Faculty Bibliography

BACKGROUND: The transition of care from hospital to home is a vulnerable time. Prior studies indicate that the amount of discharge education and anticipatory guidance that patients may receive vary widely. Suboptimal understanding of the care plan can lead to posthospitalization morbidity and readmissions. Our aim was to identify the multiple patient-, provider-, and hospital system-level factors that contribute to the quality of discharge education a patient receives prior to discharge. Direct observation on the day of discharge can help inform contributors to inequities in the patient's discharge education experience.
METHOD(S): Purposeful sampling was used to select patients designated for discharge by noon. On the day of discharge, a trained medical student sat at the bedside of a single patient from 6am until time of discharge, and documented all communication between the patient and the healthcare team. Field notes were analyzed by three independent reviewers using a constant comparison method to identify the patient-, provider- and system-level themes that played a factor into the quality of patient education received in the discharge observations.
RESULT(S): We conducted over 150 hours of observation of 30 patients' discharge days across two academic hospitals. On the patient level, we found that patients with previous hospitalizations and thus, familiarity with the hospital discharge process engaged in more question-asking and in turn, received more in-depth education to prepare them for the next care setting. This "hospital literacy" was even more paramount when patients had a previous suboptimal care transition experience, and emerged as a consistent theme of self-advocacy, more so than one's race, perceived health literacy, or the presence of a caregiver. At the provider level, healthcare teams that were focused on pending tests or outstanding consult recommendations provided less comprehensive discharge education since conversations centered on the logistics of that pending factor. The system level factors contributing to less discharge education included patient discharge to a subacute rehabilitation center or discharge over a weekend.
CONCLUSION(S): Understanding the multi-level factors that contribute to the quality of patient discharge education can alert the healthcare team to patients at risk of suboptimal care transitions. Ensuring that our patients exit the hospital with an equitable quality of information, ready to manage their health in the next care setting, will require interventions at every level

BACKGROUND: Safely and effectively discharging a patient from the hospital requires working within a multidisciplinary team. However, with multiple stakeholders responsible for the discharge and competing clinical duties, diffusion of responsibility may result in relinquished ownership, particularly as mandated administrative discharge tasks are often prioritized over taking the time to communicate discharge plans with patients. Residents are uniquely positioned to offer insight on the workings of multidisciplinary teams at discharge, since residents play a central role in the transitions of care process within academic hospital systems. Learning from residents' perspectives on discharge roles and responsibilities can shed light on gaps in order to improve accountability to the patient and increase communication efficacy among team members.
METHOD(S): Internal Medicine residents at 7 academic institutions completed a cross-sectional survey that asked them who they felt was primarily responsible to perform discharge education with patients, and at what frequency they themselves completed six key discharge communication practices with patients. Using multiple linear regression, we examined the relationship between who residents report is primarily responsible for discharge education and their own reported proportion of communication practice domains done frequently (>60% of time). We used content analysis to assess free response comments on ways in which discharge multidisciplinary team communication could be improved.
RESULT(S): Among the 613/966 resident responses (62% response rate), 35% reported they were not sure which member of the multidisciplinary team is primarily responsible for discharge education with patients If residents believed educating patients at discharge was the primary responsibility of the intern, that resident had a 19.5% (95% CI 13.2%, 25.9%) higher proportion of reported discharge communication domains addressed frequently versus those that were not sure who was responsible. To improve multidisciplinary discharge communication, residents called for explicit expectations among team members: 1) What should be communicated to the patient and by whom? 2) How do we communicate discharge plans effectively to each other? 3) What kind of discharge culture allows the patient and care team to thrive?
CONCLUSION(S): Residents report lack of clarity on who is responsible for key patient communication practices at discharge. This diffusion of ownership impacts how much residents invest in patient education, with more perceived responsibility associated with more key discharge communication practices reportedly done on a regular basis. Our results suggest we need to create and explicitly operate under a shared mental model of each team player's responsibility for communication to the patient, to each other and examine the hospital system's priorities and incentives and its impact of the discharge culture

BACKGROUND: Hospital discharge is a vulnerable time for patients, which can lead to adverse outcomes and hospital readmissions. Suboptimal communication with patients and their caregivers, as well as inadequate understanding of post-discharge plans contribute to readmissions. Prior health services research and national society guidelines have identified key components to be addressed with patients on the day of discharge. Yet, we don't know whether residents are using these best practices, or if existing transitions of care curricula are effective in fostering these practices. Critically assessing types of educational instruction and communication practices residents report using at discharge is critical to informing how we train physicians to be transitions of care champions within our fragmented healthcare system.
METHOD(S): Internal Medicine residents at seven large academic medical centers completed a cross- sectional survey characterizing the types of education on transitions of care they received and the self- reported frequency of using six communication practices at discharge. We calculated the proportion of each communication domain done frequently (>60% of the time) for each respondent. Using multiple linear regression, we explored which types of educational exposures were associated with residents using best communication practices frequently. A content analysis was done to examine a free-response question on which factors residents reported as motivation for changing their discharge practices.
RESULT(S): The response rate was 63% (613/966). The majority of residents (82.3%) received some form of instruction around transitions of care, although only about one in five (18.9%) reported being observed and getting feedback on their discharge education with patients. Resident discharge communication practices were variable, with less than half of residents reporting frequently addressing symptom expectations or selfmanagement of disease. Notably, less than a fifth of residents (17.0%) reported routinely asking patients to teach back their understanding of the discharge plans. Workplace-based learning, such as explicit teaching on rounds and direct observation and feedback on discharge education, was associated with increased proportion of discharge communication practices reported being done frequently. In open-ended comments, residents pointed to adverse events after the post-discharge continuum as their impetus for practice change.
CONCLUSION(S): This study exposes the gaps in resident discharge communication practices with patients, the impact of adverse events as a source of hidden curriculum, and the benefits of workplace-based training on discharge communication skills. Our results suggest that developing faculty to incorporate transitions of care in their rounds teaching and integrating experiences across the post-discharge continuum will foster systems-minded physicians-in-training

OBJECTIVE:To describe outcomes of people admitted to hospital with coronavirus disease 2019 (covid-19) in the United States, and the clinical and laboratory characteristics associated with severity of illness. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Single academic medical center in New York City and Long Island. PARTICIPANTS/METHODS:5279 patients with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection between 1 March 2020 and 8 April 2020. The final date of follow up was 5 May 2020. MAIN OUTCOME MEASURES/METHODS:Outcomes were admission to hospital, critical illness (intensive care, mechanical ventilation, discharge to hospice care, or death), and discharge to hospice care or death. Predictors included patient characteristics, medical history, vital signs, and laboratory results. Multivariable logistic regression was conducted to identify risk factors for adverse outcomes, and competing risk survival analysis for mortality. RESULTS:Of 11 544 people tested for SARS-Cov-2, 5566 (48.2%) were positive. After exclusions, 5279 were included. 2741 of these 5279 (51.9%) were admitted to hospital, of whom 1904 (69.5%) were discharged alive without hospice care and 665 (24.3%) were discharged to hospice care or died. Of 647 (23.6%) patients requiring mechanical ventilation, 391 (60.4%) died and 170 (26.2%) were extubated or discharged. The strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% confidence interval 26.1 to 56.0) for ages 75 years and older. Other risks were heart failure (4.4, 2.6 to 8.0), male sex (2.8, 2.4 to 3.2), chronic kidney disease (2.6, 1.9 to 3.6), and any increase in body mass index (BMI) (eg, for BMI >40: 2.5, 1.8 to 3.4). The strongest risks for critical illness besides age were associated with heart failure (1.9, 1.4 to 2.5), BMI >40 (1.5, 1.0 to 2.2), and male sex (1.5, 1.3 to 1.8). Admission oxygen saturation of <88% (3.7, 2.8 to 4.8), troponin level >1 (4.8, 2.1 to 10.9), C reactive protein level >200 (5.1, 2.8 to 9.2), and D-dimer level >2500 (3.9, 2.6 to 6.0) were, however, more strongly associated with critical illness than age or comorbidities. Risk of critical illness decreased significantly over the study period. Similar associations were found for mortality alone. CONCLUSIONS:Age and comorbidities were found to be strong predictors of hospital admission and to a lesser extent of critical illness and mortality in people with covid-19; however, impairment of oxygen on admission and markers of inflammation were most strongly associated with critical illness and mortality. Outcomes seem to be improving over time, potentially suggesting improvements in care.

Background We sought to examine whether people with a diagnosis of cardiovascular disease (CVD) experienced a greater incidence of subsequent cognitive impairment (CI) compared to people without CVD, as suggested by prior studies, using a large longitudinal cohort. Methods We used biennial data collected on adults age >=50 from the Health and Retirement Study (HRS) to compare the incidence of CI over 8 years in 1,931 participants newly diagnosed with CVD vs. 3,862 age- and gender-matched controls. Diagnosis of CVD was adjudicated with an established HRS methodology. CI was defined as <=11 on the 27-point Telephone Interview for Cognitive Status, based on a previously accepted clinical cutpoint. To examine the incidence of CI, we used a cumulative incidence function accounting for competing risk of death. Results Mean age at study entry was 70 years, and 55% were female. CI developed in 1,335 participants over 8 years. Death was more common among participants with incident CVD (20.4% vs. 13.4%, p <.001). Cumulative incidence analysis for CI, after adjusting for death, showed no significant difference in incidence of cognitive impairment between the CVD and control groups at the end of the study period (Figure). Conclusion We found no increased risk of subsequent cognitive impairment among participants with CVD (compared with no CVD), despite previous research indicating that CVD accelerates cognitive decline. This finding may be due to appropriately accounting for the competing risk of death. [Figure presented]
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OBJECTIVE. The purpose of this study is to assess the perceptions of radiologists and emergency medicine (EM) providers regarding the quality, value, and challenges associated with using outside imaging (i.e., images obtained at facilities other than their own institution). MATERIALS AND METHODS. We surveyed radiologists and EM providers at a large academic medical center regarding their perceptions of the availability and utility of outside imaging. RESULTS. Thirty-four of 101 radiologists (33.6%) and 38 of 197 EM providers (19.3%) responded. A total of 32.4% of radiologists and 55.3% of EM providers had confidence in the quality of images from outside community facilities; 20.6% and 44.7%, respectively, had confidence in the interpretations of radiologists from these outside facilities. Only 23.5% of radiologists and 5.3% of EM physicians were confident in their ability to efficiently access reports (for outside images, 47.1% and 5.3%). Very few radiologists and EM providers had accessed imaging reports from outside facilities through an available stand-alone portal. A total of 40.6% of radiologists thought that outside reports always or frequently reduced additional imaging recommendations (62.5% for outside images); 15.6% thought that reports changed interpretations of new examinations (37.5% for outside images); and 43.8% thought that reports increased confidence in interpretations of new examinations (75.0% for outside images). A total of 29.4% of EM providers thought that access to reports from outside facilities reduced repeat imaging (64.7% for outside images), 41.2% thought that they changed diagnostic or management plans (50.0% for outside images), and 50.0% thought they increased clinical confidence (67.6% for outside images). CONCLUSION. Radiologists and EM providers perceive high value in sharing images from outside facilities, despite quality concerns. Substantial challenges exist in accessing these images and reports from outside facilities, and providers are unlikely to do so using separate systems. However, even if information technology solutions for seamless image integration are adopted, providers' lack of confidence in outside studies may remain an important barrier.

The past decade has seen a growing recognition of the importance of social determinants of health for health outcomes. However, the degree to which US health systems are directly investing in community programs to address social determinants of health as opposed to screening and referral is uncertain. We searched for all public announcements of new programs involving direct financial investments in social determinants of health by US health systems from January 1, 2017, to November 30, 2019. We identified seventy-eight unique programs involving fifty-seven health systems that collectively included 917 hospitals. The programs involved at least $2.5 billion of health system funds, of which $1.6 billion in fifty-two programs was specifically committed to housing-focused interventions. Additional focus areas were employment (twenty-eight programs, $1.1 billion), education (fourteen programs, $476.4 million), food security (twenty-five programs, $294.2 million), social and community context (thirteen programs, $253.1 million), and transportation (six programs, $32 million). Health systems are making sizable investments in social determinants of health.