Faculty Bibliography

Objectives: Discharges against medical advice (AMA) occur when patients leave the hospital prior to a physician-recommended endpoint. It is unknown whether AMA discharges are associated with higher healthcare costs within 30 days of discharge. We examine healthcare costs following a hospital discharge in a commercially insured population.
Method(s): This retrospective cohort study examined individuals aged 18 to 64 with a hospitalization during 2007-2015 from a 10% random sample of enrollees in the IQVIA^TM Adjudicated Health Plan Claims Data. We included individuals with insurance coverage 6 months before and 30 days after their first hospitalization. Individuals with AMA and non-AMA discharges were matched on baseline covariates. Generalized linear models and cost ratios (CR) were used to quantify the association between AMA discharges and 30-day costs. We report CRs overall and by points of service (inpatient, emergency department (ED), physician office, non-physician outpatient encounter (NPOE) and prescription drug fill).
Result(s): Of the 467,746 individuals in the unmatched sample, 2,164 (0.46%) were discharged AMA. Mean (median) costs were 20% (5%) higher in the AMA group compared to the non-AMA group. In the matched sample and relative to those discharged routinely, individuals with an AMA discharge incurred 1.20 times (95% CI: 1.08, 1.34) higher costs. Similarly, individuals with an AMA discharge incurred higher inpatient (CR: 1.71, 95% CI: 1.45, 2.01) and ED (CR: 2.10, 95% CI: 1.84, 2.39) costs within 30 days post-discharge. Conversely, individuals with an AMA discharge incurred lower NPOE (CR: 0.84, 95% CI: 0.74, 0.95) and prescription drug fill (CR: 0.81; 95% CI: 0.73, 0.91) costs. There were no differences in physician office visit costs across the two groups.
Conclusion(s): An AMA discharge is associated with higher 30-day costs compared to those discharged routinely, particularly for acute care services. Future work should determine whether these findings extend to publicly-insured individuals.
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OBJECTIVE:Fibromyalgia (FM) is characterized by pain and fatigue, particularly during physical activity. Transcutaneous electrical nerve stimulation (TENS) activates endogenous pain inhibitory mechanisms. We evaluated if using TENS during activity would improve movement-evoked pain and other patient-reported outcomes in women with FM. METHODS:Participants were randomly assigned to receive active-TENS (n=103), placebo-TENS (n=99) or no-TENS (n=99) and instructed to use it at home 2h/day during activity for 4- weeks. TENS was applied to the lumbar and cervicothoracic regions using a modulated frequency (2-125Hz) at the highest tolerable intensity. Participants rated movement-evoked pain (primary outcome) and fatigue on an 11-point scale before and during application of TENS. Primary and secondary patient-reported outcomes were assessed at randomization and 4weeks. RESULTS:After 4-weeks, the active-TENS group reported a greater reduction in movement-evoked pain and fatigue than placebo-TENS (Pain, Group mean difference(95% CI): -1.0(-1.8, -0.2), p=0.008; Fatigue: -1.4(-2.4, -0.4), p=0.001) and no-TENS groups (Pain: -1.8(-2.6. -1.0), p<0.0001; Fatigue: -1.9(-2.9, -0.9), p=<0.0001). A greater percentage of the active-TENS group reported improvement on the global impression of change when compared to placebo-TENS (70% vs. 31%, p<0.0001) and no-TENS (9%, p<0.0001). There were no TENS-related serious adverse events and less than 5% of participants experienced minor adverse events from TENS. CONCLUSION/CONCLUSIONS:Among women with FM and stable medication, 4-weeks of active-TENS use compared with placebo-TENS or no-TENS resulted in a significant improvement in movement-evoked pain and other clinical outcomes. Further research is needed to examine effectiveness in a real world, pragmatic setting to establish clinical importance of these findings.

BACKGROUND & AIMS:Patients with inflammatory bowel diseases (IBDs) have a high risk of venous thromboembolism (VTE). We assessed the timing and risk factors associated with readmission to the hospital for VTE among patients with IBD. METHODS:We collected data from the Nationwide Readmissions Database on IBD index admissions resulting in readmission to the hospital for VTE within 60 days, from 2010 through 2014. We used univariable and multivariable regression to assess risk factors associated with VTE readmission with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Time to VTE readmission was assessed in 10-day intervals, for up to 90 days. RESULTS:We identified 872,122 index admissions of patients with IBD; 1160 resulted in readmission with VTE. More than 90% of readmissions occurred within 60 days of discharge from the index admission. Factors associated with hospital readmission with VTE included prior VTE, longer length of hospital stay, comorbidities, having a flexible sigmoidoscopy or colonoscopy at index admission, and age older than 18 years. Additional risk factors included Clostridium difficile infection at index admission (aRR, 1.47; 95% CI, 1.17-1.85) and discharge to a skilled nursing facility or intermediate care facility (aRR, 1.39; 95% CI, 1.14-1.70) or discharge with home health services (aRR, 1.65; 95% CI, 1.41-1.94). CONCLUSIONS:Among patients admitted to the hospital with IBD, most readmissions with VTE occur within 60 days of discharge. Readmission with VTE is associated with C difficile infection and discharge to a skilled nursing facility, intermediate care facility, or with home health services. Studies are needed to evaluate the potential benefit of extending VTE prophylaxis for patients admitted to the hospital with IBD for up to 2 months after discharge, to minimize risk.

Intro/Background: Virtual Urgent Care (VUC) is now a common modality for providing real-time assessment and treatment of common low acuity medical problems. However, most physicians have not had formal telemedicine training or clinical experience and therefore lack proficiency with this new modality of healthcare delivery. We created an experiential onboarding program deploying standardized patients (SPs) into a VUC platform to assess and deliver feedback to physicians, providing individual-level quality assurance and identifying program-level areas for improvement. Purpose/Objective: The objective of this program was to create an experiential training module for physicians as part of their VUC onboarding process with the goal of quality assurance and patient safety. The onboarding experience incorporated common standards for doctor-patient communication as well as the unique skills necessary for the practice of telemedicine. The encounters were unobserved by other faculty, providing participants with a safe and confidential environment to receive feedback on their communication and telemedicine skills.
Method(s): We simulated a synchronous urgent care evaluation of a 25-year-old man with lingering viral upper respiratory tract symptoms refractory to over-thecounter medications. SP training included strongly requesting an antibiotic prescription. A mock electronic medical record encounter provided physicians with demographic and prior medical history. The announced SP appointment occurred during a routine VUC shift. Our behaviorally-anchored assessment tool evaluated communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' Outcomes (if available): Twenty-one physicians provided appropriate management without prescribing antibiotics. Physicians performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. In contrast, Education and Counseling skills were less strong (32% 'well done'); few received 'well done' for checking understanding (14%); conveying and summarizing information (9%). Telemedicine skills were infrequently used: 19% performed virtual physical exam, 24% utilized audio/video interface to augment information gathering, 14% assessed sound, video or ensured backup plan should video fail.
Summary: This experiential virtual urgent care onboarding program utilizing standardized patient announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. Participating VUC physicians had 2 to 23 years of clinical experience. Results illustrate that irrespective of experience, telemedicine visits create a unique set of challenges to the traditional way physicians are taught to engage with their patients. Overall, the onboarding exercise was well received by participating physicians. At the conclusion of the visit, SPs provided immediate verbal feedback to urgent care physicians, who received a summary report and had an opportunity provide structured feedback regarding the case. A subset of urgent care physicians (n=9) provided feedback regarding the case; 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improve telehealth skills. Our innovative onboarding program utilizing highly trained standardized patients can uncover potential gaps in telemedicinespecific skills and form the basis for dedicated training for virtual urgent care physicians to assure quality and patient safety

Routinely used automated immunoassays have been found to give unrealiable measurements of thyroid hormones in the presence of either high or low levels of thyroxine-binding globulin. Thyroid hormones are not the only analytes bound to specific binding proteins that are measured by immunoassays. Preliminary data from a series of cases, comparing IA measurements to those obtained by liquid chromatography-tandem mass spectrometry, reveal for the first time that IA measurements report falsely low (by an average of 27%) serum cortisol concentrations. Initial findings suggest that IA measurements of serum cortisol are affected by high concentrations of corticosteroid binding globulin.

BACKGROUND & AIMS/OBJECTIVE:Guidelines recommend testing patients with peptic ulcer disease for Helicobacter pylori infection. We sought to identify factors associated with adherence to testing for H pylori in patients hospitalized for bleeding ulcers and to evaluate whether performing these tests affect risk for rebleeding. METHODS:We performed a retrospective study of 830 inpatients who underwent endoscopy from 2011 through 2016 for gastrointestinal bleeding from gastric or duodenal ulcers. We searched electronic medical records for evidence of tests to detect H pylori by biopsy, serologic, or stool antigen analyses. We used multivariable models to identify clinical, demographic, and endoscopic factors associated with testing for H pylori. Kaplan-Meier analysis was performed to determine whether H pylori testing altered risk for the composite outcome of rebleeding or death within 1 year of admission. RESULTS:Among the patients hospitalized for bleeding peptic ulcer disease during the 6-year period, 19% were not tested for H pylori within 60 days of index endoscopy. Hospitalization in the intensive care unit (ICU) was the factor most frequently associated with nonadherence to H pylori testing guidelines (only 66% of patients in the ICU were tested vs 90% of patients not in the ICU; P < .01), even after we adjusted for ulcer severity, coagulation status, extent of blood loss, and additional factors (adjusted odds ratio, 0.42; 95% CI, 0.27-0.66). Testing for H pylori was associated with a 51% decreased risk of rebleeding or death during the year after admission (adjusted hazard ratio 0.49; 95% CI, 0.36-0.67). CONCLUSIONS:In an analysis of hospitalized patients who underwent endoscopy for gastrointestinal bleeding from gastric or duodenal ulcers, we found admission to the ICU to be associated with failure to test for H pylori infection. Failure to test for H pylori was independently associated with increased risk of rebleeding or death within 1 year of hospital admission. We need strategies to increase testing for H pylori among inpatients with bleeding ulcers.

Members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community experience marginalization, bias, and discrimination, including in the world of academic medicine. People who are transgender and gender non-binary (TGNB) experience further marginalization compared to individuals who are lesbian, gay, bisexual, and queer. According to a recent survey, more than half of medical students who are TGNB chose not to disclose their gender identities during training due to fears of discrimination, feeling a lack of support, and concerns about future career options. Academic medicine has historically pathologized TGNB individuals, perpetuating discrimination structurally and reinforcing discriminatory behaviors in peers and faculty. In this Perspective, the authors provide a comprehensive overview of the challenges that administrators and educators face in creating a learning environment that is inclusive of TGNB trainees. They outline opportunities for change and provide strategies to address administrative and educational challenges, including those related to institutional climate, policies, data collection, physical spaces, health care, the curriculum, mentoring, and the evaluation of TGNB trainees. Finally, the authors issue a call to action for medical educators and administrators to create environments in which trainees who are TGNB can fulfill their primary mission: to learn the practice of medicine.

OBJECTIVES:This study sought to evaluate the association and burden of coronary artery calcium (CAC) with long-term, cause-specific mortality across the spectrum of baseline risk. BACKGROUND:Although CAC is a known predictor of short-term, all-cause mortality, data on long-term and cause-specific mortality are inadequate. METHODS:The CAC Consortium cohort is a multicenter cohort of 66,636 participants without coronary heart disease (CHD) who underwent CAC testing. The following risk factors (RFs) were considered: 1) current cigarette smoking; 2) dyslipidemia; 3) diabetes mellitus; 4) hypertension; and 5) family history of CHD. RESULTS:During the 12.5-years median follow-up, 3,158 (4.7%) deaths occurred; 32% were cardiovascular disease (CVD) deaths. Participants with CAC scores ≥400 had a significantly increased risk for CHD and CVD mortality (hazard ratio [HR]: 5.44; 95% confidence interval [CI]: 3.88 to 7.62; and HR: 4.15; 95% CI: 3.29 to 5.22, respectively) compared with CAC of 0. Participants with ≥3 RFs had a smaller increased risk for CHD and CVD mortality (HR: 2.09; 95% CI: 1.52 to 2.85; and HR: 1.84; 95% CI: 1.46 to 2.31, respectively) compared with those without RFs. Across RF strata, CAC added prognostic information. For example, participants without RFs but with CAC ≥400 had significantly higher all-cause, non-CVD, CVD, and CHD mortality rates compared with participants with ≥3 RFs and CAC of 0. CONCLUSIONS:Across the spectrum of RF burden, a higher CAC score was strongly associated with long-term, all-cause mortality and a greater proportion of deaths due to CVD and CHD. Absence of CAC identified people with a low risk over 12 years of follow-up, with most deaths being non-CVD in nature, regardless of RF burden.