Patient Physician Research Articles

Impact of lipid levels and high-intensity statins on vein graft patency after CABG: Midterm results of the ACTIVE trial.

High-dose atorvastatin did not improve 1-year vein graft patency in the recent Aggressive Cholesterol Therapy to Inhibit Vein Graft Events trial. However, it remains unknown whether high-intensity statins may impact graft disease in the years that follow. In the trial, patients (N = 173) were randomized to receive atorvastatin 10 or 80 mg for 1 year after coronary bypass surgery (CABG). Beyond 1 year, the choice of statin was left to the patient's physician. In this study of participants who agreed to follow-up (N = 76), low-density lipoprotein (LDL) levels were measured and graft patency was assessed 3 years after surgery. The rate of vein graft disease 3 years after surgery was not significantly reduced with atorvastatin 80 mg during the first postoperative year or the use of open-label high-intensity statin thereafter (p = NS). However, a trend was observed between higher LDL levels during the first postoperative year and a greater incidence of vein graft disease at 3 years (p = .12). Among patients who had LDL levels more than 90 mg/dl in the first year after CABG, 38.5% had vein graft disease at 3 years, compared to 19.0% for those with LDL levels less than 90 mg/dl (p = .15). Higher mean LDL levels during the first postoperative year were associated with a higher rate of vein disease 3 years after surgery both at the graft level (p = .03) and at the patient level (p = .03) in multivariate analysis. Higher LDL levels during the first postoperative year were associated with significantly greater vein graft disease 3 years after CABG.

Factores asociados al riesgo cardiovascular y enfermedad cardiovascular y renal en el estudio IBERICAN (Identificación de la poBlación Española de RIesgo CArdiovascular y reNal): resultados definitivos

ObjectiveTo analyse the prevalence in clinical practice of cardiovascular risk factors (CVRF) and cardiovascular disease (CVD), as well as their causal relationship, in the study inclusion visit. Material and methodsCross-sectional analysis of the study inclusion visit of 8,066 patients of 18 to 85years of age included in the IBERICAN study. By reviewing the medical history, analytics and medical visits, the patient's physician has collected socio-demographic information, personal and family history and prevalence of CVRF and CVD and renal disease. A multivariate analysis was carried out using a logistic regression that included the autonomous region variable as a random effect variable, in order to analyse the impact of certain variables on the development of each CVRF, metabolic syndrome, subclinical organ damage, renal disease, and CVD. ResultsDyslipidaemia was 2.4 times more frequent in diabetics, and the risk was increased by 59% in hypertensive patients. Arterial hypertension was twice as frequent in diabetics, and increased 94% in hyperuricaemic patients and 62.1% in dyslipidaemia patients. Diabetes mellitus was 2.5 times higher in dyslipidaemia patients, and 2.2 times higher in hypertensive patients. CVD was four times more frequent in patients with a family history, and the risk in women was increased by 90.8% and by 53.8% in patients with renal disease. ConclusionsThe Spanish population seen in Primary Care that were analysed in the IBERICAN study had a high prevalence of CVRF and CVD, which gives it a high CVR. The multivariate analysis performed shows a close causal relationship between the CVRF with each other, and with renal disease and CVD.

5 Close to Home: Implementation of a transfer process for paediatric inpatients from tertiary to community care

Abstract Background Patients presenting to the emergency department who require inpatient care are either admitted to our tertiary care inpatient units or transferred directly to a community hospital. When patients appropriate for community care cannot be transferred due to a lack of community beds and instead remain in a tertiary care bed, there are palpable downstream effects on patient flow. A pre-study audit confirmed that, once admitted, transfers from the inpatient unit to a community bed are rare. This project aimed to improve access to tertiary care beds by increasing inpatient transfers to community hospitals. Objectives The project aimed to transfer 25% of all eligible patients from the Paediatric Medicine inpatient units to community hospitals over a 4-month period by identifying eligible patients and streamlining the transfer process. Design/Methods An Ishikawa diagram with input from inpatient physicians and nurses and community hospital colleagues identified 4 modifiable barriers. A process map was created along with a simplified transfer process. Medical teams and nurse leaders were provided with the charts of contact numbers, geographic locations and levels of care for community hospitals. Intake nurses tracked eligible patients. Encrypted text messages were sent to inpatient physicians on their mobile devices every morning reminding them to assess specific patients for transfer. The outcomes of all identified patients including process and balancing measures were tracked. Results Multiple PDSA cycles focused on improving the success of identifying eligible patients at multiple points in the process. The study’s outcome measure was the rate of successful inpatient transfers for all eligible patients. From November 2018 to March 2019, 120 patients were identified as eligible for transfer at the time of admission: 45 (37.5%) were discharged within 24 hours, 42 (35%) were not considered clinically appropriate for transfer by the attending physician and 33 were considered appropriate for transfer. Twenty-four were approached for transfer (72.7%); 9 were not approached for non-clinical reasons. Six (18.2%) refused transfer and 10 (30%) were successfully transferred. These rates were sustained over the study period. Conclusion A streamlined transfer process can improve patient flow, optimize utilization of tertiary care beds and provide care closer to home. A more robust method of tracking patients that could flag patients and send physicians electronic reminders is needed. Most importantly, optimal use of tertiary care beds requires a culture shift to ensure every patient is considered for transfer to the community when medically appropriate.

Endocarditis prophylaxis in daily practice of pediatricians and dentists in Flanders.

Endocarditis is a potentially life-threatening disease in children with congenital heart disease (CHD) and correct prophylaxis (EP) is of utmost importance. We conducted two surveys among pediatricians and dentists in Flanders about their knowledge of EP guidelines. The survey was completed by 910 dentists and 100 pediatricians. Sixty-five percent of the dentists did not know any guideline. They relied for information on the internet or the child's physician. 87% identified low risk treatments correctly, but only 64% identified high risk procedures correctly. Eighty-three percent asked for the presence of CHD and allergy to antibiotics. Dentists asked advice of the patient's physician, but 29% would withhold treatments in high-risk patients and 50% did not know the pediatric antibiotic dosages. Forty-seven percent of the pediatricians did not know EP guidelines and they would preferably contact the child's cardiologist. Pediatricians had difficulties with the identification of low-risk procedures and would give unnecessary antibiotics. They identified most CHD at high risk, but scored lower for the identification of lower risk CHD.Conclusion: The knowledge of Flemish dentists and pediatricians of EP guidelines is low. The knowledge about EP guidelines and the communication between dentists and pediatricians should be improved. Patients should be provided with an individual EP card. What is Known: • The knowledge of dentists and cardiologists about EP is not perfect, which has already been described. • There are several guidelines about EP, and they are not identical and sometimes confusing. What is New: • This is the first article combining large scale surveys of the knowledge and application of EP by dentists and pediatricians, allowing us to compare knowledge and gaps of knowledge and use their complementarity in order to offer tailored solutions and use patient education and partnership.

Treatment Strategies by Training Specialty: Patient Consequences of Hospitalist and Specialist Practice Patterns

Although hospitalists (generalist inpatient physicians) have overlapping functions and expertise with specialist physicians, practice differences and resulting patient outcomes between the physician types are not well understood. We investigate how hospitalists and inpatient specialists differ in their treatment strategies and how such differences are associated with patient outcomes. Our identification strategy focuses on a subset of common conditions treated by both hospitalists and specialists within a single hospital such that the setting and organizational policies are the same for both physician types.We use a two‐stage design to disentangle differences in both practice patterns and patient outcomes. In the first stage, we explore whether hospitalists and specialists differ in the number of laboratories and drugs ordered using multilevel negative binomial generalized linear models, accounting for both the distribution of the data and the nesting of patients within providers. We control for patient characteristics, provider workload, and details of the admission including length of stay and any use of intensive care.In the second stage, we model the likelihood that a patient experiences an adverse event or a readmission. These multilevel logistic models expand upon the first‐stage control variables to include the number and types of laboratories and drugs ordered.We leverage data on physicians and patients in a large urban pediatric hospital between January 1, 2009, and August 31, 2015. By focusing on 57 diagnoses commonly treated by both hospitalists and specialists, we are able to distinguish differences in treatment patterns and outcomes for similar patient cases.Practice patterns differ significantly between hospitalists and specialists, and these differences are subsequently associated with differences in patient outcomes. Over the median 3‐day hospital stay, hospitalists ordered 5.0 fewer laboratories (31.3%, P < .001) compared to specialists for conditions identified as well‐known (ie, conditions with clear diagnosis and treatment protocols) and 6.3 fewer laboratoriess (45.1%, P < .001) for less well‐known conditions. Drug orders follow a similar pattern, with hospitalists placing 2.0 fewer orders (11.4%, P = .002) for well‐known conditions and 8.9 fewer orders (46.9%, P = .002) in less well‐known conditions. Specialists are associated with a 3.2 percentage point higher likelihood of patients’ experiencing an adverse drug event (P < .001) and a 5.3 percentage point higher probability of a patient experiencing any adverse event (P < .001). We find no differences in readmission rates.Patients are likely to receive substantially different treatment based on whether they are treated by hospitalists or specialists. Compared to specialists, hospitalists order fewer laboratories and drugs. These patterns are associated with increased costs and reduced adverse events, with no corresponding change in readmission rates.Hospitalists are able to perform similarly or better than specialists on key quality outcomes, despite fewer orders for laboratories and drugs. Efforts to mitigate medical overuse must recognize these differences in practice across specialties, so as to better target the source of inefficient treatment strategies.

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

Universal SARS-Cov-2 Screening in Women Admitted for Delivery in a Large Managed Care Organization.

Objective The coronavirus disease 2019 (COVID-19) pandemic has created a need for data regarding the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnant women. After implementing universal screening for COVID-19 in women admitted for delivery, we sought to describe the characteristics of COVID-19 in this large cohort of women. Study Design An observational study of women admitted to labor and delivery units in Kaiser Permanente Southern California (KPSC) hospitals between April 6 and May 11, 2020 who were universally offered testing for SARS-CoV-2 infection ( n = 3,963). Hospital inpatient and outpatient physician encounter, and laboratory records were used to ascertain universal testing levels, test results, and medical and obstetrical histories. The prevalence of SARS-CoV-2 infection was estimated from the number of women who tested positive during labor per 100 women delivered. Results Of women delivered during the study period, 3,923 (99.0%) underwent SARS-CoV-2 testing. A total of 17 (0.43%; 95% confidence interval: 0.23–0.63%) women tested positive, and none of them were symptomatic on admission. There was no difference in terms of characteristics between SARS-CoV-2 positive and negative tested women. One woman developed a headache attributed to COVID-19 3 days postpartum. No neonates had a positive test at 24 hours of life. Conclusion The findings suggest that in pregnant women admitted for delivery between April 6 and May 11, 2020 in this large integrated health care system in Southern California, prevalence of SARS-CoV-2 test positive was very low and all patients were asymptomatic on admission. Key Points The prevalence of SARS-CoV-2 infection in a large diverse cohort of term pregnant women was 0.43%.99% of women accepted SARS-CoV-2 screening on admission to labor and delivery.All women with positive test results were asymptomatic at the time of testing.

MON-611 Using Machine Learning on Electronic Health Records to Predict Inpatient Glucose Levels and Physicians’ Insulin Dosing

The current optimal inpatient diabetes management schema involves administration of basal, prandial, and correctional insulin to maintain blood glucose (BG) within a target range. Nonetheless, practical management often fails to reach the ideal in both insulin dosing regimens and patients’ BG outcomes. Given the challenges of achieving adequate BG control for hospitalized patients using guidelines and expert knowledge alone, we attempted to use machine learning methods to predict (1) individual BGs, (2) average daily BGs, and (3) physician-ordered insulin doses based on data in an electronic health record-based repository between January 2014 and December 2018. We considered inpatients on subcutaneous insulin having a BG ≥ 200 mg/dL or ≤ 70 mg/dL or with an A1c percentage ≥ 6.5%. We excluded those missing critical data (such as weight), with fewer than five BG checks in 72 hours, or those on hemodialysis, resulting in a cohort of 3,461 patients with 175,934 BG checks among them. In this cohort, the average age was 61.4 years, the average A1c was 7.1%, and the average BG was 171.6 mg/dL, with approximately 25% of BGs ≥ 200 mg/dL and 1.7% of BGs < 70 mg/dL. Using linear regression, we identified features that contributed most to prediction of each of the outcomes. For all three outcomes, the average glucose in the past 24 hours was the most important feature. For prediction of glucose levels, previous BG, BG at the same time the previous day, A1c, BG variance, recent long-acting insulin dose, and glucocorticoid dose were all in the top 10 features. Similar features were important for predicting physician-ordered insulin doses. Surprisingly, neither weight nor creatinine were identified as top features for any outcome. Using these features in our predictive model, we found that individual BGs were highly erratic and could not be predicted precisely (R2 0.24). Similarly, and perhaps unsurprisingly, how physicians would order insulin for patients was also difficult to predict (R2 0.25). However, average daily glucose levels were predicted more reliably (R2 0.36), as was prediction of frank hyperglycemia (BG ≥ 200 mg/dL) in the next day (sensitivity 0.73, specificity 0.79). Given the typical practice pattern of a clinician evaluating the previous day’s insulin regimen performance and adjusting it by anticipating BGs for the next day, prediction of hyperglycemia in the next 24 hours can support decision-making for inpatient BG management.

Characterizing physicians' information needs related to a gap in knowledge unmet by current evidence.

ObjectiveThe study sought to explore information needs arising from a gap in clinicians’ knowledge that is not met by current evidence and identify possible areas of use and target groups for a future clinical decision support system (CDSS), which will guide clinicians in cases where no evidence exists.Materials and MethodsWe interviewed 30 physicians in a large academic medical center, analyzed transcripts using deductive thematic analysis, and developed a set of themes of information needs related to a gap in knowledge unmet by current evidence. We conducted additional statistical analyses to identify the correlation between clinical experience, clinical specialty, settings of clinical care, and the characteristics of the needs.ResultsThis study resulted in a set of themes and subthemes of information needs arising from a gap in current evidence. Experienced physicians and inpatient physicians had more questions and the number of questions did not decline with clinical experience. The main areas of information needs included patients with comorbidities, elderly and children, new drugs, and rare disorders. To address these questions, clinicians most often used a commercial tool, guidelines, and PubMed. While primary care physicians preferred the commercial tool, specialty physicians sought more in-depth knowledge.DiscussionThe current medical evidence appeared to be inadequate in covering specific populations such as patients with multiple comorbidities and elderly, and was sometimes irrelevant to complex clinical scenarios. Our findings may suggest that experienced and inpatient physicians would benefit from a CDSS that generates evidence in real time at the point of care.ConclusionsWe found that physicians had information needs, which arose from the gaps in current medical evidence. This study provides insights on how the CDSS that aims at addressing these needs should be designed.

PCN350 USING REAL WORLD DATA TO DETERMINE HEALTH SYSTEM COSTS OF CANADIANS DIAGNOSED WITH CHRONIC LYMPHOCYTIC LEUKEMIA

With the recent advances of novel treatments for patients with chronic lymphocytic leukemia (CLL), and fiscal constraints of the publicly funded healthcare system in Canada, understanding the real world economic impact of CLL is critical. The objective of this study was to determine the health system costs of CLL patients treated in Ontario, Canada. Patients diagnosed and treated between January 1, 2010 and December 31, 2017 were identified in the Ontario Cancer Registry and linked to provincial administrative databases, capturing hospitalizations, cancer clinic visits, physician services and novel treatments (radiation and inexpensive chemotherapies were excluded). Total cohort, annual and mean per patient/control costs (CAD 2017) were determined using a costing methodology available at the Institute for Clinical Evaluative Sciences called GETCOST. Short-term episodes (e.g., hospitalizations) attributed costs by multiplying the encounter’s resource intensity weight by an annual cost per weighted case; long-term episodes (e.g., complex care) attributed costs by weighted days, and costs of visit-based encounters were determined by utilization. 2,572 CLL patients/cases were identified and matched with 7,611 controls (median age 68 years; 66% male). The overall total cost for cases was $254.7M (mean cost per patient was $99,900); oral medications based on list price ($56.5M), inpatient hospitalizations ($49.1M), and cancer clinic visits ($46.2M) were the top three cost contributors. The mean cost per control was $46,382 with inpatient hospitalizations, physician services and oral medications the top three cost contributors. For CLL patients, year 1 after diagnosis had the highest mean cost ($31,928) followed by year 2 ($17,665). By calendar year, 2016 and 2017 had the highest mean costs. Real world costs for CLL patients may have been increasing over time. Exploring whether investment in new novel agents resulted in improved survival would be key.

A Randomized Trial of Voice-Generated Inpatient Progress Notes: Effects on Professional Fee Billing.

Prior evaluations of automated speech recognition (ASR) to create hospital progress notes have not analyzed its effect on professional revenue billing codes. As ASR becomes a more common method of entering clinical notes, clinicians, hospital administrators, and payers should understand whether this technology alters charges associated with inpatient physician services. This study aimed to measure the difference in professional fee charges between using voice and keyboard to create inpatient progress notes. In a randomized trial of a novel voice with ASR system, called voice-generated enhanced electronic note system (VGEENS), to generate physician notes, we compared 1,613 notes created using intervention (VGEENS) or control (keyboard with template) created by 31 physicians. We measured three outcomes, as follows: (1) professional fee billing levels assigned by blinded coders, (2) number of elements within each note domain, and (3) frequency of organ system evaluations documented in review of systems (ROS) and physical exam. Participants using VGEENS generated a greater portion of high-level (99233) notes than control users (31.8 vs. 24.3%, p < 0.01). After adjustment for clustering by author, the finding persisted; intervention notes were 1.43 times more likely (95% confidence interval [CI]: 1.14-1.79) to receive a high-level code. Notes created using voice contained an average of 1.34 more history of present illness components (95% CI: 0.14-2.54) and 1.62 more review of systems components (95% CI: 0.48-2.76). The number of physical exam components was unchanged. Using this voice with ASR system as tested slightly increases documentation of patient symptom details without reliance on copy and paste and may raise physician charges. Increased provider reimbursement may encourage hospital and provider group to offer use of voice and ASR to create hospital progress notes as an alternative to usual methods.

Lifestyle modification and hypertension: prescription patterns of Nigerian general practitioners.

IntroductionImplementation of lifestyle modification (LM), a cornerstone of hypertension control has been reported to be more challenging than pharmacotherapy. We studied the LM prescription patterns of general medical practitioners (GPs) in Lagos, Nigeria for blood pressure control.MethodsGPs were assessed using anonymous self-administered questionnaire on the prescription of salt restriction, weight management, cessation of tobacco use, physical exercise, and consumption of DASH-like diet for blood pressure control. Chi-square, Fisher's exact and Student t-test were used to test for differences as appropriate. Logistic regression model was constructed to identify the determinants of adequate LM prescription.ResultsA total of 213 GPs (38% females) participated in the survey. LM prescription was over 90% for the following: salt restriction (96.7%), tobacco cessation (94.8%), weight management (94.4%). The remaining were 81.2% and 75.1% for healthy diet and physical activity respectively. The median LM prescription score (of the GPs) was 18.0 [15.0-50.0]. The single significant predictor of adequate LM prescription was total patient load of the GPs (AOR:0.98, 95% CI: 0.97-0.99, p=0.006). Eleven (5.2%), 190 (89.2%), and 12 (5.6%) GPs initiated LM prescription at blood pressure values >140/90mmHg, =140/90mmHg and <140/90mmHg respectively. LM initiation at BP <140/90mmHg was associated with female gender, shorter work experience, working in tertiary care facility and ignorance about hypertension prevention (p<0.05).ConclusionLM is widely prescribed for the treatment of hypertension, but rarely prescribed for its prevention in Nigeria. Interventions to reduce physician's patient load may engender improved LM prescription.

Paediatric clinical and social concerns identified by home visit nurses in the immediate postdischarge period.

To describe paediatric postdischarge concerns manifesting in the first 96hr after hospital discharge. Analysis of nursing documentation generated as part of a randomized controlled trial evaluating the effect of a nurse home visit on healthcare re-use. We analysed home visit records of 651 children (age <18) hospitalized at a large Midwestern children's hospital in 2015 and 2016 who were enrolled in the trial. Registered nurses documented concerns in structured fields and free-text notes in visit records. Descriptive statistics were used to summarize visit documentation. Free-text visit notes were reviewed and exemplars illustrative of quantitative findings were selected. Overall, nurses documented at least one concern in 56% (N=367) of visits. Most commonly, they documented concerns about medication safety (15% or 91 visits). Specifically, in 11% (N=58) of visits nurses were concerned that caregivers lacked a full understanding of medications and in 8% (N=49) of visits families did not have prescribed discharge medications. Pain was documented as present in 9% of all visits (N=56). Nurses completed referrals to other providers/services in 12% of visits (N=78), most frequently to primary care providers. In 13% of visits (N=85) nurses documented concerns considered beyond the immediate scope of the visit related to social needs such as housing and transportation. Inpatient and community nurses and physicians should be prepared to reconcile and manage discharge medications, assess families' medication administration practices and anticipate social needs after paediatric discharge. Little empirical data are available describing concerns manifesting immediately after paediatric hospital discharge. Concerns about medication safety were most frequent followed by concerns related to housing and general safety. The results are important for clinicians preparing children and families for discharge and for community clinicians caring for discharged children.

Changes in the parent cystic fibrosis questionnaire-revised (CFQ-R) with respiratory symptoms in preschool children with cystic fibrosis

IntroductionThe Cystic Fibrosis Questionnaire-Revised (CFQ-R) Respiratory score is a validated and widely used patient-reported outcome. This study aimed to establish changes in the score with acute respiratory events in preschool children with CF and to investigate its’ relationship with physiological outcomes. MethodsThe Parent CFQ-R, multiple breath washout test and spirometry were performed at six study visits over one year. The clinical status of participants, stable or symptomatic, was defined by the patient's physician. Linear regression and distribution-based statistical methods were used to examine the changes in the CFQ-R from the last stable visit and to investigate its relationship with physiological outcomes. ResultsThere were 272 stable and 115 symptomatic visits from 78 participants. The mean CFQ-R Respiratory score did not change between consecutive stable visits (-0.73, SD 20.4). The mean (SD) score deteriorated by 15.5 (20.7) points between stable and symptomatic visits and improved by 14.8 (20.1) points between symptomatic and stable follow-up visits. When a clinically important change is defined as 0.5SD change (10-points), the positive predictive value (PPV) was 45% and the negative predictive value (NPV) was 84%. For visits with a 10-point worsening in the CFQ-R Respiratory score and a 15% increase in LCI, the PPV was better (81%) than using either measure alone. ConclusionThe CFQ-R Respiratory score is responsive to acute respiratory events in preschool children with CF and its utility to monitor individual patients is improved when combined with LCI.

Frequency of safety net errors in the emergency department: Effect of patient handoffs.

The objective of this study was to determine physician awareness of abnormal vital signs and key clinical interventions (oxygen provision, intravenous access) in the emergency department, and to measure the effect of patient handoffs on this awareness. This was a prospective observational study at two large, urban, academic emergency departments. Emergency department physicians were asked the following about each of the physician's patients: 1) the number of IV lines, 2) whether the patient was on supplemental oxygen, and 3) whether the patient had any abnormal vital signs. Physicians were blind to the nature of the study prior to enrollment. Error rates between physician responses and actual patient status were calculated, and logistic regression, adjusted for physician clustering, was used to calculate association of errors with multiple situational factors, including handoff status. We analyzed 463 patient encounters from 74 physicians. Physicians missed abnormal vital signs in 19.4% of encounters. They made errors in oxygen status and number of IV lines in 16.6% and 35.8% of encounters, respectively. Physicians were significantly more likely to make all types of errors on patients who had undergone handoff as opposed to their primary patients. Emergency physicians make frequent errors regarding awareness of their patients' vital signs, oxygen and vascular status and patient handoffs are associated with an increased frequency of such errors.

Goals of care designations in advanced pancreatic cancer patients undergoing palliative chemotherapy.

683 Background: Discussion of goals of care (GoC) is a key part of quality care for patients with palliative cancer. Numerous studies have shown that documentation of GoC in this population remains low. In 2014, Alberta Health Services launched a health-system wide initiative to provide patients with physical copies of their GoC designation intended to be available at all health-system interactions. Here we describe rates of GoC documentation in the period surrounding this initiative. Methods: This is a retrospective cohort analysis of 240 patients with locally advanced or metastatic pancreatic cancer treated with palliative chemotherapy from 2012-2015 in Alberta, Canada. Data were obtained from outpatient electronic medical record documentation and the provincial cancer registry. Results: 63.8% (153/240) of patients had a documented GoC discussion, with 60.4% (145/240) receiving a specific GoC designation. 59.6% (143/240) of patients were referred to palliative care, with 32.5% (78/240) seen by palliative care physician. Of 334 individual GoC discussions documented, 38.6% (129/334) were by medical oncologists, 2.3% (10/334) were by radiation oncologists, 27.2% (91/334) were by palliative care, and 19.2% (64/334) were by other inpatient physicians during hospital admissions. At least 9.6% (32/334) referenced discussions that occurred prior to initial consultation with an oncology physician. Conclusions: The majority of pancreatic cancer patients undergoing palliative chemotherapy had a documented GoC designation during the study period. Providing patients with physical copies of their GoC designation may therefore represent a simple but effective means of increasing GoC documentation in the outpatient oncology setting.

Laboratory bleeding predictors in elderly patients with atrial fibrillation taking direct oral anticoagulants

Atrial fibrillation (AF) is one of the most common arrhythmias in patients ≥75 years of age. The increased risk of thrombosis due to age and the large number of concomitant diseases makes it evident that anticoagulant therapy is necessary. However, the same factors increase the risk of hemorrhagic complications, which are among the most dangerous side effects of anticoagulant therapy. That is why it is very important to identify patients with the highest probability of bleeding, whether large or small clinically significant and minor. The purpose of our study was to study the prognostic value of laboratory methods of examination with regard to the development of hemorrhagic events in elderly patients with AF taking direct oral anticoagulants (DOAC). The study enrolled 102 patients ≥75 years of age with AF of non-valve etiology taking dabigatran, apixaban, rivaroxaban at full or reduced doses. Anticoagulants were administered by outpatient and inpatient physicians. Both previous experience with DOAC prior to inclusion in the trial (if DOAC was previously prescribed) and prospective patient monitoring after inclusion in the trial were analyzed. The minimum analyzed period of DOAC intake was 18 months. Patients who underwent (n = 19) and did not undergo (n = 83) hemorrhagic events (all events were considered small by ISTH criteria) did not differ in any of the laboratory indicators potentially considered as predictors of hemorrhagic events.

The Comprehensive Care Plan: A Patient-Centered, Multidisciplinary Communication Tool for Frequently Hospitalized Patients

Comprehensive care plans are dynamic documents maintained by an interdisciplinary team that contain specific, actionable information for clinicians and staff across multiple care settings. They promote communication and continuity of care by suggesting communication strategies, medical plans, and psychosocial resources. This article describes the structure and development process of comprehensive care plans for frequently hospitalized patients enrolled in a program designed to improve care for this vulnerable population. These care plans are widely used, with inpatient physicians referring to the care plan in their notes during 92.0% of admissions.

Cost comparison of surgical management of nonsagittal synostosis: traditional open versus endoscope-assisted techniques.

Management of craniosynostosis at an early age is important for mitigating the risk of abnormal cranial development, but treatment can result in significant expenses. Previous research has shown that endoscope-assisted craniectomy (EAC) is less costly than open cranial vault remodeling (CVR) for patients with sagittal synostosis. The aim of this study was to strengthen the existing body of healthcare cost research by elucidating the charges associated with open and endoscopic treatment for patients with nonsagittal synostosis. The authors performed a retrospective analysis of data obtained in 41 patients who underwent open CVR and 38 who underwent EAC with postoperative helmet therapy for nonsagittal, single-suture craniosynostosis (metopic, coronal, and lambdoid) between 2008 and 2018. All patients were < 1 year of age at the time of surgery and had a minimum 1 year of follow-up. Inpatient charges, physician fees, helmet charges, and outpatient clinic visits in the 1st year were analyzed. The mean ages of the children treated with EAC and open CVR were 3.5 months and 8.7 months, respectively. Patients undergoing EAC with postoperative helmet therapy required more outpatient clinic visits in the 1st year than patients undergoing CVR (4 vs 2; p < 0.001). Overall, 13% of patients in the EAC group required 1 helmet, 30% required 2 helmets, 40% required 3 helmets, and 13% required 4 or more helmets; the mean total helmeting charges were $10,072. The total charges of treatment, including inpatient charges, physician fees, outpatient clinic visit costs, and helmet charges, were significantly lower for the EAC group than they were for the open CVR group ($50,840 vs $95,588; p < 0.001). Despite the additional charges for postoperative helmet therapy and the more frequent outpatient visits, EAC is significantly less expensive than open CVR for patients with metopic, coronal, and lambdoid craniosynostosis. In conjunction with the existing literature on clinical outcomes and perioperative resource utilization, these data support EAC as a cost-minimizing treatment for eligible patients with nonsagittal synostosis.

The Management of Drug-Influenced Gingival Enlargement.

<br/> Drug-influenced gingival enlargement (DIGE) is a reaction to specific medications, namely phenytoin, ciclosporin and calcium channel blockers. DIGE is encountered increasingly in clinical practice due to the widespread use of calcium channel blocker drugs particularly. Approaches to its management are discussed in this review.<br/> Methods: Narrative review of the literature and discussion of clinical implications.<br/> Findings: Management of DIGE involves nonsurgical treatment and may require surgical reduction of the overgrown gingival tissues. Management is complicated by the difficulties in achieving adequate plaque control, given the unfavourable contour of the enlarged gingival tissues, and the high frequency of recurrence of DIGE after surgical management. Replacing the drug involved can be very beneficial in selected cases, but the management of the underlying medical condition limits its application. The decision to replace a drug is not the responsibility of the dental practitioner, but the patient's physician may make it after consultation.<br/> Conclusions: Management of DIGE can be challenging and may require close co-operation between the dental practitioner and a hygienist, a periodontist and the patient's physician. Long term supportive maintenance programmes need to be in place for optimal outcomes.