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2.
J Hosp Med ; 16(10): 589-595, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34613895

RESUMO

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.


Assuntos
Analgésicos Opioides , Medicina Hospitalar , Analgésicos Opioides/uso terapêutico , Grupos Étnicos , Humanos , Alta do Paciente , Padrões de Prática Médica , Estudos Retrospectivos
4.
Hosp Pediatr ; 11(10): 1082-1114, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34561241

RESUMO

OBJECTIVES: Pediatric hospital medicine (PHM) fellowships have rapidly developed to meet established needs. The purpose of this research was to describe the research and career outcomes of PHM fellowship graduates. We hypothesized that graduates would report significant research and academic productivity. METHODS: This was an institutional review board-approved, cross-sectional survey of PHM fellowship graduates in 2018. The 88-item survey was modified from an existing survey, developed by experts to address study objectives and pilot tested, and it included quantitative and qualitative items to assess characteristics of fellowship training and research and career outcomes. RESULTS: A total of 63% of PHM fellowship graduates (143 of 228) completed the survey (graduation dates, 2000-2018). In total, 89% graduated from dedicated PHM fellowship programs, with 59% completing a 2-year fellowship and 78% now practicing primarily at a university or children's hospital. Fellows conducted research in clinical research (53%), quality improvement (41%), health services (24%), and medical education (19%). A total of 77% of graduates continued to do research after graduation, with 63% publishing and 25% obtaining grant funding. Graduates of 2- and 3-year fellowships and those with a master's degree were significantly more productive. Graduates now hold important roles in academic and health systems leadership. Graduates are highly satisfied with their decision to do PHM fellowship and identified 5 themes regarding how fellowship impacted their career outcomes. CONCLUSIONS: In this study, we document robust research activity and leadership positions among PHM fellowship graduates and can serve as a benchmark for metrics that PHM educational leaders can use to assess outcomes and improve training regarding research and career development.


Assuntos
Bolsas de Estudo , Medicina Hospitalar , Escolha da Profissão , Criança , Estudos Transversais , Educação de Pós-Graduação em Medicina , Medicina Hospitalar/educação , Hospitais Pediátricos , Hospitais de Ensino , Humanos , Inquéritos e Questionários
5.
Int J Clin Pract ; 75(11): e14859, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34516725

RESUMO

AIM: The evidence of the value of pharmaceutical care continues to grow, however, data on its effect in rural areas are still scarce. The aim of this article was to evaluate the economic impact of a clinical pharmacist's involvement in the hospital medicines policy design in a rural area, through the drug and therapeutics committee (DTC) and public procurement for medicines. METHODS: An economic evaluation was conducted in the General Hospital Bjelovar which covers the Bjelovarsko-Bilogorska County in Croatia. It included costs from denial and approval decisions of the drug and therapeutics committee, during a 1-year period between June 1, 2019 and June 1, 2020, and costs for medicines in 2018 and 2019 that were intended for public procurement. The cost-benefit analysis and cost-minimisation analyses for the DTC and public procurement data have been conducted for the evaluation of the economic impact of a clinical pharmacist. RESULTS: The involvement of a clinical pharmacist in the hospital medicines policy design through the DTC and public procurement for medicines provides an economic benefit. This resulted in a cost-benefit ratio of 14.18:1 and 18.31% and 17.58% savings through the DTC and public procurement process, respectively. To put in a different perspective, around 14 yearly gross salaries can be paid out from savings achieved by the clinical pharmacist through a 1-year period. CONCLUSION: The involvement of a clinical pharmacist in the hospital medicines policy in a rural area hospital results with an optimisation of investment in medicines and leads to substantial cost savings for the healthcare system.


Assuntos
Medicina Hospitalar , Farmacêuticos , Redução de Custos , Hospitais , Humanos , Políticas
7.
Clin Rheumatol ; 40(12): 4983-4991, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34342740

RESUMO

INTRODUCTION/OBJECTIVE: Antineutrophil cytoplasmic antibodies (ANCA) serology can aid in the diagnosis and classification of ANCA-associated vasculitides (AAV). However, it is often ordered in patients without clinical manifestations of vasculitis. In this retrospective chart review, we aim to better understand the clinical practices on ANCA testing. METHODS: We retrospectively reviewed patients' charts for the indications and diagnostic outcomes of ANCA tests. All ANCA tests ordered at two Canadian hospitals (a community hospital and an academic tertiary hospital) between January and December 2016 were included in the study. Descriptive statistics are used. RESULTS: A total of 302 ANCA tests were included. The majority (n = 198, 65.6%) were ordered without an indication for testing. For those patients with at least 1 clinical manifestation of AAV (n = 104), 25% were ANCA positive and 18.3% resulted in a diagnosis of AAV. In comparison, among those without a clinical manifestation of AAV (n = 198), only 1.5% were ANCA positive and none was diagnosed with AAV. All patients diagnosed with AAV had at least 1 indication for ANCA testing. The three most common clinical presentations in patients with a final diagnosis of AAV were glomerulonephritis (81.8%), pulmonary hemorrhage (45.5%), and multiple lung nodules (31.8%). CONCLUSION: To our knowledge, this is the first study that evaluates patients with both positive and negative ANCA test results in an inpatient setting. We demonstrated a low rate of ANCA positivity and AAV diagnosis in patients without clinical manifestations of AAV. Overall, there is a high rate of ANCA testing without an indication at our academic institution. This over-testing may be curbed by strategies such as a gating policy, culture changes, and clinician education. Key Points • AAV is a clinical-pathological diagnosis, and despite the usefulness of ANCA testing, it does not confirm nor rule out AAV. • ANCA testing for the diagnosis of AAV is generally only indicated when there is a clear manifestation of AAV. • Although patients with AAV may occasionally present without classic signs and symptoms, the diagnostic utility of ANCA serology in this setting is low, and testing is more likely to result in a false-positive or false-negative test. • If clinical suspicion remains high despite negative ANCA testing, clinicians should seek consultation with a rheumatologist.


Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos , Medicina Hospitalar , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/diagnóstico , Anticorpos Anticitoplasma de Neutrófilos , Canadá , Humanos , Peroxidase , Estudos Retrospectivos
10.
Hosp Pediatr ; 11(8): 779-785, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34312213

RESUMO

OBJECTIVES: The objectives with this study were to describe the current state of Pediatric Hospital Medicine (PHM) fellowship programs with regards to (1) diversity of fellows and programs' leadership, (2) current diversity and inclusion (D&I) programs and measures of their success, and (3) the state of cultural competency training. METHODS: In 2018, fellowship directors of the 35 active PHM fellowship programs were invited to participate in a survey of diversity, inclusion, and cultural competency at PHM fellowship programs. Participants were invited via in-person invitations at the annual PHM fellowship directors meeting and through e-mail invitations from July to September to complete an online survey. RESULTS: There was an 89% response rate of the survey. Most fellows, faculty, and program directors in PHM were female (74%, 70%, and 70%, respectively) and white (53%, 67%, and 60%, respectively). There were no African American, American Indian or Alaskan Native, or Native Hawaiian or other Pacific Islander program directors. Forty-five percent of programs reported that neither the fellowship program nor their hospital had a strategic plan that addresses D&I. Approximately 61% of programs had cultural competency training for fellows. CONCLUSIONS: This is the first survey to report on the state of D&I in PHM fellowship programs. There is lack of racial and ethnic diversity in programs fellows, faculty, and directors. Although most programs have cultural competency training, strategic planning to promote D&I is not widely implemented among PHM fellowship programs.


Assuntos
Medicina Hospitalar , Medicina , Criança , Competência Cultural , Currículo , Educação de Pós-Graduação em Medicina , Bolsas de Estudo , Feminino , Medicina Hospitalar/educação , Hospitais Pediátricos , Humanos , Inquéritos e Questionários , Estados Unidos
13.
Transfus Med Rev ; 35(2): 140-145, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-34006426

RESUMO

Blood transfusion is one of the most common procedures performed in the inpatient setting. Although ordering a transfusion is a component of routine practice for most hospitalists, prior literature has shown that non-transfusion medicine physicians have poor to intermediate transfusion medicine knowledge (TMK). No recent study has evaluated TMK among hospitalists, including both attending hospitalists and advanced practice providers (APPs). Using a validated exam and a truncated version of a validated survey, we obtained an initial impression of attitudes, perceived and actual TMK. A total of 183 hospital medicine providers nation-wide completed the 12-question online survey and 20 question exam, including 155 attending hospitalists and 28 APPs. The overall mean score was 52% (range 20%-85%). Forty-one percent of participants reported less than 1 hour of training in transfusion medicine. Five of the seven questions with the worst performance (<25% correct) were on transfusion reactions. Almost all respondents reported consenting a patient for blood transfusion and 60% believed that TMK was very or extremely important in order to provide appropriate care for patients. More than 80% believed that having additional transfusion medicine education would be at least moderately helpful. Although routinely consenting patients for transfusion, hospital medicine providers may have insufficient TMK particularly as it pertains to transfusion reactions. The majority of hospitalists rated TMK important to clinical practice and had an interest in additional training, thus continuing medical education has the potential to improve TMK and patient care.


Assuntos
Medicina Hospitalar , Médicos Hospitalares , Medicina Transfusional , Transfusão de Sangue , Humanos , Inquéritos e Questionários
15.
J Hosp Med ; 16(4): 230-235, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33734979

RESUMO

BACKGROUND: As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience. METHODS: We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures. RESULTS: Our synthesis of the literature characterizes contributors to hospitalists' procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists. CONCLUSION: We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.


Assuntos
Medicina Hospitalar , Médicos Hospitalares , Credenciamento , Hospitalização , Humanos , Encaminhamento e Consulta
16.
MedEdPORTAL ; 17: 11106, 2021 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-33768143

RESUMO

Introduction: During the COVID-19 pandemic, third-year medical students were temporarily unable to participate in onsite clinical activities. We identified the curricular components of an internal medicine (IM) clerkship that would be compromised if students learned solely from online didactics, case studies, and simulations (i.e., prerounding, oral presentations, diagnostic reasoning, and medical management discussions). Using these guiding principles, we created a virtual rounds (VR) curriculum to provide IM clerkship students with clinical exposure during a virtual learning period. Methods: Held three times a week for 2 weeks, VR consisted of three curricular components. First, clerkship students prerounded on an assigned hospitalized patient by remotely accessing the electronic health record and calling into hospital rounds. Second, each student prepared an oral presentation on their assigned patient. Third, using videoconferencing, students delivered these oral presentations to telemedicine VR small groups consisting of three to four students and three tele-instructors. Tele-instructors then provided feedback on oral presentations and taught clinical concepts. We assessed the effectiveness of VR by anonymously surveying students and tele-instructors. Results: Twenty-nine students and 34 volunteer tele-instructors participated in VR over four blocks. A majority of students felt VR improved their prerounding abilities (86%), oral presentation abilities (93%), and clinical reasoning skills (62%). All students found small group to be useful. Discussion: VR allowed students to practice rounding skills in a supportive team-based setting. The lessons learned from its implementation could facilitate education during future pandemics and could also supplement in-person clerkship education.


Assuntos
COVID-19 , Estágio Clínico/métodos , Educação à Distância/métodos , Educação de Graduação em Medicina/métodos , Medicina Interna/educação , Visitas com Preceptor/métodos , COVID-19/epidemiologia , COVID-19/prevenção & controle , Competência Clínica , Currículo , Medicina Hospitalar/educação , Medicina Hospitalar/tendências , Humanos , Satisfação Pessoal , SARS-CoV-2 , Estudantes de Medicina/psicologia , Telemedicina/métodos
17.
J Hosp Med ; 16(2): 69, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33523793
19.
Hosp Pract (1995) ; 49(3): 209-215, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33577741

RESUMO

OBJECTIVES: Procedural complications are a common source of adverse events in hospitals, especially where bedside procedures are often performed by trainees. Medical procedure services (MPS) have been established to improve procedural education, ensure patient safety, and provide additional revenue for services that are typically referred. Prior descriptions of MPS have reported outcomes over one to 2 years. We aim to describe the implementation and 5-year outcomes of a hospitalist-run MPS. METHODS: We identified all patients referred to our MPS for a procedure over the 5-year span between 2014 and 2018. We manually reviewed all charts for complications of paracentesis, thoracentesis, central venous catheterization, and lumbar punctures performed by the MPS in both inpatient and outpatient settings. Annual charges for these procedures were queried using Current Procedural Terminology (CPT) codes. RESULTS: We identified 3,634 MPS procedures. Of these, ultrasound guidance was used in 3224 (88.7%) and trainees performed 2701 (74%). Complications identified included pneumothorax (3.7%, n = 16) for thoracentesis, post-dural puncture headache (13.9%, n = 100) and bleeding (0.1%, n = 1) for lumbar puncture, ascites leak for diagnostic (1.6%, n = 8) and large volume (3.7%, n = 56) paracentesis, and bleeding (3.5%, n = 16) for central venous catheter placement. Prior to initiation of the MPS, total annual procedural charges were $90,437. After MPS implementation, charges increased to a mean of $787,352 annually in the last 4 years of the study period. CONCLUSIONS: Implementation of a hospitalist-run, academic MPS resulted in a large volume of procedures, high rate of trainee participation, low rates of complications, and significant increase in procedural charges over 5 years. Wider adoption of this model has the potential to further improve patient procedural care and trainee education.


Assuntos
Competência Clínica , Medicina Hospitalar/educação , Medicina Interna/educação , Internato e Residência/métodos , Segurança do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Medicina Hospitalar/métodos , Hospitais de Ensino/estatística & dados numéricos , Humanos , Medicina Interna/métodos
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