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Vasan V, Dullea JT, Devarajan A, Vasa D, Ali M, Nichols N, Henson P, Porras C, Lopez C, Luna D, Liou L, Iloreta AM, Govindaraj S, Bederson J, Shrivastava RK. Predictors of Prolonged Length of Stay After Pituitary Adenoma Resection: A Large Cohort Analysis Using the National Inpatient Sample (2016-2019). Am J Rhinol Allergy 2023; 37:758-765. [PMID: 37550993 DOI: 10.1177/19458924231193527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
OBJECTIVE In this nationwide retrospective study, the authors aimed to identify demographic, clinical, and baseline health risk factors predictive of a prolonged length of stay (PLOS) for patients with pituitary adenomas (PAs). METHODS The National Inpatient Sample dataset from 2016 to 2019 was utilized to identify all included hospitalizations for PA resection as identified by the appropriate diagnosis-related group code. Comorbidities were classified based on the Charlson Comorbidity Index mapping of ICD-10 codes, and PLOS was identified as any stay longer than 3 days. Univariable and multivariable logistic regression models, accounting for the sample design, were built to determine factors associated with PLOS and emergent surgery. RESULTS Overall, 30 945 patients were included in this study with 10 535 patients having PLOS. Female patients experienced an increased odds of PLOS (odds ratio [OR]: 1.29; P < .001). Black patients (OR: 1.49; P < .001) and Hispanic patients (OR: 1.30; P = .003) had 1.49 times and 1.30 times the odds of PLOS compared to White patients, respectively. Compared to patients insured by Medicare, patients insured by Medicaid had an increased odds of PLOS (OR: 1.36; P = .007) as well as emergent surgery (OR: 5.40; P < .001). When stratified by emergent surgeries, Black patients (OR: 1.89; P < .001), Hispanic patients, (OR: 2.14; P < .001), and patients on Medicaid insurance (OR: 1.71; P < .001) were at an increased risk of emergent procedures. However, female sex (OR: 0.65; P < .001), upper third quartile (OR: 0.73; P = .017), and fourth quartile (OR: 0.69; P = .014) of patients categorized by zip code income were at decreased odds of an emergent procedure. CONCLUSIONS Black and Hispanic patients, patients with Medicaid insurance, and patients of low socioeconomic status patients are at significantly higher risk of emergent PA resection and PLOS. Efforts to prevent emergent surgeries and shorten hospitalization after pituitary surgery may need to primarily focus on patient groups with select sociodemographic characteristics.
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Affiliation(s)
- Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Devarshi Vasa
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noah Nichols
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Henson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christian Porras
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christine Lopez
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diego Luna
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Lathan Liou
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alfred Marc Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Rosenthal MA, Ranji SR, Kanzaria HK, Ortiz GM, Chase J, Chodos AH, Nguyen OK, Rodriguez EG, Makam AN. Characterizing patients hospitalized without an acute care indication: A retrospective cohort study. J Hosp Med 2023; 18:294-301. [PMID: 36757173 DOI: 10.1002/jhm.13061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/04/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Hospitalizations by patients who do not meet acute inpatient criteria are common and overburden healthcare systems. Studies have characterized these alternate levels of care (ALC) but have not delineated prolonged (pALC) versus short ALC (sALC) stays. OBJECTIVE To descriptively compare pALC and sALC hospitalizations-groups we hypothesize have unique needs. DESIGNS, SETTINGS, AND PARTICIPANTS A retrospective study of hospitalizations from March-April 2018 at an academic safety-net hospital. MAIN OUTCOME AND MEASURES Levels of care for pALC (>3 days) and sALC (1-3 days) were determined using InterQual©, an industry standard utilization review tool for determining the clinical appropriateness of hospitalization. We examined sociodemographic and clinical characteristics. RESULTS Of 2365 hospitalizations, 215 (9.1%) were pALC, 277 (11.7%) were sALC, and 1873 (79.2%) had no ALC days. There were 17,683 hospital days included, and 28.3% (n = 5006) were considered ALC. Compared to patients with sALC, those with pALC were older and more likely to be publicly insured, experience homelessness, and have substance use or psychiatric comorbidities. Patients with pALC were more likely to be admitted for care meeting inpatient criteria (89.3% vs. 66.8%, p < .001), had significantly more ALC days (median 8 vs. 1 day, p < .001), and were less likely to be discharged to the community (p < .001). CONCLUSIONS Patients with prolonged ALC stays were more likely to be admitted for acute care, had greater psychosocial complexity, significantly longer lengths of stay, and unique discharge needs. Given the complexity and needs for hospitalizations with pALC days, intensive interdisciplinary coordination and resource mobilization are necessary.
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Affiliation(s)
- Molly A Rosenthal
- Department of General Internal Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Sumant R Ranji
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California, San Francisco, California, USA
- Department of Care Coordination, San Francisco Department of Public Health, San Francisco, California, USA
- Center for Vulnerable Populations, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Gabriel M Ortiz
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Jack Chase
- Department of Family and Community Medicine, University of California, San Francisco, California, USA
| | - Anna H Chodos
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Oanh K Nguyen
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
- Center for Vulnerable Populations, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Eric G Rodriguez
- Department of Care Coordination, San Francisco Department of Public Health, San Francisco, California, USA
| | - Anil N Makam
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
- Center for Vulnerable Populations, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
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Soleimanpour N, Bann M. Clinical risk calculators informing the decision to admit: A methodologic evaluation and assessment of applicability. PLoS One 2022; 17:e0279294. [PMID: 36534692 PMCID: PMC9762565 DOI: 10.1371/journal.pone.0279294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Clinical prediction and decision tools that generate outcome-based risk stratification and/or intervention recommendations are prevalent. Appropriate use and validity of these tools, especially those that inform complex clinical decisions, remains unclear. The objective of this study was to assess the methodologic quality and applicability of clinical risk scoring tools used to guide hospitalization decision-making. METHODS In February 2021, a comprehensive search was performed of a clinical calculator online database (mdcalc.com) that is publicly available and well-known to clinicians. The primary reference for any calculator tool informing outpatient versus inpatient disposition was considered for inclusion. Studies were restricted to the adult, acute care population. Those focused on obstetrics/gynecology or critical care admission were excluded. The Wasson-Laupacis framework of methodologic standards for clinical prediction rules was applied to each study. RESULTS A total of 22 calculators provided hospital admission recommendations for 9 discrete medical conditions using adverse events (14/22), mortality (6/22), or confirmatory diagnosis (2/22) as outcomes of interest. The most commonly met methodologic standards included mathematical technique description (22/22) and clinical sensibility (22/22) and least commonly met included reproducibility of the rule (1/22) and measurement of effect on clinical use (1/22). Description of the studied population was often lacking, especially patient race/ethnicity (2/22) and mental or behavioral health (0/22). Only one study reported any item related to social determinants of health. CONCLUSION Studies commonly do not meet rigorous methodologic standards and often fail to report pertinent details that would guide applicability. These clinical tools focus primarily on specific disease entities and clinical variables, missing the breadth of information necessary to make a disposition determination and raise significant validation and generalizability concerns.
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Affiliation(s)
| | - Maralyssa Bann
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America,Department of Medicine, Harborview Medical Center, Seattle, Washington, United States of America,* E-mail:
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Ferreira G, Lobo M, Richards B, Dinh M, Maher C. Hospital variation in admissions for low back pain following an emergency department presentation: a retrospective study. BMC Health Serv Res 2022; 22:835. [PMID: 35818074 PMCID: PMC9275239 DOI: 10.1186/s12913-022-08134-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background One in 6 patients with low back pain (LBP) presenting to emergency departments (EDs) are subsequently admitted to hospital each year, making LBP the ninth most common reason for hospital admission in Australia. No studies have investigated and quantified the extent of clinical variation in hospital admission following an ED presentation for LBP. Methods We used routinely collected ED data from public hospitals within the state of New South Wales, Australia, to identify presentations of patients aged between 18 and 111 with a discharge diagnosis of LBP. We fitted a series of random effects multilevel logistic regression models adjusted by case-mix and hospital variables. The main outcome was the hospital-adjusted admission rate (HAAR). Data were presented as funnel plots with 95% and 99.8% confidence limits. Hospitals with a HAAR outside the 95% confidence limit were considered to have a HAAR significantly different to the state average. Results We identified 176,729 LBP presentations across 177 public hospital EDs and 44,549 hospital admissions (25.2%). The mean (SD) age was 51.8 (19.5) and 52% were female. Hospital factors explained 10% of the variation (ICC = 0.10), and the median odds ratio (MOR) was 2.03. We identified marked variation across hospitals, with HAAR ranging from 6.9 to 65.9%. After adjusting for hospital variables, there was still marked variation between hospitals with similar characteristics. Conclusion We found substantial variation in hospital admissions following a presentation to the ED due to LBP even after controlling by case-mix and hospital characteristics. Given the substantial costs associated with these admissions, our findings indicate the need to investigate sources of variation and to determine instances where the observed variation is warranted or unwarranted. Supplementary information The online version contains supplementary material available at 10.1186/s12913-022-08134-8.
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Affiliation(s)
- Giovanni Ferreira
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia. .,School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia. .,, Camperdown, Australia.
| | - Marina Lobo
- Center for Health Technology and Services Research (CINTESIS), Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Bethan Richards
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Michael Dinh
- The RPA Green Light Institute for Emergency Care, Royal Prince Alfred Hospital, Sydney, Australia
| | - Chris Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Wang ES, Velásquez ST, Mader M, Boggan JC, Liao JE, Leykum LK, Pugh J. Triaging Admissions: A Survey of Internal Medicine Resident Experiences and Perceptions and Recommendations on Inpatient Triage Education. Am J Med 2022; 135:919-924.e6. [PMID: 35390308 DOI: 10.1016/j.amjmed.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Emily S Wang
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio.
| | - Sadie Trammell Velásquez
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio
| | - Michael Mader
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio
| | - Joel C Boggan
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jeff E Liao
- Division of Hospital Medicine, Massachusetts General Hospital, Boston
| | - Luci K Leykum
- South Texas Veterans Health Care System, Medicine Service, San Antonio; Department of Medicine, University of Texas at Austin Dell Medical School
| | - Jacqueline Pugh
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio
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Baehr A, Fought AJ, Hsia RY, Wiler JL, Ginde AA. The association between area deprivation index and emergency department discharge rates and revisits. Acad Emerg Med 2022; 29:902-904. [PMID: 35304928 DOI: 10.1111/acem.14486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Avi Baehr
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
| | - Angela J. Fought
- Center for Innovative Design & Analysis, Department of Biostatistics & Informatics Colorado School of Public Health, University of Colorado Aurora Colorado USA
| | - Renee Y. Hsia
- Department of Emergency Medicine University of California San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy Studies University of California San Francisco San Francisco California USA
| | - Jennifer L. Wiler
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Adit A. Ginde
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
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Changing Admission Patterns in Pediatric Emergency Departments during the COVID-19 Pandemic in Italy Were Due to Reductions in Inappropriate Accesses. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8110962. [PMID: 34828676 PMCID: PMC8620376 DOI: 10.3390/children8110962] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/14/2021] [Accepted: 10/23/2021] [Indexed: 12/23/2022]
Abstract
During the initial phase of the national lockdown, we found that there were sharp decreases in admissions to two pediatric emergency departments (EDs) in northern Italy (Cremona and Novara). Here we present a detailed analysis of these admission patterns and types of admissions over a longer timeframe. ED admissions data were anonymously extracted from the departmental management software. Admissions data from 2019 and 2020 were analyzed and compared separately for each ED and combined. There was a 73.2% decrease in total admissions compared with the same period in 2019. With respect to admission diagnoses, there was a significant (p < 0.001) drop in infectious (-51%), respiratory (-25.5%), and nervous systems diseases (-50%) and injuries and poisoning (-17%) but not endocrine, metabolic, neoplastic, circulatory, or musculoskeletal diseases. White codes (patients with minor injuries for whom ED medical care is not required) significantly decreased by 56.3% (p < 0.001). Even if the COVID-19 pandemic represented an enormous healthcare burden in Italy, especially during the first months of the pandemic (late February to May), the workload of pediatric EDs was significantly reduced, especially for unnecessary accesses (white codes).
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Isaia G, Brunetti E, Presta R, Salone B, Carignano G, Sappa M, Fonte G, Raspo S, Lauria G, Riccardini F, Lupia E, Bo M. Prevalence, determinants and practical implications of inappropriate hospitalizations in older subjects: A prospective observational study. Eur J Intern Med 2021; 90:89-95. [PMID: 33947625 DOI: 10.1016/j.ejim.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Abstract
In a context of high demand for hospital services among older people, we aimed to assess the rate and determinants of inappropriate hospitalizations of older patients, and to what extent they were associated with inappropriate hospital stay. This prospective observational multicentre study evaluated a random sample of consecutive patients aged ≥ 70 years accessing the Emergency Department (ED) of two Italian tertiary hospitals. A standardized comprehensive geriatric assessment was carried out in each patient, including the Blaylock Risk Assessment Screen Scale (BRASS) for identification of patients at risk of difficult discharge. Inappropriate hospitalization was defined by the ED physician when patients did not necessitate hospital-provided procedures but was due to social reasons or lack of an alternative care-setting. Among 1877 patients (median age 80.7 years, 50.1% male), with a high prevalence of functional dependence and social isolation (around 30% and 25%, respectively), 767 (40.9%) were hospitalized. Incidence of inappropriate hospitalization was 14.6% (95% CI 12.1%-17.1%) and was associated with moderate-high risk of difficult discharge at BRASS (OR = 1.98, 95% CI 1.16-3.39, p = 0.013) and the presence of dementia with behavioural disorders (OR = 1.79, 95% CI 1.10-2.91, p = 0.020). Compared with patients appropriately admitted, inappropriate hospitalizations had shorter length of hospital stay but accounted for 1059/9154 days of stay (11.6%). Inappropriate hospitalizations occurred in less than 15% of cases, mainly accounted for by patients no longer manageable at home, but contributed to the greatest proportion of inappropriate hospital stay. These findings highlight the need of implementing appropriate home-care services and ensuring rapid access to suitable care-facilities for community-dwelling frail older patients.
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Affiliation(s)
- Gianluca Isaia
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy.
| | - Bianca Salone
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Giulia Carignano
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy; Section of Geriatrics, AO Santa Croce e Carle, Cuneo, Italy
| | - Matteo Sappa
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy; Section of Geriatrics, AO Santa Croce e Carle, Cuneo, Italy
| | - Gianfranco Fonte
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Silvio Raspo
- Section of Geriatrics, AO Santa Croce e Carle, Cuneo, Italy
| | - Giuseppe Lauria
- Emergency Medicine Department, AO Santa Croce e Carle, Cuneo, Italy
| | - Franco Riccardini
- Emergency Medicine Department, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Enrico Lupia
- Emergency Medicine Department, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza - Molinette, Turin, Italy
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Trinh T, Elfergani A, Bann M. Qualitative analysis of disposition decision making for patients referred for admission from the emergency department without definite medical acuity. BMJ Open 2021; 11:e046598. [PMID: 34261682 PMCID: PMC8281073 DOI: 10.1136/bmjopen-2020-046598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To map the physician approach when determining disposition for a patient who presents without the level of definite medical acuity that would generally warrant hospitalisation. DATA SOURCES/STUDY SETTING Since 2018, our US academic county hospital/trauma centre has maintained a database in which hospitalists ('triage physicians') document the rationale and outcomes of requests for admission to the acute care medical ward during each shift. STUDY DESIGN Narrative text from the database was analysed using a grounded theory approach to identify major themes and subthemes, and a conceptual model of the admission decision-making process was constructed. PARTICIPANTS Database entries were included (n=300) if the admission call originated from the emergency department and if the triage physician characterised the request as potentially inappropriate because the patient did not have definite medical acuity. RESULTS Admission decision making occurs in three main phases: evaluation of unmet needs, assessment of risk and re-evaluation. Importantly, admission decision making is not solely based on medical acuity or clinical algorithms, and patients without a definite medical need for admission are hospitalised when physicians believe a potential issue exists if discharged. In this way, factors such as homelessness, substance use disorder, frailty, etc, contribute to admission because they raise concern about patient safety and/or barriers to appropriate treatment. Physician decision making can be altered by activities such as care coordination, advocacy by the patient or surrogate, interactions with other physicians or a change in clinical trajectory. CONCLUSIONS The decision to admit ultimately remains a clinical determination constructed between physician and patient. Physicians use a holistic process that incorporates broad consideration of the patient's medical and social needs with emphasis on risk assessment; thus, any analysis of hospitalisation trends or efforts to impact such should seek to understand this individual-level decision making.
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Affiliation(s)
- Tina Trinh
- University of Washington, Seattle, Washington, USA
| | | | - Maralyssa Bann
- Division of General Internal Medicine/Hospital Medicine, Department of Medicine, Harborview Medical Center, Seattle, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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