Journal of hospital medicine最新文献

Background: Hospitalists working outside the Veterans Affairs (VA) system frequently will serve Veterans receiving care for acute conditions and/or awaiting transfer to VA facilities.

Objective: To perform a scoping review of health conditions and associated outcomes relevant to hospital medicine in US Veterans who served in active duty or reserve deployed roles after November 9, 2001.

Methods: A search of MEDLINE and Embase was performed using a combination of terms related to military service period and health conditions, yielding 5634 citations published after January 1, 2013.

Study selection and data extraction: Two reviewers performed independent screening at the title/abstract and later at the full-text levels. Conflicts at both stages were resolved through discussion. Single reviewers extracted data and synthesized results into three categories: (1) mental health and nonblast trauma, (2) neurologic outcomes, and (3) other conditions, including cardiovascular and respiratory outcomes.

Results: Of 85 included studies, 19 focused on cardiovascular, respiratory, autoimmune, and multisystem outcomes; 38 focused on mental health and nonblast trauma; and 28 focused on traumatic brain injury and neurologic outcomes. Studies showed high rates of comorbid mental health diagnoses and suicide-related behaviors relative to non-Veteran populations, as well as relatively younger incidence of cardiovascular and respiratory chronic conditions, such as atrial fibrillation.

Conclusions: Most studied health conditions among Veterans of post-9/11 conflicts have focused on areas of particular importance to the VA. However, significant gaps remain, particularly in understanding the correlation between specific exposures and clinical outcomes currently observed and to be anticipated in the future in this population.

Background: Despite the central role of experiential learning in residency training, the actual clinical experiences residents participate in are not well characterized. A better understanding of the type, volume, and variation in residents' clinical experiences is essential to support precision medical education strategies.

Objective: We sought to characterize the entirety of the clinical experiences had by individual internal medicine residents throughout their time in training.

Method: We evaluated the clinical experiences of medicine residents (n = 51) who completed training at NYU Grossman School of Medicine's Brooklyn campus between 2020 and 2023. Residents' inpatient and outpatient experiences were identified using notes written, orders placed, and care team sign-ins; principal ICD-10 codes for each encounter were converted into medical content categories using a previously described crosswalk tool.

Results: Of 152,426 clinical encounters with available ICD-10 codes, 132,284 were mapped to medical content categories (94.5% capture). Residents' clinical experiences were particularly enriched in infectious and cardiovascular disease; most had very little exposure to allergy, dermatology, oncology, or rheumatology. Some trainees saw twice as many cases in a given content area as did others. There was little concordance between actual frequency of clinical experience and expected content frequency on the ABIM certification exam.

Conclusions: Individual residents' clinical experiences in training vary widely, both in number and in type. Characterizing these experiences paves the way for exploration of the relationships between clinical exposure and educational outcomes, and for the implementation of precision education strategies that could fill residents' experiential gaps and complement strengths with targeted educational interventions.

Background: Stigma within the healthcare environment limits access to treatment for opioid use disorder (OUD), even as OUD results in significant morbidity and mortality. Language in clinical documentation affects patient experience and future care through the transmission of stigma or positive regard. With the passage of the 21st Century Cures Act, patients have full access to their medical records online.

Objectives: The objective of our study was to understand providers' use of stigmatizing and affirming language in the electronic health record (EHR) for OUD patients with long hospital stays.

Methods: We selected patients with a first-time referral to the Duke University Hospital OUD consult service who met diagnostic criteria for OUD with a hospital stay ≥28 days from July 2019 to February 2022. Two reviewers independently evaluated each admission and discharge note for stigmatizing or affirming language and the group met weekly to validate coding reliability.

Results: Forty-eight patients (96 notes) met our inclusion criteria. We identified 434 occurrences of stigmatizing and 47 occurrences of affirming language. One-third (34%) of stigmatizing language appeared in system-generated fields (drop-down categories and diagnosis codes) and the rest was authored by providers.

Conclusions: Stigmatizing language was present in both provider- and system-generated language and was nine times more frequent than affirming language in the medical records of hospitalized patients with OUD. While provider education may reduce stigmatizing language, institutional level changes to the EHR and International Classification of Disease codes are necessary to decrease stigmatizing language within medical records.

Background: Despite nationally endorsed treatment guidelines and stewardship programs, variation and deviation from evidence-based antibiotic prescribing occur, contributing to inappropriate use and medication-related adverse events. Measures of antibiotic prescribing variability can aid in quantifying this problem but are not adequate.

Objective: The objective of this study is to develop a standardized metric to quantify antibiotic prescribing variability (diversity) within and across children's hospitals, and to examine its association with outcomes.

Methods: We performed a cross-sectional study of empiric antibiotic exposure among children hospitalized during 2017-2019 with one of 15 common pediatric infections using the Pediatric Health Information System database. Encounters for children with complex chronic conditions, transfers in, and birth hospitalizations were excluded. Using the Shannon-Weiner entropy index, we quantified antibiotic diversity for each infection type using the d-measure of diversity. Generalized linear mixed-effects models were used to examine the association between hospital-level antibiotic diversity and risk-adjusted length of stay and costs.

Results: A total of 79,515 hospitalizations for common pediatric infections were included. Antibiotic diversity varied within and across hospitals. Infections with low mean antibiotic diversity included appendicitis (mean diversity [mDiv] = 4.9, SD = 2.5) and deep neck space infections (mDiv = 5.9, SD = 1.9). Infections with high mean antibiotic diversity included pneumonia (mDiv = 23.4, SD = 5.6) and septicemia/bacteremia (mDiv = 28.5, SD = 12.1). There was no statistically significant association between hospital-level antibiotic diversity and risk-adjusted LOS or costs.

Conclusions: We developed and applied a novel metric to quantify diversity in antibiotic prescribing that permits comparisons across hospitals and can be leveraged to identify high-priority areas for local and national stewardship interventions.