Faculty Bibliography

OBJECTIVE:Curricula designed to teach and assess the communication skills of pediatric residents variably integrates the parent perspective. We compared pediatric residents' communication skills in an objective structured clinical exam (OSCE) case as assessed by Family Faculty (FF), parents of pediatric patients, versus standardized patients (SP). METHODS:Residents participated in an OSCE case with a SP acting as a patient's parent. We compared resident performance as assessed by FF and SP with a behaviorally-anchored checklist. Items were rated as not done, partly done or well done, with well-done indicating mastery. The residents evaluated the experience. RESULTS:42 residents consented to study participation. FF assessed a lower percentage of residents as demonstrating skill mastery as compared to SP in 19 of the 23 behaviors. There was a significant difference between FF and SP for Total Mastery Score and Mastery of the Competency Scores in three domains (Respect and Value, Information Sharing and Participation in Care and Decision Making). The majority of residents evaluated the experience favorably. CONCLUSION/CONCLUSIONS:Involving parents of pediatric patients in the instructive and assessment components of a communication curriculum for pediatric residents adds a unique perspective and integrates the true stakeholders in parent-physician communication.

OBJECTIVE:Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP). DESIGN/METHODS:This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate. SETTING AND PARTICIPANTS/METHODS:Patients with a primary hospital discharge diagnosis of HF discharged to SNF. METHODS:Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level. RESULTS:Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11). CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.

BACKGROUND:The mechanisms underlying long-term sequelae after AKI remain unclear. Vessel instability, an early response to endothelial injury, may reflect a shared mechanism and early trigger for CKD and heart failure. METHODS:To investigate whether plasma angiopoietins, markers of vessel homeostasis, are associated with CKD progression and heart failure admissions after hospitalization in patients with and without AKI, we conducted a prospective cohort study to analyze the balance between angiopoietin-1 (Angpt-1), which maintains vessel stability, and angiopoietin-2 (Angpt-2), which increases vessel destabilization. Three months after discharge, we evaluated the associations between angiopoietins and development of the primary outcomes of CKD progression and heart failure and the secondary outcome of all-cause mortality 3 months after discharge or later. RESULTS:Median age for the 1503 participants was 65.8 years; 746 (50%) had AKI. Compared with the lowest quartile, the highest quartile of the Angpt-1:Angpt-2 ratio was associated with 72% lower risk of CKD progression (adjusted hazard ratio [aHR], 0.28; 95% confidence interval [CI], 0.15 to 0.51), 94% lower risk of heart failure (aHR, 0.06; 95% CI, 0.02 to 0.15), and 82% lower risk of mortality (aHR, 0.18; 95% CI, 0.09 to 0.35) for those with AKI. Among those without AKI, the highest quartile of Angpt-1:Angpt-2 ratio was associated with 71% lower risk of heart failure (aHR, 0.29; 95% CI, 0.12 to 0.69) and 68% less mortality (aHR, 0.32; 95% CI, 0.15 to 0.68). There were no associations with CKD progression. CONCLUSIONS:A higher Angpt-1:Angpt-2 ratio was strongly associated with less CKD progression, heart failure, and mortality in the setting of AKI.

INTRODUCTION/BACKGROUND:Financial toxicity is common and pervasive among cancer patients. Research suggests that gynecologic cancer patients experiencing financial toxicity are at increased risk for engaging in harmful cost-coping strategies, including delaying/skipping treatment because of costs, or forsaking basic needs to pay medical bills. However, little is known about patients' preferences for interventions to address financial toxicity. METHODS:Cross-sectional surveys to assess financial toxicity [Comprehensive Score for Financial Toxicity (COST)], cost-coping strategies, and preferences for intervention were conducted in a gynecologic cancer clinic waiting room. Associations with cost-coping were determined using multivariate modeling. Unadjusted odds ratios (ORs) explored associations between financial toxicity and intervention preferences. RESULTS:Among 89 respondents, median COST score was 31.9 (IQR: 21-38); 35% (N = 30) scored < 26, indicating they were experiencing financial toxicity. Financial toxicity was significantly associated with cost-coping (adjusted OR = 3.32 95% CI: 1.08, 14.34). Intervention preferences included access to transportation vouchers (38%), understanding treatment costs up-front (35%), minimizing wait times (33%), access to free food at appointments (25%), and assistance with minimizing/eliminating insurance deductibles (23%). In unadjusted analyses, respondents experiencing financial toxicity were more likely to select transportation assistance (OR = 2.67, 95% CI: 1.04, 6.90), assistance with co-pays (OR = 9.17, 95% CI: 2.60, 32.26), and assistance with deductibles (OR = 12.20, 95% CI: 3.47, 43.48), than respondents not experiencing financial toxicity. CONCLUSIONS:Our findings confirm the presence of financial toxicity in gynecologic cancer patients, describe how patients attempt to cope with financial hardship, and provide insight into patients' needs for targeted interventions to mitigate the harm of financial toxicity.

Although the Affordable Care Act requires nonprofit hospital organizations to report how they identify and invest in community health needs, the utility of mandated reporting documents for tracking investments in the social determinants of health has been questioned. Using public reporting documents and focusing on housing as a social determinant of health, we describe how nonprofit hospital organizations in 5 communities with the highest rates of homelessness document needs and investments related to housing on their Community Health Needs Assessments, Implementation Strategies, and Schedule H (990H) tax forms. Of 47 organizations, 55% identified housing as a health need, 36% described housing-related implementation strategies, and 26% reported relevant 990H spending. Overall concordance among identified needs, strategies, and spending was low, with only 15% of organizations addressing housing across all 3 documents. Regulatory reform could help promote accountability and transparency in organizations' efforts to address housing and other health-related social needs.

Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.

CONTEXT:As of 2015, an estimated 116000 New York City (NYC) residents had chronic hepatitis C, many of them undiagnosed. Although effective medications have been available since 2014 with the advent of direct-acting antivirals, provider-based barriers to treatment remain. The NYC Department of Health and Mental Hygiene (Health Department) coordinated the Hepatitis C Clinical Exchange Network (HepCX) from 2015 to 2019. The main goal of HepCX was to promote hepatitis C screening and treatment by hospital-based providers. PROGRAM:The Health Department recruited hepatitis C champions (Champions) from acute care hospitals (n = 40) to promote improved hepatitis C care at their institutions. The Health Department provided technical assistance for hospitals to improve electronic medical record (EMR) systems and implement reflex RNA testing, coordinated trainings to increase capacity to treat hepatitis C, and distributed dashboards containing facility-specific testing and treatment metrics. IMPLEMENTATION:By the end of the project period (2019), most hospitals (36/40; 90%) reported having a screening alert for baby boomers in their EMR system and 34 (85%) reported performing reflex RNA testing after a positive hepatitis C antibody test. The Health Department coordinated opportunities for Champions to share their work with providers from network hospitals at meetings and webinars and provided clinical education on hepatitis C treatment in partnership with a local nonprofit organization focused on liver health. Facility-specific dashboards were distributed annually to hospital leadership. RNA confirmation testing increased from an average of 57% in 2015 to 85% in 2018. Treatment initiation rates remained similar over 2 years, averaging 39% in 2017 and 38% in 2018. DISCUSSION:HepCX was a multipronged initiative designed to promote hepatitis C testing and treatment initiation among providers at NYC acute care hospitals. Improvements were observed in confirmatory testing rates; however, treatment initiation rates did not change. Further efforts should be targeted to hospitals in need of additional resources for linkage to care and treatment of hepatitis C.

BACKGROUND AND OBJECTIVES/OBJECTIVE:AKI is a common complication of coronavirus disease 2019 (COVID-19) and is associated with high mortality. Palliative care, a specialty that supports patients with serious illness, is valuable for these patients but is historically underutilized in AKI. The objectives of this paper are to describe the use of palliative care in patients with AKI and COVID-19 and their subsequent health care utilization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS/METHODS:We conducted a retrospective analysis of New York University Langone Health electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. Regression models were used to examine characteristics associated with receiving a palliative care consult. RESULTS:=0.002). Despite greater use of palliative care, patients with AKI had a significantly longer length of stay, more intensive care unit admissions, and more use of mechanical ventilation. Those with AKI did have a higher frequency of discharges to inpatient hospice (6% versus 3%) and change in code status (34% versus 7%) than those without AKI. CONCLUSIONS:Palliative care was utilized more frequently for patients with AKI and COVID-19 than historically reported in AKI. Despite high mortality, consultation occurred late in the hospital course and was not associated with reduced initiation of life-sustaining interventions. PODCAST/UNASSIGNED:This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_24_CJN11030821.mp3.