Racial, Ethnic, and Language-Based Inequities in Inpatient Opioid Prescribing by Diagnosis from Internal Medicine Services, a Retrospective Cohort Study.

Introduction: Opioid administration is extremely common in the inpatient setting, yet we do not know how the administration of opioids varies across different medical conditions and patient characteristics on internal medicine services. Our goal was to assess racial, ethnic, and language-based inequities in opioid prescribing practices for patients admitted to internal medicine services. Methods: We conducted a retrospective cohort study of all adult patients admitted to internal medicine services from 2013 to 2021 and identified subcohorts of patients treated for the six most frequent primary hospital conditions (pneumonia, sepsis, cellulitis, gastrointestinal bleed, pyelonephritis/urinary tract infection, and respiratory disease) and three select conditions typically associated with pain (abdominal pain, acute back pain, and pancreatitis). We conducted a negative binomial regression analysis to determine how average administered daily opioids, measured as morphine milligram equivalents (MMEs), were associated with race, ethnicity, and language, while adjusting for additional patient demographics, hospitalization characteristics, medical comorbidities, prior opioid therapy, and substance use disorders. Results: The study cohort included 61,831 patient hospitalizations. In adjusted models, we found that patients with limited English proficiency received significantly fewer opioids (66 MMEs, 95% CI: 52, 80) compared to English-speaking patients (101 MMEs, 95% CI: 91, 111). Asian (59 MMEs, 95% CI: 51, 66), Latinx (89 MMEs, 95% CI: 79, 100), and multi-race/ethnicity patients (81 MMEs, 95% CI: 65, 97) received significantly fewer opioids compared to white patients (103 MMEs, 95% CI: 94, 112). American Indian/Alaska Native (227 MMEs, 95% CI: 110, 344) patients received significantly more opioids. Significant inequities were also identified across race, ethnicity, and language groups when analyses were conducted within the subcohorts. Most notably, Asian and Latinx patients received significantly fewer MMEs and American Indian/Alaska Native patients received significantly more MMEs compared to white patients for the top six most frequent conditions. Most patients from minority groups also received fewer MMEs compared to white patients for three select pain conditions. Discussion. There are notable inequities in opioid prescribing based on patient race, ethnicity, and language status for those admitted to inpatient internal medicine services across all conditions and in the subcohorts of the six most frequent hospital conditions and three pain-associated conditions. This represents an institutional and societal opportunity for quality improvement initiatives to promote equitable pain management.

The Tea House Series: Striving Together to be Antiracist.

BACKGROUND: Though awareness of health care structures that are racist and oppressive is increasing among health care professionals, there is a gap in continuing education curricula focused on antiracist anti-oppressive practices, and limited faculty and staff development to guide individuals towards action. AIM: To develop, implement, and evaluate a novel antiracist faculty and staff development program called the Tea House Series. SETTING AND PARTICIPANTS: A five-part continuing education series with an accompanying online community for faculty and staff at the divisions of Hospital Medicine in one institution in the western United States. PROGRAM DESCRIPTION: The four foundational pillars integral to the Tea House Series were as follows: educational framework based on the pedagogy of Paulo Freire, local disparities data, welcoming space to establish a community of practice and accountability. Each session contained participant dialogue in small group activities. PROGRAM EVALUATION: Qualitative analysis of participant survey responses demonstrated transformation towards a hope to act with a sense of community. Quantitative analysis measured increased confidence for the program learning objectives. DISCUSSION: The Tea House Series may be used as a model for continuing education to provide the tools and the community to confront systems of racism and oppression in any institution.

Point-of-Care Ultrasound Predicts Clinical Outcomes in Patients With COVID-19.

OBJECTIVES: Point-of-care ultrasound (POCUS) detects the pulmonary manifestations of COVID-19 and may predict patient outcomes. METHODS: We conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID-19. Inclusion criteria included adult patients hospitalized for COVID-19 who received lung POCUS with a 12-zone protocol. Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage. RESULTS: N = 160 patients were included. Among critically ill patients, B-lines (94 vs 76%; P < .01) and consolidations (70 vs 46%; P < .01) were more common. For scans collected within 24 hours of admission (N = 101 patients), early B-lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71-14.30]; P < .01) or consolidations (OR 2.49 [95% CI: 1.35-4.86]; P < .01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01-4.70]; P = .047). Patients with a normal scan within 24 hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09-0.75]; P < .01) or supplemental oxygen (OR 0.26 [95% CI: 0.11-0.61]; P < .01). Ultrasound findings did not dynamically change over a 28-day scanning window after symptom onset. CONCLUSIONS: Lung POCUS findings detected within 24 hours of admission may provide expedient risk stratification for important COVID-19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24 hours of admission appears protective. POCUS findings appeared stable over a 28-day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications.

Racial and Ethnic Disparities in Discharge Opioid Prescribing From a Hospital Medicine Service.

BACKGROUND: Differential opioid prescribing patterns have been reported in non-White patient populations. However, these disparities have not been well described among hospitalized medical inpatients. OBJECTIVE: To describe differences in opioid prescribing patterns among inpatients discharged from the general medicine service based on race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS: For this retrospective study, we performed a multivariable logistic regression for patient race/ethnicity and whether patients received an opioid prescription at discharge and a negative binomial regression for days of opioids prescribed at discharge. The study included all 10,953 inpatients discharged from the general medicine service from June 2012 to November 2018 at University of California San Francisco Medical Center who received opioids during the last 24 hours of their hospitalization. MAIN OUTCOMES AND MEASURES: We examined two primary outcomes: whether a patient received an opioid prescription at discharge, and, for patients prescribed opioids, the number of days dispensed. RESULTS: Compared with White patients, Black patients were less likely to receive an opioid prescription at discharge (predicted population rate of 47.6% vs 50.7%; average marginal effect [AME], -3.1%; 95% CI, -5.5% to -0.8%). Asian patients were more likely to receive an opioid prescription on discharge (predicted population rate, 55.6% vs 50.7%; AME, +4.9; 95% CI, 1.5%-8.3%). We also found that Black patients received a shorter duration of opioid days compared with White patients (predicted days of opioids on discharge, 15.7 days vs 17.8 days; AME, -2.1 days; 95% CI, -3.3 to -0.9). CONCLUSION: Black patients were less likely to receive opioids and received shorter courses at discharge compared with White patients, adjusting for covariates. Asian patients were the most likely to receive an opioid prescription.

Evaluating an Oncology Video Curriculum Designed to Promote Asynchronous Subspecialty Learning for Internal Medicine Residents.

Internal medicine (IM) residents frequently see patients in subspecialty clinics. However, there are few published core subspecialty curricula targeted to residents' learning and practical needs, and little guidance exists regarding delivery of core subspecialty content to residents rotating across multiple clinical sites. Our study objective was to evaluate a novel oncology video curriculum for IM residents as a model for asynchronous subspecialty resident learning. Using the cognitive theory of multimedia learning, we developed a five-part oncology video curriculum targeted specifically to the needs of IM residents. All second- and third-year residents rotating in oncology clinics from October 2018 to March 2019 at a single training program were invited to participate. We evaluated curricular demand, efficacy, and acceptability, using completion rates, knowledge tests, and a survey. Twenty-eight of 31 (90.3%) residents utilized the curriculum. Resident knowledge improved after utilizing the modules, by 36.9% from pre- to posttests (95% CI [31.3-42.5]; P<0.001) and 13.7% from pre- to delayed posttests (95% CI [7.5-20.0]; P<0.001). Twenty-four of 31 (77.4%) answered the survey. Most residents agreed or strongly agreed that the curriculum contributed to their knowledge (95.2%) and added educational value beyond the clinical rotation (93.1%). Our curriculum evaluation supports the asynchronous delivery of oncology education targeted to the learning needs of IM residents using a novel core video curriculum. These curricular methods provide a model for delivering subspecialty education to IM residents with complex and busy schedules.

Evaluation of a novel metric for personalized opioid prescribing after hospitalization.

BACKGROUND: The duration of an opioid prescribed at hospital discharge does not intrinsically account for opioid needs during a hospitalization. This discrepancy may lead to patients receiving much larger supplies of opioids on discharge than they truly require. OBJECTIVE: Assess a novel discharge opioid supply metric that adjusts for opioid use during hospitalization, compared to the conventional discharge prescription signature. DESIGN, SETTING, & PARTICIPANTS: Retrospective study using electronic health record data from June 2012 to November 2018 of adults who received opioids while hospitalized and after discharge from a single academic medical center. MEASURES & ANALYSIS: We ascertained inpatient opioids received and milligrams of opioids supplied after discharge, then determined days of opioids supplied after discharge by the conventional prescription signature opioid-days ("conventional days") and novel hospital-adjusted opioid-days ("adjusted days") metrics. We calculated descriptive statistics, within-subject difference between measurements, and fold difference between measures. We used multiple linear regression to determine patient-level predictors associated with high difference in days prescribed between measures. RESULTS: The adjusted days metric demonstrates a 2.4 day median increase in prescription duration as compared to the conventional days metric (9.4 vs. 7.0 days; P<0.001). 95% of all adjusted days measurements fall within a 0.19 to 6.90-fold difference as compared to conventional days measurements, with a maximum absolute difference of 640 days. Receiving a liquid opioid prescription accounted for an increased prescription duration of 135.6% by the adjusted days metric (95% CI 39.1-299.0%; P = 0.001). Of patients who were not on opioids prior to admission and required opioids during hospitalization but not in the last 24 hours, 325 (8.6%) were discharged with an opioid prescription. CONCLUSIONS: The adjusted days metric, based on inpatient opioid use, demonstrates that patients are often prescribed a supply lasting longer than the prescription signature suggests, though with marked variability for some patients that suggests potential under-prescribing as well. Adjusted days is more patient-centered, reflecting the reality of how patients will take their prescription rather than providers' intended prescription duration.

Fostering medical students' lifelong learning skills with a dashboard, coaching and learning planning.

INTRODUCTION: To develop lifelong learning skills, students need feedback, access to performance data, and coaching. A new medical curriculum incorporated infrastructural supports based on self-regulated learning theory and the Master Adaptive Learner framework to engage students in reflection and learning planning. This study examines students' experience with a performance dashboard, longitudinal coaching, and structured time for goal-setting. METHODS: Focus groups with first-year medical students explored performance dashboard usage, coaching and learning planning. We analyzed findings using thematic analysis. Results informed development of a 29-item survey rated strongly disagree (1) to strongly agree (5) to investigate experience with the dashboard, coaching and learning goals program. The survey was distributed to one first-year medical student class. We performed descriptive statistics and factor analysis. RESULTS: In three focus groups with 21 participants, students endorsed using the dashboard to access performance information but had trouble interpreting and integrating information. They valued coaches as sources of advice but varied in their perceptions of the value of discussing learning planning. Of 152 students, 114 (75%) completed the survey. Exploratory factor analysis yielded 5 factors explaining 57% of the variance: learning goals development (α = 0.88; mean 3.25 (standard deviation 0.91)), dashboard usage (α = 0.82; 3.36 (0.64)), coaching (α = 0.71; 3.72 (0.64)), employment of learning strategies (α = 0.81; 3.67 (0.79)), and reflection (α = 0.63; 3.68 (0.64)). DISCUSSION: The student performance dashboard provides efficient feedback access, yet students' use of this information to guide learning is variable. These results can inform other programs seeking to foster lifelong learning skills.

Severely impaired terminal erythroid differentiation as an independent prognostic marker in myelodysplastic syndromes.

Anemia is the defining feature in most patients with myelodysplastic syndromes (MDS), yet defects in erythropoiesis have not been well characterized. We examined freshly obtained bone marrow (BM) samples for stage-specific abnormalities during terminal erythroid differentiation (TED) from 221 samples (MDS, n = 205 from 113 unique patients; normal, n = 16) by measuring the surface expression of glycophorin A, band 3, and integrin α-4. Clinical and biologic associations were sought with presence or absence of TED and the specific stage of erythroid arrest. In 27% of MDS samples (56/205), there was no quantifiable TED documented by surface expression of integrin α-4 and band 3 by terminally differentiating erythroblasts. Absence of quantifiable TED was associated with a significantly worse overall survival (56 vs 103 months, P = .0001) and SRSF2 mutations (7/23, P < .05). In a multivariable Cox proportional hazards regression analysis, absence of TED remained independently significant across International Prognostic Scoring System-Revised (IPSS-R) categories, myeloid/erythroid ratio, and mutations in several genes. In 149/205 MDS samples, the proportion of cells undergoing TED did not follow the expected 1:2:4:8:16 doubling pattern in successive stages. Absence of TED emerged as a powerful independent prognostic marker of poor overall survival across all IPSS-R categories in MDS, and SRSF2 mutations were more frequently associated with absence of TED.