Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:As the COVID-19 pandemic brought surges of hospitalized patients, it was important to focus on reducing overuse of tests and procedures to not only reduce potential harm to patients but also reduce unnecessary exposure to staff. The objective of this study was to create a Choosing Wisely in COVID-19 list to guide clinicians in practicing high-value care at our health system. METHODS:A Choosing Wisely in COVID-19 list was developed in October 2020 by an interdisciplinary High Value Care Council at New York City Health + Hospitals, the largest public health system in the United States. The first phase involved gathering areas of overuse from interdisciplinary staff across the system. The second phase used a modified Delphi scoring process asking participants to rate recommendations on a 5-point Likert scale based on criteria of degree of evidence, potential to prevent patient harm, and potential to prevent staff harm. RESULTS:The top 5 recommendations included avoiding tracheal intubation without trial of noninvasive ventilation (4.4); not placing routine central venous catheters (4.33); avoiding routine daily laboratory tests and batching laboratory draws (4.19); not ordering daily chest radiographs (4.17); and not using bronchodilators in the absence of reactive airway disease (4.13). CONCLUSION/CONCLUSIONS:We successfully developed Choosing Wisely in COVID-19 recommendations that focus on evidence and preventing patient and staff harm in a large safety net system to reduce overuse.

BACKGROUND:While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. OBJECTIVE:We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. DESIGNS, SETTINGS AND PARTICIPANTS/UNASSIGNED:A quality improvement initiative was implemented across 11 safety net hospitals in New York City. INTERVENTION/METHODS:The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed "low risk." Prescribing rates were compared through a three-segment interrupted time series linear regression design. RESULTS:Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p = .38) or over time (slope difference of 0.20 orders per 1000 patient days, p = .08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p = .04) but increased thereafter (slope difference of 0.24, p = .03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.

Similar to the early phases of the COVID-19 pandemic, New York City was the national epicenter of the ongoing 2022 mpox (formerly monkeypox) outbreak. Cases quickly began to rise in July 2022, primarily in gay, bisexual, or other men who have sex with men. Tools in the form of a reliable diagnostic test, an effective vaccine, and a viable treatment option have been available from the onset, although logistically complex to roll out. The special pathogens program at NYC Health + Hospitals/Bellevue, the flagship facility for the largest public hospital system in the United States, collaborated with multiple departments within Bellevue, the hospital system, and the NYC Department of Health and Mental Hygiene, to swiftly establish ambulatory testing, immunizations, patient-centered inpatient care, and outpatient therapeutics. With the ongoing mpox outbreak, hospitals and local health departments must prepare a systemwide response to identify and isolate patients and provide high-quality care. Findings from our experience can help guide institutions in developing a multipronged, comprehensive response to the ongoing mpox outbreak.

BACKGROUND:It is not yet known whether socioeconomic factors (ie, social determinants of health) are associated with readmission following hospitalization for coronavirus disease 2019 (COVID-19). METHODS:We conducted a retrospective cohort study of 6191 adult patients hospitalized with COVID-19 in a large New York City safety-net hospital system between March 1 and June 1, 2020. Associations between 30-day readmission and selected demographic characteristics, socioeconomic factors, prior health care utilization, and relevant features of the index hospitalization were analyzed using a multivariable generalized estimating equation model. RESULTS:The readmission rate was 7.3%, with a median of 7 days between discharge and readmission. The following were risk factors for readmission: age 65 and older [adjusted odds ratio (aOR): 1.32; 95% confidence interval (CI): 1.13-1.55], history of homelessness, (aOR: 2.03 95% CI: 1.49-2.77), baseline coronary artery disease (aOR: 1.68; 95% CI: 1.34-2.10), congestive heart failure (aOR: 1.34; 95% CI: 1.20-1.49), cancer (aOR: 1.68; 95% CI: 1.26-2.24), chronic kidney disease (aOR: 1.74; 95% CI: 1.46-2.07). Patients' sex, race/ethnicity, insurance, and presence of obesity were not associated with increased odds of readmission. A longer length of stay (aOR: 0.98; 95% CI: 0.97-1.00) and use of noninvasive supplemental oxygen (aOR: 0.68; 95% CI: 0.56-0.83) was associated with lower odds of readmission. Upon readmission, 18.4% of patients required intensive care, and 13.7% expired. CONCLUSION:We have found some factors associated with increased odds of readmission among patients hospitalized with COVID-19. Awareness of these risk factors, including patients' social determinants of health, may ultimately help to reduce readmission rates.

Statement of Problem Or Question (One Sentence): Is enrollment in a Care Transitions Program (CTP) associated with decrease in 90-day hospital admissions compared to standard discharge care for high utilizers in a large safety-net city hospital? Objectives of Program/Intervention (No More Than Three Objectives): 1. Implement a team to follow high-utilizers for 30 days post-discharge; 2. Assess patient needs with a home visit or other face-to-face visit and coordinate care based on needs, and 3. Decrease hospital admissions of high utilizers Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): In a large safety-net hospital, high utilizers were Medicaid-insured or uninsured patients who had four or more admissions in the prior year. Inpatient medical teams made referrals to CTP. In CTP, a multidisciplinary team of a social worker, nurse, community liaison and, at times, a medicine resident followed the patient for 30 days post-discharge. Interventions included medication reconciliation, weekly phone calls, and either a home visit or face-to-face visit at a preferred location for the patient. Eligible high utilizers not referred to CTP received standard discharge follow-up and served as controls in this quasi-experimental study. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We identified all admissions of high-utilizers eligible for CTP enrollment between 4/1/17 and 9/30/17. Patients were categorized as enrolled in CTP, with or without a home or face-to-face visit, or not enrolled in CTP. Changes in 90-day admission rates before and after the eligible admission were compared in the CTP and control groups, with the eligible admission included in the pre-intervention period. Subgroup comparisons were also performed. The decrease in 90-day admission rates across groups were compared using ANOVA. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Of the 358 admissions of eligible high-utilizers, 31% (112) were enrolled in CTP. Of those in CTP, 54% had either a home visit (28) or a face-to-face visit (32). Within control patients, 90-day admission rates fell from 2.90 to 1.26, a decrease of 50.6% (95% CI 39.0%-62.3%). Within CTP patients, admission rates fell from 2.53 to 1.02, a decrease of 54.6% (95% CI 41.0%-67.6%). The difference in 90-day admission reductions between CTP and control groups, 3.7% (95% CI-22.8%-30.2%), was not significant. Per-protocol analysis of the CTP subgroups who had either a home visit or a face-to-face visit showed decreases in 90-day admissions of 68.7% (95% CI 51.2%-86.2%) and 64.0% (95% CI 46.9%-81.1%) respectively. The differences in 90-day admission reductions between CTP patients with home or face-to-face visit vs. controls, 18% (95% CI-13%-49%, p=0.59) and 13.3% (95% CI-17.8%-44.5%, p=0.84) respectively, were not significant. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): The trend towards greater decrease in 90-day admissions for high utilizers that had a home or face-to-face visit suggests that assessing high utilizers in their community environment may improve care for these patients. Given the small sample size and non-randomized allocation, interpretation of the Results is preliminary, and subsequent, randomized, adequately powered study with criteria-based high-utilizer referral to these high-intensity resources is warranted