Comparison of COVID-19 versus influenza on the incidence, features, and recovery from acute kidney injury in hospitalized United States Veterans.

Acute kidney injury is a common complication in patients hospitalized with SARSCoV-2 (COVID-19), with prior studies implicating multiple potential mechanisms of injury. Although COVID-19 is often compared to other respiratory viral illnesses, few formal comparisons of these viruses on kidney health exist. In this retrospective cohort study, we compared the incidence, features, and outcomes of acute kidney injury among Veterans hospitalized with COVID-19 or influenza and adjusted for baseline conditions using weighted comparisons. A total of 3402 hospitalizations for COVID-19 and 3680 hospitalizations for influenza admitted between October 1, 2019 and May 31, 2020 across 127 Veterans Administration hospitals nationally were studied using the electronic medical record. Acute kidney injury occurred more frequently among those with COVID-19 compared to those with influenza (40.9% versus 29.4%, weighted analysis) and was more severe. Patients with COVID-19 were more likely to require mechanical ventilation and vasopressors and experienced higher mortality. Proteinuria and hematuria were frequent in both groups but more common in COVID-19. Recovery of kidney function was less common in patients with COVID-19 and acute kidney injury but was similar among survivors. Thus, findings from this study confirm that acute kidney injury is more common and severe among patients hospitalized with COVID-19 compared to influenza, a finding that may be driven largely by illness severity. Hence, the combined impact of these two illnesses on kidney health may be significant and have important implications for resource allocation.

Renin-angiotensin aldosterone inhibitor use at hospital discharge among patients with moderate to severe acute kidney injury and its association with recurrent acute kidney injury and mortality.

Recurrent episodes of acute kidney injury (AKI) are common among AKI survivors. Renin-angiotensin aldosterone inhibitors (RAASi) are often indicated for these patients but may increase the risk for recurrent AKI. Here, we examined whether RAASi associates with a higher risk for recurrent AKI and mortality among survivors of moderate to severe AKI in a retrospective cohort of Veterans who survived Stage II or III AKI. The primary exposure was RAASi at hospital discharge and the primary endpoint was recurrent AKI within 12 months. Cox proportional hazards models were fit on a propensity score-weighted cohort to compare time to recurrent AKI and mortality by RAASi exposure. Among 96,983 patients, 40% were on RAASi at discharge. Compared to patients who continued RAASi use, those discontinuing use experienced no difference in risk for recurrent AKI but had a significantly higher risk of mortality [hazard ratio 1.33 (95% confidence interval1.26-1.41)]. No differences in recurrent AKI risk was observed for non-users started or not on RAASi compared to prevalent users who continued RAASi. Subgroup analyses among those with diabetes, chronic kidney disease, heart failure, and malignancy were similar with exception of a modest reduction in recurrent AKI risk among RAASi discontinuers with chronic kidney disease. Thus, RAASi use among survivors of moderate to severe AKI was associated with little to no difference in risk for recurrent AKI but was associated with improved survival. Reinitiating or starting RAASi among patients with strong indications is warranted but should be balanced with individual overall risk for recurrent AKI and with adequate monitoring.

Timing of Recovery From Moderate to Severe AKI and the Risk for Future Loss of Kidney Function.

RATIONALE & OBJECTIVE: The extent of recovery of kidney function following acute kidney injury (AKI) is known to be associated with future chronic kidney disease. Less is known about how the timing of recovery affects the rate of future loss of kidney function. STUDY DESIGN: We performed a retrospective cohort study examining the independent association between the timing of recovery from moderate to severe AKI and future loss of kidney function. SETTING & PARTICIPANTS: 47,903 adult US veterans with stage 2 or 3 AKI who recovered to within 120% of baseline creatinine level within 90 days of peak injury. EXPOSURE: The timing of recovery of kidney function from peak inpatient serum creatinine level grouped into 1 to 4, 5 to 10, 11 to 30, and 31 to 90 days. OUTCOME: A sustained 40% decline in estimated glomerular filtration rate below that calculated from the last serum creatinine level available during the 90-day recovery period or kidney failure (2 outpatient estimated glomerular filtration rates<15mL/min/1.73m2, dialysis procedures > 90 days apart, kidney transplantation, or registry within the US Renal Data System). ANALYTICAL APPROACH: Time to the primary outcome was examined using multivariable Cox proportional hazards regression. RESULTS: Among 47,903 patients, 29,316 (61%), 10,360 (22%), 4,520 (9%), and 3,707 (8%) recovered within 1 to 4, 5 to 10, 11 to 30, and 31 to 90 days, respectively. With a median follow-up of 42 months, unadjusted incidence rates for the kidney outcome were 2.01, 3.55, 3.86, and 3.68 events/100 person-years, respectively. Compared with 1 to 4 days, recovery within 5 to 10, 11 to 30, and 31 to 90 days was associated with increased rates of the primary outcome: adjusted HRs were 1.33 (95% CI, 1.24-1.43), 1.41 (95% CI, 1.28-1.54), and 1.58 (95% CI, 1.43-1.75), respectively. LIMITATIONS: Predominately male population, residual confounding, and inability to make causal inferences because of the retrospective observational study design. CONCLUSIONS: The timing of recovery provides an added dimension to AKI phenotyping and prognostic information regarding the future occurrence of loss of kidney function. Studies to identify effective interventions on the timing of recovery from AKI are warranted.

Predicting 30-Day Hospital Readmission Risk in a National Cohort of Patients with Cirrhosis.

BACKGROUND: Early hospital readmission for patients with cirrhosis continues to challenge the healthcare system. Risk stratification may help tailor resources, but existing models were designed using small, single-institution cohorts or had modest performance. AIMS: We leveraged a large clinical database from the Department of Veterans Affairs (VA) to design a readmission risk model for patients hospitalized with cirrhosis. Additionally, we analyzed potentially modifiable or unexplored readmission risk factors. METHODS: A national VA retrospective cohort of patients with a history of cirrhosis hospitalized for any reason from January 1, 2006, to November 30, 2013, was developed from 123 centers. Using 174 candidate variables within demographics, laboratory results, vital signs, medications, diagnoses and procedures, and healthcare utilization, we built a 47-variable penalized logistic regression model with the outcome of all-cause 30-day readmission. We excluded patients who left against medical advice, transferred to a non-VA facility, or if the hospital length of stay was greater than 30 days. We evaluated calibration and discrimination across variable volume and compared the performance to recalibrated preexisting risk models for readmission. RESULTS: We analyzed 67,749 patients and 179,298 index hospitalizations. The 30-day readmission rate was 23%. Ascites was the most common cirrhosis-related cause of index hospitalization and readmission. The AUC of the model was 0.670 compared to existing models (0.649, 0.566, 0.577). The Brier score of 0.165 showed good calibration. CONCLUSION: Our model achieved better discrimination and calibration compared to existing models, even after local recalibration. Assessment of calibration by variable parsimony revealed performance improvements for increasing variable inclusion well beyond those detectable for discrimination.

Propofol Versus Dexmedetomidine for Procedural Sedation in a Pediatric Population.

OBJECTIVES: Frequently, infants and children require sedation to facilitate noninvasive procedures and imaging studies. Propofol and dexmedetomidine are used to achieve deep procedural sedation in children. The objective of this study was to compare the clinical safety and efficacy of propofol versus dexmedetomidine in pediatric patients undergoing sedation in a pediatric sedation unit. METHODS: A retrospective analysis of patients sedated with either propofol or dexmedetomidine in a pediatric sedation unit by pediatric emergency physicians was performed. Both medications were dosed per protocol with propofol 2 mg/kg induction and 150 µg · kg-1 · min-1 maintenance and dexmedetomidine 3 µg/kg induction for 10 minutes and 2 µg · kg-1 · h-1maintenance. The variables collected included drug dose, sedation time (time that the drug was given to the completion of the procedure), recovery time (end of the study to the return to the presedation sedation score for 15 minutes), need for dose rate changes, airway management, and adverse events. RESULTS: A total of 2432 children were included- 1503 who received propofol and 929 who received dexmedetomidine. Propofol and dexmedetomidine resulted in successful completion of the study in 98.8% and 99.7%, respectively (P = 0.02). The mean recovery time for propofol was 34.3 minutes, compared with 65.6 minutes for dexmedetomidine (P < 0.001). The need for unexpected airway management was 9.7% for propofol and 2.2% for dexmedetomidine (P < 0.001). Adverse events occurred in 8.6% and 6% of patients in the propofol and dexmedetomidine groups, respectively (P = 0.02). CONCLUSIONS: Propofol use led to significantly shorter recovery times, with an increased need for airway management, but rates of bag-mask ventilation (2.3%), airway obstruction (1.1%), and desaturation (1.6%) were low. No patients required intubation. Propofol is a reasonable alternative to dexmedetomidine, with a clinically acceptable safety profile.

Acute Kidney Injury and Risk of Incident Heart Failure Among US Veterans.

BACKGROUND: Acute kidney injury (AKI) is common and associated with poor outcomes. Heart failure is a leading cause of cardiovascular disease among patients with chronic kidney disease. The relationship between AKI and heart failure remains unknown and may identify a novel mechanistic link between kidney and cardiovascular disease. STUDY DESIGN: Observational study. SETTING & PARTICIPANTS: We studied a national cohort of 300,868 hospitalized US veterans (2004-2011) without a history of heart failure. PREDICTOR: AKI was the predictor and was defined as a 0.3-mg/dL or 50% increase in serum creatinine concentration from baseline to the peak hospital value. Patients with and without AKI were matched (1:1) on 28 in- and outpatient covariates using optimal Mahalanobis distance matching. OUTCOMES: Incident heart failure was defined as 1 or more hospitalization or 2 or more outpatient visits with a diagnosis of heart failure within 2 years through 2013. RESULTS: There were 150,434 matched pairs in the study. Patients with and without AKI during the index hospitalization were well matched, with a median preadmission estimated glomerular filtration rate of 69mL/min/1.73m2. The overall incidence rate of heart failure was 27.8 (95% CI, 19.3-39.9) per 1,000 person-years. The incidence rate was higher in those with compared with those without AKI: 30.8 (95% CI, 21.8-43.5) and 24.9 (95% CI, 16.9-36.5) per 1,000 person-years, respectively. In multivariable models, AKI was associated with 23% increased risk for incident heart failure (HR, 1.23; 95% CI, 1.19-1.27). LIMITATIONS: Study population was primarily men, reflecting patients seen at Veterans Affairs hospitals. CONCLUSIONS: AKI is an independent risk factor for incident heart failure. Future studies to identify underlying mechanisms and modifiable risk factors are needed.

Urgent Care Transfers to an Academic Pediatric Emergency Department.

OBJECTIVES: The aim of this study was to investigate the hypothesis that a significant percentage of urgent care center to pediatric ED transfers can be discharged home without emergency department (ED) resource utilization. METHODS: A retrospective chart review was completed for a 6-month period on all patients transferred from urgent care centers. A data collection tool focusing on demographics, diagnoses, reason for transfer, ED resource utilization, ED disposition, and 72-hour ED return was used. Each encounter was classified as "urgent" or "nonurgent" based on resource utilization criteria. Descriptive statistics were reported for demographics, encounter data, and 72-hour ED return stratified by nonurgent versus urgent classification. Two-sample t, χ, and Fisher exact tests were used to assess differences in characteristics between the nonurgent and urgent groups. RESULTS: One hundred nine patients met inclusion criteria. Of these, 93 (85%) were discharged from the ED. Twenty nine (27%) of the transferred patients were discharged without ED resource utilization. Seventy-two-hour return was noted for only 1 patient who was again discharged at the subsequent encounter. CONCLUSIONS: A large proportion of patients transferred from urgent care centers were directly discharged from the ED without any ED resource utilization. Eliminating or reducing such transfers has the potential to limit the amount of nonurgent ED visits, thus producing cost savings and better patient care.

Childhood obesity in pediatric patients with difficult-to-control asthma in a tertiary pediatric subspecialty clinic.

BACKGROUND: Identifying clinical features associated with difficult-to-control asthma will help address overall control and more-effective asthma management. OBJECTIVE: To evaluate our clinical observation that the proportion of patients who are overweight or obese is significantly higher in patients with difficult-to-control asthma than in patients with well-controlled asthma. METHODS: This was a retrospective chart review of 400 patients, ages 5 to 18 years. Cases (n = 200) were identified as 100 subjects with difficult-to-control asthma and an inhaled corticosteroid dose of ≥1000 µg/day and 100 subjects with well-controlled asthma and an inhaled corticosteroid dose of ≤500 µg/day. The control group included 200 subjects without asthma. Multivariable logistic regression models were used to assess the relationships between asthma status and weight status, age, race, and sex. RESULTS: The mean body mass index percentile (± standard deviation at 95% confidence interval) was significantly higher in the difficult-to-control asthma group versus the well-controlled asthma group versus the control group (74.66 ± 28.19 versus 54.25 ± 29.92 versus 55.19 ± 32.54; p < 0.001). Thirty-six percent of the difficult-to-control patients with asthma were obese (versus 6% of the patients with well-controlled asthma [p < 0.001] versus 13% of patients without asthma [p = 0.002]), and 47% normal weight (versus 79% of the patients with well-controlled asthma versus 75% of patients without asthma; p < 0.001). The mean age and the proportion of African Americans in the difficult-to-control asthma group were significantly higher than in the well-controlled asthma group and in the control group (p < 0.001). CONCLUSION: The results of this study demonstrated a significant association between severe persistent difficult-to-control asthma and obesity, age, and race. Patients who are obese and have difficult-to-control asthma need treatment approaches that address both asthma control and weight management.

Expedited Delivery of Pain Medication for Long-Bone Fractures Using an Intranasal Fentanyl Clinical Pathway.

OBJECTIVE: This study aims to determine whether a pathway designed to facilitate the use of intranasal (IN) fentanyl for long-bone fractures will expedite the delivery of pain medication, decrease the total length of emergency department (ED) stay, and provide faster analgesia compared with intravenous (IV) morphine. METHODS: A pain pathway for IN fentanyl in long-bone fractures was instituted in our ED in July 2011. We performed a retrospective and prospective chart review of patients aged 3 to 21 years who presented to the ED with a clinically suspected long-bone fracture and either received IV morphine or were placed on IN fentanyl pain pathway. RESULTS: A total of 94 patients met our inclusion criteria; 71 received IV morphine, and 23 received IN fentanyl, per pathway protocol. The mean length of time to pain medication administration was statistically significantly faster for IN fentanyl (37 minutes) than for IV morphine (62 minutes) (P = 0.002). The mean total length of stay for patients who received IN fentanyl versus patients who received IV morphine was not statistically significantly different after excluding patients who needed reduction or surgery. Effectiveness of pain control was not statistically significantly different between the IN fentanyl group and the IV morphine group. CONCLUSIONS: Use of the IN fentanyl pain pathway significantly decreases time to pain medication administration in pediatric patients with suspected long-bone fractures.

Intensive care unit readmission during childhood after preterm birth with respiratory failure.

OBJECTIVE: To determine the incidence and risk factors for readmission to the intensive care unit (ICU) among preterm infants who required mechanical ventilation at birth. STUDY DESIGN: We studied preterm newborns (birth weight 500-1250 g) who required mechanical ventilation at birth and were enrolled in a multicenter trial of inhaled nitric oxide therapy. Patients were assessed up to 4.5 years of age via annual in-person evaluations and structured telephone interviews. Univariate and multivariable analyses of baseline and birth hospitalization predictors of ICU readmission were performed. RESULTS: Of 512 subjects providing follow-up data, 58% were readmitted to the hospital (51% of these had multiple readmissions, averaging 3.9 readmissions per subject), 19% were readmitted to an ICU, and 12% required additional mechanical ventilation support. In univariate analyses, ICU readmission was more common among male subjects (OR 2.01; 95% CI 1.27-3.18), infants with grade 3-4 intracranial hemorrhage (OR 2.13; 95% CI 1.23-3.69), increasing duration of birth hospitalization (OR 1.01 per day; 95% CI 1.00-1.02), and prolonged oxygen therapy (OR 1.01 per day; 95% CI 1.00-1.01). In the first year after birth hospitalization, children readmitted to an ICU incurred greater health care costs (median $69,700 vs $30,200 for subjects admitted to the ward and $9600 for subjects never admitted). CONCLUSIONS: Small preterm infants who were mechanically ventilated at birth have substantial risk for readmission to an ICU and late mechanical ventilation, require extensive health care resources, and incur high treatment costs.

Knowledge regarding hymens and the sex education of parents.

The objective of this study was to ascertain beliefs and knowledge of pediatricians and parents regarding the hymen and to evaluate parental and pediatrician attitudes regarding sex education by pediatricians. Surveys were distributed anonymously to parents and pediatricians. Survey questions included knowledge of the female hymen and questions regarding attitudes toward sexual health education. There was a statistically significant difference in mean knowledge scores between pediatricians and parents regarding the hymen (3.7 versus 1.3; p < 0.0001). Almost two-thirds of pediatricians (63%) felt comfortable providing sexual health education directly to their patients, but only 41% felt comfortable educating parents. Pediatricians and parents demonstrate knowledge gaps about the hymen.

Parental knowledge of radiation exposure in medical imaging used in the pediatric emergency department.

OBJECTIVES: We sought to quantify the knowledge base among parents and legal guardians presenting to our pediatric emergency department regarding radiation exposure during medical imaging and potential risks to children resulting from ionizing radiation. We sought to examine if a child's previous exposure to medical imaging changed caregiver knowledge base and discern caregivers' preference for future education on this topic. METHODS: A prospective convenience sample survey was performed of caregivers who presented with their child to our tertiary pediatric emergency department. Parents or legal guardians (18-89 years) who accompanied a child (0-17 years) were eligible for inclusion and approached for enrollment. A structured questionnaire was administered by trained interviewers, and a chart review was conducted to ascertain if their child had a history of previous imaging. RESULTS: Sixty percent of caregivers interviewed (n = 205 of 340) did not associate any long-term negative effects with medical imaging. Among participants who did express a perceived risk from medical imaging radiation exposure, only 50% could indicate a known negative effect from exposure. We found no significant association between a child having had documented imaging studies and awareness of long-term negative effects (P = 0.22). Participants preferred to learn more about this topic from an Internet-based resource (50%), informational pamphlet (38%), or via treating physician (33%). CONCLUSIONS: Parents and legal guardians are largely unaware that exposure to radiation during medical imaging carries an inherent risk for their child. Health care providers wishing to educate caregivers should utilize reliable Internet sources, educational pamphlets, and direct communication.

Penile diameter during puberty in boys: a retrospective analysis of longitudinally obtained data.

OBJECTIVES: Tanner staging is the standard for rating sexual maturation (SMR) in boys (pubic hair (PH) and genital (G) development). G staging is tripartite in nature and is prone to ambiguity because it is based upon somewhat vague visual cues that may lead to erroneous assessments and medical errors. Measurement of penile growth (penile girth or diameter) may provide an additional tool (in addition to the orchidometer) to make G staging more valid. Although studies on penile growth (either circumference of width) have been reported, none were longitudinal. Therefore, our objective was to compare penile development in boys - measured as penile diameter (PD) - to PH stage and testicular volume (TV) and secondarily to G stage; moreover, to do so on a longitudinal basis. METHODS: Charts of 61 boys, ages 6-21 years of age, who were seen longitudinally, were reviewed. Each boy had his PD and TV measured along with his PH and G stage assessed on a quarterly to semi-annual basis. RESULTS: PD increased significantly among PH stages II, III, and IV only. PD increased significantly among G stages I, II, III and IV only. PD correlated well with TV. There were significant correlations between PD and TV in all PH stages. However, for G stage correlations were not significant for stages II, III, and IV. PH stage was a better predictor of PD than G stage. CONCLUSIONS: Measuring PD may be another tool to help in objectifying male SMR during puberty and overcome the vagueness encountered with the visual SMR G stage scales.

Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways.

OBJECTIVES: Previous reports have shown a high rate of ventilation failure via direct laryngoscopy as compared with the King LT-D airway. This difference is further divergent in the pediatric population. The goal of this study was to compare the difference in efficacy of ventilation by prehospital providers in a simulated environment between direct laryngoscopy and Pedi-King LT-D. METHODS: In this study, 37 paramedics were exposed to 2 identical 5-minute clinical scenarios in a simulation center using a pediatric simulation tool. In the first scenario, the provider was given all of the standard laryngoscopy equipment. In the second scenario, they were given access only to the Pedi-King LT-D. A comparison of adequate ventilation time between the scenarios was performed. RESULTS: A mean improvement of 102 seconds was found when using the Pedi-King airway, with a clinically significant P < 0.0001. CONCLUSIONS: With a significant improvement in ventilation time in these simulated airways, consideration should be made to practice placement of the King Airway Device as first-line airway stabilization. Further live prospective studies would aid in this recommendation.

Information Extraction From Electronic Health Records to Predict Readmission Following Acute Myocardial Infarction: Does Natural Language Processing Using Clinical Notes Improve Prediction of Readmission?

Background Social risk factors influence rehospitalization rates yet are challenging to incorporate into prediction models. Integration of social risk factors using natural language processing (NLP) and machine learning could improve risk prediction of 30-day readmission following an acute myocardial infarction. Methods and Results Patients were enrolled into derivation and validation cohorts. The derivation cohort included inpatient discharges from Vanderbilt University Medical Center between January 1, 2007, and December 31, 2016, with a primary diagnosis of acute myocardial infarction, who were discharged alive, and not transferred from another facility. The validation cohort included patients from Dartmouth-Hitchcock Health Center between April 2, 2011, and December 31, 2016, meeting the same eligibility criteria described above. Data from both sites were linked to Centers for Medicare & Medicaid Services administrative data to supplement 30-day hospital readmissions. Clinical notes from each cohort were extracted, and an NLP model was deployed, counting mentions of 7 social risk factors. Five machine learning models were run using clinical and NLP-derived variables. Model discrimination and calibration were assessed, and receiver operating characteristic comparison analyses were performed. The 30-day rehospitalization rates among the derivation (n=6165) and validation (n=4024) cohorts were 15.1% (n=934) and 10.2% (n=412), respectively. The derivation models demonstrated no statistical improvement in model performance with the addition of the selected NLP-derived social risk factors. Conclusions Social risk factors extracted using NLP did not significantly improve 30-day readmission prediction among hospitalized patients with acute myocardial infarction. Alternative methods are needed to capture social risk factors.

Development of Electronic Health Record-Based Prediction Models for 30-Day Readmission Risk Among Patients Hospitalized for Acute Myocardial Infarction.

Importance: In the US, more than 600 000 adults will experience an acute myocardial infarction (AMI) each year, and up to 20% of the patients will be rehospitalized within 30 days. This study highlights the need for consideration of calibration in these risk models. Objective: To compare multiple machine learning risk prediction models using an electronic health record (EHR)-derived data set standardized to a common data model. Design, Setting, and Participants: This was a retrospective cohort study that developed risk prediction models for 30-day readmission among all inpatients discharged from Vanderbilt University Medical Center between January 1, 2007, and December 31, 2016, with a primary diagnosis of AMI who were not transferred from another facility. The model was externally validated at Dartmouth-Hitchcock Medical Center from April 2, 2011, to December 31, 2016. Data analysis occurred between January 4, 2019, and November 15, 2020. Exposures: Acute myocardial infarction that required hospital admission. Main Outcomes and Measures: The main outcome was thirty-day hospital readmission. A total of 141 candidate variables were considered from administrative codes, medication orders, and laboratory tests. Multiple risk prediction models were developed using parametric models (elastic net, least absolute shrinkage and selection operator, and ridge regression) and nonparametric models (random forest and gradient boosting). The models were assessed using holdout data with area under the receiver operating characteristic curve (AUROC), percentage of calibration, and calibration curve belts. Results: The final Vanderbilt University Medical Center cohort included 6163 unique patients, among whom the mean (SD) age was 67 (13) years, 4137 were male (67.1%), 1019 (16.5%) were Black or other race, and 933 (15.1%) were rehospitalized within 30 days. The final Dartmouth-Hitchcock Medical Center cohort included 4024 unique patients, with mean (SD) age of 68 (12) years; 2584 (64.2%) were male, 412 (10.2%) were rehospitalized within 30 days, and most of the cohort were non-Hispanic and White. The final test set AUROC performance was between 0.686 to 0.695 for the parametric models and 0.686 to 0.704 for the nonparametric models. In the validation cohort, AUROC performance was between 0.558 to 0.655 for parametric models and 0.606 to 0.608 for nonparametric models. Conclusions and Relevance: In this study, 5 machine learning models were developed and externally validated to predict 30-day readmission AMI hospitalization. These models can be deployed within an EHR using routinely collected data.

Development of a national Department of Veterans Affairs mortality risk prediction model among patients with cirrhosis.

OBJECTIVE: Cirrhotic patients are at high hospitalisation risk with subsequent high mortality. Current risk prediction models have varied performances with methodological room for improvement. We used current analytical techniques using automatically extractable variables from the electronic health record (EHR) to develop and validate a posthospitalisation mortality risk score for cirrhotic patients and compared performance with the model for end-stage liver disease (MELD), model for end-stage liver disease with sodium (MELD-Na), and the CLIF Consortium Acute Decompensation (CLIF-C AD) models. DESIGN: We analysed a retrospective cohort of 73 976 patients comprising 247 650 hospitalisations between 2006 and 2013 at any of 123 Department of Veterans Affairs hospitals. Using 45 predictor variables, we built a time-dependent Cox proportional hazards model with all-cause mortality as the outcome. We compared performance to the three extant models and reported discrimination and calibration using bootstrapping. Furthermore, we analysed differential utility using the net reclassification index (NRI). RESULTS: The C-statistic for the final model was 0.863, representing a significant improvement over the MELD, MELD-Na, and the CLIF-C AD, which had C-statistics of 0.655, 0.675, and 0.679, respectively. Multiple risk factors were significant in our model, including variables reflecting disease severity and haemodynamic compromise. The NRI showed a 24% improvement in predicting survival of low-risk patients and a 30% improvement in predicting death of high-risk patients. CONCLUSION: We developed a more accurate mortality risk prediction score using variables automatically extractable from an EHR that may be used to risk stratify patients with cirrhosis for targeted postdischarge management.

Descriptive Usability Study of CirrODS: Clinical Decision and Workflow Support Tool for Management of Patients With Cirrhosis.

BACKGROUND: There are gaps in delivering evidence-based care for patients with chronic liver disease and cirrhosis. OBJECTIVE: Our objective was to use interactive user-centered design methods to develop the Cirrhosis Order Set and Clinical Decision Support (CirrODS) tool in order to improve clinical decision-making and workflow. METHODS: Two work groups were convened with clinicians, user experience designers, human factors and health services researchers, and information technologists to create user interface designs. CirrODS prototypes underwent several rounds of formative design. Physicians (n=20) at three hospitals were provided with clinical scenarios of patients with cirrhosis, and the admission orders made with and without the CirrODS tool were compared. The physicians rated their experience using CirrODS and provided comments, which we coded into categories and themes. We assessed the safety, usability, and quality of CirrODS using qualitative and quantitative methods. RESULTS: We created an interactive CirrODS prototype that displays an alert when existing electronic data indicate a patient is at risk for cirrhosis. The tool consists of two primary frames, presenting relevant patient data and allowing recommended evidence-based tests and treatments to be ordered and categorized. Physicians viewed the tool positively and suggested that it would be most useful at the time of admission. When using the tool, the clinicians placed fewer orders than they placed when not using the tool, but more of the orders placed were considered to be high priority when the tool was used than when it was not used. The physicians' ratings of CirrODS indicated above average usability. CONCLUSIONS: We developed a novel Web-based combined clinical decision-making and workflow support tool to alert and assist clinicians caring for patients with cirrhosis. Further studies are underway to assess the impact on quality of care for patients with cirrhosis in actual practice.

Risk of Hypoglycemia Following Hospital Discharge in Patients With Diabetes and Acute Kidney Injury.

OBJECTIVE: Hypoglycemia is common in patients with diabetes. The risk of hypoglycemia after acute kidney injury (AKI) is not well defined. The purpose of this study was to compare the risk for postdischarge hypoglycemia among hospitalized patients with diabetes who do and do not experience AKI. RESEARCH DESIGN AND METHODS: We performed a propensity-matched analysis of patients with diabetes, with and without AKI, using a retrospective national cohort of veterans hospitalized between 2004 and 2012. AKI was defined as a 0.3 mg/dL or 50% increase in serum creatinine from baseline to peak serum creatinine during hospitalization. Hypoglycemia was defined as hospital admission or an emergency department visit for hypoglycemia or as an outpatient blood glucose <60 mg/dL. Time to incident hypoglycemia within 90 days postdischarge was examined using Cox proportional hazards models. Prespecified subgroup analyses by renal recovery, baseline chronic kidney disease, preadmission drug regimen, and HbA1c were performed. RESULTS: We identified 65,151 propensity score-matched pairs with and without AKI. The incidence of hypoglycemia was 29.6 (95% CI 28.9-30.4) and 23.5 (95% CI 22.9-24.2) per 100 person-years for patients with and without AKI, respectively. After adjustment, AKI was associated with a 27% increased risk of hypoglycemia (hazard ratio [HR] 1.27 [95% CI 1.22-1.33]). For patients with full recovery, the HR was 1.18 (95% CI 1.12-1.25); for partial recovery, the HR was 1.30 (95% CI 1.23-1.37); and for no recovery, the HR was 1.48 (95% CI 1.36-1.60) compared with patients without AKI. Across all antidiabetes drug regimens, patients with AKI experienced hypoglycemia more frequently than patients without AKI, though the incidence of hypoglycemia was highest among insulin users, followed by glyburide and glipizide users, respectively. CONCLUSIONS: AKI is a risk factor for hypoglycemia in the postdischarge period. Studies to identify risk-reduction strategies in this population are warranted.