Faculty Bibliography

Purpose/UNASSIGNED:To evaluate pulmonary embolism (PE) prevalence at CT pulmonary angiography in patients testing positive for coronavirus disease 2019 (COVID-19) and factors associated with PE severity. Materials and Methods/UNASSIGNED:value < .05 was considered significant. Results/UNASSIGNED:< .001). One additional patient with negative results at CT pulmonary angiography had deep venous thrombosis, thus resulting in 38.7% with PE or deep venous thrombosis, despite 40% receiving prophylactic anticoagulation. Other factors did not demonstrate significant PE association. Conclusion/UNASSIGNED:© RSNA, 2020.

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

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

Importance/UNASSIGNED:Black and Hispanic populations have higher rates of coronavirus disease 2019 (COVID-19) hospitalization and mortality than White populations but lower in-hospital case-fatality rates. The extent to which neighborhood characteristics and comorbidity explain these disparities is unclear. Outcomes in Asian American populations have not been explored. Objective/UNASSIGNED:To compare COVID-19 outcomes based on race and ethnicity and assess the association of any disparities with comorbidity and neighborhood characteristics. Design, Setting, and Participants/UNASSIGNED:This retrospective cohort study was conducted within the New York University Langone Health system, which includes over 260 outpatient practices and 4 acute care hospitals. All patients within the system's integrated health record who were tested for severe acute respiratory syndrome coronavirus 2 between March 1, 2020, and April 8, 2020, were identified and followed up through May 13, 2020. Data were analyzed in June 2020. Among 11 547 patients tested, outcomes were compared by race and ethnicity and examined against differences by age, sex, body mass index, comorbidity, insurance type, and neighborhood socioeconomic status. Exposures/UNASSIGNED:Race and ethnicity categorized using self-reported electronic health record data (ie, non-Hispanic White, non-Hispanic Black, Hispanic, Asian, and multiracial/other patients). Main Outcomes and Measures/UNASSIGNED:The likelihood of receiving a positive test, hospitalization, and critical illness (defined as a composite of care in the intensive care unit, use of mechanical ventilation, discharge to hospice, or death). Results/UNASSIGNED:Among 9722 patients (mean [SD] age, 50.7 [17.5] years; 58.8% women), 4843 (49.8%) were positive for COVID-19; 2623 (54.2%) of those were admitted for hospitalization (1047 [39.9%] White, 375 [14.3%] Black, 715 [27.3%] Hispanic, 180 [6.9%] Asian, 207 [7.9%] multiracial/other). In fully adjusted models, Black patients (odds ratio [OR], 1.3; 95% CI, 1.2-1.6) and Hispanic patients (OR, 1.5; 95% CI, 1.3-1.7) were more likely than White patients to test positive. Among those who tested positive, odds of hospitalization were similar among White, Hispanic, and Black patients, but higher among Asian (OR, 1.6, 95% CI, 1.1-2.3) and multiracial patients (OR, 1.4; 95% CI, 1.0-1.9) compared with White patients. Among those hospitalized, Black patients were less likely than White patients to have severe illness (OR, 0.6; 95% CI, 0.4-0.8) and to die or be discharged to hospice (hazard ratio, 0.7; 95% CI, 0.6-0.9). Conclusions and Relevance/UNASSIGNED:In this cohort study of patients in a large health system in New York City, Black and Hispanic patients were more likely, and Asian patients less likely, than White patients to test positive; once hospitalized, Black patients were less likely than White patients to have critical illness or die after adjustment for comorbidity and neighborhood characteristics. This supports the assertion that existing structural determinants pervasive in Black and Hispanic communities may explain the disproportionately higher out-of-hospital deaths due to COVID-19 infections in these populations.

BACKGROUND:The environment in which a patient lives influences their health outcomes. However, the degree to which community factors are associated with readmissions is uncertain. OBJECTIVE:To estimate the influence of community factors on the Centers for Medicare & Medicaid Services risk-standardized hospital-wide readmission measure (HWR)-a quality performance measure in the U.S. RESEARCH DESIGN/METHODS:We assessed 71 community variables in 6 domains related to health outcomes: clinical care; health behaviors; social and economic factors; the physical environment; demographics; and social capital. SUBJECTS/METHODS:Medicare fee-for-service patients eligible for the HWR measure between July 2014-June 2015 (n = 6,790,723). Patients were linked to community variables using their 5-digit zip code of residence. METHODS:We used a random forest algorithm to rank variables for their importance in predicting HWR scores. Variables were entered into 6 domain-specific multivariable regression models in order of decreasing importance. Variables with P-values <0.10 were retained for a final model, after eliminating any that were collinear. RESULTS:Among 71 community variables, 19 were retained in the 6 domain models and in the final model. Domains which explained the most to least variance in HWR were: physical environment (R2 = 15%); clinical care (R2 = 12%); demographics (R2 = 11%); social and economic environment (R2 = 7%); health behaviors (R2 = 9%); and social capital (R2 = 8%). In the final model, the 19 variables explained more than a quarter of the variance in readmission rates (R2 = 27%). CONCLUSIONS:Readmissions for a wide range of clinical conditions are influenced by factors relating to the communities in which patients reside. These findings can be used to target efforts to keep patients out of the hospital.

The COVID-19 pandemic has challenged front-line clinical decision-making, leading to numerous published prognostic tools. However, few models have been prospectively validated and none report implementation in practice. Here, we use 3345 retrospective and 474 prospective hospitalizations to develop and validate a parsimonious model to identify patients with favorable outcomes within 96 h of a prediction, based on real-time lab values, vital signs, and oxygen support variables. In retrospective and prospective validation, the model achieves high average precision (88.6% 95% CI: [88.4-88.7] and 90.8% [90.8-90.8]) and discrimination (95.1% [95.1-95.2] and 86.8% [86.8-86.9]) respectively. We implemented and integrated the model into the EHR, achieving a positive predictive value of 93.3% with 41% sensitivity. Preliminary results suggest clinicians are adopting these scores into their clinical workflows.

OBJECTIVE:<0.001). Rates of adverse events increased with the magnitude of D-dimer elevation; individuals with presenting D-dimer >2000 ng/mL had the highest risk of critical illness (66%), thrombotic event (37.8%), acute kidney injury (58.3%), and death (47%). CONCLUSIONS:Abnormal D-dimer was frequently observed at admission with COVID-19 and was associated with higher incidence of critical illness, thrombotic events, acute kidney injury, and death. The optimal management of patients with elevated D-dimer in COVID-19 requires further study.

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health and mental health of patients one month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 liters of oxygen during admission, had intact baseline cognitive and functional status and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS Dyspnea Characteristics and PROMIS Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs. 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p<0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p <0.001. A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health and mental health for at least several weeks after hospital discharge.