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department:Medicine. General Internal Medicine

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Predictors of Overtesting in Pulmonary Embolism Diagnosis

Richardson, Safiya; Lucas, Eugene; Cohen, Stuart L; Zhang, Meng; Qiu, Guang; Khan, Sundas; McGinn, Thomas
BACKGROUND:The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting. METHODS:This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass index, number of comorbidities, race, and ethnicity, provider factors: type (resident, fellow, attending, physician assistant) and environment factors: test time of day, season of visit, and crowdedness of the department. RESULTS:A total of 14,782 CTPAs were reviewed, of which 1366 were found to be positive for PE, resulting in an overall CTPA yield of 9.24%. Provider type was not associated with a difference in yield. Testing was less likely to be positive in younger patients, females, those with lower body mass indexes and those identifying as Asian or Hispanic. Testing was also less likely to be positive when ordered during the overnight shift and during the winter and spring seasons. CONCLUSION:Our study identified several patient and environmental factors associated with low CTPA yield suggesting potential targets for overtesting. Targeting education and clinical decision support to assist providers in these circumstances may meaningfully improve yields.
PMID: 31155486
ISSN: 1878-4046
CID: 4996152

In the room where it happens: do physicians need feedback on their real-world communication skills? [Editorial]

Zabar, Sondra; Hanley, Kathleen; Wilhite, Jeffrey A; Altshuler, Lisa; Kalet, Adina; Gillespie, Colleen
PMID: 31704892
ISSN: 2044-5423
CID: 4186612

Home health care services to persons with dementia and language preference

Ma, Chenjuan; Herrmann, Linda; Miner, Sarah; Stimpfel, Amy Witkoski; Squires, Allison
Despite the rapid increase in the number of persons with dementia (PWD) receiving home health care (HHC), little is known of HHC services patterns to PWD of varied backgrounds, including language preference other than English. Analyzing data of 12,043 PWD from an urban home health agency, we found on average PWD received 2.48 skilled visits or 1.88-hour skilled care and 5.81 aide visits or 24.13-hour aide care weekly. Approximately 63% of the skilled visits were from nurses. More non-English preferred PWD received aide visits, compared to English preferred PWD (44% vs. 36%). The type and intensity of HHC services were associated with language preference; when stratified by insurance, non-English preference was still significantly associated with more HHC aide care. Our study indicated that HHC services (both type and amount) varied by language preference and insurance type as an indicator of access disparities was a significant contributor to the observed differences.
PMID: 31668782
ISSN: 1528-3984
CID: 4162532

A Multifaceted, Student-Led Approach to Improving the Opioid Prescribing Practices of Hospital Medicine Clinicians

Tsega, Surafel; Hernandez-Meza, Gabriela; DiRisio, Aislyn C; D'Andrea, Megan R; Cho, Hyung J
BACKGROUND:The development of guidelines for opioid prescribing, including those from the Society of Hospital Medicine and the Centers for Disease Control and Prevention, has been associated with changes in prescription patterns. However, many providers remain unaware of best practices surrounding appropriate opioid prescribing. METHODS:The research team implemented a multimodal quality improvement intervention, led by first-year medical students, designed to increase clinician adherence to current prescribing guidelines for patients discharged on opioids. This intervention included an awareness campaign, educational sessions for providers, and weekly performance feedback. RESULTS:A total of 4,993 discharges were identified in the baseline period and 4,811 discharges in the intervention period. During the baseline period, 12.3% of all patients discharged were discharged with opioid prescriptions vs. 11.4% during the intervention period (p = 0.165). Of these, approximately 60% were new opioid prescriptions during both periods (p = 0.991). The study's efforts were associated with a decrease in the percentage of patients discharged with opioid prescriptions longer than seven days (45.2% preintervention to 39.5% postintervention, p < 0.042); an increase in the percentage of patients with follow-up appointments within seven days of discharge (38.6% to 65.9%, p = 0.001); and an increase in documentation of prescription history obtained from the state Prescription Monitoring Program registry (32.5% to 39.7%, p = 0.042). CONCLUSION/CONCLUSIONS:This intervention provided a successful framework to engage learners in improving opioid prescribing practices. The results are promising, but the experiences highlight the significant effort and resources needed to change prescriber practices, potentially limiting sustainability.
PMID: 31899157
ISSN: 1938-131x
CID: 4255922

Introducing EPIDEMIC with Dr. Celine Gounder and Ron Klain [Sound Recording]

Gounder, Celine R; Klain, Ron
ORIGINAL:0015291
ISSN: n/a
CID: 4980462

Where do we go from here? [Sound Recording]

Gounder, Celine R; Hogg, David; Yamane, David; Creighton, Kevin; Roberts, Tyah-Amoy
ORIGINAL:0015290
ISSN: n/a
CID: 4980452

Patient Preferences for Physician Attire: A Multicenter Study in Japan

Kamata, Kazuhiro; Kuriyama, Akira; Chopra, Vineet; Saint, Sanjay; Houchens, Nathan; Petrilli, Christopher M; Kuhn, Latoya; Snyder, Ashley; Ishimaru, Naoto; Takahashi, Hiromizu; Tokuda, Yasuharu
BACKGROUND:Previous studies have shown that patients have specific expectations regarding physician dress. Japan has a cultural background that is in many ways distinct from western countries. Thus, physician attire may have a different impact in Japan. METHODS:We conducted a multicenter, cross-sectional study to examine patients' preferences for and perceptions of physician attire in Japan. The questionnaire was developed using photographs of either a male or female physician dressed in seven different forms of attire, and it was randomly distributed to inpatients and outpatients. Respondents were asked to rate the provider pictured; they were also asked to provide preferences for different forms of attire in varied clinical settings. Preference was evaluated for five domains (knowledgeable, trustworthy, caring, approachable, and comfortable). We also assessed variation in preferences for attire by respondent characteristics. RESULTS:A total of 1,233 (61%) patients indicated that physician dress was important, and 950 (47%) patients agreed that it influenced their satisfaction with care. Compared with all forms, casual attire with a white coat was the most preferred dress. Older patients more often preferred formal attire with a white coat in primary care and hospital settings. In addition, physician attire had a greater impact on older respondents' satisfaction and experience. CONCLUSION/CONCLUSIONS:The majority of Japanese patients indicated that physician attire is important and influenced their satisfaction with care. Geography, settings of care, and patient age appear to play a role in patient preferences.
PMID: 32118558
ISSN: 1553-5606
CID: 4339582

TB transmission is associated with prolonged stay in a low socio-economic, high burdened TB and HIV community in Cape Town, South Africa

Tadokera, Rebecca; Bekker, Linda-Gail; Kreiswirth, Barry N; Mathema, Barun; Middelkoop, Keren
BACKGROUND:While several studies have assessed the associations between biological factors and tuberculosis (TB) transmission, our understanding of the associations between TB transmission and social and economic factors remains incomplete. We aimed to explore associations between community TB transmission and socio-economic factors within a high TB-HIV burdened setting. METHODS:We conducted a cross-sectional molecular epidemiology study among adult patients attending a routine TB clinic. Demographic and clinical data were extracted from TB registers and clinical folders; social and economic data were collected using interviewer-administered questionnaires; Mycobacterium tuberculosis isolates were genotyped and classified as clustered/non-clustered using IS6110-based Restriction Fragment Length Polymorphism. Composite "social" and "economic" scores were generated from social and economic data. Data were analyzed using StataCorp version 15.0 software. Stratified, bivariable analyses were performed using chi-squared. Wilcoxon signed rank tests; univariable and multivariable logistic regression models were developed to explore associations in the social, economic, traditional and composite TB risk factors with TB transmission. RESULTS:Of the 505 patient Mtb  strains, 348(69%) cases were classified as clustered and 157(31%) were non-clustered. Clustered cases were more likely to have lived longer in the study community, (odds ratio [OR] = 1.05, 95% Confidence interval [C.I]:1.02-1.09, p = 0.006); in the same house (OR = 1.04, C.I: 0.99-1.08, p = 0.06); and had increased household crowding conditions (i.e fewer rooms used for sleeping, OR = 0.45, C.I:0.21-0.95, p = 0.04). Although a higher proportion of clustered cases had a low economic score, no statistically significant association was found between clustering and either the economic score (p = 0.13) or social score (p = 0.26). CONCLUSIONS:We report a novel association between Mtb transmission and prolonged stay within a high burdened community. Transmission was also associated with fewer rooms for sleeping in a household. Increased social interaction and prolonged residence in a high burdened community are important factors linked to Mtb transmission, possibly due to increased probability of higher effective contact rates. The possible importance of degrees of poverty within low socio-economic setting warrants further study.
PMCID:7011372
PMID: 32041530
ISSN: 1471-2334
CID: 4311422

Here all along [Sound Recording]

Gounder, Celine R; Smith, Anthony; Hogan, Al; Hicks, Kayla; Brown, Jeffrey
ORIGINAL:0015289
ISSN: n/a
CID: 4980442

Association Between Posttraumatic Stress Disorder and Mortality Among Responders and Civilians Following the September 11, 2001, Disaster

Giesinger, Ingrid; Li, Jiehui; Takemoto, Erin; Cone, James E; Farfel, Mark R; Brackbill, Robert M
Importance/UNASSIGNED:Posttraumatic stress disorder (PTSD) has been associated with increased mortality, primarily in studies of veterans. The World Trade Center Health Registry (Registry) provides a unique opportunity to study the association between PTSD and mortality among a population exposed to the World Trade Center attacks in New York, New York, on September 11, 2001 (9/11). Objectives/UNASSIGNED:To assess whether 9/11-related probable PTSD (PTSD) is associated with increased mortality risk, as well as whether this association differs when including repeated measures of PTSD over time vs a single baseline assessment. Design, Setting, and Participants/UNASSIGNED:A longitudinal cohort study of 63 666 Registry enrollees (29 270 responders and 34 396 civilians) was conducted from September 5, 2003, to December 31, 2016, with PTSD assessments at baseline (wave 1: 2003-2004) and 3 follow-up time points (wave 2: 2006-2007, wave 3: 2011-2012, wave 4: 2015-2016). Data analyses were conducted from December 4, 2018, to May 20, 2019. Exposures/UNASSIGNED:Posttraumatic stress disorder was defined using the 17-item PTSD Checklist-Specific (PCL-S) self-report measure (score ≥50) at each wave (waves 1-4). Baseline PTSD was defined using wave 1 PCL-S, and time-varying PTSD was defined using the PCL-S assessments from all 4 waves. Main Outcomes and Measures/UNASSIGNED:Mortality outcomes were ascertained through National Death Index linkage from 2003 to 2016 and defined as all-cause, cardiovascular, and external-cause mortality. Results/UNASSIGNED:Of 63 666 enrollees (38 883 men [61.1%]; mean [SD] age at 9/11, 40.4 [10.4] years), 6689 (10.8%) had PTSD at baseline (responders: 2702 [9.5%]; civilians: 3987 [12.0%]). Participants who were middle aged (2022 [12.5%]), female (3299 [13.8%]), non-Latino black (1295 [17.0%]), or Latino (1835 [22.2%]) were more likely to have PTSD. During follow-up, 2349 enrollees died (including 230 external-cause deaths and 487 cardiovascular deaths). Among all enrollees in time-varying analyses, PTSD was associated with all-cause, cardiovascular, and external-cause mortality, with adjusted hazard ratios (AHRs) of greater magnitude compared with analyses examining baseline PTSD. Among responders, time-varying PTSD was significantly associated with increased risk of all-cause (AHR, 1.91; 95% CI, 1.58-2.32), cardiovascular (AHR, 1.95; 95% CI, 1.25-3.04), and external-cause (AHR, 2.40; 95% CI, 1.47-3.91) mortality. Among civilians, time-varying PTSD was significantly associated with increased risk of all-cause (AHR, 1.54; 95% CI, 1.28-1.85), cardiovascular (AHR, 1.72; 95% CI, 1.15-2.58), and external-cause (AHR, 2.11; 95% CI, 1.06-4.19) mortality. Conclusions and Relevance/UNASSIGNED:The risk of mortality differed in examination of baseline PTSD vs repeated measures of PTSD over time, suggesting that longitudinal data should be used where possible. Comparable findings between responders and civilians suggest that 9/11-related PTSD is associated with an increased mortality risk.
PMID: 32022879
ISSN: 2574-3805
CID: 4300352