Search

Background: Among patients with nonvalvular atrial fibrillation (NVAF) who have sustained an upper gastrointestinal bleed (UGIB), the benefits and harms of oral anticoagulation change over time. Early resumption of anticoagulation increases recurrent bleeding, while delayed resumption exposes patients to a higher risk of ischemic stroke. We therefore set out to estimate the expected benefit of resuming anticoagulation as a function of time after UGIB among patients with NVAF., Methods: We created a decision-analytic model estimating discounted quality-adjusted life-years when patients with NVAF resume anticoagulation on each day following UGIB. We simulated from a health system perspective over a lifelong time horizon., Results: Peak utility for warfarin was achieved by resumption 41 days after hemostasis from the index UGIB. Resumption between days 32 and 51 produced greater than 99.9% of the peak utility. Peak utility for apixaban was achieved by resumption 32 days after the index UGIB. Resumption between days 21 and 47 produced greater than 99.9% of the peak utility. Of input parameters, results were most sensitive to underlying stroke risk. Specifically, across the range of CHA 2 DS 2 -Vasc scores, the optimal day of resumption varied by around 11 days for patients resuming warfarin and by around 15 days for patients resuming apixaban. Results were less sensitive to underlying risk of rebleeding., Conclusions: For patients with NVAF following UGIB, warfarin is optimally restarted approximately six weeks following hemostasis, and apixaban is optimally restarted approximately one month following hemostasis. Modest changes to this timing based on probability of thromboembolic stroke are reasonable.

Introduction: Inadequate bowel preparation (IBP) is a common problem in hospitalized patients; however, little is known about how to prevent IBP. In a large, multihospital system, we evaluated the association between modifiable factors and IBP rate., Methods: We reviewed data from adult (≥18 years) inpatients undergoing colonoscopy between January 2011 and June 2017. Colonoscopies performed in the intensive care unit or lacking descriptions of bowel preparation quality were excluded. Multivariate logistic regression analysis was performed to identify factors associated with IBP. A counterfactual analysis was performed to assess the potential contribution of modifiable factors to IBP., Results: Of 8,819 patients that were included (median age of 64 years; 50.5% female), 51% had IBP. Patients with IBP stayed in the hospital one day longer than those with adequate bowel preparation (P < .001). Modifiable factors associated with IBP include opiate use within three days of colonoscopy (OR, 1.31; 95% CI, 1.18, 1.45), colonoscopy performed after 12:00 pm (OR, 1.25; 95% CI, 1.1, 1.41), and solid diet the day before colonoscopy (OR, 1.37; 95% CI, 1.18, 1.59). In the counterfactual analysis, if all patients avoided these three conditions, adjusted IBP rates were reduced by 5.6%., Conclusions: Among hospitalized patients undergoing colonoscopy, IBP rates are high and associated with an increased length of stay. Avoiding opiates before colonoscopy, performing colonoscopy before noon, and maintaining patients on a liquid diet or nil per os might significantly reduce IBP rates.

Background: Recent studies in the outpatient setting have demonstrated high rates of opioid prescribing and overdose-related deaths. Prescribing practices in hospitalized patients are unexamined., Objective: To investigate patterns and predictors of opioid utilization in nonsurgical admissions to US hospitals, variation in use, and the association between hospital-level use and rates of severe opioid-related adverse events., Design, Setting, and Patients: Adult nonsurgical admissions to 286 US hospitals., Measurements: Opioid exposure and severe opioid-related adverse events during hospitalization, defined using hospital charges and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes., Results: Of 1.14 million admissions, opioids were used in 51%. The mean ± standard deviation daily dose received in oral morphine equivalents was 68 ± 185 mg; 23% of exposed received a total daily dose of ≥100 mg oral morphine equivalents. Opioid-prescribing rates ranged from 5% in the lowest-prescribing hospital to 72% in the highest-prescribing hospital (mean, 51% ± 10%). After adjusting for patient characteristics, the adjusted opioid-prescribing rates ranged from 33% to 64% (mean, 50% ± standard deviation 4%). Among exposed, 0.60% experienced severe opioid-related adverse events. Hospitals with higher opioid-prescribing rates had higher adjusted relative risk of a severe opioid-related adverse event per patient exposed (relative risk: 1.23 [1.14-1.33] for highest-prescribing compared with lowest-prescribing quartile)., Conclusions: The majority of hospitalized nonsurgical patients were exposed to opioids, often at high doses. Hospitals that used opioids most frequently had increased adjusted risk of a severe opioid-related adverse event per patient exposed. Interventions to standardize and enhance the safety of opioid prescribing in hospitalized patients should be investigated., (© 2013 Society of Hospital Medicine.)

Background: The objective of this study was to evaluate trends in hospitalization, cost, and short-term outcomes in acute respiratory failure (ARF) between 2001 and 2009 in the United States., Methods: Using the Nationwide Inpatient Sample we identified cases of ARF based on International Classification for Diseases, Ninth Revision, Clinical Modification codes. We calculated weighted frequencies of ARF hospitalizations by year and estimated population-adjusted incidence and mortality rates. We used logistic regression to examine hospital mortality rates over time while adjusting for changes in demographic characteristics and comorbidities of patients., Results: The number of hospitalizations with a diagnosis of ARF rose from 1,007,549 in 2001 to 1,917,910 in 2009, with an associated increase in total hospital costs from $30.1 billion to $54.3 billion. During the same period we observed a decrease in hospital mortality from 27.6% in 2001 to 20.6% in 2009, a slight decline in average length of stay from 7.8 days to 7.1 days, and no significant change in the mean cost per case ($15,900). Rates of mechanical ventilation (noninvasive [NIV] or invasive mechanical ventilation [IMV]) remained stable over the 9-year period, and the use of NIV increased from 4% in 2001 to 10% in 2009., Conclusions: Over the period of 2001 to 2009, there was a steady increase in the number of hospitalizations with a discharge diagnosis of ARF, with a decrease in inpatient mortality. There was a significant shift during this time toward the use of NIV, with a decrease in the rates of IMVuse., (Copyright © 2012 Society of Hospital Medicine.)

Background: The effect of Medical Emergency Teams (METs) on cardiopulmonary arrests (codes) and fatal codes remains unclear and widely debated., Objective: To describe the implementation of a hospitalist-led MET and compare the number of code calls and code deaths before and after implementation., Design: Interrupted time series., Setting: Tertiary care academic medical center., Patients: All hospitalized patients., Intervention: Implementation of an MET, consisting of a critical care nurse, respiratory therapist, intravenous therapist, and the patient's physician., Measurements: Number of MET calls, code calls, cardiac arrests and other medical crises, and code deaths per 1000 admissions, stratified by location (inside vs outside critical care)., Results: From implementation in March 2006 through December 2009, the MET logged 2717 calls, most commonly for respiratory distress (33%), cardiovascular instability (25%), and neurological abnormality (20%). Overall code calls declined significantly between pre-implementation and post-implementation of the MET from 7.30 (95% confidence interval [CI] 5.81, 9.16) to 4.21 (95% CI 3.42, 5.18) code calls per 1000 admissions. Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards, primarily due to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards. Code calls within critical care also declined. The rate of fatal codes was not affected., Conclusions: A hospitalist-led MET decreased code call rates but did not affect mortality rates., (Copyright © 2011 Society of Hospital Medicine.)

Background: Compared to hospital care provided by primary care physicians (PCPs), the hospitalist model provides equal-to-superior efficiency and outcomes; however, little is known about how the model affects patient satisfaction., Methods: Random patient satisfaction telephone interviews were conducted on discharged adult medicine inpatients at 3 Massachusetts hospitals between 2003 and 2009. Questionnaires included variables assessing patient satisfaction with various physician care domains. Patient age, gender, admission year, education level, language, illness severity, emergency room admission status, institution, and attending physician type were extracted from billing records. We used adjusted multivariable models to compare patient satisfaction with hospitalists and PCPs for domains of: physician care quality, physician behavior, pain management, communication., Results: Inpatients completed discharge surveys for 8295 encounters (3597 hospitalist, 4698 PCP). Multivariate-adjusted satisfaction scores for physician care quality were slightly higher for PCPs than hospitalists (4.24 vs 4.20, P = 0.04); there was no statistical difference at any individual hospital, and no difference among different hospitalist groups. Patient ratings of hospitalists and PCPs for behavior, pain control, and communication were equivalent (all P values >0.23). In multivariable models, hospitalists and PCPs had similar adjusted proportions in the highest satisfaction category (79.2% vs 80.5%, respectively, P = 0.17) and lowest category (5.1% vs 4.5%, respectively, P = 0.19). Quality ratings of both groups improved equivalently (P slope interaction = 0.47) but significantly over time (PCP 4.21 (2003) to 4.36 (2009), hospitalist 4.11 to 4.33, P Δ <0.001)., Conclusions: Patients appear similarly satisfied with inpatient care provided by several hospitalist models and by primary care physicians., (Copyright © 2011 Society of Hospital Medicine.)