Wall-mounted folding chairs to promote resident physician sitting at the hospital bedside.

BACKGROUND: Sitting at the bedside may improve patient-clinician communication; however, many clinicians do not regularly sit during inpatient encounters. OBJECTIVE: To determine the impact of adding wall-mounted folding chairs inside patient rooms, beyond any impact from a resident education campaign, on the patient-reported frequency of sitting at the bedside by internal medicine resident physicians. DESIGN, SETTING, AND PARTICIPANTS: Prospective, controlled pre-post trial between 2019 and 2022 (data collection paused 2020-2021 due to COVID-19) at an academic hospital in Baltimore, Maryland. Folding chairs were installed in two of four internal medicine units and educational activities were delivered equally across all units. MAIN OUTCOME AND MEASURES: Patient-reported frequency of sitting at bedside, assessed as means on Likert-type items with 1 being "never" and 5 being "every single time." We also examined the frequency of other patient-reported communication behaviors. RESULTS: Two hundred fifty six and 206 patients enrolled in the pre and post-intervention periods, respectively. The mean frequency of patient-reported sitting by resident physicians increased from 1.8 (SD 1.2) to 2.3 (1.2) on education-only units (absolute difference 0.48 [95% CI: 0.21-0.75]) and from 2.0 (1.3) to 3.2 (1.4) on units receiving chairs (1.16, [0.87-1.45]). Comparing differences between groups using ordered logistic regression adjusting for clustering within residents, units with added chairs had greater increases in sitting (odds ratio 2.05 [1.10-3.82]), spending enough time at the bedside (2.43 [1.32-4.49]), and checking for understanding (3.04 [1.44-6.39]). Improvements in sitting and other behaviors were sustained on both types of units. CONCLUSIONS: Adding wall-mounted folding chairs may help promote effective patient-clinician communication.

Sitting at the Bedside: Patient and Internal Medicine Trainee Perceptions.

BACKGROUND: Sitting at the bedside may strengthen physician-patient communication and improve patient experience. Yet despite the potential benefits of sitting, hospital physicians, including resident physicians, may not regularly sit down while speaking with patients. OBJECTIVE: To examine the frequency of sitting by internal medicine residents (including first post-graduate year [PGY-1] and supervising [PGY-2/3] residents) during inpatient encounters and to assess the association between patient-reported sitting at the bedside and patients' perceptions of other physician communication behaviors. We also assessed residents' attitudes towards sitting. DESIGN: In-person survey of patients and email survey of internal medicine residents between August 2019 and January 2020. PARTICIPANTS: Patients admitted to general medicine teaching services and internal medicine residents at The Johns Hopkins Hospital. MAIN MEASURES: Patient-reported frequency of sitting at the bedside, patients' perceptions of other communication behaviors (e.g., checking for understanding); residents' attitudes regarding sitting. KEY RESULTS: Of 334 eligible patients, 256 (76%) completed a survey. Among these 256 respondents, 198 (77%) and 166 (65%) reported recognizing the PGY-1 and PGY-2/3 on their care team, respectively, for a total of 364 completed surveys. On most surveys (203/364, 56%), patients responded that residents "never" sat. Frequent sitting at the bedside ("every single time" or "most of the time," together 48/364, 13%) was correlated with other positive behaviors, including spending enough time at the bedside, checking for understanding, and not seeming to be in a rush (p < 0.01 for all). Of 151 residents, 77 (51%) completed the resident survey; 28 of the 77 (36%) reported sitting frequently. The most commonly cited barrier to sitting was that chairs were not available (38 respondents, 49%). CONCLUSIONS: Patients perceived that residents sit infrequently. However, sitting was associated with other positive communication behaviors; this is compatible with the hypothesis that promoting sitting could improve overall patient perceptions of provider communication.

Cost-effectiveness of a Digital Health Intervention for Acute Myocardial Infarction Recovery.

BACKGROUND: Acute myocardial infarction (AMI) is a common cause of hospital admissions, readmissions, and mortality worldwide. Digital health interventions (DHIs) that promote self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction may improve health outcomes in this population. The "Corrie" DHI consists of a smartphone application, smartwatch, and wireless blood pressure monitor to support medication tracking, education, vital signs monitoring, and care coordination. We aimed to assess the cost-effectiveness of this DHI plus standard of care in reducing 30-day readmissions among AMI patients in comparison to standard of care alone. METHODS: A Markov model was used to explore cost-effectiveness from the hospital perspective. The time horizon of the analysis was 1 year, with 30-day cycles, using inflation-adjusted cost data with no discount rate. Currencies were quantified in US dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). The results were interpreted as an incremental cost-effectiveness ratio at a threshold of $100,000 per QALY. Univariate sensitivity and multivariate probabilistic sensitivity analyses tested model uncertainty. RESULTS: The DHI reduced costs and increased QALYs on average, dominating standard of care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2750 per patient, use of the DHI leads to a cost-savings of $7274 per patient compared with standard of care alone. CONCLUSIONS: Our results demonstrate that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI. DHIs that promote improved adherence with guideline-based health care can reduce hospital readmissions and associated costs.

REPLACING INSULIN WITH ANTI-VIRALS: A CLINICAL VIGNETTE ON DIABETES AND HCV TREATMENT.

OBJECTIVE: There is growing evidence to support a connection between type 2 diabetes mellitus (T2DM) and chronic hepatitis C virus (HCV). Patients with hepatitis C have a substantially higher risk for developing type 2 diabetes and recently there have been several proposed mechanisms. Several retrospective studies have demonstrated a small but significant improvement in glycemic control after treatment of underlying hepatitis C virus. We describe a case that demonstrates the greatest recorded improvement in glycemic control after treatment of HCV in the setting of self-discontinuation of insulin therapy without behavioral modification. METHODS: A 38-year-old obese female with uncontrolled T2DM (hemoglobin A1c [HbA1c] of 11.6% [103 mmol/mol]) was temporarily lost to follow-up and reported nonadherence to insulin therapy, metformin therapy, diet, or exercise. During this time, she was successfully treated for hepatitis C and became euglycemic without other interventions. RESULTS: The patient's HbA1c decreased from 11.6 to 5.7% (103 to 39 mmol/mol) in the presence of weight gain and in the absence of any intervention other than hepatitis C treatment. CONCLUSION: Hepatitis C treatment may offer significant potential for improving insulin sensitivity and decreasing long-term complications of type 2 diabetes in certain patients. Universal treatment of HCV could offer benefits in both hepatic and extrahepatic clinical outcomes.