Journal of hospital medicine最新文献

Background: A systematic tool to identify hospitalized patients with high mortality risk may be beneficial for targeting palliative care to those in greatest need.

Objective: Evaluate the performance of the End-of-life Index (EOLI; Epic Systems Corporation) in identifying patients at the highest 6-month mortality risk among hospitalized patients with cancer.

Methods: We conducted a retrospective study of adults with cancer admitted to oncology services in a 959-bed hospital between July 1 and December 31, 2023. We evaluated EOLI score performance in determining mortality risk using the area under the receiver operating characteristic curve (AUC). The primary outcome was 6-month mortality for patients with an EOLI score above and below the optimal threshold value. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, intensive care unit (ICU) utilization, palliative care consultation, do-not-resuscitate status on discharge, and discharge disposition.

Results: The EOLI score had moderate accuracy in identifying patients at higher risk of 6-month mortality (AUC: 0.71) with an optimal threshold value of 40. For patients with EOLI > 40 and < 40, the 6-month mortality was 45.9% and 16.3%, respectively (p < .001). Patients with EOLI > 40 had higher ICU utilization (12.4% vs. 6.5%, p = .002) and were more likely to be discharged to a location other than home (13.5% vs. 5.3%; p < .001).

Conclusions: For hospitalized patients with cancer, the EOLI shows moderate accuracy in identifying patients with a high risk of 6-month mortality. As a screening tool, the EOLI can be used to identify patients who may benefit from timely palliative care.

Introduction: Adverse events (AEs) during transitions from hospitals to ambulatory settings occur in 19%-28% of cases, posing a significant threat to patient safety. Early screening for worrisome symptoms and deterioration in overall health is critical for older adult patients with multiple chronic conditions (MCCs). Clinically integrated apps that remotely monitor symptoms and collect patient-reported outcomes (PROs) can predict AEs when combined with electronic health record (EHR) data. This innovative intervention may enable more timely detection, escalation, and mitigation of harm from AEs for patients with MCCs during transitions.

Methods: This remote monitoring intervention leverages evidence-based frameworks for care transitions and health technologies. We will develop and validate a prediction model of postdischarge AEs using validated symptoms, PRO questionnaires, and EHR data. Existing digital infrastructure will be adapted to facilitate remote monitoring. We will employ a user-centered approach to identify patient and clinician requirements to guide the design and development of our intervention. Interoperable data exchange standards and application programming interfaces will be utilized to integrate the intervention with vendor EHRs and patient portals. A randomized controlled trial will be conducted to compare the effect of our intervention versus usual care on postdischarge AEs in MCC patients transitioning from the hospital. A mixed-methods evaluation will be performed to generate best practices for disseminating this intervention at institutions with different EHRs.

Discussion: A patient-centric, digitally enabled surveillance strategy that monitors symptoms and electronic PROs, educates patients about risks, and ensures communication with clinicians has the potential to transform care for patients with MCCs during transitions.

Background: Sarcopenia, characterized by age-related loss of muscle mass and function, significantly impacts the quality of life of older adults. This condition is prevalent among elderly patients with hip fractures.

Objective: To investigate the association of sarcopenia and sarcopenic obesity with mortality and length of hospital stay in patients admitted for hip fracture. Additionally, this study aims to investigate possible risk factors associated with higher mortality rates in the same patient groups.

Methods: A retrospective cohort study was conducted involving patients aged 60 and older who underwent hip fracture surgery between February 2019 and April 2023 at a single tertiary care hospital. Sarcopenia was defined using appendicular skeletal muscle mass index (ASMI) and psoas muscle index values derived from preoperative computed tomography scans. Patients were categorized into sarcopenic, sarcopenic obese, and non-sarcopenic groups. Primary outcomes included 1-year mortality, and secondary outcomes included hospital stay duration. Cox regression and binary logistic regression analyses were performed, adjusting for potential confounders including age, sex, and comorbidities.

Results: The study included 311 patients (mean age 79.7 years). After adjustment for confounders, sarcopenia, as defined by ASMI, was associated with a higher 1-year mortality risk (hazard ratio [HR]: 1.80, 95% confidence interval [CI]: 1.04-3.13, p = .034). Sarcopenic obesity further increased mortality risk (HR: 2.68, 95% CI: 1.10-2.57, p = .016). Sarcopenia alone was not significantly associated with prolonged hospital stays after adjustment.

Conclusions: Sarcopenia remained independently associated with mortality in patients with hip fractures after adjustment for various factors. Sarcopenic obesity was associated with a higher risk of mortality than sarcopenia alone. These findings underscore the prognostic significance of sarcopenia in this vulnerable population.

Background: Transitioning from hospital to home is fraught with anxiety and risk, as patients and family members assume responsibility for caring for themselves.

Objectives: We aimed to explore patients' experiences with reading their discharge summaries and the impact of having this information during the posthospitalization period. We focus on opportunities to address common concerns-such as medication changes, follow-up steps, and documentation errors.

Methods: An email-based survey of hospitalized patients with portal accounts discharged to home was conducted between May 2022 and February 2023 at two academic health care centers in Boston, MA. We used qualitative and quantitative methods to analyze closed-ended and free-text survey responses. The primary outcomes were patient concerns about medications and the next steps.

Results: Three hundred and ninety-two patients responded (hospital 1 = 321, response rate [RR] = 19.5%; hospital 2 = 71, RR = 4.9%). Patients reported positive effects of reading their discharge summary, including understanding the reason for hospitalization (66.9%) and next steps in managing their care (72.1%), and knowing how to take their medications (74%). Five percent reported a concern about taking a medication and 9.4% had a concern about next steps. In qualitative analysis of patient-reported concerns, the most commonly noted were related to explanations and next steps.

Conclusions: Rapidly spreading information transparency could transform how patients engage in care and communicate with clinicians. Patients and families report benefits from reading discharge summaries; however, over a quarter reported a concern. More work is needed in the inpatient arena to understand how to capitalize on data transparency in a way that benefits patients, families, clinicians, and organizations.

Increasing clinical demands and a reduction in traditional teaching opportunities at academic medical centers threaten the ability of hospitalists to participate in their institution's educational mission. Hospitalists with teaching as part of their career focus benefit from faculty development or the creation of teaching activities to stimulate interest in academic medicine and overcome pre-existing barriers to education. Our large, multi-site hospital medicine division sought to engage hospitalists from various practice settings in educational opportunities to expand their skill sets as teachers. An Education Council introduced seven initiatives embedded with educator roles for faculty: clinicopathological conference, clinical vignette competition, Grand Rounds, peer observation of teaching, teaching competition, visiting professorship, and ward teacher workshop. Program opportunities generated directorships, faculty, and peer development roles. Multimodal assessment demonstrated increased attendance, evaluations, recognition, scholarship, and events over time. This innovative heptad of faculty educational opportunities within an academic hospital medicine program is feasible, effective, and scalable.

Background: It is widely accepted that corticosteroids cause leukocytosis. Clinicians must decide whether a rise in white blood cell (WBC) count is due to steroids versus other processes like developing infection.

Objective: The objective of this study is to measure the increase in white blood cell count after corticosteroid administration in hospitalized patients without malignancy, infection, or immune dysfunction.

Methods: This is a retrospective cohort study from 2017 to 2018 in a single large healthcare system. We analyzed the trajectory of WBC count stratified by steroid dose. The study included nonsurgical patients admitted with at least two complete blood count measurements. Patients were excluded if they had immunosuppression, infection, malignancy, or steroid use within 2 weeks before admission. The main outcome was mean WBC count by day following corticosteroid administration.

Results: Our sample included 28,425 patients with at least two WBC measurements, 1608 (5.7%) of which received steroids. WBC response peaked at 48 h after steroid administration with a mean increase of 2.4 × 10⁹/L WBCs. In all patients on steroids, across doses, the mean increase was 0.3 × 10⁹/L WBCs, 1.7 × 10⁹/L WBCs, and 4.84 × 10⁹/L WBCs in low, medium, and high dose groups, respectively. For patients not on steroids, the mean WBC count decreased during hospitalization.

Conclusions: When interpreting WBC counts after initiating steroids, increases of up to 4.84 × 10⁹/L cells may be seen within 48 h after high-dose steroids. Larger increases, and any increase after low-dose steroids, suggest other causes of leukocytosis.