Medicine For Patients Research Articles

A survey-based study: assessing inpatient attending perspectives on teaching learners, feeling valued, and symptoms of burnout

BackgroundPhysician burnout is rising, especially among academic physicians facing pressures to increase their clinical workload, lead administrative tasks and committees, and be active in research. There is a concern this could have downstream effects on learners’ experiences and academic physician’s ability to teach learners on the team.MethodsA 29-question RedCap survey was electronically distributed to 54 attending physicians within an academic learning health system who oversaw the General Medicine inpatient teaching services during the 2022–2023 academic year. The aims were to assess this cohort of attending physicians’ experiences, attitudes, and perceptions on their ability to effectively teach learners on the team, feeling valued, contributors to work-life balance and symptoms of burnout, Fisher’s Exact Tests were used for data analysis.ResultsResponse rate was 56%. Attendings splitting time 50% inpatient / 50% outpatient felt that team size and type of admissions model affected their ability to effectively teach learners (p = 0.022 and p = 0.049). Attendings with protected administrative time felt that non-patient care obligations affected their ability to effectively teach the learners (p = 0.019). Male attendings and attendings with ≤ 5 years of General Medicine inpatient teaching experience felt less valued by residency leadership (p = 0.019 and p = 0.026). 80% of attendings experienced emotional exhaustion, and those with > 10 weeks on a General Medicine inpatient teaching service were more likely to experience emotional exhaustion (p = 0.041). Attendings with > 10 weeks on a General Medicine inpatient teaching service and those who were a primary caregiver were more likely to experience depersonalization (p = 0.012 and p = 0.031). 57% of attendings had reduced personal achievement.ConclusionsInstitutions should seek an individual and organizational approach to professional fulfillment. Special attention to these certain groups is warranted to understand how they can be better supported. Further research, such as with focus groups, is needed to address these challenges.

Antibiotic use by clinical presentation across all healthcare providers in rural Burkina Faso: a healthcare visit exit survey.

To guide antibiotic stewardship interventions, understanding for what indications antibiotics are used is essential. In rural Burkina Faso, we measured antibiotic dispensing across all healthcare providers. From October 2021 to February 2022, we surveyed patients in Nanoro district, Burkina Faso, following visits to health centres (3), pharmacies (2), informal medicine vendors (5) and inpatients in health centres. We estimated prevalence of antibiotic use and the proportion of Watch group antibiotics by provider type and by clinical presentation, assessing compliance with WHO's AWaRe Antibiotic Book. We estimated per capita antibiotic use by multiplying prevalence of antibiotic use, mean DDD per adult treatment course, and the rate of healthcare visits per 1000 inhabitants per day, estimated from a prior household survey. Outpatient antibiotic use was more frequent after health centre visits (54.8%, of which 16.5% Watch, n = 1249) than after visits to pharmacies (26.2%, 16.3% Watch, n = 328) and informal medicine vendors (26.9%, 50.0% Watch, n = 349). The frequency of antibiotic use was highest for bronchitis (79.9% antibiotic use, of which 12.6% Watch), malaria (31.9%, 23.1% Watch), gastroenteritis (76.0%, 31.7% Watch), rhinopharyngitis (40.4%, 8.3% Watch) and undifferentiated fever (77.0%, 44.8% Watch). Compliance with WHO AWaRe guidance could have averted at least 68.4% of all Watch antibiotic use in outpatients at health centres. Community-wide, 2.9 DDD (95% CI 1.9-3.9) were used per 1000 adult inhabitants per day. Most Watch antibiotic use at community level or primary care deviated from WHO guidance. Antibiotic stewardship should focus on key clinical presentations and include primary care and self-medication.

Navigating the COVID-19 Pandemic with DPLD: Insights from a Case Report for Healthcare Providers

The COVID-19 pandemic brought significant challenges to global healthcare systems, particularly for individuals with underlying health conditions. This article reports a case of a 65-year-old man with a medical history of diabetes mellitus, hypertension, and diffuse parenchymal lung disease (DPLD), who succumbed to severe COVID-19 infection. He presented to the Medicine inpatient of a tertiary care hospital, with fever and extreme lethargy during the second wave of the COVID-19 pandemic early in 2021. Upon presentation, his oxygen saturation (SPO2) was 31%. High-resolution computed tomography (HRCT) chest findings revealed extensive ground glass opacity, and his nasal swabs tested positive for COVID-19 via reverse transcription-polymerase chain reaction (RT-PCR). He was diagnosed with type 1 respiratory failure and was subsequently admitted to the intensive care unit (ICU), where his condition rapidly deteriorated and he passed away.This case highlights the heightened vulnerability of individuals with pre-existing comorbidities to severe COVID-19 complications and thus intensifies the importance of early recognition and intervention in such high-risk populations.

Frontline assessors’ opinions about grading committees in a medicine clerkship

BackgroundCollective decision-making by grading committees has been proposed as a strategy to improve the fairness and consistency of grading and summative assessment compared to individual evaluations. In the 2020–2021 academic year, Washington University School of Medicine in St. Louis (WUSM) instituted grading committees in the assessment of third-year medical students on core clerkships, including the Internal Medicine clerkship. We explored how frontline assessors perceive the role of grading committees in the Internal Medicine core clerkship at WUSM and sought to identify challenges that could be addressed in assessor development initiatives.MethodsWe conducted four semi-structured focus group interviews with resident (n = 6) and faculty (n = 17) volunteers from inpatient and outpatient Internal Medicine clerkship rotations. Transcripts were analyzed using thematic analysis.ResultsParticipants felt that the transition to a grading committee had benefits and drawbacks for both assessors and students. Grading committees were thought to improve grading fairness and reduce pressure on assessors. However, some participants perceived a loss of responsibility in students’ grading. Furthermore, assessors recognized persistent challenges in communicating students’ performance via assessment forms and misunderstandings about the new grading process. Interviewees identified a need for more training in formal assessment; however, there was no universally preferred training modality.ConclusionsFrontline assessors view the switch from individual graders to a grading committee as beneficial due to a perceived reduction of bias and improvement in grading fairness; however, they report ongoing challenges in the utilization of assessment tools and incomplete understanding of the grading and assessment process.

A Qualitative Study of Physicians' Views on the Reuse of Electronic Health Record Data for Secondary Analysis.

Electronic health records (EHRs) have become ubiquitous in clinical practice. Given the rich biomedical data captured for a large panel of patients, secondary analysis of these data for health research is also commonplace. Yet, there are many caveats to EHR data that the researchers must be aware of, such as the accuracy of and motive for documentation, and the reason for patients' visits to the clinic. The clinician-the author of the documentation-is thus central to the correct interpretation of EHR data for research purposes. In this study, I interviewed 11 physicians in various clinical specialties to bring attention to their view on the validity of research using EHR data. Qualitative, in-depth, one-on-one interviews were conducted with practicing physicians in inpatient and outpatient medicine. Content analysis using a data-driven, inductive approach to identify themes related to challenges and opportunities in the reuse of EHR data for secondary analysis generated seven themes. Themes that reflected challenges of EHRs for research included (1) audience, (2) accuracy of data, (3) availability of data, (4) documentation practices, and (5) representativeness. Themes that reflected opportunities of EHRs for research included (6) endorsement and (7) enablers. The greatest perceived barriers reflected the intended audience of the EHR, the interpretation and meaning of the data, and the quality of the data for research purposes. Physicians generally expressed more perceived challenges than opportunities in the reuse of EHR data for research purposes; however, they remained optimistic.

Financial toxicity in the background of free health care: A cross-sectional survey in a tertiary care hospital in India.

e13685 Background: The financial toxicity of cancer treatment is a known fact in low to middle-income countries due to poverty, lack of health insurance and illiteracy. We tried to estimate the financial strain and its contributing factors in an Indian population with access to free cancer treatment. Methods: All government employees and their dependents are eligible to receive free treatment including inpatient management, investigations and medicines at our institute. All cancer patients ≥18 years were invited to participate in a survey. The survey included their demographic, cancer and therapy details, the COST-FACIT questionnaire, and information about increase in expenses since cancer diagnosis and source of additional finances. Results: 300 cancer patients completed the survey. 61.3% of the respondents were females and the mean patient age was 43.14 years. Breast cancer was the most common malignancy and stage IV was the most common stage. 44% were residents of a rural area. The average duration of treatment was 8.03 months. Prior to cancer diagnosis, 37.2% of the patients had average monthly expenses between INR 10-25,000 (USD 120 to 300). The approximate increase in monthly expenditures after cancer diagnosis was between INR 5-10,000 (USD 60 to 120) for 33.4% and between INR 10-25,000 (USD 120 to 300) for 31.4% of the population. The primary income source for 65.7% respondents was the salary of the government employee while 48% had two or more earning members in the family. Cancer treatment negatively affected the earning capacity of the patient alone in 40% of the population, while in 28% it affected the earning capacity of the patient and caregiver. 51% had to utilise their savings, 39% sold fixed assets, and 31% borrowed or took a loan to cope with the additional financial strain. Commonest expenses were travel, accommodation, and food (75.7%). 34.5% spent money on other therapy-related costs (second opinion or alternative therapy). The mean COST-FACIT score was 21.38,(20-24) demonstrating mild financial toxicity. Predictors of high financial toxicity were a single-earning member, familial discord and long duration of treatment (> 6 months). Conclusions: Though all participants had access to free cancer treatment, all experienced mild financial toxicity due to non-therapeutic expenses. Despite desperate financial measures to complete treatment, most participants did not express severe financial toxicity. This may be attributed to the stigma of expected high expenditure associated with cancer treatment in India. COST-FACIT scoring may not have suitably assessed the financial strain experienced by patients with free healthcare. Additional financial information collected by the survey, (monthly expenses, earning members, source of additional funds), helped us to better understand financial impact of cancer treatment and identify gaps in our healthcare.

Building Geriatric Trauma Programs in Resource-Constrained Environments: Trauma Quality Improvement Program Guideline Implementation at Two Safety Net Hospitals in Southern California.

Background: To improve care of geriatric trauma patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) updated guidelines in 2021. Amid geriatrician shortages in Southern California, 2 Los Angeles County safety net hospitals were tasked with creating a strategy to meet geriatric trauma guidelines despite constrained resources. Methods: All trauma patients ≥ 60years admitted to a safety net hospital in Southern California were enrolled without exclusions (August 2022-April 2023). Primary outcome was frailty screening with documentation to identify older trauma patients at a high risk for adverse outcomes. Results: Needs assessment discovered no standardized process to identify high-risk geriatric patients, no geriatric care guidelines, and no inpatient geriatric consultation service. An action plan composed of a resident-led frailty screen resulted in identification of high-risk patients. Overall, 217 patients met criteria. Ninety-six patients (44%) successfully underwent frailty screening. Frailty screening compliance increased over the study, beginning at 37% capture in the first month and increasing to 81% in the final study month. After achieving nearly uniform frailty screening, a form was developed for the EMR for ease of documentation, data capture/tracking, and compliance monitoring. Discussion: In this study, creativity, collaboration, and resourcefulness allowed TQIP guideline implementation at 2 county hospitals. A systematic process is now in place to identify and triage high-risk geriatric trauma patients based on frailty screen to receive inpatient medicine consultation for medical comorbidity optimization. Continued interdisciplinary and interfacility collaboration will be crucial for continued delivery of the optimal care to older injured patients.

Hospital and out-of-hospital services provided by public geriatric medicine departments in Australia and New Zealand.

To describe the types of hospital and out-of-hospital services provided by public geriatric medicine departments in Australia and New Zealand, and to explore head of department (HOD) views on issues in current and future service provision. An electronic survey was sent to HODs of public geriatric medicine departments. Seventy-six (89%) of 85 identified HODs completed the survey. Seventy-one (93%) departments admit inpatients and 51 (67%) admit acute inpatients, with variable admission criteria. Sixty-four (84%) have hospitals with an inpatient general medicine service, and 58 (91%) of these admit older patients with acute geriatric issues. Sixty (79%) departments provide inpatient rehabilitation. Forty (53%) have beds for behavioural symptoms of dementia and/or delirium. Seventy (92%) provide a proactive orthogeriatric service. In terms of out-of-hospital services, 74 (97%) departments have outpatient clinics, 59 (78%) have telehealth and 68 (89%) perform home visits. Forty-five (59%) provide an inreach/outreach service to nursing homes. The most frequent gaps in service provision identified by HODs were acute geriatrics, surgical liaison, a designated dementia/delirium behavioural management unit, geriatricians in Emergency, outreach/inreach to residential care and shared care with some medical specialities. Increasing staff numbers and government policy change were the most frequently identified ways to address these gaps. Geriatric medicine service provision is variable across Australia and New Zealand, with key gaps identified. These findings will inform future directions in implementation of geriatric medicine models of care and discussions with various levels of government about the ongoing development of geriatric medicine services.

The "Difficult" Inpatient, a Qualitative Study of Physician Perspectives.

Previous studies exploring difficult inpatients have mostly focused on psychiatric inpatients. To explore the characteristics of difficult medicine inpatients. Qualitative study using focus groups and semi-structured interviews. Transcripts were recorded, transcribed, and coded (MAXQDA) using thematic content analysis. Medicine inpatient providers at a tertiary care facility. Our sample consisted of 28 providers (6 hospitalists, 10 medicine attendings, 6 medicine residents, and 6 interns). Theme 1: Provider experience: Difficult inpatients were time-consuming and evoked emotional responses including frustration and dysphoria. Theme 2: Patient characteristics: Included having personality disorders or mental health issues, being uncooperative, manipulative, angry, demanding, threatening, or distrustful. Difficult patients also had challenging social situations and inadequate support, unrealistic care expectations, were self-destructive, tended to split care-team messages, and had unclear diagnoses. Theme 3: Difficult families: Shared many characteristics of difficult patients including being distrustful, demanding, manipulative, threatening, or angry. Difficult families were barriers to care, disagreed with the treatment plan and each other, did not act in the patient's best interest, suggested inappropriate treatment, or had unrealistic expectations. Approaches to dealing with difficult patients or families included building trust, being calm, and having a consistent message. Communication approaches included naming the emotion, empathetic listening, identifying patient priorities and barriers, and partnering. Difficult patients induced emotional responses, dysphoria, and self-doubt among providers. Underlying personality disorders were often mentioned. Difficult patients and families shared many characteristics. Communication and training were highlighted as key strategies.

Association of Opioid and Concurrent Benzodiazepine, Skeletal Muscle Relaxant, and Gabapentinoid Usage on Healthcare Expenditure and Resource Utilization: A Serial Cross-Sectional Study, 2009 to 2019.

Healthcare providers may be utilizing central nervous system (CNS) depressants to reduce opioid use due to recent changes in public policy. Combination use of these agents with opioids increases the risk of respiratory depression and death. Healthcare expenditures by individuals using these drug combinations have not been previously quantified. We sought to characterize healthcare costs and expenditures associated with a population reporting concurrent CNS depressants and opioid use compared with nonopioid analgesics in the United States from 2009 to 2019. A serial cross-sectional design was used to compare the healthcare expenditures of adult Medical Expenditure Panel Survey respondents who were prescribed nonopioid analgesics, opioids only, opioids/benzodiazepines (BZD), opioids/BZD/skeletal muscle relaxants (SMR), or opioids/gabapentin (gaba) using pooled data from 2009 to 2019. Expenditure (cost and resource utilization) categories included inpatient, outpatient, office-based, and prescription medicine. Average marginal effects were used to compare survey-weighted annual costs and resource utilizations across the groups as compared to nonopioid analgesic respondents, adjusted for covariates. A weighted total of 34 241 838 individuals were identified. Most were opioid-only respondents (46.5%), followed by nonopioid analgesic (43.4%), opioid/BZD (5.3%), opioid-gaba (3.5%), and opioid/BZD/SMR respondents (1.3%). In comparison to the study groups with nonopioid analgesics, opioid-gaba users had the highest significant incremental cost difference among the different pairings (+$11 684, P < .001). Opioid-gaba, opioid/BZD, and opioid/BZD/SMR respondents had significantly higher inpatient, emergency department, and prescription drug costs and use compared to nonopioid analgesic respondents. Opioid-only respondents had higher outpatient and office-based costs and visits compared to nonopioid analgesic respondents. As healthcare providers seek to utilize fewer opioids for pain management, attention must be paid to ensuring safe and effective use of concurrent CNS depressants to mitigate high healthcare costs and burden.

ChatGPT as a Tool for Medical Education and Clinical Decision-Making on the Wards: Case Study.

Large language models (LLMs) are computational artificial intelligence systems with advanced natural language processing capabilities that have recently been popularized among health care students and educators due to their ability to provide real-time access to a vast amount of medical knowledge. The adoption of LLM technology into medical education and training has varied, and little empirical evidence exists to support its use in clinical teaching environments. The aim of the study is to identify and qualitatively evaluate potential use cases and limitations of LLM technology for real-time ward-based educational contexts. A brief, single-site exploratory evaluation of the publicly available ChatGPT-3.5 (OpenAI) was conducted by implementing the tool into the daily attending rounds of a general internal medicine inpatient service at a large urban academic medical center. ChatGPT was integrated into rounds via both structured and organic use, using the web-based "chatbot" style interface to interact with the LLM through conversational free-text and discrete queries. A qualitative approach using phenomenological inquiry was used to identify key insights related to the use of ChatGPT through analysis of ChatGPT conversation logs and associated shorthand notes from the clinical sessions. Identified use cases for ChatGPT integration included addressing medical knowledge gaps through discrete medical knowledge inquiries, building differential diagnoses and engaging dual-process thinking, challenging medical axioms, using cognitive aids to support acute care decision-making, and improving complex care management by facilitating conversations with subspecialties. Potential additional uses included engaging in difficult conversations with patients, exploring ethical challenges and general medical ethics teaching, personal continuing medical education resources, developing ward-based teaching tools, supporting and automating clinical documentation, and supporting productivity and task management. LLM biases, misinformation, ethics, and health equity were identified as areas of concern and potential limitations to clinical and training use. A code of conduct on ethical and appropriate use was also developed to guide team usage on the wards. Overall, ChatGPT offers a novel tool to enhance ward-based learning through rapid information querying, second-order content exploration, and engaged team discussion regarding generated responses. More research is needed to fully understand contexts for educational use, particularly regarding the risks and limitations of the tool in clinical settings and its impacts on trainee development.

Study Of the Adverse Drug Reaction (ADR) On Geriatric Patients in Internal Medicine Inpatient at A Private Hospital in Bukittinggi City, West Sumatera

Geriatri merupakan populasi yang beresiko tinggi mengalami efek samping obat merugikan (ESO). Hal ini disebabkan karena perubahan farmakokinetik dan farmakodinamik obat akibat penurunan fungsi organ. Penelitian ini bertujuan untuk mengetahui pengetahuan, pengalaman, penanganan dan pelaporan ESO yang terjadi pada pasien geriatrik oleh tenaga kesehatan di suatu rumah sakit swasta di Kota Bukittinggi, Sumatera Barat secara kualitatif. Pengumpulan data dilakukan melalui wawancara semi terstruktur terhadap 12 orang informan yang terdiri dari Dokter, Perawat, dan Apoteker. Topik wawancara meliputi pengetahuan informan tentang farmakovigilans dan ESO, pengalaman tentang kejadian, penanganan dan pelaporan ESO, pendapat tentang upaya yang harus dilakukan untuk menurunkan ESO. Wawancara direkam dan ditranskipsi, kemudian dilakukan analisis dengan pendekatan content analysis menggunakan software NVivo versi 12. Hasil penelitian menunjukkan sebagian besar informan belum memiliki pengetahuan yang cukup mengenai farmakovigilans dan ESO. Informan umumnya pernah menemukan ESO pada pasien geriatri selama dirawat di rumah sakit. Sebagian informan mengetahui alur penanganan dan pelaporan kejadian ESO, namun belum terlaksana dengan baik. Pendapat tentang upaya yang harus dilakukan untuk menurunkan ESO adalah dengan mengadakan pelatihan, adanya monitoring dan evaluasi, adanya diskusi dan diseminasi ilmu, mengurangi polifarmasi serta adanya SOP yang jelas.

Improving inpatient paediatric de-labelling of allergies to beta-lactams: a quality improvement study

ObjectiveTo evaluate the implementation of an antimicrobial stewardship programme-led inpatient beta-lactam allergy de-labelling programme using a direct oral provocation test (OPT).DesignOne-year quality improvement study using a before–after design.SettingFree-standing tertiary care...

Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study.

Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit. To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization. We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups. Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction. Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.

Acute kidney injury in hospitalized patients with nonmalignant pleural effusions: a retrospective cohort study

BackgroundNonmalignant pleural effusion (NMPE) is common and remains a definite health care problem. Pleural effusion was supposed to be a risk factor for acute kidney injury (AKI). Incidence of AKI in NMPE patients and whether there is correlation between the size of effusions and AKI is unknown.ObjectiveTo assess the incidence of AKI in NMPE inpatients and its association with effusion size. Study design and methodWe conducted a retrospective cohort study of inpatients admitted to the Chinese PLA General Hospital with pleural effusion from 2018-2021. All patients with pleural effusions confirmed by chest radiography (CT or X-ray) were included, excluding patients with diagnosis of malignancy, chronic dialysis, end-stage renal disease (ESRD), community-acquired AKI, hospital-acquired AKI before chest radiography, and fewer than two serum creatinine tests during hospitalization. Multivariate logistic regression and LASSO logistic regression models were used to identify risk factors associated with AKI. Subgroup analyses and interaction tests for effusion volume were performed adjusted for the variables selected by LASSO. Causal mediation analysis was used to estimate the mediating effect of heart failure, pneumonia, and eGFR < 60 ml/min/1.73m2 on AKI through effusion volume. ResultsNMPE was present in 7.8% of internal medicine inpatients. Of the 3047 patients included, 360 (11.8%) developed AKI during hospitalization. After adjustment by covariates selected by LASSO, moderate and large effusions increased the risk of AKI compared with small effusions (moderate: OR 1.47, 95%CI 1.11-1.94 p = 0.006; large: OR 1.86, 95%CI 1.05-3.20 p = 0.028). No significant modification effect was observed among age, gender, diabetes, bilateral effusions, and eGFR. Volume of effusions mediated 6.8% (p = 0.005), 4.0% (p = 0.046) and 4.6% (p < 0.001) of the effect of heart failure, pneumonia and low eGFR on the development of AKI respectively. ConclusionThe incidence of AKI is high among NMPE patients. Moderate and large effusion volume is independently associated with AKI compared to small size. The effusion size acts as a mediator in heart failure, pneumonia, and eGFR.

Pragmatic trial evaluating the impact of simulation training on high-risk prescribing to older adults by junior physicians.

High-risk medications like benzodiazepines, sedative hypnotics, and antipsychotics are commonly prescribed for hospitalized older adults, despite guidelines recommending avoidance. Prior interventions have not fully addressed how physicians make such prescribing decisions, particularly when experiencing stress or cognitive overload. Simulation training may help improve prescribing decision-making but has not been evaluated for overprescribing. In this two-arm pragmatic trial, we randomized 40 first-year medical resident physicians (i.e., interns) on inpatient general medicine services at an academic medical center to either intervention (a 40-minute immersive simulation training) or control (online educational training) groups. The primary outcome was the number of new benzodiazepine, sedative hypnotic, or antipsychotic orders for treatment-naïve older adults during hospitalization. Secondary outcomes included the same outcome by all providers, being discharged on one of the medications, and orders for related or control medications. Outcomes were measured using electronic health record data over each intern's service period (~2 weeks). Outcomes were evaluated using generalized estimating equations, adjusting for clustering. In total, 522 treatment-naïve older adult patients were included in analyses. Over follow-up, interns prescribed ≥1 high-risk medication for 13 (4.9%) intervention patients and 13 (5.0%) control patients. The intervention led to no difference in the number of new prescriptions (Rate Ratio [RR]: 0.85, 95%CI: 0.31-2.35) versus control and no difference in secondary outcomes. In secondary analyses, intervention interns wrote significantly fewer "as-needed" ("PRN") order types for the high-risk medications (RR: 0.29, 95%CI: 0.08-0.99), and instead tended to write more "one-time" orders than control interns, though this difference was not statistically significant (RR: 2.20, 95%CI: 0.60-7.99). Although this simulation intervention did not impact total high-risk prescribing for hospitalized older adults, it did influence how the interns prescribed, resulting in fewer PRN orders, suggesting possibly greater ownership of care. Future interventions should consider this insight and implementation lessons raised. Clinicaltrials.gov(NCT04668248).

Treatment Complications Associated With Hospital Admission in Oropharyngeal Cancer Patients.

Oropharyngeal cancer (OPC) survivorship is a nursing priority because patients are living longer while significant short-term and long-term treatment complications that require nursing care are increasing. Hospital readmission is costly and reflects the quality of care patients receive. This secondary analysis aimed to determine the prevalence of treatment complications resulting in hospital admissions among persons with OPC and examine the relationship between treatment complications resulting in hospital admission among persons with OPC and all other persons with head and neck cancer. Using the National Inpatient Survey 2008-2019 database, we identified persons with relevant head and neck cancer diagnoses using specific International Classification of Disease ICD-9 and ICD-10 codes. Complications were operationalized by diagnosis-related codes; persons with codes for major elective surgery were excluded as our focus was posttreatment symptoms requiring hospitalization. Descriptive statistics were used to characterize persons with OPC hospitalized between 2008 and 2019. Binary logistic regression was used to assess complications using crude comparisons. The Elixhauser Comorbidity Index was used for controlling for comorbidities. The final analysis samples included 751,533: 164,770 persons with OPC and 586,763 with other head and cancers. The most prevalent diagnoses observed in those with OPC were esophagitis, nutrition disorder, hematological disorder, and renal failure; the least common diagnoses were sepsis, respiratory tract infection, and pneumonia. Binary regression revealed that persons with OPC experienced significantly more esophagitis, nutrition disorders, hematological disorders, and renal failure compared to persons with other head and neck cancers. Treatment of survivors of OPC requires more intensive monitoring for early symptoms associated with treatment, including esophagitis, nutrition disorders, bleeding disorders, and renal failure, than persons with other head and neck cancers. Monitoring laboratory values and clinical manifestations of these conditions is imperative. Nurses may encounter persons with OPC in emergency departments, outpatient radiology, or inpatient general medicine floors to manage swallowing difficulties, dehydration, malnutrition, and bleeding. Delayed or ineffective treatment of these conditions contributes to readmission, financial burden, and impairment of patient's quality of life. Future research should investigate the relationship between targeted treatment for expected complications and readmission rates in persons with OPC.

Aligning patient values and code status: Choice of Diction's Effect (CODE) study.

Decisions regarding resuscitation after cardiac arrest are critical from ethical, patient satisfaction, outcome, and healthcare cost standpoints. Physician-reported discussion barriers include topic discomfort, fear of time commitment, and difficulty articulating end-of-life concepts. The influence of language used in these discussions has not been tested. This study explored whether utilizing the alternate term "allow (a) natural death" changed code status decisions in hospitalized patients versus "do not resuscitate" (DNR). All patients age 65 and over admitted to a general medicine hospital teaching service were screened (English-speaking, not ICU-level care, no active psychiatric illness, no substance misuse, no active DNR). Participants were randomized to resuscitation discussions with either DNR or "allow natural death" as the "no code" phrasing. Outcomes included patient resuscitation decision, satisfaction with and duration of the conversation, and decision correlation with illness severity and predicted resuscitation success. 102 participants were randomized to the "allow natural death" (N = 49) or DNR (N = 53) arms. The overall "no code" rate for our sample of hospitalized general medicine inpatients age >65 was 16.7%, with 13% in the DNR and 20.4% in the "allow natural death" arms (p = 0.35). Discussion length was similar in the DNR and "allow natural death" arms (3.9 + 3.2 vs. 4.9 + 3.9 minutes), and not significantly different (p = 0.53). Over 90% of participants were highly satisfied with their code status decision, without difference between arms (p = 0.49). Participants' code status discussions did not differ in "no code" rate between "allow natural death" and DNR arms but were short in length and had high patient satisfaction. Previously reported code status discussion barriers were not encountered. It is appropriate to screen code status in all hospitalized patients regardless of phrasing used.

Internal Medicine Residents' Perceptions of Their Continuity Clinic Training.

Internal Medicine (IM) residents have reported dissatisfaction with continuity clinic (CC) training, which may contribute to the increasing shortage of primary care physicians. Studies show balancing inpatient and outpatient duties as a driver of dissatisfaction, but few studies have compared CC with inpatient (IP) training, following transition to an X + Y model, or assessed the impact of show rates, continuity, and telemedicine use on resident perceptions. The aim of this study was to adapt a validated survey to compare residents' perceptions of their CC with their inpatient medicine training and examine the impact of objective clinic measures on training. This quantitative cross-sectional study included a survey that was sent to 152 residents at an academic IM program in May-June 2021. Clinic measures such as show versus no-show rates, continuity with the residents' own patients, and visit modality were obtained through the electronic health records at Veterans Affairs and non-Veterans Affairs CCs. The survey response rate was 78% (118/152). Residents were more satisfied with inpatient general medicine rotations than their CC experience (4.5 vs 3.3 on a 5-point scale, P < 0.001). Residents were more likely to pursue a profession in inpatient IM than in primary care (3.7 vs 2.3, P < 0.001). No correlation was found between higher show rates, continuity with patients, or proportion of visits conducted through telemedicine and resident satisfaction with CC. This study aligns with previous findings of IM resident dissatisfaction with CC training while adding a side-by-side comparison to inpatient training and including objective CC data. We identified new areas for improvement of CC training, including residents' medical knowledge through review of quality metrics, making CC representative of real-world practice, and mentorship from faculty.

Effect of ordering thyroid-stimulating hormone levels on subsequent clinical management of internal medicine in-patients admitted with delirium

Effect of ordering thyroid-stimulating hormone levels on subsequent clinical management of internal medicine in-patients admitted with delirium