Multi-Level Predictors of Discharges Against Medical Advice: Identifying Contributors to Variation Using an All-Payer Database.

ABSTRACT: There is increasing evidence of the role of non-patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non-patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.

Anti-NMDAR Encephalitis: A Multidisciplinary Approach to Identification of the Disorder and Management of Psychiatric Symptoms.

BACKGROUND: The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently been developed, has led to a lack of information on assessment and treatment of its variable behavioral manifestations. METHOD: In this article, we discuss 4 challenging cases of anti-NMDAR encephalitis, focusing on the importance of a multidisciplinary approach to identification and management of the disorder and the necessity of close collaboration in the acute hospital setting for management of the behavioral symptoms. CONCLUSION: The cases we discuss highlight some of the medication and nonpharmacologic treatment strategies that may facilitate management of psychiatric symptoms, both while the medical workup is ongoing and after the diagnosis has been confirmed.

Adverse safety events in patients with Chronic Kidney Disease (CKD).

INTRODUCTION: Chronic kidney disease (CKD) confers a higher risk of adverse safety events as a result of many factors including medication dosing errors and use of nephrotoxic drugs, which can cause kidney injury and renal function decline. CKD patients may also have comorbidities such as hypertension and diabetes for which they require more frequent care from different providers, and for which standard, but countervailing treatments, may put them at risk for adverse safety events. Areas covered: In addition to the well-known agents such as iodinated radiocontrast, antimicrobials, diuretics and angiotensin converting enzyme (ACE) inhibitors which can directly affect renal function, safety considerations in the treatment of common CKD complications such as anemia, diabetes, analgesia and thrombosis will also be discussed. Expert opinion: Better outcomes in CKD may be achieved by alerting care providers to the special care needs of kidney patients and encouraging patients to self-manage their disease with the decision support of multidisciplinary patient care teams.

Evaluating transitions of care of hospitalized medical patients to long-term care facilities: a retrospective review of venous thromboembolism prophylaxis.

Venous thromboembolism (VTE) is a significant but preventable cause of hospital-related morbidity and mortality. Prevention of in-hospital VTE, thus, has become a major quality improvement initiative within hospitals. However, addressing VTE prophylaxis rates and appropriateness on transition to other facilities has not been fully characterized to date. The authors of this study retrospectively evaluated VTE prophylaxis on transfer from medical inpatient settings to long-term care facilities. Analysis indicated that on transfer to other facilities, VTE prophylaxis recommendations were not routinely documented. Interfacility communication is crucial to ensure that appropriate prophylaxis recommendations are addressed during transitions of care. New processes evaluating VTE prophylaxis recommendations at the time of care transfer warrant further study.