Characteristics Associated with Spirometry Guideline Adherence in VA Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends at least annual spirometry for patients with chronic obstructive pulmonary disease (COPD). Since spirometry acquisition is variable in clinical practice, identifying characteristics associated with annual spirometry may inform strategies to improve care for patients with COPD. METHODS: We included veterans hospitalized for COPD at Veterans Health Administration (VHA) facilities from 10/2012 to 09/2015. Our primary outcome was spirometry within 1 year of COPD hospitalization. Patient demographics, health factors, and comorbidities as well as practice and geographic variables were identified using Corporate Data Warehouse; provider characteristics were obtained from the Survey of Healthcare Experiences of Patients. We used logistic regression with a random intercept to account for potential clustering within facilities. RESULTS: Spirometry was completed 1 year before or after hospitalization for 20,683/38,148 (54.2%) veterans across 114 facilities. Patients with spirometry were younger, (mean=67.2 years (standard deviation (SD)=9.3) vs. 69.4 (10.3)), more likely non-white (21.3% vs. 19.7%), and more likely to have comorbidities (p<0.0001 for asthma, depression, and post-traumatic stress disorder). Pulmonary clinic visit was most strongly associated with spirometry (odds ratio (OR)=3.14 [95% confidence interval 2.99-3.30]). There was no association for facility complexity. In a secondary analysis including provider-level data (3862 patients), results were largely unchanged. There was no association between primary care provider age, gender, or type (physician vs. advanced practice registered nurse vs. physician assistant) and spirometry. CONCLUSION: In a cohort of high-risk COPD patients, just over half completed spirometry within 1 year of hospitalization. Pulmonary clinic visit was most strongly associated with 1-year spirometry, though provider variables were not. Spirometry completion for high-risk COPD patients remains suboptimal and strategies to improve post-hospitalization care for patients not seen in pulmonary clinic should be developed to ensure guideline concordant care.

Improving the Quality of Inpatient Discharge Instructions: An Evaluation and Implementation of Best Practices.

OBJECTIVES: Little is known about whether improving the quality of written discharge instructions can result in improved readmission rates and whether there are differences in the quality of discharge instructions based on provider and patient characteristics. We set out to determine provider characteristics associated with high quality discharge instructions and whether redesigned discharge instructions would lead to improvement in their quality and reduce hospital readmission rates. METHODS: We instituted sequential interventions of educational outreach and a redesigned discharge instructions template and evaluated their quality using 11 metrics based on established best practices and subsequent 30-day readmission rates. RESULTS: In total, 225 randomly selected charts were reviewed during a 15-month period. An average of 5.36 quality metrics were completed before our interventions, which increased to 5.61 after educational outreach and 7.16 after the template was redesigned. The risk standardized 30-day readmission rate fluctuated from a baseline of 10.48% to 12.71% and 10.97% following each intervention, respectively. Medical students completed significantly more quality metrics than interns, residents, or attendings (P < 0.05 for all) and residents completed significantly more than attendings (P = 0.014). CONCLUSIONS: Although an education intervention was ineffective in improving discharge instruction quality, a redesigned discharge instructions template did improve the quality of patient discharge instructions. Neither intervention led to a meaningful change in readmission rates. We also found significant differences in the quality of discharge instructions based on the level of training of the author of the discharge instructions.

Rate of Preventable Mortality in Hospitalized Patients: a Systematic Review and Meta-analysis.

BACKGROUND: The number of preventable inpatient deaths in the USA is commonly estimated as between 44,000 and 98,000 deaths annually. Because many inpatient deaths are believed to be preventable, mortality rates are used for quality measures and reimbursement. We aimed to estimate the proportion of inpatient deaths that are preventable. METHODS: A systematic literature search of Medline, Embase, Web of Science, and the Cochrane Library through April 8, 2019, was conducted. We included case series of adult patients who died in the hospital and were reviewed by physicians to determine if the death was preventable. Two reviewers independently performed data extraction and study quality assessment. The proportion of preventable deaths from individual studies was pooled using a random-effects model. RESULTS: Sixteen studies met inclusion criteria. Eight studies of consecutive or randomly selected cohorts including 12,503 deaths were pooled. The pooled rate of preventable mortality was 3.1% (95% CI 2.2-4.1%). Two studies also reported rates of preventable mortality limited to patients expected to live longer than 3 months, ranging from 0.5 to 1.0%. In the USA, these estimates correspond to approximately 22,165 preventable deaths annually and 7150 deaths for patients with greater than 3-month life expectancy. DISCUSSION: The number of deaths due to medical error is lower than previously reported and the majority occur in patients with less than 3-month life expectancy. The vast majority of hospital deaths are due to underlying disease. Our results have implications for the use of hospital mortality rates for quality reporting and reimbursement. STUDY REGISTRATION: PROSPERO registration number CRD42018095140.

The Development of an Innovative Crowdsourced Resident Procedure Team Model to Improve Bedside Procedural Proficiency in the Inpatient Setting.

Background Bedside procedures are a necessary skill for many residents. Practice changes, including the discontinuation of a minimum number of procedures required by the American Board of Internal Medicine, may have resulted in decreased incentive for residents to seek procedural opportunities. Objective To improve residents' procedural output and confidence in abdominal paracentesis, arterial and central venous line placement, nasogastric intubation, and ultrasound-guided peripheral intravenous catheter insertions (USPIV). Methods A novel Resident Procedure Team (RPT) model was created using crowdsourced proficient (having completed ≥5 procedures) near-peers in combination with peer-led USPIV simulation workshops to increase the number of supervising residents available. Procedure logs and the number of residents who became qualified to perform and supervise procedures were tracked from July 2018 to June 2022 and compared before and after the implementation of the RPT in July 2020. Results Implementing the novel RPT model significantly increased the number of procedures performed (1875 procedures post-RPT vs 1292 pre-RPT; P=.02). Abdominal paracentesis increased from 411 to 482 (17.3%), central venous line placement increased from 344 to 401 (16.6%), USPIV increased from 318 to 389 (22.3%), arterial line placement increased from 189 to 360 (90.5%), and nasogastric intubation increased from 30 to 243 (710.0%). Resident confidence levels increased significantly after RPT-led USPIV workshops (P<.05 for all). Conclusions Implementation of a novel, crowdsourced, resident-led procedure team and peer-led USPIV workshops helped increase the number of procedures performed by residents.

Room of Hazards: A Comparison of Differences in Safety Hazard Recognition Among Various Hospital-Based Healthcare Professionals and Trainees in a Simulated Patient Room.

OBJECTIVES: Adverse events in hospitals are common. While studies have used simulated patient rooms to assess healthcare trainees' skills in detecting safety hazards, few have explored the characteristics of safety hazards that make them more or less identifiable to healthcare workers. We sought to determine differences in hospital-based safety hazard identification among physicians, nurses, and other staff members. METHODS: Healthcare workers were invited to identify safety hazards in a simulated patient room with intentionally placed hazards. Responses were transcribed and compared between physicians (MD), nurses (RN), and other hospital-based healthcare professionals and trainees (other). Data were analyzed using nonparametric statistical analysis. RESULTS: Twelve physicians, 29 nurses, and 26 other staff members participated in this study. Different professions identified different numbers of total hazards with nurses identifying more hazards than other professions (RN: 9.59, MD: 9.17, other: 6.35; P = 0.001). All professions had difficulty identifying hazards associated with omission (e.g., no precaution sign: MD: 8.3%, RN: 3.4%, other: 0%) or hazards requiring 2-step logical thinking (e.g., intravenous heparin for patient with head laceration: MD: 0%, RN: 6.9%, other: 0%). CONCLUSIONS: Physicians, nurses, and others identified different numbers of total hazards, and few participants identified hazards associated with omission or 2-step logical thinking. While previous studies have found differences in types of hazards identified among different healthcare members, we identified hazards that were collectively challenging for all participants to identify. Future studies should target identification of these types of hazards, using human factor engineering to decrease risk of patient harm.

Room of Hazards: An Interprofessional Evaluation of Safety Risks in a Simulated Patient Room.

OBJECTIVES: Approximately 3.7% of patients experience adverse events in health care facilities, many of which are preventable. Patient safety requires effective training and an interprofessional culture of safety, but few studies compare the safety skills of different hospital professions. We sought to assess skills in safety hazards identification among staff from different health care disciplines with a pilot study. METHODS: An exercise with a simulated room of an inpatient ward with a patient mannequin in a hospital bed with 34-intentionally planted safety hazards was set up. Health care staff members from various professions walked around the room and independently documented observed safety hazards. Identified hazards were separated based on staff disciplines, grouped into 5 categories (patient, medications, equipment, environment, care processes), and analyzed using analysis of variance. Because participants identified more hazards than the 34 intentionally planted hazards, these were analyzed separately. RESULTS: The study included 111 staff: nurses (n = 68), nursing students (n = 5), medical students (n = 3), physicians (n = 11), social workers (n = 5), pharmacists (n = 6), certified nursing assistants (n = 9), and psychologists (n = 4). There were significant differences among professions in the following categories: medications, equipment, and total number of safety hazards (P < 0.05 for all). Nurses found more intended equipment hazards than did social workers (38.8% versus 4.4%, P < 0.001), pharmacists (38.8% versus 11.1%, P = 0.004), medical students (38.8% versus 7.4%, P = 0.021), and psychologists (38.8% versus 8.3%, P = 0.001) and more medication hazards than nursing students (20.3% versus 16.7%, P = 0.008), whereas certified nursing assistants also found more equipment hazards than did social workers (25.9% versus 4.4%, P = 0.016). CONCLUSIONS: There were significant differences in patterns of safety hazards identified among health care professions, with nurses identifying more hazards than several other professions. This finding suggests that each health care profession's unique training and responsibilities result in varying ability to identify safety hazards and that interdisciplinary safety teams may be more effective than those from only a single profession. Our study provides a starting point to encourage diversification of hospital professions in simulation-based safety trainings, although further work is needed to validate these findings moving forward.

Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis.

BACKGROUND: Diagnostic error is commonly defined as a missed, delayed or wrong diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review has attempted to estimate the prevalence and nature of harmful diagnostic errors in hospitalised patients. METHODS: A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochrane library from database inception through 9 July 2019. We included all studies of hospitalised adult patients that used physician review of case series of admissions and reported the frequency of diagnostic adverse events. Two reviewers independently screened studies for inclusion, extracted study characteristics and assessed risk of bias. Harmful diagnostic error rates were pooled using random-effects meta-analysis. RESULTS: Twenty-two studies including 80 026 patients and 760 harmful diagnostic errors from consecutive or randomly selected cohorts were pooled. The pooled rate was 0.7% (95% CI 0.5% to 1.1%). Of the 136 diagnostic errors that were described in detail, a wide range of diseases were missed, the most common being malignancy (n=15, 11%) and pulmonary embolism (n=13, 9.6%). In the USA, these estimates correspond to approximately 249 900 harmful diagnostic errors yearly. CONCLUSION: Based on physician review, at least 0.7% of adult admissions involve a harmful diagnostic error. A wide range of diseases are missed, including many common diseases. Fourteen diagnoses account for more than half of all diagnostic errors. The finding that a wide range of common diagnoses are missed implies that efforts to improve diagnosis must target the basic processes of diagnosis, including both cognitive and system-related factors. PROSPERO REGISTRATION NUMBER: CRD42018115186.

Patient and hospital characteristics associated with ticagrelor uptake in acute MI: An analysis of the Chest Pain-MI Registry.

BACKGROUND: ACC/AHA guidelines support the use of the P2Y12 inhibitors clopidogrel, prasugrel, or ticagrelor in acute myocardial infarction (AMI). Little is known about trends in P2Y12 inhibitor selection over time. METHODS: Multicenter, longitudinal analysis of patients and hospitals in the National Cardiovascular Data Registry (NCDR) Chest Pain - MI Registry from the third quarter of 2013 to the first quarter of 2017. RESULTS: A total of 362,354 AMI patients treated at 801 hospitals were included in our analysis. Ticagrelor use increased over time, from 6.1% in 2013 to 33.7% in 2017, with corresponding reductions in the use of clopidogrel and prasugrel (p < 0.001 for all trends). In multivariable models, patients of white race, with private insurance, or STEMI were more likely to receive ticagrelor (p < 0.05 for all). Hospitals in the highest quartile of ticagrelor uptake had use rates ranging from 29% to 88%, and were more likely to have the lowest volume of MI patients. The correlation between prasugrel and ticagrelor adoption was weakly positive (correlation coefficient: 0.15, p = 0.004); hospitals with the lowest early adoption of prasugrel started with the lowest rate of ticagrelor use and had the slowest rate of increase in ticagrelor use. CONCLUSIONS: There has been a rapid increase in use of ticagrelor since its approval by the FDA and both patient and hospital characteristics were associated with variation in its adoption and utilization. Further examination of the characteristics associated with the rapid adoption of new evidence may provide insights about improving health system performance.

Variation in the Use of Warfarin and Direct Oral Anticoagulants in Atrial Fibrillation and Associated Cost Implications.

BACKGROUND: Little is known about national patterns of anticoagulant use among patients with atrial fibrillation after the availability of direct oral anticoagulants (DOACs) and the associated implications for healthcare spending. METHODS: The Medical Expenditure Panel Survey, a nationally representative survey, collects detailed information about prescription drug use, cost, and medical diagnoses. Using International Classification of Disease Ninth Edition (ICD-9) codes and self-reporting, adults with atrial fibrillation were estimated between 2010 and 2014. We examined proportions of patients receiving warfarin and DOACs overall and across sociodemographic and clinical groups. Total drug expenditures and out-of-pocket spending were calculated adjusting to 2014 US dollars. RESULTS: The study population ranged from 364 (equivalent to 4.7 million) in 2010 to 409 (equivalent to 5.5 million) in 2014. Overall use of any anticoagulant increased from 32.4% to 40.1%. DOAC use increased from 0.56% to 17.2%, and warfarin use declined from 32.8% to 22.9% (p trend < 0.01). This trend was seen in nearly all subgroups evaluated. Estimated prescription drug spending on DOACs and warfarin during this time rose from $330 million to $1.9 billion. Out-of-pocket costs for DOACs increased from $10 million to $218 million. CONCLUSION: In a large, nationwide cohort of adults with atrial fibrillation, we observed a rapid increase in the use of DOACs, significant disparities in medication use based on sociodemographic and clinical factors, and an increase in overall and out-of-pocket costs for anticoagulants corresponding to the increased use of DOACs. These patterns have important implications for healthcare quality, equity, and spending.

Economics of psychosocial factors in patients with cardiovascular disease.

Growing evidence supports a causal relationship between cardiovascular disease and psychosocial factors such as mental health and behavioral disorders, acute and chronic stress, and low socioeconomic status. While this has enriched our understanding of the interaction between cardiovascular risk factors, much less is known about its economic implications. In this review, we evaluate the economic impact of psychosocial factors in persons at risk for or diagnosed with cardiovascular disease. Most studies have focused on depression and almost uniformly conclude that patients with cardiovascular disease and comorbid depression use a greater number of ambulatory and hospital services and incur higher overall costs. Additionally, comorbid depression may also reduce employment productivity in patients with cardiovascular disease, further magnifying its economic impact. Recent randomized trials have demonstrated that innovative care delivery models that target depression may reduce costs or at least be cost neutral while improving quality of life. The growing population burden and overlap of cardiovascular disease, comorbid mental illness, and other psychosocial factors suggest that future research identifying cost-effective or cost-saving treatment models may have significant health and economic implications.

The nuclear receptor corepressor (NCoR) controls thyroid hormone sensitivity and the set point of the hypothalamic-pituitary-thyroid axis.

The role of nuclear receptor corepressor (NCoR) in thyroid hormone (TH) action has been difficult to discern because global deletion of NCoR is embryonic lethal. To circumvent this, we developed mice that globally express a modified NCoR protein (NCoRΔID) that cannot be recruited to the thyroid hormone receptor (TR). These mice present with low serum T(4) and T(3) concentrations accompanied by normal TSH levels, suggesting central hypothyroidism. However, they grow normally and have increased energy expenditure and normal or elevated TR-target gene expression across multiple tissues, which is not consistent with hypothyroidism. Although these findings imply an increased peripheral sensitivity to TH, the hypothalamic-pituitary-thyroid axis is not more sensitive to acute changes in TH concentrations but appears to be reset to recognize the reduced TH levels as normal. Furthermore, the thyroid gland itself, although normal in size, has reduced levels of nonthyroglobulin-bound T(4) and T(3) and demonstrates decreased responsiveness to TSH. Thus, the TR-NCoR interaction controls systemic TH sensitivity as well as the set point at all levels of the hypothalamic-pituitary-thyroid axis. These findings suggest that NCoR levels could alter cell-specific TH action that would not be reflected by the serum TSH.

State dependence of olfactory perception as a function of taste cortical inactivation.

As anyone who has suffered through a head cold knows, food eaten when the olfactory system is impaired tastes 'wrong', an experience that leads many to conclude that taste stimuli are processed normally only when the olfactory system is unimpaired. Evidence that the taste system influences olfactory perception, however, has been vanishingly rare. We found just such an influence; if taste cortex was inactivated when an odor was first presented, later presentations were properly appreciated only if taste cortex was again inactivated.