Addiction Consult Service and Inpatient Outcomes Among Patients with Alcohol Use Disorder

BACKGROUND

Alcohol use disorder (AUD) is the most prevalent substance use disorder, but evidence-based medications to treat AUD (MAUD), including naltrexone and acamprosate, are substantially underutilized. Hospitalization provides an opportunity to start MAUD for patients who may not otherwise seek treatment. Addiction consultation services (ACSs) have been increasingly utilized to ensure appropriate treatment. There is little research examining the effect of an ACS on health outcomes among patients with AUD.

OBJECTIVE

To determine the association between an ACS consultation and provision of MAUD during admission and MAUD at discharge among admissions with AUD.

DESIGN

Retrospective study comparing admissions which received an ACS consult and propensity score-matched historical control admissions. Subjects A total of 215 admissions with a primary or secondary diagnosis of AUD who received an ACS consult and 215 matched historical control admissions. Intervention ACS consultation from a multidisciplinary team offering withdrawal management, substance use disorder treatment, patient-centered counseling, discharge planning, and linkage to outpatient care for patients with substance use disorders, including AUD. Main Measures Primary outcomes were initiation of new MAUD during admission and new MAUD at discharge. Secondary outcomes were patient-directed discharge, time to 7- and 30-day readmission, and time to 7- and 30-day post-discharge ER visit. Key Results Among 430 admissions with AUD, those that received an ACS consultation were significantly more likely to receive new inpatient MAUD (33.0% vs 0.9%; OR 52.5 [CI 12.6-218.6]) and significantly more likely to receive new MAUD at discharge (41.4% vs 1.9%; OR 37.3 [13.3-104.6]), compared with historical controls. ACS was not significantly associated with patient-directed discharge, time to readmission, or time to post-discharge ER visit.

CONCLUSIONS

ACS was associated with a large increase in provision of new inpatient MAUD and new MAUD at discharge when compared to propensity-matched historical controls.

Self-Reported Injuries in Indoor Gym-Based Rock Climbers: A Retrospective Study of Predictors of Prolonged Injury and Seeking Medical Care

INTRODUCTION

Indoor climbing injuries are often related to overuse, and climbers choose between self-management and seeing a medical practitioner. This study evaluated predictors of prolonged injury and seeking medical care for indoor climbing injuries.

METHODS

A convenience sample of adult climbers from 5 gyms in New York City was interviewed about injuries over the past 3 y, because of which they stopped climbing for at least a week or saw a medical practitioner.

RESULTS

In total, 122 of 284 (43%) participants had at least 1 injury, for a total of 158 injuries. Fifty (32%) were prolonged, lasting at least 12 wk. Predictors of prolonged injury included older age (odds ratio [OR], 2.28, per 10-y increase; 95% CI, 1.31-3.96), hours per week spent climbing (OR, 1.14, per 1-h increase; 95% CI, 1.06-1.24), climbing difficulty (OR, 2.19, per difficulty group increase; 95% CI, 1.31-3.66), and years of climbing experience (OR, 3.99, per 5-y increase; 95% CI, 1.61-9.84). Only 38% of injuries were seen by a medical practitioner. Predictors of seeking care included prolonged injury (OR, 3.04; 95% CI, 1.39-6.64) and rope climbing preference (OR, 1.98; 95% CI, 1.02-3.82). The most common theme for seeking care was serious pain or interference with climbing or daily activities.

CONCLUSIONS

Despite prolonged injuries being common, especially in older, more experienced, and higher-level climbers, only a third of climbers with injuries seek medical care. Outside of injuries causing minimal pain or limitation, those who self-managed reported receiving advice from other climbers or online research as a prominent reason for that choice.

RSV causes more severe respiratory illness than influenza in admitted children under 2-years-old

INTRODUCTION

Both respiratory syncytial virus (RSV) and influenza-associated lower respiratory tract infections (LRTI) cause serious respiratory infections in infants and toddlers. We aimed to assess the frequency of complex hospital courses among patients admitted with influenza versus RSV LRTI.

METHODS

A retrospective cohort study was performed on admissions of children <2 years who were admitted for LRTI and tested positive for influenza or RSV from 2016 to 2019. The primary outcome, complex hospital course, was a composite including: intensive care unit admission, respiratory support, nasogastric tube feeds, prolonged length of stay, and death. Secondary outcomes included 7-day readmission and time to respiratory support. Differences between RSV and influenza groups were assessed and unadjusted and adjusted regression models and competing risks time to event models were developed.

RESULTS

There were 1094 (89%) RSV admissions and 134 (11%) influenza admissions. Children admitted for influenza were significantly older (336 vs. 165 days, p < 0.001), more likely to present with an abnormal heart rate for age (84.3% vs. 73.5%, p < 0.01) and a fever (27.6% vs. 18.9%, p = 0.02). Admissions with RSV were significantly more likely to experience a complex hospital course (OR_adj  = 3.5, 95% CI: 2.2-5.6). In time to event analysis, RSV admissions had a significantly higher rate of respiratory support (HR_adj  = 3.2, 95% CI: 2.0, 5.2). Readmission rates were similar.

CONCLUSIONS

RSV admissions were associated with a higher risk for a complex hospital course and required higher rates of respiratory support than influenza admissions. This information may help in evaluating hospital resources and admissions.

Medical Student Personality Traits and Clinical Grades in the Internal Medicine Clerkship

BACKGROUND

Third year clerkship grades include subjective evaluations. The purpose of this study is to identify if personality traits and self-esteem predispose students to better clerkship performance.

METHODS

Third-year medical students completed the OCEAN Five Factor Model Personality Test and Rosenberg Self-Esteem Scale. Clerkship grades were matched to survey results. Chi-squared and linear regression analyses assessed the correlation between students' clerkship grades, personality traits, and self-esteem.

RESULTS

There was no association between OCEAN personality domains and any component of clerkship grade. In secondary post hoc analysis, students who are "deep thinking" (OR 2.97, 95% CI 1.26-7.01, p = 0.01), "sophisticated" (OR 2.70, 95% CI 1.12-6.50, p = 0.03), and "outgoing" (OR 2.45, 95% CI 1.02-5.89, p = 0.04) were significantly more likely to get an overall clerkship grade of Honors. "Deep thinking" (OR 3.44, 95% CI 1.47-8.04, p = 0.004) and "efficient" (OR 2.87, 95% CI 1.12-7.36, p = 0.03) students scored better on shelf exams, while "shy" students scored worse (OR 0.30, 95% CI 0.13-0.69, p = 0.004); "aloof" students received worse clinical scores (OR 0.57, 95% CI 0.37-0.89, p = 0.03), and "rude" (OR 5.08, 95% CI 1.03-24.94, p = 0.03) and "sophisticated" (OR 2.47, 95% CI 1.02-6.00, p = 0.04) students received higher preceptor scores. There was no correlation between self-esteem and clerkship grades.

CONCLUSION

Students with certain personality traits may be predisposed to success during clerkships. Medical educators should be cognizant of biases favoring certain personalities and help students maximize success by recognizing their strengths and identifying gaps.

Teamwork and Leadership Under Fire at the Epicenter of the COVID-19 Epidemic in the Bronx

The first Covid-19 patient was admitted to Montefiore Medical Center (MMC) on March 10, 2020. Soon thereafter there was a rapid and exponential surge of Covid-19 admissions to MMC that could have resulted in catastrophic consequences if MMC had been overwhelmed, as happened in Europe. To adjust to this crisis our institution, under the inspiring leadership of Dr. Philip Ozuah, President and CEO of Montefiore Medicine, adopted an "all hands on deck" approach, mobilizing our entire workforce to expand our units to accommodate the growing number of patients being admitted. Given that the internal medicine (IM) and ICU units are part of the department of medicine (DOM), the DOM was at the center of this mobilization. The DOM is the largest department at MMC and mobilizing it required careful planning, seamless teamwork, and strong leadership. To achieve that goal, we applied a framework that we designate the "3C framework," denoting Coordination, Communication, and Collaboration. In this report we describe the many initiatives the Montefiore Einstein DOM implemented during the Covid-19 pandemic using the 3C framework. These included establishing the Medicine Covid-19 Taskforce to lead our efforts, starting a daily newsletter for up-to-date communications, rapidly expanding the ICU and IM units, converting most specialty inpatient consults to eConsults, coordinating research studies, and more. The goal of this report is to serve as a guide on how the 3C framework helped us organize, mobilize, and energize the department of medicine effectively and efficiently during this unprecedented crisis.

Early and Significant Reduction in C-Reactive Protein Levels After Corticosteroid Therapy Is Associated With Reduced Mortality in Patients With COVID-19

BACKGROUND

Corticosteroids may be beneficial in a subset of patients with coronavirus disease 2019 (COVID-19), but predictors of therapeutic response remain unknown. C-reactive protein (CRP) is a routinely measured biomarker, and reduction in its levels after initiation of therapy may predict inpatient mortality.

METHODS

In this retrospective cohort study, the charts of patients who were admitted to Montefiore Medical Center between March 10, 2020, and May 2, 2020 for the management of COVID-19 were examined. Of all patients who met inclusion criteria, patients who received corticosteroid treatment were categorized as CRP responders (≥50% CRP level reduction) and CRP nonresponders (<50% CRP level reduction) based on change in CRP within 72 hours of corticosteroid treatment initiation. The outcomes of interest were two-fold: (1) CRP response after treatment with corticosteroid, and (2) differences in mortality among patients with CRP response compared those without.

RESULTS

Of 2,707 patients admitted during the study period, 324 received corticosteroid treatment. Of patients who received corticosteroid treatment, CRP responders had reduced risk of death compared with risk among CRP nonresponders (25.2% vs 47.8%; unadjusted odds ratio [OR], 0.37; 95% CI, 0.21-0.65; P <.001). This effect remained strong and significant after adjustment for potential confounders (adjusted OR, 0.27; 95% CI, 0.14-0.54; P <.001).

CONCLUSION

Reduction in CRP by 50% or more within 72 hours of initiating corticosteroid therapy potentially predicts inpatient mortality. This may serve as an early biomarker of response to corticosteroid therapy in patients with COVID-19.

Effect of Real-Time Feedback Devices on Primary Care Patient Experience Scores: A Cluster-Randomized Trial

Patient experience is a critical measure for ambulatory primary care, although it is unclear how to best improve patient experience scores. This study aimed to determine whether use of a real-time feedback (RTF) device improved patient experience scores in a cluster-randomized trial. The primary outcomes were change from baseline in 9 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) question and domain scores most closely related to the RTF questions asked in a linear mixed effects model. There were no observed statistically significant intervention-related differences in CG-CAHPS scores in any of the 9 CG-CAHPS questions or domains (P = .12-.99). In intervention clinics, there were no statistically significant correlation between CG-CAHPS top box scores and RTF device scores (P = .23-.98). Clinics in an urban primary care network randomized to receive RTF devices did not significantly improve related CG-CAHPS question or domain scores nor were those scores correlated with RTF device scores. More research is needed to identify effective interventions to improve ambulatory primary care patient experience.

Effect of Systemic Glucocorticoids on Mortality or Mechanical Ventilation in Patients With COVID-19

The efficacy of glucocorticoids in COVID-19 is unclear. This study was designed to determine whether systemic glucocorticoid treatment in COVID-19 patients is associated with reduced mortality or mechanical ventilation. This observational study included 1,806 hospitalized COVID-19 patients; 140 were treated with glucocorticoids within 48 hours of admission. Early use of glucocorticoids was not associated with mortality or mechanical ventilation. However, glucocorticoid treatment of patients with initial C-reactive protein (CRP) ≥20 mg/dL was associated with significantly reduced risk of mortality or mechanical ventilation (odds ratio, 0.23; 95% CI, 0.08-0.70), while glucocorticoid treatment of patients with CRP <10 mg/dL was associated with significantly increased risk of mortality or mechanical ventilation (OR, 2.64; 95% CI, 1.39-5.03). Whether glucocorticoid treatment is associated with changes in mortality or mechanical ventilation in patients with high or low CRP needs study in prospective, randomized clinical trials.

Reducing peripherally inserted central catheters and midline catheters by training nurses in ultrasound-guided peripheral intravenous catheter placement

BACKGROUND

Training nurses in ultrasound-guided peripheral intravenous catheter placement might reduce the use of more invasive venous access devices (peripherally inserted central catheters (PICC) and midline catheters).

METHODS

We implemented an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit and provided a portable ultrasound device for 10 months.

RESULTS

Nurses on this unit placed 99 ultrasound-guided peripheral intravenous catheters with a high level of success. During the implementation period, PICC and midline catheter placement decreased from a mean 4.8 to 2.5 per month, meeting criteria for special cause variation. In the postimplementation period, the average catheter use reverted to 4.3 per month on the intervention unit. A comparison inpatient medical unit without training or access to a portable ultrasound device experienced no significant change in PICC and midline catheter use throughout the study period (mean of 6.0 per month).

CONCLUSIONS

These results suggest that an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit is sufficient to reduce PICC and midline catheters.

Assessing and counseling the obese patient: Improving resident obesity counseling competence

OBJECTIVE

To evaluate obesity counseling competence among residents in a primary care training program METHODS: We delivered a 3h obesity curriculum to 28 Primary Care residents and administered a pre-curriculum and post curriculum survey looking specifically at self-assessed obesity counseling competence.

RESULTS

Nineteen residents completed both the pre curriculum survey and the post curriculum survey. The curriculum had a positive impact on residents' ability to ascertain patient's stage of change, use different methods to obtain diet history (including 24h recall, food record or food frequency questionnaire), respond to patient's questions regarding treatment options, assist patients in setting realistic goals for weight loss based on making permanent lifestyle changes, and use of motivational interviewing to change behavior. When looking at the 5As domains, there was a significant improvement in the domains of Assess, Advise, and Assist. The proportion of residents with a lower level of self-assessed obesity counseling competence reduced from 75% before the curriculum to 37.5% (p=0.04) after the curriculum.

CONCLUSION

Our curriculum addressing weight loss counseling using the 5As model increased obesity counseling competence among residents in a primary care internal medicine residency program.

Discharge service as a determinant of 30-day readmission in a cohort of maintenance hemodialysis patients: a retrospective cohort study

Background

End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis.

Methods

One thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis.

Results

Patients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43–4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16–1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01–2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46–0.91) and 0.71(95%CI:0.66–0.77) respectively).

Conclusions

Patients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.

30-Day Readmission Rates in Patients Admitted for Heart Failure Exacerbation with and without Palliative Care Consultation: A Retrospective Cohort Study

BACKGROUND

Palliative care consultation improves quality of care through symptom management, communication, care coordination, and earlier hospice referral, and it may decrease burdensome hospital readmissions at the end of life.

OBJECTIVES

To compare 30-day readmission rates for patients admitted with exacerbation of congestive heart failure (CHF) receiving palliative care consultation services compared with controls.

DESIGN

Retrospective cohort study using propensity score matching. A secondary, subgroup analysis compared patients with palliative care consults and patients with an incomplete consult order. Settings/Subjects: Single-center study in an academic acute inpatient setting. Of a pool of 8215 admissions from January 1, 2011 to April 6, 2014, 356 included a palliative care consultation, and 356 matched controls were found.

RESULTS

The 30-day readmission rate was 50.8% for admissions including a palliative care consult and 36.0% for controls (OR 1.8, 95% CI 1.4-2.5). Those with a completed consult had fewer readmissions compared with those with an incomplete order, but this difference was not statistically significant (43% vs. 53%, χ² = 1.9, p = 0.171).

CONCLUSION

No reduction in the risk of 30-day readmission was observed in the palliative care group, suggesting that palliative care services may not have the same effect on readmission rates in CHF patients compared with others. The subgroup analysis suggests that the difference between palliative care and control groups may reflect residual confounding, possibly due to critical social variables that are not captured in the electronic medical record, highlighting the difficulty in studying this population.

Features of successful academic hospitalist programs: Insights from the SCHOLAR (SuCcessful HOspitaLists in academics and research) project

BACKGROUND

As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important.

OBJECTIVE

To develop and validate a quantifiable definition of academic success for AHPs.

METHODS

A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey.

RESULTS

Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6-18 years) and mean size of 36 faculty (range, 18-95). The mean total grant funding/program was $4 million (range, $0-$15 million), with mean funding/FTE of $364,000 (range, $0-$1.4 million); both were significantly higher than the comparison sample. The majority of SCHOLAR faculty (82%) were junior, a lower percentage than the comparison sample. The mean number of research abstracts presented over 2 years was 10.8 (range, 9-23).

DISCUSSION

Our approach effectively identified a subset of successful AHPs. Despite the relative maturity and large size of the programs in the SCHOLAR cohort, they were comprised of relatively few senior faculty members and varied widely in the quantity of funded research and scholarship. Journal of Hospital Medicine 2016;11:708-713. © 2016 Society of Hospital Medicine.

Clinical Profile, Acute Care, and Middle-Term Outcomes of Cocaine-Associated ST-Segment Elevation Myocardial Infarction in an Inner-City Community

Although cocaine is a well-recognized risk factor for coronary disease, detailed information is lacking regarding related behavioral and clinical features of cocaine-associated ST-segment elevation myocardial infarction (STEMI), particularly in socioeconomically disadvantaged urban settings. Nor are systematic or extended follow-up data available on outcomes for cocaine-associated STEMI in the contemporary era of percutaneous coronary intervention. We leveraged a prospective STEMI registry from a large health system serving an inner-city community to characterize the clinical features, acute management, and middle-term outcomes of cocaine-related versus cocaine-unrelated STEMI. Of the 1,003 patients included, 60% were black or Hispanic. Compared with cocaine-unrelated STEMI, cocaine-related STEMI (n = 58) was associated with younger age, male gender, lower socioeconomic score, current smoking, high alcohol consumption, and human immunodeficiency virus seropositivity but less commonly with diabetes or hypertension. Cocaine users less often received drug-eluting stents or β blockers at discharge. During median follow-up of 2.7 years, rates of death, death or any rehospitalization, and death or cardiovascular rehospitalization did not differ significantly between cocaine users and nonusers but were especially high for death or any hospitalization in the 2 groups (31.4 vs 32.4 per 100 person-years, p = 0.887). Adjusted hazard ratios for outcomes were likewise not significantly different. In conclusion, in this low-income community, cocaine use occurred in a substantial fraction of STEMI cases, who were younger than their nonuser counterparts but had more prevalent high-risk habits and exhibited similarly high rates of adverse outcomes. These data suggest that programs targeting cocaine abuse and related behaviors could contribute importantly to disease prevention in disadvantaged communities.

Treatment with Dalteparin is Associated with a Lower Risk of Bleeding Compared to Treatment with Unfractionated Heparin in Patients with Renal Insufficiency

BACKGROUND

Low molecular weight heparins (LMWHs) have been cautiously used in patients with chronic kidney disease (CKD) due to fear of accumulation. Dalteparin, however, has shown minimal tendency to accumulate in patients with CKD and may be safe to use in this patient population.

OBJECTIVE

We compared the incidence of clinically significant bleeding in patients with CKD receiving therapeutic doses of dalteparin to that of patients with CKD receiving therapeutic doses of UFH.

DESIGN

This was a retrospective cohort study.

SUBJECTS

Inpatients with CKD (GFR < 60 ml/min) who were treated with therapeutic dalteparin or UFH were included in the study

MAIN MEASURES

Primary outcome was major bleeding within 10 days of anticoagulation, identified by ICD-9 code and confirmed by chart review. Demographic characteristics, laboratory values, comorbidities, prior bleeding history and inpatient medications were extracted for each admission from the electronic medical record. Logistic regression models were created to examine the association between choice of anticoagulant and bleeding rates, after adjustment for demographic and clinical characteristics.

KEY RESULTS

Dalteparin-treated patients were significantly less likely to experience a major bleed than patients treated with UFH (1.14 % vs. 3.49 %, p < 0.001). The reduced likelihood of bleeding associated with dalteparin treatment remained significant after adjustment for patient characteristics (HR 0.39, 95 % CI: 0.21-0.70, p < 0.0001). A stratified analysis for subgroups with GFR< 30 mL/min and with GFR between 30 and 60 mL/min showed that dalteparin was still associated with lower odds of bleeding compared to treatment with unfractionated heparin, but the difference was nonsignificant for GFR< 30 (HR 0.35, 95 % CI: 0.11-1.15), even after adjustment (OR 0.37, 95 % CI: 0.11-1.22).

CONCLUSION

In patients with CKD, treatment with therapeutic dose dalteparin was associated with lower rates of bleeding than treatment with unfractionated heparin. For patients with severe CKD (GFR< 30), dalteparin was shown to be at least as safe as unfractionated heparin.

Use of Temporary Names for Newborns and Associated Risks

BACKGROUND

Because there can be no delay in providing identification wristbands to newborns, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs. To determine the level of risk associated with nondistinct naming conventions, we performed an intervention study to evaluate if assigning distinct first names at birth would result in a reduction in wrong-patient errors.

METHODS

We conducted a 2-year before/after implementation study to examine the effect of a distinct naming convention that incorporates the mother's first name into the newborn's first name (eg, Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient within the next 10 minutes.

RESULTS

The reduction in RAR events post- versus preintervention was 36.3%. After accounting for clusters of orders within order sessions, the odds ratio of an RAR event post- versus preintervention was 0.64 (95% confidence interval: 0.42-0.97).

CONCLUSIONS

The study results suggest that nondistinct naming conventions are associated with an increased risk of wrong-patient errors and that this risk can be mitigated by changing to a more distinct naming convention.

A "reverse july effect": association between timing of admission, medical team workload, and 30-day readmission rate

BACKGROUND

High teaching team workload has been associated with poor supervision and worse patient outcomes, yet it is unclear whether this association is more pronounced during the early months of the academic year when the residents are less experienced.

OBJECTIVE

We examined the associations between teaching team workload, timing of admission, and the 30-day readmission rate.

METHODS

In this retrospective observational study, all admissions to an urban internal medicine teaching service over a 16-month period were divided into 2 groups based on admission date: early in the academic year (July-September) or late (October-June) and further defined as being admitted to "busy" versus "less busy" teams based on number of monthly admissions. The primary outcome was 30-day readmission rate. Multivariate logistic regression was used to determine the independent association between teaching team workload and readmission rates, stratified by time of year of admission after adjustment for demographic and clinical characteristics.

RESULTS

Of 12 118 admissions examined, 2352 (19.4%) were admitted early in the year, and 9766 (80.6%) were admitted later. After multivariate adjustment, we found that patients admitted to busy versus less busy teams in the first quarter had similar 30-day readmission rate (odds ratio [OR]adj  =  1.03 [0.82-1.30]). Later year admission to a busy team was associated with increased risk of readmission after adjustment (ORadj  =  1.16 [1.03-1.30]).

CONCLUSIONS

Admission to busy teams early in the year was not associated with increased odds of 30-day readmission, whereas admission later in the year to busy teams was associated with 16% increased odds of readmission.

The impact of the number of admissions to the inpatient medical teaching team on patient safety outcomes

INTRODUCTION

The clinical work in academic internal medicine inpatient units is done by teaching teams. To date, few studies have investigated how team workload affects patient safety outcomes.

OBJECTIVE

We examined the association between the number of patients seen by a teaching team, 30-day readmission, and 60-day mortality.

METHODS

In this retrospective observational study we defined each team as "less busy" (total monthly admissions ≤49, the median for all teams) or "more busy" (total monthly admissions >49). We compared patients in both groups' demographic characteristics, comorbidities (Charlson score), severity of illness (the Laboratory-based Acute Physiology Score [LAPS]), and length of stay using t tests, χ(2) tests, and rank sum tests, as appropriate. Logistic regression models were constructed to determine whether there was an association between assignment to a busy team and readmission and mortality.

RESULTS

Of 12 119 admissions examined, 6398 (52.8%) were assigned to the less busy teams and 5721 (47.2%) were assigned to busy teams. Mean length of stay was not statistically different between the groups (5.2 vs 5.3 days; P  =  .08). After adjustment for demographic and clinical characteristics (LAPS and Charlson score), care by a busy team was associated with greater 30-day readmission rate (odds ratio, 1.21; 95% confidence interval [CI], 1.10-1.34) but not with increased risk of mortality (odds ratio, 1.05; 95% CI, 0.88-1.27). There was a significant linear association between the number of monthly admissions to teams and the readmission rate.

CONCLUSIONS

Admission to a busier teaching team is associated with a 21% increase in the odds of 30-day readmission. Sixty-day mortality was not affected by the number of monthly admissions to the teaching team.

Serum alkaline phosphatase and phosphate and risk of mortality and hospitalization

BACKGROUND AND OBJECTIVES

Elevated alkaline phosphatase (AlkPhos) and phosphate levels are associated with cardiovascular morbidity and mortality in patients receiving dialysis. A retrospective cohort study was conducted to test these associations in outpatients with an estimated GFR > or =60 ml/min/1.73 m(2).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients with serum AlkPhos and phosphate levels measured between 2000 and 2002 (n = 10,743) at Montefiore Medical Center (MMC) clinics were followed through September 11, 2008 (median 6.8 years). Mortality data were obtained via Social Security Administration records (n = 949 deaths). Hospitalization data were obtained from MMC records.

RESULTS

The mean age was 51 years, 64% were women, 22% were white, 26% were non-Hispanic black, 16% were Hispanic, 13% had a diagnosis of hypertension, 9% had diabetes mellitus, and 8% had cardiovascular disease at baseline. AlkPhos and phosphate were independently associated with mortality and cardiovascular-related hospitalization after multivariable adjustment. Comparing patients in the highest (> or =104 U/L) versus lowest quartile of AlkPhos (< or =66 U/L), the adjusted hazard ratio (HR) for mortality was 1.65 (P trend across quartiles <0.001). For the highest compared with the lowest quartile of serum phosphate (> or =3.8 mg/dl versus < or =3.0 mg/dl), the adjusted HR for mortality was 1.29 (P trend across quartiles = 0.008). High AlkPhos but not phosphate levels were also associated with all-cause, infection-related, and fracture-related hospitalization.

CONCLUSIONS

Higher levels of serum AlkPhos and phosphate were associated with increased mortality and cardiovascular-related hospitalization in an inner-city clinic population. Further studies are needed to elucidate mechanisms underlying these associations.

The incremental value of troponin-I testing in patients with intermediate risk unstable angina

BACKGROUND

Classification of patients with unstable angina (UA) by Agency for Health Care Policy and Research (AHCPR) guidelines in the emergency department reliably stratifies risk of death or myocardial infarction (MI) for triage to outpatient evaluation (low-risk), hospitalization (high-risk), or additional testing (intermediate-risk). Cardiac troponin-I elevation may identify patients at higher risk, but the incremental value may vary with AHCPR clinical risk.

HYPOTHESIS

The objective of this study was to determine whether cardiac troponin-I had any additional value beyond triage based upon history, physical examination, and electrocardiogram, in the evaluation of patients with UA.

METHODS

In all, 212 consecutive patients with UA and normal serum creatine kinase (CK)-MB levels and elevated troponin-I were risk stratified by AHCPR guidelines to evaluate the incremental value of adding routine troponin-I measurements to our current model for risk stratification.

RESULTS

Primary events (death/nonfatal MI) occurred in 35% of high-risk, 15% of intermediate-risk, and 0% of low-risk patients (p < 0.001 by chi-square for trend). High troponin-I (> or =2.0 ng/dl) occurred in 48% of high-risk, 21% of intermediate-risk, and 19% of low-risk patients. The remaining patients in each risk group had indeterminate troponin-I levels (> or =0.4 < 2 ng/dl). Of those with high troponin-I, a primary event occurred in 36, 42, and 0% in the respective high-, intermediate-, and low-risk groups (p < 0.001). High troponin-I levels corresponded with a statistically significant increased rate of primary events only in patients at AHCPR intermediate risk: 42.4 vs. 7.3%, p < 0.001.

CONCLUSION

The AHCPR guidelines risk stratify patients with UA. High troponin-I adds significant (p < 0.001) prognostic value in the patients at AHCPR intermediate risk and should be evaluated further in larger trials of such patients.

The effect of 12-O-tetradecanoylphorbol-13-acetate (TPA) on phospholipid metabolism of human epidermal keratinocytes in culture

The tumor promoter 12-O-tetradecanoylphorbol-13-acetate (TPA) stimulated the release of [3H]choline from prelabelled membrane phospholipids of cultured keratinocytes obtained from normal human skin. In contrast, TPA in the concentration range of 10(-12) to 10(-6) g/ml failed to induce deacylation of [3H]arachidonic acid or stimulate [3H]prostaglandin production in prelabelled keratinocytes. In addition, TPA did not induce [3H]choline incorporation into the membrane phospholipids of these cells. The previously reported inability of TPA to stimulate a proliferative response in these cell cultures may be related to the resistance of these cells to TPA-induced alterations of arachidonate metabolism.