Underuse and Overuse of Osteoporosis Screening in a Regional Health System: a Retrospective Cohort Study

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with dual-energy x-ray absorptiometry (DXA) for women aged ≥ 65 years and younger women with increased risk. “Choosing Wisely” initiatives advise avoiding DXA screening in women younger than 65 years without osteoporosis risk factors.

OBJECTIVE

We aimed to determine the extent to which DXA screening is used in accordance with USPSTF recommendations within a regional health system.

DESIGN

This was a retrospective longitudinal cohort study within 13 primary care clinics in the Sacramento, CA region.

PATIENTS

The study included 50,995 women aged 40–85 years without prior osteoporosis screening, diagnosis, or treatment attending primary care visits from 2006 to 2012, observed for a mean of 4.4 years.

MAIN MEASURES

We examined incidence of DXA screening. Covariates included age, race/ethnicity, and osteoporosis risk factors (body mass index < 20, glucocorticoid use, secondary osteoporosis, prior high-risk facture, rheumatoid arthritis, alcohol abuse, and current smoking).

KEY RESULTS

Among previously unscreened women for whom the USPSTF recommends screening, 7-year cumulative incidence of DXA screening was 58.8 % among women aged 60–64 years with ≥ 1 risk factor (95 % CI: 51.9–65.8 %), 57.8 % for women aged 65–74 years (95 % CI: 55.6–60.0 %), and 42.7 % for women aged ≥ 75 years (95 % CI: 38.7–46.7 %). Among women for whom the USPSTF does not recommend screening, 7-year cumulative incidence was 45.5 % among women aged 50–59 years (95 % CI 44.1–46.9 %) and 58.6 % among women aged 60–64 years without risk factors (95 % CI 55.9–61.4 %).

CONCLUSIONS

DXA screening was underused in women at increased fracture risk, including women aged ≥ 65 years. Meanwhile, DXA screening was common among women at low fracture risk, such as younger women without osteoporosis risk factors. Interventions may be needed to augment the value of population screening for osteoporosis.KEY WORDS: osteoporosis, screening, dual-energy x-ray absorptiometry, overuse, underuse     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Hospitalization-Associated Disability in Adults Admitted to a Safety-Net Hospital

Background

Little is known about hospitalization-associated disability (HAD) in older adults who receive care in safety-net hospitals.

Objectives

To describe HAD and to examine its association with age in adults aged 55 and older hospitalized in a safety-net hospital.

Design

Secondary post hoc analysis of a prospective cohort from a discharge intervention trial, the Support from Hospital to Home for Elders.

Setting

Medicine, cardiology, and neurology inpatient services of San Francisco General Hospital, a safety-net hospital.

Participants

A total of 583 participants 55 and older who spoke English, Spanish, or Chinese. We determined the incidence of HAD 30 days post-hospitalization and ORs for HAD by age group.

Measurements

The outcome measure was death or HAD at 30 days after hospital discharge. HAD is defined as a new or additional disability in one or more activities of daily living (ADL) that is present at hospital discharge compared to baseline. Participants’ functional status at baseline (2 weeks prior to admission) and 30 days post-discharge was ascertained by self-report of ADL function.

Results

Many participants (75.3 %) were functionally independent at baseline. By age group, HAD occurred as follows: 27.4 % in ages 55–59, 22.2 % in ages 60–64, 17.4 % in ages 65–69, 30.3 % in ages 70–79, and 61.7 % in ages 80 or older. Compared to the youngest group, only the adjusted OR for HAD in adults over 80 was significant, at 2.45 (95 % CI 1.17, 5.15).

Conclusions

In adults at a safety-net hospital, HAD occurred in similar proportions among adults aged 55–59 and those aged 70–79, and was highest in the oldest adults, aged ≥ 80. In safety-net hospitals, interventions to reduce HAD among patients 70 years and older should consider expanding age criteria to adults as young as 55.KEY WORDS: Hospitalization, Hospitalization-associated disability, Activities of daily living, Frail elderly, Vulnerable populations     

Variation in Inpatient Consultation Among Older Adults in the United States

BACKGROUND

Differences among hospitals in the use of inpatient consultation may contribute to variation in outcomes and costs for hospitalized patients, but basic epidemiologic data on consultations nationally are lacking.

OBJECTIVE

The purpose of the study was to identify physician, hospital, and geographic factors that explain variation in rates of inpatient consultation.

DESIGN

This was a retrospective observational study.

SETTING AND PARTICIPANTS

This work included 3,118,080 admissions of Medicare patients to 4,501 U.S. hospitals in 2009 and 2010.

MAIN MEASURES

The primary outcome measured was number of consultations conducted during the hospitalization, summarized at the hospital level as the number of consultations per 1,000 Medicare admissions, or “consultation density.”

KEY RESULTS

Consultations occurred 2.6 times per admission on average. Among non-critical access hospitals, use of consultation varied 3.6-fold across quintiles of hospitals (933 versus 3,390 consultations per 1,000 admissions, lowest versus highest quintiles, p < 0.001). Sicker patients received greater intensity of consultation (rate ratio [RR] 1.18, 95 % CI 1.17–1.18 for patients admitted to ICU; and RR 1.19, 95 % CI 1.18–1.20 for patients who died). However, even after controlling for patient-level factors, hospital characteristics also predicted differences in rates of consultation. For example, hospital size (large versus small, RR 1.31, 95 % CI 1.25–1.37), rural location (rural versus urban, RR 0.78, CI 95 % 0.76–0.80), ownership status (public versus not-for-profit, RR 0.94, 95 % CI 0.91–0.97), and geographic quadrant (Northeast versus West, RR 1.17, 95 % CI 1.12–1.21) all influenced the intensity of consultation use.

CONCLUSIONS

Hospitals exhibit marked variation in the number of consultations per admission in ways not fully explained by patient characteristics. Hospital “consultation density” may constitute an important focus for monitoring resource use for hospitals or health systems.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3216-7) contains supplementary material, which is available to authorized users.KEY WORDS: consultation, hospital care, variation, medicare     

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial

Background

Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals.

Objective

To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients.

Design

Randomized controlled trial.

Participants

General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls.

Interventions

PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management.

Main Measures

The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls).

Key Results

Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1 % decrease [95 % CI: −8.0 %, -0.2 %] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8 % increase [95 % CI: 4.4 %, 19.0 %] in readmission with no change in 30-day outpatient follow-up.

Conclusions

A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3185-x) contains supplementary material, which is available to authorized users.KEY WORDS: care transitions, continuity of care, health care delivery, patient safety, underserved populations     

Patient Perceptions of Whom is Most Involved in Their Care with Successive Duty Hour Limits

BACKGROUND

Although direct patient care is necessary for experiential learning during residency, inpatient perceptions of the roles of resident and attending physicians in their care may have changed with residency duty hours.

OBJECTIVE

We aimed to assess if patients’ perceptions of who is most involved in their care changed with residency duty hours.

DESIGN

This was a prospective observational study over 12 years at a single institution.

PARTICIPANTS

Participants were 22,408 inpatients admitted to the general medicine teaching service from 2001 to 2013, who completed a 1-month follow-up phone interview.

MAIN MEASURES

Percentage of inpatients who reported an attending, resident, or intern as most involved in their care by duty hour period (pre-2003, post-2003–pre-2011, post-2011).

KEY RESULTS

With successive duty hour limits, the percentage of patients who reported the attending as most involved in their care increased (pre-2003 20 %, post-2003–pre-2011 29 %, post-2011 37 %, p < 0.001). Simultaneously, fewer patients reported a housestaff physician (resident or intern) as most involved in their care (pre-2003 20 %, post-2003–pre-2011 17 %, post-2011 12 %, p < 0.001). In multinomial regression models controlling for patient age, race, gender and hospitalist as teaching attending, the relative risk ratio of naming the resident versus the attending was higher in the pre-2003 period (1.44, 95 % CI 1.28-1.62, p < 0.001) than the post-2003–pre-2011 (reference group). In contrast, the relative risk ratio for naming the resident versus the attending was lower in the post-2011 period (0.79, 95 % CI 0.68-0.93, p = 0.004) compared to the reference group.

CONCLUSIONS

After successive residency duty hours limits, hospitalized patients were more likely to report the attending physician and less likely to report the resident or intern as most involved in their hospital care. Given the importance of experiential learning to the formation of clinical judgment for independent practice, further study on the implications of these trends for resident education and patient safety is warranted.KEY WORDS: resident duty hours, patient perceptions, hospital care     

Control Beliefs and Risk for Death,Stroke and Myocardial Infarction in Middle-aged and Older Adults: An Observational Study

Background

Chronic health conditions account for the largest proportion of illness-related mortality and morbidity as well as most of healthcare spending in the USA. Control beliefs may be important for outcomes in individuals with chronic illness.

Objective

To determine whether control beliefs are associated with the risk for death, incident stroke and incident myocardial infarction (MI), particularly for individuals with diabetes mellitus (DM) and/or hypertension.

Design

Retrospective cohort study.

Participants

A total of 5,662 respondents to the Health and Retirement Study with baseline health, demographic and psychological data in 2006, with no history of previous stroke or MI.

Main Measures

Perceived global control, measured as two dimensions—“constraints” and “mastery”—and health-specific control were self-reported. Event-free survival was measured in years, where “event” was the composite of death, incident stroke and MI. Year of stroke or MI was self-reported; year of death was obtained from respondents’ family.

Key Results

Mean baseline age was 66.2 years; 994 (16.7 %) had DM and 3,023 (53.4 %) hypertension. Overall, 173 (3.1 %) suffered incident strokes, 129 (2.3 %) had incident MI, and 465 (8.2 %) died. There were no significant interactions between control beliefs and baseline DM or hypertension in predicting event-free survival. Elevated adjusted hazard ratios (HRs) were associated with DM (1.33, 95 % CI 1.07–1.67), hypertension (1.31, 95 % CI 1.07–1.61) and perceived constraints in the third (1.55, 95 % CI 1.12–2.15) and fourth quartiles (1.61, 95 % CI 1.14–2.26). Health-specific control scores in the third (HR 0.78, 95 % CI 0.59–1.03) and fourth quartiles (HR 0.70, 95 % CI 0.53–0.92) were protective, but only the latter category had a statistically significant decreased risk. Combined high perceived constraints and low health-specific control had the highest risk (HR 1.93, 95 % CI 1.41–2.64).

Conclusions

Control beliefs were not associated with differential risk for those with DM and/or hypertension, but they predicted significant differences in event-free survival for the general cohort.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3275-9) contains supplementary material, which is available to authorized users.KEY WORDS: control beliefs, mortality, cardiovascular risk     

Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial

BACKGROUND

Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve.

OBJECTIVE

We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans.

DESIGN

This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans.

PARTICIPANTS

Homeless Veterans not receiving primary care participated in the study.

INTERVENTIONS

An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented.

MAIN MEASURE

We measured receipt of primary care within 4 weeks of study enrollment.

KEY RESULTS

Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6 % were male, 43.0 % were from a minority population, 12.0 % were unsheltered, 25.5 % were staying in a dusk-to-dawn emergency shelter, 26.1 % were in transitional housing, while 27.7 % were in an unstable, doubled-up arrangement. At one month, 77.3 % of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7 % had been seen in primary care. This was followed by the CO-only group, 50.0 % of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0 % and the Usual Care arm at 30.6 %. Chi-squared tests by group were significant (p < 0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care.

CONCLUSIONS

Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.KEY WORDS: homeless persons, patient engagement, community outreach, Veterans     

Diagnosis and Treatment of Incident Hypertension Among Patients with Diabetes: a U.S. Multi-Disciplinary Group Practice Observational Study

BACKGROUND

Early hypertension control reduces the risk of cardiovascular complications among patients with diabetes mellitus. There is a need to improve hypertension management among patients with diabetes mellitus.

OBJECTiVE

We aimed to evaluate rates and associations of hypertension diagnosis and treatment among patients with diabetes mellitus and incident hypertension.

DESIGN

This was a 4-year retrospective analysis of electronic health records.

PARTICIPANTS

Adults ≥18 years old (n = 771) with diabetes mellitus, who met criteria for incident hypertension and received primary care at a large, Midwestern academic group practice from 2008 to 2011 were included

MAIN MEASURES

Cut-points of 130/80 and 140/90 mmHg were used to identify incident cases of hypertension. Kaplan-Meier analysis estimated the probability of receiving: 1) an initial hypertension diagnosis and 2) antihypertensive medication at specific time points. Cox proportional-hazard frailty models (HR; 95 % CI) were fit to identify associations of time to hypertension diagnosis and treatment.

KEY RESULTS

Among patients with diabetes mellitus who met clinical criteria for hypertension, 41 % received a diagnosis and 37 % received medication using the 130/80 mmHg cut-point. At the 140/90 mmHg cut-point, 52 % received a diagnosis and 49 % received medication. Atrial fibrillation (HR 2.18; 1.21–4.67) was associated with faster diagnosis rates; peripheral vascular disease (HR 0.18; 0.04–0.74) and fewer primary care visits (HR 0.93; 0.88–0.98) were associated with slower diagnosis rates. Atrial fibrillation (HR 3.07; 1.39–6.74) and ischemic heart disease/congestive heart failure (HR 2.16; 1.24–3.76) were associated with faster treatment rates; peripheral vascular disease (HR 0.16; 0.04–0.64) and fewer visits (HR 0.93; 0.88–0.98) predicted slower medication initiation. Diagnosis and treatment of incident hypertension were similar using cut-points of 130/80 and 140/90 mmHg.

CONCLUSIONS

Among patients with diabetes mellitus, even using a cut-point of 140/90 mmHg, approximately 50 % remained undiagnosed and untreated for hypertension. Future interventions should target patients with multiple comorbidities to improve hypertension and diabetes clinical care.KEY WORDS: hypertension, diabetes mellitus, diagnosis, electronic health records     

The effect of weekend versus weekday admission on outcomes of esophageal variceal hemorrhage

BACKGROUND

Hospital staffing is often lower on weekends than weekdays, and may contribute to higher mortality in patients admitted on weekends. Because esophageal variceal hemorrhage (EVH) requires complex management and urgent endoscopic intervention, limitations in physician expertise and the availability of endoscopy on weekends may be associated with increased EVH mortality.

OBJECTIVE

To assess the differences in mortality, hospital length of stay (LOS), and costs between patients admitted on weekends versus patients who were admitted on weekdays.

METHODS

The United States Nationwide Inpatient Sample database was used to identify patients hospitalized for EVH between 1998 and 2005. Differences in mortality, LOS, and costs between patients admitted on weekends and weekdays were evaluated using regression models with adjustment for patient and clinical factors, including the timing of endoscopy.

RESULTS

Between 1998 and 2005, 36,734 EVH admissions to 2207 hospitals met the inclusion criteria. Compared with patients admitted on weekdays, individuals admitted on the weekend were slightly less likely to undergo endoscopy on the day of admission (45% versus 43%, respectively; P=0.01) and by the second day (81% versus 75%; P<0.0001). However, mortality (11.3% versus 10.8%; P=0.20) and the requirement for endoscopic therapy (70% versus 69%; P=0.08) or portosystemic shunt insertion (4.4% versus 4.7%; P=0.32) did not differ between weekend and weekday admissions. After adjusting for confounding factors, including the timing of endoscopy, the risk of mortality was similar between weekend and weekday admissions (OR 1.05; 95% CI 0.97 to 1.14). Although LOS was similar between groups, adjusted hospital charges were 4.0% greater (95% CI 2.3 to 5.8%) for patients hospitalized on the weekend.

CONCLUSIONS

In patients with EVH, admission on the weekend is associated with a small delay in receiving endoscopic intervention, but no difference in mortality or the requirement for portosystemic shunt insertion. The weekend effect observed for some medical and surgical conditions does not apply to patients with EVH.     

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Background

Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions.

Objective

To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases.

Design

The study was designed as a patient-level randomized controlled trial.

Participants

Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5 %) but could have well-controlled HTN.

Interventions

All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention).

Main Outcomes and Measures

Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point.

Results

Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD = 1 %) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention – control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (−0.3, 0.5), p = 0.51] and SBP [diff = −0.9 mmH g, 95% CI (−5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points.

Conclusions

In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.KEY WORDS: Diabetes, Hypertension, Implementation     

Cognitive Function and Health Literacy Decline in a Cohort of Aging English Adults

BACKGROUND

Low health literacy is common among aging patients and is a risk factor for morbidity and mortality. We aimed to describe health literacy decline during aging and to investigate the roles of cognitive function and decline in determining health literacy decline.

METHODS

Data were from 5,256 non-cognitively impaired adults aged ≥ 52 years in the English Longitudinal Study of Ageing. Health literacy was assessed using a four-item reading comprehension assessment of a fictitious medicine label, and cognitive function was assessed in a battery administered in-person at baseline (2004–2005) and at follow-up (2010–2011).

RESULTS

Overall, 19.6 % (1,032/5,256) of participants declined in health literacy score over the follow-up. Among adults aged ≥ 80 years at baseline, this proportion was 38.2 % (102/267), compared to 14.8 % (78/526) among adults aged 52–54 years (OR = 3.21; 95 % CI: 2.26–4.57). Other sociodemographic predictors of health literacy decline were: male sex (OR = 1.20; 95 % CI: 1.04–1.38), non-white ethnicity (OR = 2.42; 95 % CI: 1.51–3.89), low educational attainment (OR = 1.58; 95 % CI: 1.29–1.95 for no qualifications vs. degree education), and low occupational class (OR = 1.67; 95 % CI: 1.39–2.01 for routine vs. managerial occupations). Higher baseline cognitive function scores protected against health literacy decline, while cognitive decline (yes vs. no) predicted decline in health literacy score (OR = 1.59; 95 % CI: 1.35–1.87 for memory decline and OR = 1.56; 95 % CI: 1.32–1.85 for executive function decline).

CONCLUSIONS

Health literacy decline appeared to increase with age, and was associated with even subtle cognitive decline in older non-impaired adults. Striking social inequalities were evident, whereby men and those from minority and deprived backgrounds were particularly vulnerable to literacy decline. Health practitioners must be able to recognize limited health literacy to ensure that clinical demands match the literacy skills of diverse patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3206-9) contains supplementary material, which is available to authorized users.KEY WORDS: health literacy, cognition, aging, epidemiology     

Pre-transplant portal vein thrombosis is an independent risk factor for graft loss due to hepatic artery thrombosis in liver transplant recipients

Background

Hepatic artery thrombosis is an uncommon but catastrophic complication following liver transplantation. We hypothesize that recipients with portal vein thrombosis are at increased risk.

Methods

Data on all liver transplants in the U.S. during the MELD era through September 2014 were obtained from UNOS. Status one, multivisceral, living donor, re-transplants, pediatric recipients and donation after cardiac death were excluded. Logistic regression models were constructed for hepatic artery thrombosis with resultant graft loss within 90 days of transplantation.

Results

63,182 recipients underwent transplantation; 662 (1.1%) recipients had early hepatic artery thrombosis; of those, 91 (13.8%) had pre-transplant portal vein thrombosis, versus 7.5% with portal vein thrombosis but no hepatic artery thrombosis (p < 0.0001). Portal vein thrombosis was associated with an increased independent risk of hepatic artery thrombosis (OR 2.17, 95% CI 1.71–2.76, p < 0.001) as was donor risk index (OR 2.02, 95% CI 1.65–2.48, p < 0.001). Heparin use at cross clamp, INR, and male donors were all significantly associated with lower risk.

Discussion

Pre-transplant portal vein thrombosis is associated with post-transplant hepatic artery thrombosis independent of other factors. Recipients with portal vein thrombosis might benefit from aggressive coagulation management and careful donor selection. More research is needed to determine causal mechanism.     

Role-Modeling Cost-Conscious Care—A National Evaluation of Perceptions of Faculty at Teaching Hospitals in the United States

BACKGROUND

Little is known about how well faculty at teaching hospitals role-model behaviors consistent with cost-conscious care.

OBJECTIVE

We aimed to evaluate whether residents and program directors report that faculty at their program consistently role-model cost-conscious care, and whether the presence of a formal residency curriculum in cost-conscious care impacted responses.

DESIGN

Cost-conscious care surveys were administered to internal medicine residents during the 2012 Internal Medicine In-Training Examination and to program directors during the 2012 Association of Program Directors in Internal Medicine Annual Survey. Respondents stated whether or not they agreed that faculty in their program consistently role-model cost-conscious care. To evaluate a more comprehensive assessment of faculty behaviors, resident responses were matched with those of the director of their residency program. A multivariate logistic regression model was fit to the outcome variable, to identify predictors of responses that faculty do consistently role-model cost-conscious care from residency program, resident, and program director characteristics.

PARTICIPANTS

Responses from 12,623 residents (58.4 % of total sample) and 253 program directors (68.4 %) from internal medicine residency programs in the United States were included.

MAIN MEASURES

The primary outcome measure was responses to questionnaires on faculty role-modeling cost-conscious care.

KEY RESULTS

Among all responses in the final sample, 6,816 (54.0 %) residents and 121 (47.8 %) program directors reported that faculty in their program consistently role-model cost-conscious care. Among paired responses of residents and their program director, the proportion that both reported that faculty do consistently role-modeled cost-conscious care was 23.0 % for programs with a formal residency curriculum in cost-conscious care, 26.3 % for programs working on a curriculum, and 23.7 % for programs without a curriculum. In the adjusted model, the presence of a formal curriculum in cost-conscious care did not have a significant impact on survey responses (odds ratio [OR], 1.04; 95 % Confidence Interval [CI], 0.52–2.06; p value [p] = 0.91).

CONCLUSIONS

Responses from residents and program directors indicate that faculty at US teaching hospitals were not consistently role-modeling cost-conscious care. The presence of a formal residency curriculum in cost-conscious care did not impact responses. Future efforts should focus on placing more emphasis on faculty development and on combining curricular improvements with institutional interventions to adapt the training environment.KEY WORDS: cost-conscious care, high-value , role-modeling, resident, program director, residency program, teaching hospitals, faculty, medical education     

Increased Risk of Mortality among Patients Cared for by Physicians with Short Length-of-Stay Tendencies

Background

Since the introduction of the prospective payment system in 1983, U.S. hospitals have been financially incentivized to reduce inpatient length of stay, and average length of stay has shortened dramatically.

Objective

The purpose of this study was to determine whether short length of stay is associated with worse patient outcomes.

Design

We used a quasi-experimental design to compare the outcomes of admissions assigned to physicians with short versus long length-of-stay tendencies. We used each physician’s mean length of stay to define their length of stay tendency. We then compared the outcomes of admissions assigned to physicians with short versus long length-of-stay tendencies in propensity score-matched and adjusted analyses using mixed-effects and conditional logistic regression models.

Patients

The study included all admissions for 10 common diagnoses among patients admitted to the medical teaching service of an urban academic hospital from 7/1/2002 through 6/30/2008.

Main Measure

The primary outcome was 30-day mortality.

Results

We examined 12,341 admissions among 79 physicians. After propensity score matching, admission groups were similar with respect to all demographic and clinical characteristics. Admissions of patients receiving care from short length-of-stay physicians were associated with significantly increased risk of 30-day mortality in adjusted (OR 1.43, 95 % CI: 1.11–1.85), propensity score-matched (OR 1.33, 95 % CI: 1.08–1.63), and matched and adjusted analyses (OR 1.36, 95 % CI: 0.98–1.90).

Conclusions

Policies that incentivize short length of stay may lead to worse patient outcomes. The financial benefits of shortening inpatient length of stay should be weighed against the potential harm to patients.KEY WORDS: Hospital economics, Incentives, Outcomes, Health services