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Bahar P, Shah KM, Rushin CC, Li S, Cheloff AZ, Dechen T, Weinstein AR. An Interprofessional Student-Faculty Telehealth Program to Address Uncontrolled Diabetes and Social Determinants of Health. J Gen Intern Med 2024:10.1007/s11606-024-08740-8. [PMID: 38530616 DOI: 10.1007/s11606-024-08740-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/15/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Piroz Bahar
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - Sienna Li
- Harvard Medical School, Boston, MA, USA
| | | | - Tenzin Dechen
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Amy R Weinstein
- Harvard Medical School, Boston, MA, USA.
- Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Sokol-Hessner L, Dechen T, Folcarelli P, McGaffigan P, Stevens JP, Thomas EJ, Bell S. Associations Between Organizational Communication and Patients' Experience of Prolonged Emotional Impact Following Medical Errors. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00071-0. [PMID: 38565471 DOI: 10.1016/j.jcjq.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The emotional impact of medical errors on patients may be long-lasting. Factors associated with prolonged emotional impacts are poorly understood. METHODS The authors conducted a subanalysis of a 2017 survey (response rate 36.8% [2,536/6,891]) of US adults to assess emotional impact of medical error. Patients reporting a medical error were included if the error occurred ≥ 1 year prior. Duration of emotional impact was categorized into no/short-term impact (impact lasting < 1 month), prolonged impact (> 1 month), and especially prolonged impact (> 1 year). Based on their reported experience with communication about the error, patients' experience was categorized as consistent with national disclosure guidelines, contrary to guidelines, mixed, or neither. Multinomial regression was used to examine associations between patient factors, event characteristics, and organizational communication with prolonged emotional impact (> 1 month, > 1 year). RESULTS Of all survey respondents, 17.8% (451/2,536) reported an error occurring ≥ 1 year prior. Of these, 51.2% (231/451) reported prolonged/especially prolonged emotional impact (30.8% prolonged, 20.4% especially prolonged). Factors associated with prolonged emotional impact included female gender (adjusted odds ratio 2.1 [95% confidence interval 1.5-2.9]); low socioeconomic status (SES; 1.7 [1.1-2.7]); physical impact (7.3 [4.3-12.3]); no organizational disclosure and no patient/family error reporting (1.5 [1.03-2.3]); communication contrary to guidelines (4.0 [2.1-7.5]); and mixed communication (2.2 [1.3-3.7]). The same factors were significantly associated with especially prolonged emotional impact (female, 1.7 [1.2-2.5]; low SES, 2.2 [1.3-3.6]; physical impact, 6.8 [3.8-12.5]; no disclosure/reporting, 1.9 [1.2-3.2]; communication contrary to guidelines, 4.6 [2.2-9.4]; mixed communication, 2.1 [1.1-3.9]). CONCLUSION Prolonged emotional impact affected more than half of Americans self-reporting a medical error. Organizational failure to communicate according to disclosure guidelines after patient-perceived errors may exacerbate harm, particularly for patients at risk of health care disparities.
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Anderson TS, O'Donoghue AL, Herzig SJ, Cohen ML, Aung N, Dechen T, Landon BE, Stevens JP. Differences in Primary Care Follow-up After Acute Care Discharge Within and Across Health Systems: a Retrospective Cohort Study. J Gen Intern Med 2024:10.1007/s11606-024-08610-3. [PMID: 38228989 DOI: 10.1007/s11606-024-08610-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024]
Abstract
BACKGROUND Timely primary care follow-up after acute care discharge may improve outcomes. OBJECTIVE To evaluate whether post-discharge follow-up rates differ among patients discharged from hospitals directly affiliated with their primary care clinic (same-site), other hospitals within their health system (same-system), and hospitals outside their health system (outside-system). DESIGN Retrospective cohort study. PATIENTS Adult patients of five primary care clinics within a 14-hospital health system who were discharged home after a hospitalization or emergency department (ED) stay. MAIN MEASURES Primary care visit within 14 days of discharge. A multivariable Poisson regression model was used to estimate adjusted rate ratios (aRRs) and risk differences (aRDs), controlling for sociodemographics, acute visit characteristics, and clinic characteristics. KEY RESULTS The study included 14,310 discharges (mean age 58.4 [SD 19.0], 59.5% female, 59.5% White, 30.3% Black), of which 57.7% were from the same-site, 14.3% same-system, and 27.9% outside-system. By 14 days, 34.5% of patients discharged from the same-site hospital received primary care follow-up compared to 27.7% of same-system discharges (aRR 0.88, 95% CI 0.79 to 0.98; aRD - 6.5 percentage points (pp), 95% CI - 11.6 to - 1.5) and 20.9% of outside-system discharges (aRR 0.77, 95% CI [0.70 to 0.85]; aRD - 11.9 pp, 95% CI - 16.2 to - 7.7). Differences were greater for hospital discharges than ED discharges (e.g., aRD between same-site and outside-system - 13.5 pp [95% CI, - 20.8 to - 8.3] for hospital discharges and - 10.1 pp [95% CI, - 15.2 to - 5.0] for ED discharges). CONCLUSIONS Patients discharged from a hospital closely affiliated with their primary care clinic were more likely to receive timely follow-up than those discharged from other hospitals within and outside their health system. Improving care transitions requires coordination across both care settings and health systems.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Ashley L O'Donoghue
- Harvard Medical School, Boston, MA, USA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Marc L Cohen
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Naing Aung
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Bruce E Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jennifer P Stevens
- Harvard Medical School, Boston, MA, USA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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O'Donoghue AL, Reichheld A, Anderson TS, Zera CA, Dechen T, Stevens JP. Decline in Prenatal Buprenorphine/Naloxone Fills during the COVID-19 Pandemic in the United States. J Addict Med 2023; 17:e399-e402. [PMID: 37934549 DOI: 10.1097/adm.0000000000001228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVES Pregnancy provides a critical opportunity to engage individuals with opioid use disorder in care. However, before the COVID-19 pandemic, there were multiple barriers to accessing buprenorphine/naloxone during pregnancy. Care disruptions during the pandemic may have further exacerbated these existing barriers. To quantify these changes, we examined trends in the number of individuals filling buprenorphine/naloxone prescriptions during the COVID-19 pandemic. METHODS We estimated an interrupted time series model using linked national pharmacy claims and medical claims data from prepandemic (May 2019 to February 2020) to the pandemic period (April 2020 to December 2020). We estimated changes in the growth rate in the monthly number of individuals filling buprenorphine/naloxone prescriptions in the 6 months preceding a delivery claim, per 100,000 pregnancies, during the COVID-19 pandemic. RESULTS We identified 2947 pregnant individuals filling buprenorphine/naloxone prescriptions. Before the pandemic, there was positive growth in the monthly number of individuals filling buprenorphine/naloxone prescriptions (4.83%; 95% confidence interval [CI], 3.82-5.84%). During the pandemic, this monthly growth rate declined for both individuals on commercial insurance and individuals on Medicaid (all payers: -5.53% [95% CI, -6.65% to -4.41%]; Medicaid: -7.66% [95% CI, -10.14% to -5.18%]; Commercial: -3.59% [95% CI, -5.32% to -1.87%]). CONCLUSION The number of pregnant individuals filling buprenorphine/naloxone prescriptions was increasing, but this growth has been lost during the pandemic.
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Affiliation(s)
- Ashley L O'Donoghue
- From the Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA (ALO, AR, TSA, TD, JPS); Harvard Medical School, Boston, MA (ALO, TSA, CAZ, JPS); Tufts University School of Medicine, Boston, MA (AR); Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA (TSA); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (CAZ); and Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (JPS)
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Mechanic OJ, Lee EM, Sheehan HM, Dechen T, O'Donoghue AL, Anderson TS, Annas C, Harvey LB, Perkins AA, Severo MA, Stevens JP, Kimball AB. Evaluation of Telehealth Visit Attendance After Implementation of a Patient Navigator Program. JAMA Netw Open 2022; 5:e2245615. [PMID: 36480202 PMCID: PMC9856233 DOI: 10.1001/jamanetworkopen.2022.45615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE The dramatic rise in use of telehealth accelerated by COVID-19 created new telehealth-specific challenges as patients and clinicians adapted to technical aspects of video visits. OBJECTIVE To evaluate a telehealth patient navigator pilot program to assist patients in overcoming barriers to video visit access. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study investigated visit attendance outcomes among those who received navigator outreach (intervention group) compared with those who did not (comparator group) at 2 US academic primary care clinics during a 12-week study period from April to July 2021. Eligible participants had a scheduled video visit without previous successful telehealth visits. INTERVENTIONS The navigator contacted patients with next-day scheduled video appointments by phone to offer technical assistance and answer questions on accessing the appointment. MAIN OUTCOMES AND MEASURES The primary outcome was appointment attendance following the intervention. Return on investment (ROI) accounting for increased clinic adherence and costs of implementation was examined as a secondary outcome. RESULTS A total 4066 patients had video appointments scheduled (2553 [62.8%] women; median [IQR] age: intervention, 55 years [38-66 years] vs comparator, 52 years [36-66 years]; P = .02). Patients who received the navigator intervention had significantly increased odds of attending their appointments (odds ratio, 2.0; 95% CI, 1.6-2.6) when compared with the comparator group, with an absolute increase of 9% in appointment attendance for the navigator group (949 of 1035 patients [91.6%] vs 2511 of 3031 patients [82.8%]). The program's ROI was $11 387 over the 12-week period. CONCLUSIONS AND RELEVANCE In this quality improvement study, we found that a telehealth navigator program was associated with significant improvement in video visit adherence with a net financial gain. Our findings have relevance for efforts to reduce barriers to telehealth-based health care and increase equity.
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Affiliation(s)
- Oren J Mechanic
- Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Emma M Lee
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Heidi M Sheehan
- Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashley L O'Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Timothy S Anderson
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Catherine Annas
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Leanne B Harvey
- Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Allison A Perkins
- Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael A Severo
- Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alexa B Kimball
- Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Lam B, Celmen M, Graham T, Dechen T, Zerillo JA. Changing the electronic health record to optimize pre-chemotherapy lab orders. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
434 Background: National guidelines support screening for infectious diseases and pregnancy before starting cancer-directed treatment. Providers also check liver and kidney function to ensure safe medication dosing. Forgetting to order these tests has implications for patient safety and treatment area throughput. Our aim was to modify the provider order entry (POE) screen in the electronic health record (EHR) to reduce missed laboratory orders for hepatitis B, pregnancy tests, and organ function.Methods: We revised the hematology/oncology POE screens so that labs were grouped by organ system rather than listed alphabetically. A new Pre-Treatment Screening (PTS) order set includes urine pregnancy and a hepatitis B panel. We collected retrospective ordering data at our medical center’s ambulatory academic and community sites from the pre-intervention (10/20 – 9/21) and post-intervention (10/21 – 4/22) time periods. Data was analyzed to determine the pre/post change in percentage of add-on chemistry tests, rate of ordered urine pregnancy and hepatitis B tests in new patients, and proportion of positive hepatitis B tests. Results: There were 165,360 total chemistry lab orders pre-intervention and 91,948 post-intervention. The percentage of add-ons decreased from 0.50% (834/165,360) to 0.38% (351/91,948). There were 1,109 pre-intervention new treatment starts (92/month) and 673 post-intervention (96/month). The rate of hepatitis B screening increased from 86/month to 99/month and the rate of urine pregnancy testing remained the same at 4/month. The proportion of positive hepatitis B surface antigen tests increased from 0.72% (8/1109) to 0.89% (6/673). The proportion of positive hepatitis B core antibody tests decreased from 9.83% (109/1109) to 9.51% (64/673). Conclusions: Simple changes to an electronic ordering screen were associated with increased adherence to pre-treatment screening guidelines. Further PDSA cycles are needed to explore what changes to POE can optimize appropriate utilization of lab orders, especially for pregnancy screening. This has far-reaching consequences not only for new chemotherapy patients but also for other populations receiving immunosuppressive treatments.
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Affiliation(s)
- Barbara Lam
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Melis Celmen
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Tim Graham
- Beth Israel Deaconess Medical Center, Boston, MA
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Russell B, O’Donoghue AL, Dechen T, Lee EM, Sato-DiLorenzo A, Stevens JP, Zerillo JA. Evaluation of the impact of an oncology urgent care clinic on preventable emergency department visits. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
338 Background: OP-35 is a publicly reported quality metric aimed at reducing preventable emergency department (ED) visits and hospitalizations in patients with cancer on chemotherapy. During the COVID-19 surge, one academic medical center opened the Respiratory Emergent Evaluation Service (REES) Unit, an urgent care clinic for patients with cancer and symptoms of COVID-19. In addition to preventing potential COVID-19 exposures in the clinic, this oncology-staffed urgent care evaluated patients who may have otherwise presented to the ED. We investigated the association between the REES urgent care clinic and patient ED evaluations for OP-35 diagnoses. Methods: This single center retrospective analysis included patients with cancer receiving infusion and oral chemotherapy who presented to the ED within 30 days of treatment. ED visits occurred between 1/2019-12/2021, including when the REES unit was open (3/2020-6/2021). Preventable ED visits were defined as having one of ten primary diagnoses, which have been identified by OP-35. Of these, COVID-related diagnoses included fever, pneumonia, sepsis, neutropenia and diarrhea. Interrupted time series analyses were utilized to investigate the association between the REES unit opening and preventable ED visits. Results: 3,107 patients on chemotherapy were assessed in the ED from 1/2019-12/2021. Per week, there were 19.9 ED visits, 39.7% of which were for OP-35 diagnoses. When the REES unit opened, there was a 30% (95% CI -53% to -7%) reduction in preventable ED visits, corresponding to 2.62 (95% CI -4.61 to -0.63) fewer preventable ED evaluations per week. The primary driver of this reduction were presentations for COVID-related diagnoses, as there were 38% (95% CI -76% to -0.3%) fewer preventable ED visits weekly. During this period, there were approximately 6.9 patient visits per week to the REES unit. Conclusions: The introduction of an oncology urgent care clinic focusing on patients with symptoms of COVID-19 was associated with a reduction in potentially preventable ED visits. This analysis demonstrates the potential value of oncology urgent care clinics in reducing ED overcrowding and decreasing OP-35 related evaluations, which has patient experience, infection exposure and financial implications.[Table: see text]
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Affiliation(s)
| | | | | | - Emma M. Lee
- Beth Israel Deaconess Medical Center, Boston, MA
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Abstract
This cross-sectional study uses time-series data to evaluate the administration of bamlanivimab-etesevimab and casirivimab-imdevimab monoclonal antibody treatments for SARS-CoV-2 infection after the US Food and Drug Administration deauthorized their use in early 2022.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashley O’Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Oren Mechanic
- Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Riviello ED, Dechen T, O’Donoghue AL, Cocchi MN, Hayes MM, Molina RL, Moraco NH, Mosenthal A, Rosenblatt M, Talmor N, Walsh DP, Sontag DN, Stevens JP. Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19. JAMA Netw Open 2022; 5:e221744. [PMID: 35289860 PMCID: PMC8924715 DOI: 10.1001/jamanetworkopen.2022.1744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. OBJECTIVE To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. EXPOSURES Race, ethnicity, Social Vulnerability Index. MAIN OUTCOMES AND MEASURES The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. RESULTS Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. CONCLUSIONS AND RELEVANCE In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.
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Affiliation(s)
- Elisabeth D. Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashley L. O’Donoghue
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael N. Cocchi
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rose L. Molina
- Harvard Medical School, Boston, Massachusetts
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicole H. Moraco
- Division of General Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Anne Mosenthal
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Michael Rosenblatt
- Division of Surgical Critical Care, Department of Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Noa Talmor
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel P. Walsh
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Critical Care, Beth Israel Deaconess Hospital–Plymouth, Plymouth, Massachusetts
| | - David N. Sontag
- Harvard Medical School, Boston, Massachusetts
- Office of the General Counsel, Beth Israel Lahey Health, Cambridge, Massachusetts
- Ethics Advisory Committee, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer P. Stevens
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Fernandez L, O'Donoghue A, Shorett P, Blair J, Markson L, Dechen T, Stevens J, Wright S. 570. Prioritized Access to COVID-19 Vaccines Among Vulnerable Communities Increases Vaccination Rates. Open Forum Infect Dis 2021. [PMCID: PMC8644591 DOI: 10.1093/ofid/ofab466.768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Based on national recommendations,1 Beth Israel Lahey Health (BILH) in Eastern Massachusetts (MA) prioritized vulnerable communities in our distribution of COVID-19 vaccines. We hypothesized that creating prioritized access to appointments for patients in these communities would increase the likelihood vaccination. Methods The BILH health system sent vaccine invitations first to patients of two clinics in vulnerable neighborhoods in Boston (Wave 1), followed by other patients from vulnerable communities (Wave 2) up to 1 day later, and then by all other patients (Wave 3) after up to 1 more day later. To identify whether early access/prioritization increased the likelihood of receipt of vaccine at any site or a vaccine at a BILH clinic, we compared patients in Wave 1 in a single community with high cumulative incidence of COVID-19 (Dorchester) to patients in Wave 2 during a period of limited vaccine access, 1/27/21-2/24/21. Each wave was modeled using logistic regression, adjusted for language and race. By taking the difference between these two differences, we are left with the impact of early vaccination invitation in Wave 1 for a subset of our most vulnerable patients (termed difference-in-differences; Stata SE 16.0). Results In our study of Waves 1 and 2, we offered vaccinations to 24,410 patients. Of those, 6,712 (27.5%) scheduled the vaccine at BILH (Table 1). Patients in Wave 1 were much more likely to be vaccinated at BILH than patients in Wave 2. Patients offered the vaccine in Wave 1 and living in Dorchester were 1.7 percentage points more likely to be vaccinated at all (p=0.445) and 9.4 percentage points more likely to be vaccinated at BILH than another site in MA (p-value = 0.001), relative to patients living outside of Dorchester and offered the vaccine in Wave 2 (Table 2). ![]()
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The coefficient of interest is on Wave1*Dorchester, 0.094. This indicates that residents of Dorchester who were offered the vaccine in Wave 1 were 9.4 percentage points more likely to receive the vaccine at BILH, given that they were vaccinated, relative to patients living outside of Dorchester and offered the vaccine in Wave 2. Conclusion Patients residing in an urban community given prioritized access to vaccination had a higher likelihood of vaccination at our health system, given that they were vaccinated, than patients in other urban communities without prioritized access. We provide an example of a successful effort to move towards equity in access to COVID-19- vaccines, in contrast to larger national trends.2,3 Health systems can use a prioritization approach to improve vaccination equity. ![]()
Disclosures All Authors: No reported disclosures
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Anderson TS, O'Donoghue AL, Dechen T, Mechanic O, Stevens JP. Uptake of Outpatient Monoclonal Antibody Treatments for COVID-19 in the United States: a Cross-Sectional Analysis. J Gen Intern Med 2021; 36:3922-3924. [PMID: 34495464 PMCID: PMC8425019 DOI: 10.1007/s11606-021-07109-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/19/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA. .,Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Ashley L O'Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Oren Mechanic
- Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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12
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Diamond JE, McIlvaine S, Korjian S, Cruden P, Dechen T, Piatkowski G, Kazi DS, Gavin M. Patterns of Recovery in Cardiovascular Care after the COVID-19 Pandemic Surge. Am J Med Sci 2021; 363:305-310. [PMID: 34597690 PMCID: PMC8481002 DOI: 10.1016/j.amjms.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/05/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
Background Cardiovascular disease remains the number one cause of death globally. Patients with cardiovascular disease are at risk of poor outcomes from deferral of healthcare during the coronavirus disease 2019 (COVID-19) pandemic. Little is known about recovery of cardiovascular hospitalizations or procedural volume following the COVID-19 surges. We sought to examine the cardiovascular diagnoses requiring healthcare utilization surrounding the first and second COVID-19 waves and characterize trends in return to pre-pandemic levels at a tertiary care center in Massachusetts. Materials and Methods Using electronic health records and administrative claims data, we performed a retrospective analysis of patients undergoing cardiovascular procedures and admitted to inpatient cardiology services throughout the first two COVID surges. ICD-10 codes were used to categorize admissions. Results Patients who presented for care during the initial COVID-19 surge were younger, had higher comorbidity burden, and longer length-of-stay compared with pre- and post-surge. Marked declines in admissions in the first wave (to 29% of pre-surge levels) followed eventually by complete recovery were noted across all cardiac diagnoses, with smaller declines seen in the second wave. Cardiac procedural volume declined significantly during the initial surge but quickly rebounded post-surge, eventually eclipsing pre-COVID volume. Conclusions There was a gradual but initially incomplete recovery to pre-surge levels of hospitalizations and procedures during the reopening phase, which eventually rebounded to meet or exceed pre-COVID-19 levels. To the extent that this reflects deferred or foregone essential care, it may adversely affect long-term cardiovascular outcomes. These results should inform planning for cardiovascular care delivery during future pandemic surges.
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Affiliation(s)
- Jamie E Diamond
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA, USA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Susan McIlvaine
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Serge Korjian
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Patrick Cruden
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Gail Piatkowski
- Department of Decision Support, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Dhruv S Kazi
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA, USA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Michael Gavin
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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13
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Stevens JP, Dechen T, Schwartzstein RM, O'Donnell CR, Baker K, Banzett RB. Association of dyspnoea, mortality and resource use in hospitalised patients. Eur Respir J 2021; 58:1902107. [PMID: 33653806 DOI: 10.1183/13993003.02107-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/17/2021] [Indexed: 12/30/2022]
Abstract
As many as one in 10 patients experience dyspnoea at hospital admission but the relationship between dyspnoea and patient outcomes is unknown. We sought to determine whether dyspnoea on admission predicts outcomes.We conducted a retrospective cohort study in a single, academic medical centre. We analysed 67 362 consecutive hospital admissions with available data on dyspnoea, pain and outcomes. As part of the Initial Patient Assessment by nurses, patients rated "breathing discomfort" using a 0 to 10 scale (10="unbearable"). Patients reported dyspnoea at the time of admission and recalled dyspnoea experienced in the 24 h prior to admission. Outcomes included in-hospital mortality, 2-year mortality, length of stay, need for rapid response system activation, transfer to the intensive care unit, discharge to extended care, and 7- and 30-day all-cause readmission to the same institution.Patients who reported any dyspnoea were at an increased risk of death during that hospital stay; the greater the dyspnoea, the greater the risk of death (dyspnoea 0: 0.8% in-hospital mortality; dyspnoea 1-3: 2.5% in-hospital mortality; dyspnoea ≥4: 3.7% in-hospital mortality; p<0.001). After adjustment for patient comorbidities, demographics and severity of illness, increasing dyspnoea remained associated with inpatient mortality (dyspnoea 1-3: adjusted OR 2.1, 95% CI 1.7-2.6; dyspnoea ≥4: adjusted OR 3.1, 95% CI 2.4-3.9). Pain did not predict increased mortality. Patients reporting dyspnoea also used more hospital resources, were more likely to be readmitted and were at increased risk of death within 2 years (dyspnoea 1-3: adjusted hazard ratio 1.5, 95% CI 1.3-1.6; dyspnoea ≥4: adjusted hazard ratio 1.7, 95% CI 1.5-1.8).We found that dyspnoea of any rating was associated with an increased risk of death. Dyspnoea ratings can be rapidly collected by nursing staff, which may allow for better monitoring or interventions that could reduce mortality and morbidity.
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Affiliation(s)
- Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division for Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Richard M Schwartzstein
- Division for Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Carl R O'Donnell
- Division for Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kathy Baker
- Lois E. Silverman Dept of Nursing, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert B Banzett
- Division for Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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14
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Doolin JW, Berry JL, Forbath NS, Tocci NX, Dechen T, Li S, Hartwell RA, Espiritu JK, Roberts DA, Zerillo JA, Shea M. Implementing Electronic Patient-Reported Outcomes for Patients With New Oral Chemotherapy Prescriptions at an Academic Site and a Community Site. JCO Clin Cancer Inform 2021; 5:631-640. [PMID: 34097439 DOI: 10.1200/cci.20.00191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Oral chemotherapy challenges providers' abilities to safely monitor patients' symptoms, adherence, and financial toxicity. COVID-19 has increased the urgency of caring for patients remotely. Collection of electronic patient-reported outcomes (ePROs) has demonstrated efficacy for patients on intravenous chemotherapy, but limited data support their use in oral chemotherapy. We undertook a pilot project to assess the feasibility of implementing an ePRO system for patients starting oral chemotherapy at our cancer center, which includes both an academic site and a community site. METHODS Patients initiating oral chemotherapy were asked to participate. A five-question tool was built in REDCap. Concerning responses triggered outreach within one business day. The primary outcome was time to first symptom assessment. For comparison, we used a historical cohort of patients who had been prescribed oral chemotherapies by providers in the same disease groups at the cancer center. RESULTS Twenty-five of 62 (40%) patients completed ePRO assessments. Fifty historical charts were reviewed. Time to first symptom assessment was 7 days (IQR, 4-14 days) in the historical group compared with 3 days (IQR, 2-4 days) in the ePRO group. Time to clinical action was 14 days (7-35 days) in the historical group compared with 8 days (4-19 days) in the ePRO group. No statistically significant differences were detected in 30-day emergency department visit or hospitalization (12% for both groups) or 90-day emergency department visit or hospitalization rates (historical 28% and ePRO 20%). CONCLUSION An ePRO tool monitoring patient concerns about adherence, cost, and toxicities for patients with new oral chemotherapy regimens is feasible and improves time to symptom assessment. Further investigation is needed to improve patient engagement with ePROs and evaluate the long-term impacts for patients on oral chemotherapy.
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Affiliation(s)
- Jim W Doolin
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jonathan L Berry
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Natalia S Forbath
- Center for Healthcare Deliver Science, Beth Israel Deaconess Medical Center, Boston, MA
| | - Noah X Tocci
- Center for Healthcare Deliver Science, Beth Israel Deaconess Medical Center, Boston, MA
| | - Tenzin Dechen
- Center for Healthcare Deliver Science, Beth Israel Deaconess Medical Center, Boston, MA
| | - Stephanie Li
- Center for Healthcare Deliver Science, Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | - Jessica A Zerillo
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Meghan Shea
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA
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15
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Anderson TS, O'Donoghue AL, Dechen T, Herzig SJ, Stevens JP. Trends in telehealth and in-person transitional care management visits during the COVID-19 pandemic. J Am Geriatr Soc 2021; 69:2745-2751. [PMID: 34124776 PMCID: PMC8447440 DOI: 10.1111/jgs.17329] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/01/2021] [Accepted: 06/06/2021] [Indexed: 11/28/2022]
Abstract
Background/Objectives Transitional care management (TCM) visits delivered following hospitalization have been associated with reductions in mortality, readmissions, and total costs; however, uptake remains low. We sought to describe trends in TCM visit delivery during the COVID‐19 pandemic. Design Cross‐sectional study of ambulatory electronic health records from December 30, 2019 and January 3, 2021. Setting United States. Participants Forty four thousand six hundred and eighty‐one patients receiving transitional care management services. Measurements Weekly rates of in‐person and telehealth TCM visits before COVID‐19 was declared a national emergency (December 30, 2019 to March 15, 2020), during the initial pandemic period (March 16, 2020 to April 12, 2020) and later period (April 12, 2020 to January 3, 2021). Characteristics of patients receiving in‐person and telehealth TCM visits were compared. Results A total of 44,681 TCM visits occurred during the study period with the majority of patients receiving TCM visits age 65 years and older (68.0%) and female (55.0%) Prior to the COVID‐19 pandemic, nearly all TCM visits were conducted in‐person. In the initial pandemic, there was an immediate decline in overall TCM visits and a rise in telehealth TCM visits, accounting for 15.4% of TCM visits during this period. In the later pandemic, the average weekly number of TCM visits was 841 and 14.0% were telehealth. During the initial and later pandemic periods, 73.3% and 33.6% of COVID‐19‐related TCM visits were conducted by telehealth, respectively. Across periods, patterns of telehealth use for TCM visits were similar for younger and older adults. Conclusion The study findings highlight a novel and sustained shift to providing TCM services via telehealth during the COVID‐19 pandemic, which may reduce barriers to accessing a high‐value service for older adults during a vulnerable transition period. Further investigations comparing outcomes of in‐person and telehealth TCM visits are needed to inform innovation in ambulatory post‐discharge care.
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Ashley L O'Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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16
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Horng S, O'Donoghue A, Dechen T, Rabesa M, Shammout A, Markson L, Jegadeesan V, Tandon M, Stevens JP. Secondary Use of COVID-19 Symptom Incidence Among Hospital Employees as an Example of Syndromic Surveillance of Hospital Admissions Within 7 Days. JAMA Netw Open 2021; 4:e2113782. [PMID: 34137827 DOI: 10.1001/jamanetworkopen.2021.13782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Alternative methods for hospital occupancy forecasting, essential information in hospital crisis planning, are necessary in a novel pandemic when traditional data sources such as disease testing are limited. OBJECTIVE To determine whether mandatory daily employee symptom attestation data can be used as syndromic surveillance to estimate COVID-19 hospitalizations in the communities where employees live. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted from April 2, 2020, to November 4, 2020, at a large academic hospital network of 10 hospitals accounting for a total of 2384 beds and 136 000 discharges in New England. The participants included 6841 employees who worked on-site at hospital 1 and lived in the 10 hospitals' service areas. EXPOSURE Daily employee self-reported symptoms were collected using an automated text messaging system from a single hospital. MAIN OUTCOMES AND MEASURES Mean absolute error (MAE) and weighted mean absolute percentage error (MAPE) of 7-day forecasts of daily COVID-19 hospital census at each hospital. RESULTS Among 6841 employees living within the 10 hospitals' service areas, 5120 (74.8%) were female individuals and 3884 (56.8%) were White individuals; the mean (SD) age was 40.8 (13.6) years, and the mean (SD) time of service was 8.8 (10.4) years. The study model had a MAE of 6.9 patients with COVID-19 and a weighted MAPE of 1.5% for hospitalizations for the entire hospital network. The individual hospitals had an MAE that ranged from 0.9 to 4.5 patients (weighted MAPE ranged from 2.1% to 16.1%). For context, the mean network all-cause occupancy was 1286 during this period, so an error of 6.9 is only 0.5% of the network mean occupancy. Operationally, this level of error was negligible to the incident command center. At hospital 1, a doubling of the number of employees reporting symptoms (which corresponded to 4 additional employees reporting symptoms at the mean for hospital 1) was associated with a 5% increase in COVID-19 hospitalizations at hospital 1 in 7 days (regression coefficient, 0.05; 95% CI, 0.02-0.07; P < .001). CONCLUSIONS AND RELEVANCE This cohort study found that a real-time employee health attestation tool used at a single hospital could be used to estimate subsequent hospitalizations in 7 days at hospitals throughout a larger hospital network in New England.
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Affiliation(s)
- Steven Horng
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ashley O'Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthew Rabesa
- Employee Health, Beth Israel Lahey Health, Boston, Massachusetts
| | - Ayad Shammout
- Information Systems, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lawrence Markson
- Information Systems, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Venkat Jegadeesan
- Information Systems, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Manu Tandon
- Information Systems, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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17
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O’Donoghue AL, Biswas N, Dechen T, Anderson TS, Talmor N, Punnamaraju A, Stevens JP. Trends in Filled Naloxone Prescriptions Before and During the COVID-19 Pandemic in the United States. JAMA Health Forum 2021; 2:e210393. [PMID: 35977309 PMCID: PMC8796899 DOI: 10.1001/jamahealthforum.2021.0393] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/12/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ashley L. O’Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nayantara Biswas
- Department of Economics, Clark University, Worcester, Massachusetts
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Timothy S. Anderson
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Noa Talmor
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Atulita Punnamaraju
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer P. Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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18
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Abstract
Daratumumab is an anti-CD38 monoclonal antibody approved for multiple myeloma. The initial infusion is administered over a median of 7.5 hours with subsequent infusions given over 3 to 4 hours. Studies show high incidence of infusion related reactions (IRRs) with the initial dose which decreases with subsequent infusions. Accelerated 90 minute daratumumab infusions following the second dose of standard administration are widely accepted in practice including at Beth Israel Deaconess Medical Center (BIDMC) despite limited data from small safety studies. The objective of this study is to evaluate the safety of accelerated daratumumab administration compared to standard administration. The primary outcome is the incidence of common terminology criteria for adverse events (CTCAE) version 5.0 grade 1 or higher for IRRs in accelerated and standard infusions. Secondary outcomes include non-IRR adverse events and amount of supportive care medications used pre- and post- and during accelerated and standard infusions. A total of seventy five patients received a daratumumab infusion between November 2015 and August 2019. There were a total of 420 daratumumab infusions evaluated, 317 (75.5%) were standard infusions of which 152 infusions were standard infusions that preceded an accelerated infusion. There were a total of 103 (24.5%) accelerated infusions. IRRs occurred in a total of 38 (9%) of the infusions with CTCAE grade 2 reactions occurring in total of 21 (5%) infusions and grade 1 occurring in 15 (3.6%) infusions. Overall accelerated daratumumab administration is safe and well tolerated when given following at least two standard infusions.
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Affiliation(s)
- Ashka Patel
- Pharmacy Department, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefanie Clark
- Pharmacy Department, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jennifer Espiritu
- Pharmacy Department, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tenzin Dechen
- Pharmacy Department, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Qua Tran
- Pharmacy Department, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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19
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O'Donoghue A, Dechen T, Pavlova W, Boals M, Moussa G, Madan M, Thakkar A, DeFalco FJ, Stevens JP. Author Correction: Reopening businesses and risk of COVID-19 transmission. NPJ Digit Med 2021; 4:67. [PMID: 33824428 PMCID: PMC8024264 DOI: 10.1038/s41746-021-00444-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Ashley O'Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Whitney Pavlova
- Department of Statistics, Pennsylvania State University, University Park, PA, USA
| | | | | | | | | | | | - Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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20
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O'Donoghue A, Dechen T, Pavlova W, Boals M, Moussa G, Madan M, Thakkar A, DeFalco FJ, Stevens JP. Reopening businesses and risk of COVID-19 transmission. NPJ Digit Med 2021; 4:51. [PMID: 33727636 PMCID: PMC7966767 DOI: 10.1038/s41746-021-00420-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/16/2021] [Indexed: 11/08/2022] Open
Abstract
The true risk of a COVID-19 resurgence as states reopen businesses is unknown. In this paper, we used anonymized cell-phone data to quantify the potential risk of COVID-19 transmission in business establishments by building a Business Risk Index that measures transmission risk over time. The index was built using two metrics, visits per square foot and the average duration of visits, to account for both density of visits and length of time visitors linger in the business. We analyzed trends in traffic patterns to 1,272,260 businesses across eight states from January 2020 to June 2020. We found that potentially risky traffic behaviors at businesses decreased by 30% by April. Since the end of April, the risk index has been increasing as states reopen. There are some notable differences in trends across states and industries. Finally, we showed that the time series of the average Business Risk Index is useful for forecasting future COVID-19 cases at the county-level (P < 0.001). We found that an increase in a county's average Business Risk Index is associated with an increase in positive COVID-19 cases in 1 week (IRR: 1.16, 95% CI: (1.1-1.26)). Our risk index provides a way for policymakers and hospital decision-makers to monitor the potential risk of COVID-19 transmission from businesses based on the frequency and density of visits to businesses. This can serve as an important metric as states monitor and evaluate their reopening strategies.
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Affiliation(s)
- Ashley O'Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Whitney Pavlova
- Department of Statistics, Pennsylvania State University, University Park, PA, USA
| | | | | | | | | | | | - Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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21
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Berry JL, Doolin JW, Diltz G, Dechen T, Forbath N, Zerillo JA, Shea M. Oral chemotherapy education: Hitting the mark? J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
221 Background: ASCO’s Quality Oncology Practice Initiative (QOPI) includes process measures on oral chemotherapy education. Whether achievement of these measures has an impact on clinical outcomes and if an intervention to improve these measures can improve outcomes is not yet known. Methods: A retrospective analysis was conducted of patients initiated on oral chemotherapy in an academic medical center site and a community oncology practice between January 2016 and October 2019. The primary aim was to compare the time to emergency department (ED) within 90 days from initiation of oral chemotherapy of patients who met the QOPI process measure through an intervention of pharmacist-driven education with a comparison group of patients who had not received formal education. A secondary aim was to assess for a difference in oral chemotherapy medication persistence. Data were also analyzed by demographics, concurrent parenteral therapy, intent of therapy, and disease group. Results: 285 patients in the education group and 284 patients in the non-education group were analyzed. The education group had a higher proportion of patients with gastrointestinal and gynecologic cancers, and a lower proportion of patients with hematologic malignancies, compared to the non-education group. The education group also had a higher proportion of patients treated at the community practice compared to the non-education group. There was no statistical difference in median time-to-ED, with 49 days (IQR 37-74) in the education group and 59 days (IQR 41-60) in the non-education group (p=0.15). Conclusions: In patients receiving oral chemotherapy, pharmacist-driven education with improvement in QOPI process measures did not result in an improvement in time to ED. One factor contributing to this result may be that only 20% of patients required ED-level care within 90 days of starting oral We continue to collect data regarding medication persistence, which may be a more sensitive outcome measure. At this point, further work is needed to determine if achievement or modification of the QOPI oral chemotherapy process measures results in a clinically significant change in outcome. [Table: see text]
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Affiliation(s)
| | - Jim W Doolin
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | - Meghan Shea
- Beth Israel Deaconess Medical Center, Boston, MA
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22
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Schulson L, Novack V, Smulowitz PB, Dechen T, Landon BE. Emergency Department Care for Patients with Limited English Proficiency: a Retrospective Cohort Study. J Gen Intern Med 2018; 33:2113-2119. [PMID: 30187374 PMCID: PMC6258635 DOI: 10.1007/s11606-018-4493-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/30/2018] [Accepted: 05/11/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limited English proficiency (LEP) patients may be particularly vulnerable in the high acuity and fast-paced setting of the emergency department (ED). OBJECTIVE To compare the care processes of LEP patients in the ED. DESIGN Retrospective cohort study. SETTING ED in a large tertiary care academic medical center. PATIENTS Adult LEP and English Proficient (EP) patients during their index presentation to the ED from September 1, 2013, to August 31, 2015. LEP patients were identified as those who selected a preferred language other than English when registering for care. MAIN MEASURES Rates of diagnostic studies, admission, and return visits for those originally discharged from the ED. KEY RESULTS We studied 57,435 visits of which 5241 (9.1%) were for patients with LEP. In adjusted analyses, LEP patients were more likely to receive an X-ray/ultrasound (OR 1.11, CI 1.03-1.19) and be admitted to the hospital (OR 1.09, CI 1.01-1.19). There was no difference in 72-h return visits (OR 0.98, CI 0.73-1.33). LEP patients presenting with complaints related to the cardiovascular system were more likely to receive a stress test (OR 1.51, CI 1.22-1.86), and those with gastrointestinal diagnoses were more likely to have an X-ray/ultrasound (OR 1.31, CI 1.02-1.68). In stratified analyses, Spanish speakers were less likely to be admitted (OR 0.8, CI 0.70-0.91), but those preferring "other" languages, which were all languages with < 500 patients, had a statistically significant higher adjusted rate of admission (OR 1.35, CI 1.17-1.57). CONCLUSIONS ED patients with LEP experienced both increased rates of diagnostic testing and of hospital admission. Research is needed to examine why these differences occurred and if they represent inefficiencies in care.
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Affiliation(s)
- Lucy Schulson
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Victor Novack
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Clinical Research Center, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Peter B Smulowitz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Bruce E Landon
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
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O'Brien A, O'Reilly K, Dechen T, Demosthenes N, Kelly V, Mackinson L, Corey J, Zieja K, Stevens JP, Cocchi MN. Redesigning Rounds in the ICU: Standardizing Key Elements Improves Interdisciplinary Communication. Jt Comm J Qual Patient Saf 2018; 44:590-598. [PMID: 30064951 DOI: 10.1016/j.jcjq.2018.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Daily multidisciplinary rounds (MDR) in the ICU represent a mechanism by which health care professionals from different disciplines and specialties can meet to synthesize data, think collectively, and form complete patient care plans. It was hypothesized that providing a standardized, structured approach to the daily rounds process would improve communication and collaboration in seven distinct ICUs in a single academic medical center. METHODS Lean-inspired methodology and information provided by frontline staff regarding inefficiencies and barriers to optimal team functioning were used in designing a toolkit for standardization of rounds in the ICUs. Staff perceptions about communication were measured, and direct observations of rounds were conducted before and after implementation of the intervention. RESULTS After implementation of the intervention, nurse participation during presentation of patient data increased from 17/47 (36.2%) to 56/78 (71.8%) (p < 0.0002) in the surgical ICUs and from 8/23 (34.8%) to 107/107 (100%) (p <0.0001) in the medical ICUs. Nurse participation during generation of the daily plan increased in the surgical ICUs from 24/47 (51.1%) to 63/78 (80.8%) (p = 0.0005) and from 7/23 (30.4%) to 106/107 (99.1%) (p < 0.0001) in the medical ICUs. Miscommunications and errors were corrected in nearly half of the rounding episodes observed. CONCLUSION This study demonstrated that the implementation of a simple toolkit that can be incorporated into existing work flow and rounding culture in several different types of ICUs can result in improvements in engagement of nursing staff and in overall communication.
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Stevens JP, Dechen T, Schwartzstein R, O'Donnell C, Baker K, Howell MD, Banzett RB. Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission. J Pain Symptom Manage 2018; 56:15-22.e2. [PMID: 29476798 PMCID: PMC6317868 DOI: 10.1016/j.jpainsymman.2018.02.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/14/2018] [Accepted: 02/14/2018] [Indexed: 11/22/2022]
Abstract
CONTEXT Dyspnea is an uncomfortable and distressing sensation experienced by hospitalized patients. OBJECTIVES There is no large-scale study of the prevalence and intensity of patient-reported dyspnea at the time of admission to the hospital. METHODS Between March 2014 and September 2016, we conducted a prospective cohort study among all consecutive hospitalized patients at a single tertiary care center in Boston, MA. During the first 12 hours of admission to medical-surgical and obstetric units, nurses at our institution routinely collect a patient's 1) current level of dyspnea on a 0-10 scale with 10 anchored at "unbearable," 2) worst dyspnea in the past 24 hours before arrival at the hospital on the same 0-10 scale, and 3) activities that were associated with dyspnea before admission. The prevalence of dyspnea was identified, and tests of difference were performed across patient characteristics. RESULTS We analyzed 67,362 patients, 12% of whom were obstetric patients. Fifty percent of patients were admitted to a medical-surgical unit after treatment in the emergency department. Among all noncritically ill inpatients, 16% of patients experienced dyspnea in the 24 hours before the admission. Twenty-three percent of patients admitted through the emergency department reported any dyspnea in the past 24 hours. Eleven percent experienced some current dyspnea when interviewed within 12 hours of admission with 4% of patients experiencing dyspnea that was rated 4 or greater. Dyspnea of 4 or more was present in 43% of patients admitted with respiratory diagnoses and 25% of patients with cardiovascular diagnoses. After multivariable adjustment for severity of illness and patient comorbidities, patients admitted on the weekend or during the overnight nursing shift were more likely to report dyspnea on admission. CONCLUSION Dyspnea is a common symptom among all hospitalized patients. Routine documentation of dyspnea is feasible in a large tertiary care center.
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Affiliation(s)
- Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Richard Schwartzstein
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Carl O'Donnell
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Kathy Baker
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael D Howell
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, Illinois, USA; Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Robert B Banzett
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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25
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Gurbel PA, Bliden K, Bell R, Taheri H, Tehrani B, Dechen T, Armstrong K, Tantry U. VORAPAXAR PHARMACODYNAMICS: EFFECTS ON THROMBOGENICITY, ENDOTHELIAL FUNCTION, AND INTERACTIONS WITH CLOPIDOGREL AND ASPIRIN. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30617-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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26
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Gargano LM, Dechen T, Cone JE, Stellman SD, Brackbill RM. Psychological Distress in Parents and School-Functioning of Adolescents: Results from the World Trade Center Registry. J Urban Health 2017; 94:597-605. [PMID: 28321793 PMCID: PMC5610121 DOI: 10.1007/s11524-017-0143-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Poor school-functioning can be indicative of parent and adolescent mental health and adolescent behavior problems. This study examined 472 adolescents enrolled in the World Trade Center (WTC) Health Registry, with a two-step path analysis, using regression-based models, to unravel the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on the outcome school-functioning. WTC exposure was associated with UHCN and parental mental health was a significant mediator. There was no evidence that family WTC exposure was associated with UHCN independent of its effect on parental mental health. For the second path, after accounting for the effects of adolescent mental health, behavioral problems, and UHCN, there remained a significant association between parental mental health and school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health, and behavioral problems, as efforts to address any of these alone may not be sufficient.
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Affiliation(s)
- Lisa M Gargano
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, 7th Floor, Long Island City, NY, 11101, USA.
| | - Tenzin Dechen
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, 7th Floor, Long Island City, NY, 11101, USA
| | - James E Cone
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, 7th Floor, Long Island City, NY, 11101, USA
| | - Steven D Stellman
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, 7th Floor, Long Island City, NY, 11101, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Robert M Brackbill
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, 7th Floor, Long Island City, NY, 11101, USA
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Jukosky J, Gosselin BJ, Foley L, Dechen T, Fiering S, Crane-Godreau MA. In vivo Cigarette Smoke Exposure Decreases CCL20, SLPI, and BD-1 Secretion by Human Primary Nasal Epithelial Cells. Front Psychiatry 2015; 6:185. [PMID: 26793127 PMCID: PMC4710704 DOI: 10.3389/fpsyt.2015.00185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 12/18/2015] [Indexed: 11/30/2022] Open
Abstract
Smokers and individuals exposed to second-hand cigarette smoke have a higher risk of developing chronic sinus and bronchial infections. This suggests that cigarette smoke (CS) has adverse effects on immune defenses against pathogens. Epithelial cells are important in airway innate immunity and are the first line of defense against infection. Airway epithelial cells not only form a physical barrier but also respond to the presence of microbes by secreting antimicrobials, cytokines, and chemokines. These molecules can lyse infectious microorganisms and/or provide signals critical to the initiation of adaptive immune responses. We examined the effects of CS on antimicrobial secretions of primary human nasal epithelial cells (PHNECs). Compared to non-CS-exposed individuals, PHNEC from in vivo CS-exposed individuals secreted less chemokine ligand (C-C motif) 20 (CCL20), Beta-defensin 1 (BD-1), and SLPI apically, less BD-1 and SLPI basolaterally, and more CCL20 basolaterally. Cigarette smoke extract (CSE) exposure in vitro decreased the apical secretion of CCL20 and beta-defensin 1 by PHNEC from non-CS-exposed individuals. Exposing PHNEC from non-CS exposed to CSE also significantly decreased the levels of many mRNA transcripts that are involved in immune signaling. Our results show that in vivo or in vitro exposure to CS alters the secretion of key antimicrobial peptides from PHNEC, but that in vivo CS exposure is a much more important modifier of antimicrobial peptide secretion. Based on the gene expression data, it appears that CSE disrupts multiple immune signaling pathways in PHNEC. Our results provide mechanistic insight into how CS exposure alters the innate immune response and increases an individual's susceptibility to pathogen infection.
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Affiliation(s)
- James Jukosky
- Department of Natural Science, Colby-Sawyer College , New London, NH , USA
| | - Benoit J Gosselin
- Department of Otolaryngology, Dartmouth Hitchcock Medical Center , Lebanon, NH , USA
| | - Leah Foley
- Department of Natural Science, Colby-Sawyer College , New London, NH , USA
| | - Tenzin Dechen
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth , Lebanon, NH , USA
| | - Steven Fiering
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth , Lebanon, NH , USA
| | - Mardi A Crane-Godreau
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth , Lebanon, NH , USA
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Crane-Godreau MA, Black CC, Giustini AJ, Dechen T, Ryu J, Jukosky JA, Lee HK, Bessette K, Ratcliffe NR, Hoopes PJ, Fiering S, Kelly JA, Leiter JC. Modeling the influence of vitamin D deficiency on cigarette smoke-induced emphysema. Front Physiol 2013; 4:132. [PMID: 23781205 PMCID: PMC3679474 DOI: 10.3389/fphys.2013.00132] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 05/20/2013] [Indexed: 12/27/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. While the primary risk factor for COPD is cigarette smoke exposure, vitamin D deficiency has been epidemiologically implicated as a factor in the progressive development of COPD-associated emphysema. Because of difficulties inherent to studies involving multiple risk factors in the progression of COPD in humans, we developed a murine model in which to study the separate and combined effects of vitamin D deficiency and cigarette smoke exposure. During a 16-week period, mice were exposed to one of four conditions, control diet breathing room air (CD-NS), control diet with cigarette smoke exposure (CD-CSE), vitamin D deficient diet breathing room air (VDD-NS) or vitamin D deficient diet with cigarette smoke exposure (VDD-CSE). At the end of the exposure period, the lungs were examined by a pathologist and separately by morphometric analysis. In parallel experiments, mice were anesthetized for pulmonary function testing followed by sacrifice and analysis. Emphysema (determined by an increase in alveolar mean linear intercept length) was more severe in the VDD-CSE mice compared to control animals and animals exposed to VDD or CSE alone. The VDD-CSE and the CD-CSE mice had increased total lung capacity and increased static lung compliance. There was also a significant increase in the matrix metalloproteinase-9: tissue inhibitor of metalloproteinases-1 (TIMP-1) ratio in VDD-CSE mice compared with all controls. Alpha-1 antitrypsin (A1AT) expression was reduced in VDD-CSE mice as well. In summary, vitamin D deficiency, when combined with cigarette smoke exposure, seemed to accelerate the appearance of emphysemas, perhaps by virtue of an increased protease-antiprotease ratio in the combined VDD-CSE animals. These results support the value of our mouse model in the study of COPD.
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Affiliation(s)
- Mardi A Crane-Godreau
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth Lebanon, NH, USA ; Veteran's Administration Research Facility, White River Junction VT, USA
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Larsson L, Pehrson C, Dechen T, Crane-Godreau M. Microbiological components in mainstream and sidestream cigarette smoke. Tob Induc Dis 2012; 10:13. [PMID: 22898193 PMCID: PMC3444954 DOI: 10.1186/1617-9625-10-13] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/08/2012] [Indexed: 11/10/2022] Open
Abstract
Background Research has shown that tobacco smoke contains substances of microbiological origin such as ergosterol (a fungal membrane lipid) and lipopolysaccharide (LPS) (in the outer membrane of Gram-negative bacteria). The aim of the present study was to compare the amounts of ergosterol and LPS in the tobacco and mainstream (MS) and sidestream (SS) smoke of some popular US cigarettes. Methods We measured LPS 3-hydroxy fatty acids and fungal biomass biomarker ergosterol in the tobacco and smoke from cigarettes of 11 popular brands purchased in the US. University of Kentucky reference cigarettes were also included for comparison. Results The cigarette tobacco of the different brands contained 6.88-16.17 (mean 10.64) pmol LPS and 8.27-21.00 (mean 14.05) ng ergosterol/mg. There was a direct correlation between the amounts of ergosterol and LPS in cigarette tobacco and in MS smoke collected using continuous suction; the MS smoke contained 3.65-8.23% (ergosterol) and 10.02-20.13% (LPS) of the amounts in the tobacco. Corresponding percentages were 0.30-0.82% (ergosterol) and 0.42-1.10% (LPS) for SS smoke collected without any ongoing suction, and 2.18% and 2.56% for MS smoke collected from eight two-second puffs. Conclusions Tobacco smoke is a bioaerosol likely to contain a wide range of potentially harmful bacterial and fungal components.
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