ED-based ACP. After adjustment for patient demographics and triage score, there was a non-statistically significant increase in ACP activity (OR = 2.71, 95% CI: 0.93-8.64; P = .08). CONCLUSION: A rapid and simple physician-facing educational intervention demonstrated a trend, though lacking in statistical significance, towards increased ED-based ACP activities for patients with COVID-19.

Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems.

STUDY OBJECTIVE: People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States. METHODS: Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm. RESULTS: Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic. CONCLUSION: Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.

Venous thromboembolism in metastatic urothelial carcinoma or variant histologies: incidence, associative factors, and effect on survival.

Venous thromboembolism (VTE) is common in cancer patients. However, little is known about VTE risk in metastatic urothelial carcinoma or variant histologies (UC/VH). We sought to characterize the incidence, associative factors, including whether various chemotherapy regimens portend different risk, and impact of VTE on survival in metastatic UC/VH patients. Patients diagnosed with metastatic UC/VH from 2000 to 2013 were included in this multicenter retrospective, international study from 29 academic institutions. Cumulative and 6-month VTE incidence rates were determined. The association of first-line chemotherapy (divided into six groups) and other baseline characteristics on VTE were analyzed. Each chemotherapy treatment group and statistically significant baseline clinical characteristics were assessed in a multivariate, competing-risk regression model. VTE patients were matched to non-VTE patients to determine the impact of VTE on overall survival. In all, 1762 patients were eligible for analysis. There were 144 (8.2%) and 90 (5.1%) events cumulative and within the first 6 months, respectively. VTE rates based on chemotherapy group demonstrated no statistical difference when gemcitabine/cisplatin was used as the comparator. Non-urotheilal histology (SHR: 2.67; 95% CI: 1.72-4.16, P < 0.001), moderate to severe renal dysfunction (SHR: 2.12; 95% CI: 1.26-3.59, P = 0.005), and cardiovascular disease (CVD) or CVD risk factors (SHR: 2.27; 95% CI: 1.49-3.45, P = 0.001) were associated with increased VTE rates. Overall survival was worse in patients with VTE (median 6.0 m vs. 10.2 m, P < 0.001). Thus, in metastatic UC/VH patients, VTE is common and has a negative impact on survival. We identified multiple associated potential risk factors, although different chemotherapy regimens did not alter risk.

The Khorana Score in Predicting Venous Thromboembolism for Patients With Metastatic Urothelial Carcinoma and Variant Histology Treated With Chemotherapy.

BACKGROUND: The Khorana score is a predictive risk model for venous thromboembolism (VTE) in patients with cancer planning to receive chemotherapy. Urothelial carcinoma and variant histologies (UC/VH) were underrepresented in the model. We sought to evaluate whether the Khorana score predicts for VTE in a retrospective multinational data set of patients with metastatic UC/VH. METHODS: Patients diagnosed with metastatic UC/VH who received chemotherapy were eligible. Those with incomplete or miscoded data were excluded. Khorana scores were calculated based on the pretreatment data and categorized into high (≥3) or intermediate (1-2) VTE risk. Other patient-, tumor-, and therapy-related factors were also analyzed. The χ2 and logistic regression analyses were used to assess differences in VTE rates based on the clinical characteristics. Subgroup analyses were performed to evaluate the Khorana score and associated variables for early (<3 months) and late (>3 months) VTE. RESULTS: A total of 943 patients were eligible for analysis. The cumulative VTE rate was 9.9%. There was no statistical difference in overall VTE rate between Khorana high- and intermediate-risk groups ( P = .16). In the multivariate analysis, nonurothelial histology (odds ratio [OR] = 2.56; P = .002) and the presence of cardiovascular disease (CVD) or CVD risk factors (OR = 2.14; P = .002) were associated with increased VTE risk. In the first 3 months from initiation of chemotherapy, Khorana high risk (OR = 2.08; P = .04) was associated with higher VTE rates. White blood cell (WBC) count (OR = 1.05; P = .04) was the only significant Khorana variable for early VTE. CONCLUSIONS: The Khorana score stratifies early but not overall VTE risk in patients with metastatic UC/VH. The WBC count drives the increased early VTE risk seen with the Khorana score.

The Relationship between Centralization of Care and Geographic Barriers to Cystectomy for Bladder Cancer.

Background: Centralization of cystectomy treatment for bladder cancer, while associated with improved outcomes, may impose geographic barriers to care. However, whether this effect may be counterbalanced by an increased number of high volume centers has not previously been explored. Objective: To characterize changes in geographic disparities to high volume cystectomy centers over time. Methods: Data on all inpatient admissions for cystectomy in New York State (NYS) from 1997-2011 was obtained from the Department of Health. Using these data, we classified hospitals according to cystectomy volume and measured patient distance traveled to a cystectomy center. Population weights, from the US Census, were used to describe changes in minimum travel distance to high- or very high-volume (HV/VHV) facilities across the NYS population. Results: Bladder cancer patients underwent cystectomies at 195 hospitals during the study period. In 1997-2001, eleven HV/VHV facilities accounted for 37.5% of all cystectomies, while sixteen HV/VHV hospitals accounted for 71.5% of all procedures during 2007-2011. Median distance traveled by cystectomy patients to all hospitals increased from 9.6 to 14.4 miles in 1997-2001 to 2007-2011, respectively. In the same time span, the median travel distance for the NYS population to a HV/VHV center decreased by 1.9 and 9.4 miles at the median and 75th percentile, respectively. Conclusions: Our findings demonstrate a complicated relationship between centralization and geographic access. While centralization has led to a decrease in overall access to cystectomy facilities, the process simultaneously improved access to high volume centers.

INTRAVENOUS PAMIDRONATE IS ASSOCIATED WITH REDUCED MORTALITY IN PATIENTS WITH CHRONIC CRITICAL ILLNESS.

OBJECTIVE: Chronic critical illness (CCI), characterized by prolonged mechanical ventilation and tracheostomy, commonly manifests with elevated bone resorption, which has previously been shown to abate after treatment with intravenous (IV) bisphosphonates. Our study assessed the impact of pamidronate administration on clinical outcomes in a CCI cohort. METHODS: A retrospective case series was performed on 148 patients admitted to The Mount Sinai Hospital Respiratory Care Unit (RCU) from 2009-2010. We identified patients with CCI who did (n = 30) or did not (n = 118) receive IV pamidronate (30 to 90 mg). Both groups included patients with normal and abnormal renal function. Pamidronate was administered for elevated urine or serum N-telopeptide, hypercalciuria, or hypercalcemia. RESULTS: RCU and 1-year mortality were significantly lower in the pamidronate group (0 and 20%, respectively) compared to nonreceivers (19 and 56%, respectively) (P = .0077 and P = .0004, respectively). After adjusting for differences in baseline creatinine, estimated glomerular filtration rate, and serum calcium, the association with reduced mortality remained significant at 1 year (P = .0132) and with borderline significance for RCU mortality (P = .0911). Creatinine was significantly lower 7 days following pamidronate administration (P = .0025), with no significant difference at 14 days compared to baseline. Pamidronate receivers showed a greater increase in albumin during the RCU stay (2.49 to 3.23 g/dL), compared to nonreceivers (2.43 to 2.64 g/dL) (P = .0007). Pamidronate administration was associated with a significantly reduced rate of hypoglycemia compared to RCU patients not receiving pamidronate (0.09 versus 0.12; P = .0071). CONCLUSION: Pamidronate use in a CCI population is associated with reduced mortality, lower hypoglycemia rates, improved albumin, and stable renal function. ABBREVIATIONS: BMI = body mass index CCI = chronic critical illness CI = confidence interval CKD = chronic kidney disease CTx = C-telopeptide eGFR = estimated glomerular filtration rate ICU = intensive care unit IV = intravenous NTx = N-telopeptide PMV = prolonged mechanical ventilation RCU = respiratory care unit.

The Impact of Regionalization of Cystectomy on Racial Disparities in Bladder Cancer Care.

PURPOSE: Regionalization of surgical care has improved the quality of care for patients with bladder cancer. We explored whether regionalization has benefited white and black patients equally. MATERIALS AND METHODS: We used a New York State inpatient database to identify all patients who underwent cystectomy for bladder cancer from 1997 to 2011. Hospital volume was classified in quintiles based on the number of cystectomies performed in the first 5 years of the study. Logistic regression was done to assess the association between race and low volume/very low volume hospitals. Racial disparities were further characterized using stratification by time and by the racial composition of the patient community. RESULTS: A total of 8,168 patients treated with cystectomy for bladder cancer were included in analysis. Compared with white race, black race was associated with a higher likelihood of low volume/very low volume hospital use (OR 1.59, 95% CI 1.26-2.02). The disparity was most prominent in 2002 to 2006 (OR 2.51, 95% CI 1.64-3.85) but it did not persist in 2007 to 2011 (OR 1.46, 95% CI 0.92-2.32). Black patients living in a black community had the highest likelihood of low volume/very low volume hospitalization during all periods of increased regionalization (2002 to 2006 OR 4.14, 95% CI 1.84-9.34 and 2007 to 2011 OR 2.40, 95% CI 1.07-5.39). CONCLUSIONS: Regionalization of cystectomy transiently worsened the racial disparity in bladder cancer care, although the disparity did not persist with time. Specific efforts may be needed to address the consequences of regionalization in particularly vulnerable subpopulations, such as black patients who live in a black community where disparities have persisted.

Association of glycemic control parameters with clinical outcomes in chronic critical illness.

OBJECTIVE: Chronic critical illness (CCI) is a term used to designate patients requiring prolonged mechanical ventilation and tracheostomy with associated poor outcomes. The present study assessed the impact of glycemic parameters on outcomes in a CCI population. METHODS: A retrospective case series was performed including 148 patients in The Mount Sinai Hospital Respiratory Care Unit (2009-2010). Utilizing a semi-parametric mixture model, trajectories for the daily mean blood glucose (BG), BG range, and hypoglycemia rate over time identified low- (n = 87) and high-risk (n = 61) hyperglycemia groups and low- (n = 90) and high-risk (n = 58) hypoglycemia groups. The cohort was also classified into diabetes (DM, n = 48), stress hyperglycemia (SH, n = 85), and normal glucose (n = 15) groups. RESULTS: Hospital- (28% vs. 13%, P = .0199) and 1-year mortality (66% vs. 46%, P = .0185) rates were significantly greater in the high- versus low-risk hyperglycemia groups, respectively. The hypoglycemia rate (<70 mg/dL) was lower among ventilator-liberated patients compared to those who failed to liberate (0.092 vs. 0.130, P<.0001). In the SH group, both hospital mortality (high-risk hyperglycemia 48% and low-risk hyperglycemia 15%, P = .0013) and 1-year mortality (high-risk 74% and low-risk 50%, P = .0482) remained significantly different, while no significant difference in the diabetes group was observed. There were lower hypoglycemia rates with SH compared to diabetes (<70 mg/dL: 0.086 vs. 0.182, P<.0001; <40 mg/dL: 0.012 vs. 0.022, P = .0118, respectively). CONCLUSION: Tighter glycemic control was associated with improved outcomes in CCI patients with SH but not in CCI patients with diabetes. Confirmation of these findings may lead to stratified glycemic control protocols in CCI patients based on the presence or absence of diabetes.

Anti-Obesity Agents and the US Food and Drug Administration.

Despite the growing market for obesity care, the US Food and Drug Administration (FDA) has approved only two new pharmaceutical agents-lorcaserin and combination phentermine/topiramate-for weight reduction since 2000, while removing three agents from the market in the same time period. This article explores the FDA's history and role in the approval of anti-obesity medications within the context of a public health model of obesity. Through the review of obesity literature and FDA approval documents, we identified two major barriers preventing fair evaluation of anti-obesity agents including: (1) methodological pitfalls in clinical trials and (2) misaligned values in the assessment of anti-obesity agents. Specific recommendations include the use of adaptive (Bayesian) design protocols, value-based analyses of risks and benefits, and regulatory guidance based on a comprehensive, multi-platform obesity disease model. Positively addressing barriers in the FDA approval process of anti-obesity agents may have many beneficial effects within an obesity disease model.

Disconcordance in statistical models of bisphenol A and chronic disease outcomes in NHANES 2003-08.

BACKGROUND: Bisphenol A (BPA), a high production chemical commonly found in plastics, has drawn great attention from researchers due to the substance's potential toxicity. Using data from three National Health and Nutrition Examination Survey (NHANES) cycles, we explored the consistency and robustness of BPA's reported effects on coronary heart disease and diabetes. METHODS AND FINDINGS: We report the use of three different statistical models in the analysis of BPA: (1) logistic regression, (2) log-linear regression, and (3) dose-response logistic regression. In each variation, confounders were added in six blocks to account for demographics, urinary creatinine, source of BPA exposure, healthy behaviours, and phthalate exposure. Results were sensitive to the variations in functional form of our statistical models, but no single model yielded consistent results across NHANES cycles. Reported ORs were also found to be sensitive to inclusion/exclusion criteria. Further, observed effects, which were most pronounced in NHANES 2003-04, could not be explained away by confounding. CONCLUSIONS: Limitations in the NHANES data and a poor understanding of the mode of action of BPA have made it difficult to develop informative statistical models. Given the sensitivity of effect estimates to functional form, researchers should report results using multiple specifications with different assumptions about BPA measurement, thus allowing for the identification of potential discrepancies in the data.