177 results on '"Daniel J. Brotman"'
Search Results
2. A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training
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Brian Thomas Garibaldi, Timothy Niessen, Allan Charles Gelber, Bennett Clark, Yizhen Lee, Jose Alejandro Madrazo, Reza Sedighi Manesh, Ariella Apfel, Brandyn D. Lau, Gigi Liu, Jenna VanLiere Canzoniero, C. John Sperati, Hsin-Chieh Yeh, Daniel J. Brotman, Thomas A. Traill, Danelle Cayea, Samuel C. Durso, Rosalyn W. Stewart, Mary C. Corretti, Edward K. Kasper, and Sanjay V. Desai
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Medical education ,Physical examination skills ,Cardiopulmonary exam ,Bedside medicine ,Special aspects of education ,LC8-6691 ,Medicine - Abstract
Abstract Background Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. Methods One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). Results Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing ‘a’ from ‘v’ waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. Conclusions A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.
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- 2017
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3. Potential role of coronary computed tomography-angiography for guiding perioperative cardiac management for non-cardiac surgery
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Leonard S. Feldman, Daniel J. Brotman, Armin Arbab-Zadeh, and Amit K. Pahwa
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computed coronary tomography angiography, myocardial perfusion imaging, cardiac event ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Perioperative cardiac events can be a major consequence of surgery. The American College of Cardiology Foundation/American Heart Association has set out guidelines to aid physicians in identifying patients at the highest risk for these events. The guidelines do recommend for some patients to undergo non-invasive cardiac stress testing for further risk stratification, but their sensitivity and specificity for predicting cardiac events is not optimal. With more data emerging of the superior performance of computed coronary tomography angiography (CCTA) compared to non-invasive stress testing, CCTA could be more useful in risk stratification for these patients.
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- 2013
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4. Baclofen and the Risk of Encephalopathy: A Real-World, Active-Comparator Cohort Study
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Y. Joseph Hwang, Alex R. Chang, Daniel J. Brotman, Lesley A. Inker, Morgan E. Grams, and Jung-Im Shin
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General Medicine - Published
- 2023
5. The Effect of Eliminating Intermediate Severity Drug-Drug Interaction Alerts on Overall Medication Alert Burden and Acceptance Rate.
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Amy M. Knight, Joyce Maygers, Kimberly A. Foltz, Isha S. John, Hsin Chieh Yeh, and Daniel J. Brotman
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- 2019
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6. Adding financial insult to physical injury: Economic impacts of having COVID
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Amelita Woodruff, Daniel J. Brotman, and Sarah J. Conway
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Leadership and Management ,Health Policy ,Fundamentals and skills ,General Medicine ,Assessment and Diagnosis ,Care Planning - Published
- 2023
7. Faculty Development in Academic Hospital Medicine: a Scoping Review
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Gregory J. Misky, Bradley Sharpe, A. Charlotta Weaver, Ashwini Niranjan-Azadi, Ashwin Gupta, Stephanie Rennke, Steve Ludwin, Christi Piper, null MLIS, Vivien K. Sun, Daniel J. Brotman, and Maria Frank
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Internal Medicine - Published
- 2023
8. Characterizing the Relationship Between Payer Mix and Diagnostic Intensity at the Hospital Level
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Michael I. Ellenbogen, Laura Prichett, and Daniel J. Brotman
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Cross-Sectional Studies ,Medicaid ,Internal Medicine ,Humans ,Health Care Costs ,Medicare ,United States ,Hospitals ,Aged - Abstract
Overuse of diagnostic testing in the hospital setting contributes to high healthcare costs, yet the drivers of diagnostic overuse in this setting are not well-understood. If financial incentives play an important role in perpetuating hospital-level diagnostic overuse, then hospitals with favorable payer mixes might be more likely to exhibit high levels of diagnostic intensity.To apply a previously developed hospital-level diagnostic intensity index to characterize the relationship between payer mix and diagnostic intensity.Cross-sectional analysis SUBJECTS: Acute care hospitals in seven states MAIN MEASURES: We utilized a diagnostic intensity index to characterize the level of diagnostic intensity at a given hospital (with higher index values and tertiles signifying higher levels of diagnostic intensity). We used two measures of payer mix: (1) a hospital's ratio of discharges with Medicare and Medicaid as the primary payer to those with a commercial insurer as the primary payer, (2) a hospital's disproportionate share hospital ratio.A 5-fold increase in the Medicare or Medicaid to commercial insurance ratio was associated with an adjusted odds ratio of 0.24 (95% CI 0.16-0.36) of being in a higher tertile of the intensity index. A ten percentage point increase in the disproportionate share hospital ratio was associated with an adjusted odds ratio of 0.56 (95% CI 0.42-0.74) of being in a higher intensity index tertile.At the hospital level, a favorable payer mix is associated with higher diagnostic intensity. This suggests that financial incentives may be a driver of diagnostic overuse.
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- 2022
9. Behaviorally and environmentally induced non–24-hour sleep-wake rhythm disorder in sighted patients
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Jonathan S. Emens, Alfred J. Lewy, Elizabeth B. Klerman, Melissa A. St. Hilaire, Daniel J. Brotman, Charles A. Czeisler, and Amber Lin
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Sleep Wake Disorders ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,genetic structures ,business.industry ,Audiology ,Scientific Investigations ,Circadian Rhythm ,Melatonin ,Rhythm ,Neurology ,Sleep Disorders, Circadian Rhythm ,medicine ,Humans ,Hour sleep ,Neurology (clinical) ,Circadian rhythm ,Sleep ,Letters to the Editor ,business ,medicine.drug - Abstract
STUDY OBJECTIVES: To determine whether there was evidence of circadian or sleep-regulatory dysfunction in sighted individuals with non–24-hour sleep-wake rhythm disorder. METHODS: Three sighted individuals with signs and/or symptoms of non–24-hour sleep-wake rhythm disorder were studied. Thirty-five- to 332-day laboratory and home-based assessments of sleep-wake and circadian timing, endogenous circadian period, photic input to the circadian pacemaker, and/or circadian and sleep-wake–dependent regulation of sleep were conducted. RESULTS: No evidence of circadian dysfunction was found in these individuals. Instead, sleep-wake timing appeared to dissociate from the circadian timing system, and/or self-selected sleep-wake and associated light/dark timing shifted the circadian pacemaker later, rather than the circadian pacemaker determining sleep-wake timing. CONCLUSIONS: These findings suggest that the etiology of this disorder may be light- and/or behaviorally induced in some sighted people, which has implications for the successful treatment of this disorder. CITATION: Emens JS, St Hilaire MA, Klerman EB, et al. Behaviorally and environmentally induced non–24-hour sleep-wake rhythm disorder in sighted patients. J Clin Sleep Med. 2022;18(2):453–459.
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- 2022
10. The Paradox of Readmission Prevention Interventions: Missing Those Most in Need
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Daniel J. Brotman, Amy Deutschendorf, Rosalyn W. Stewart, Diane Lepley, Curtis Leung, Blair Golden, Erik H. Hoyer, Melissa Richardson, and Geoff B. Dougherty
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Male ,Patient Transfer ,medicine.medical_specialty ,Psychological intervention ,Aftercare ,030204 cardiovascular system & hematology ,Logistic regression ,Patient Readmission ,Risk Assessment ,Odds ,03 medical and health sciences ,Sex Factors ,0302 clinical medicine ,Intervention (counseling) ,Preventive Health Services ,medicine ,Humans ,030212 general & internal medicine ,Generalized estimating equation ,Socioeconomic status ,Aged ,Maryland ,business.industry ,General Medicine ,Continuity of Patient Care ,Patient Acceptance of Health Care ,Readmission rate ,Patient Discharge ,Socioeconomic Factors ,Emergency medicine ,Female ,business ,Medicaid - Abstract
Background Post-hospitalization transition interventions remain a priority in preventing rehospitalization. However, not all patients referred for readmission prevention interventions receive them. We sought to 1) define patient characteristics associated with non-receipt of readmission prevention interventions (among those eligible for them), and 2) determine whether these same patient characteristics are associated with hospital readmission at the state level. Methods We used state-wide data from the Maryland Health Services Cost Review Commission to determine patient-level factors associated with state-wide readmissions. Concurrently, we conducted a retrospective analysis of discharged patients referred to receive 1 of 3 post-discharge interventions between January 2013 and July 2019—a nurse transition guide, post-discharge phone call, or follow-up appointment in our post-discharge clinic—to determine patient-level factors associated with not receiving the intervention. Multivariable generalized estimating equation logistic regression models were used to calculate the odds of not accepting or not receiving the interventions. Results Older age, male gender, black race, higher expected readmission rate, and lower socioeconomic status were significantly associated with 30-day readmission in hospitalized Maryland patients. Most of these variables (age, sex, race, payer type [Medicaid or non-Medicaid], and socioeconomic status) were also associated with non-receipt of intervention. Conclusions We found that many of the same patient-level characteristics associated with the highest readmission risk are also associated with non-receipt of readmission reduction interventions. This highlights the paradox that patients at high risk of readmission are least likely to accept or receive interventions for preventing readmission. Identifying strategies to engage hard-to-reach high-risk patients continues to be an unmet challenge in readmission prevention.
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- 2021
11. Healthcare utilization differences between an apixaban-based and warfarin-based strategy for acute venous thromboembolism in patients with end-stage kidney disease
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Shirin Ardeshirrouhanifard, Michael I. Ellenbogen, Jodi B. Segal, Michael B. Streiff, Steven B. Deitelzweig, and Daniel J. Brotman
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Hematology - Abstract
Evidence suggests that an apixaban-based strategy to treat acute venous thromboembolism (VTE) in patients with End-Stage Kidney Disease (ESKD) may be safer than a warfarin-based strategy. Apixaban has an additional advantage of not requiring bridging with heparin which often necessitates long hospitalizations for patients with ESKD. We sought to determine if an apixaban-based strategy is associated with less healthcare utilization than a warfarin-based strategy.We employed a new-user, active-comparator retrospective cohort study using inverse probability of treatment weights (IPTW) to adjust for confounding demographic and clinical variables. Patients with ESKD newly initiated on either apixaban or warfarin for an acute VTE between 2014 and 2018 in the United States Renal Data System were included. Outcomes were presence of index hospitalization, length of index hospitalization, total hospital days, total hospital days excluding index hospitalization, total emergency department (ED) visits that did not result in hospitalization, and total skilled nursing facility days.At six months, patients who received apixaban were less likely to have an index hospitalization, had a shorter index hospitalization (median of 4.0 vs 8.0 days, p 0.001), and had fewer total hospital days. The IPTW and index year-adjusted incidence rate ratios of total hospital days at one, three, and six months were 0.83 (95 % confidence intervals (CI) 0.79-0.86), 0.84 (95 % CI 0.81-0.88), and 0.88 (95 % CI 0.83-0.92) for apixaban compared to warfarin.Among patients with ESKD and VTE, resource utilization for an apixaban-based strategy appears to be lower than for a warfarin-based strategy.
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- 2022
12. Safety and effectiveness of apixaban versus warfarin for acute venous thromboembolism in patients with end-stage kidney disease: A national cohort study
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Michael I. Ellenbogen, Shirin Ardeshirrouhanifard, Jodi B. Segal, Michael B. Streiff, Steven B. Deitelzweig, and Daniel J. Brotman
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Adult ,Venous Thrombosis ,Leadership and Management ,Pyridones ,Health Policy ,Anticoagulants ,General Medicine ,Venous Thromboembolism ,Assessment and Diagnosis ,United States ,Cohort Studies ,Humans ,Kidney Failure, Chronic ,Pyrazoles ,Fundamentals and skills ,Warfarin ,Gastrointestinal Hemorrhage ,Care Planning ,Retrospective Studies - Abstract
Patients with end-stage kidney disease (ESKD) are at significantly increased risk for both thrombosis and bleeding relative to those with normal renal function. The optimal therapy of venous thromboembolism (VTE) in patients with ESKD is unknown.To compare the safety and effectiveness of apixaban relative to warfarin in patients with ESKD and acute VTE.New-user, active-comparator retrospective United States population-based cohort with inverse probability of treatment weighting, using the United States Renal Data System data from 2014 to 2018. We included adults with ESKD on hemodialysis or peritoneal dialysis who were newly initiated on apixaban or warfarin for an acute VTE.The coprimary outcomes were major bleeding, recurrent VTE, and all-cause mortality within 6 months of anticoagulant initiation. Secondary outcomes were intracranial hemorrhage and gastrointestinal bleeding. The primary analyses were based on intent-to-treat defined by the first drug received and accounted for competing risks of death. Sensitivity analyses included varied follow-up time, as-treated analyses, and dose-specific apixaban subgroups.The apixaban and warfarin cohorts included 2302 and 9263 patients, respectively. Apixaban was associated with a lower risk of major bleeding (hazard ratio [HR] 0.81, 95% confidence interval [CI]: 0.70-0.94), intracranial bleeding (HR 0.69, 95% CI 0.48-0.98), and gastrointestinal bleeding (HR 0.82, 95% CI 0.69-0.96). Recurrent VTE and all-cause mortality were not significantly different between the groups.Apixaban was associated with a lower risk of bleeding relative to warfarin when used to treat acute VTE in patients with ESKD on dialysis.
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- 2022
13. A unit-based, multi-center evaluation of adopting mobility measures and daily mobility goals in the hospital setting
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Erik H. Hoyer, Michael Friedman, Annette Lavezza, Eleni Flanagan, Sowmya Kumble, Michelle D'Alessandro, Morning Gutierrez, Elizabeth Colantuoni, Daniel J. Brotman, and Daniel L. Young
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General Nursing - Published
- 2023
14. Development of a Simple Index to Measure Overuse of Diagnostic Testing at the Hospital Level Using Administrative Data
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Daniel J. Brotman, Laura Prichett, Michael I. Ellenbogen, and Pamela T. Johnson
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medicine.medical_specialty ,Index (economics) ,Leadership and Management ,030204 cardiovascular system & hematology ,Assessment and Diagnosis ,Medicare ,Ordinal regression ,03 medical and health sciences ,0302 clinical medicine ,Physicians ,Humans ,Medicine ,030212 general & internal medicine ,Medical diagnosis ,Care Planning ,Aged ,Original Research ,Measure (data warehouse) ,Diagnostic Tests, Routine ,business.industry ,Health Policy ,Diagnostic test ,Hospital level ,General Medicine ,Odds ratio ,Hospitals ,United States ,Benchmarking ,Emergency medicine ,Fundamentals and skills ,Metric (unit) ,business - Abstract
OBJECTIVE: We developed a diagnostic overuse index that identifies hospitals with high levels of diagnostic intensity by comparing negative diagnostic testing rates for common diagnoses. METHODS: We prospectively identified candidate overuse metrics, each defined by the percentage of patients with a particular diagnosis who underwent a potentially unnecessary diagnostic test. We used data from seven states participating in the State Inpatient Databases. Candidate metrics were tested for temporal stability and internal consistency. Using mixed-effects ordinal regression and adjusting for regional and hospital characteristics, we compared results of our index with three Dartmouth health service area-level utilization metrics and three Medicare county-level cost metrics. RESULTS: The index was comprised of five metrics with good temporal stability and internal consistency. It correlated with five of the six prespecified overuse measures. Among the Dartmouth metrics, our index correlated most closely with physician reimbursement, with an odds ratio of 2.02 (95% CI, 1.11-3.66) of being in a higher tertile of the overuse index when comparing tertiles 3 and 1 of this Dartmouth metric. Among the Medicare county-level metrics, our index correlated most closely with standardized costs of procedures per capita, with an odds ratio of 2.03 (95% CI, 1.21-3.39) of being in a higher overuse index tertile when comparing tertiles 3 and 1 of this metric. CONCLUSIONS: We developed a novel overuse index that is preliminary in nature. This index is derived from readily available administrative data and shows some promise for measuring overuse of diagnostic testing at the hospital level.
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- 2021
15. COVID-19 coagulopathy and thrombosis: Analysis of hospital protocols in response to the rapidly evolving pandemic
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Vijay Duggirala, Eric R. Schumacher, Michael B. Streiff, Kevin J. O'Leary, Justin J Choi, Geraldine E. Ménard, Margaret C. Fang, David F. Hemsey, Michael Y. Lin, Daniel J. Brotman, Jeffrey L. Schnipper, David G. Sterken, S Ryan Greysen, James E. Anstey, Shoshana J. Herzig, Todd E.H. Hecht, Anna L. Parks, Kwame Dapaah-Afriyie, Anne S. Linker, Daniel P. Hunt, Neera Ahuja, Valerie M. Vaughn, Andrew Dunn, Andrew D. Auerbach, William Collins, Melissa L. P. Mattison, Matthew A. Pappas, and Sanjay Bhandari
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Pulmonary embolism (PE) ,medicine.medical_specialty ,Consensus ,Deep vein thrombosis (DVT) ,Coronavirus disease 2019 (COVID-19) ,Letter to the Editors-in-Chief ,Risk Assessment ,Anticoagulation ,Clinical Protocols ,Risk Factors ,Coagulopathy ,Pandemic ,medicine ,Humans ,Thrombophilia ,Venous thromboembolism (VTE) ,cardiovascular diseases ,Dosing ,Healthcare Disparities ,Practice Patterns, Physicians' ,Intensive care medicine ,Blood Coagulation ,Venous Thrombosis ,Academic Medical Centers ,business.industry ,Anticoagulants ,COVID-19 ,Thrombosis ,Venous Thromboembolism ,Hematology ,Heparin ,medicine.disease ,United States ,COVID-19 Drug Treatment ,Coronavirus ,Treatment Outcome ,Pulmonary Embolism ,business ,Venous thromboembolism ,medicine.drug - Abstract
As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines., Highlights • COVID-19 protocols agreed on heparin-based venous thromboembolism prophylaxis. • Disagreement on thrombosis risk and diagnosis, D-dimer, empiric anticoagulation • Cumulative incidence of COVID-19 did not correlate with specific recommendations. • Framework for frontline providers and hospitals to evaluate practices and outcomes
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- 2020
16. Telemedicine in the Care of Kidney Transplant Recipients With Coronavirus Disease 2019: Case Reports
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Deidra C. Crews, Mohammad Abuzeineh, Robin K. Avery, Daniel C. Brennan, Dorry L. Segev, Fawaz Al Ammary, Daniel J. Brotman, and Abimereki D. Muzaale
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Male ,medicine.medical_specialty ,Telemedicine ,Pneumonia, Viral ,MEDLINE ,030230 surgery ,Article ,Betacoronavirus ,Immunocompromised Host ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Pandemic ,Health care ,Humans ,Outpatient clinic ,Medicine ,Intensive care medicine ,Pandemics ,Kidney transplantation ,COVID ,Transplantation ,SARS-CoV-2 ,business.industry ,COVID-19 ,Emergency department ,Middle Aged ,medicine.disease ,Kidney Transplantation ,Triage ,Telehealth ,Female ,030211 gastroenterology & hepatology ,Surgery ,Coronavirus Infections ,business - Abstract
Kidney transplant recipients who develop symptoms consistent with COVID-19 are bringing unique challenges to health care professionals. Telemedicine has surged dramatically since the pandemic in efforts to maintain patient care and reduce the risk of COVID-19 exposure to patients, healthcare workers, and the public. Herein we present reports of three kidney transplant recipients with COVID-19 that were managed using telemedicine via synchronous video visits integrated with an electronic medical records system, from home to inpatient settings. We demonstrate how telemedicine helped assess, diagnose, triage, and treat patients with COVID-19 while avoiding an emergency room or outpatient clinic visit. While there is limited information about the duration of viral shedding for immunosuppressed patients, our findings underscore the importance of using telemedicine in the follow-up care for kidney transplant recipients with COVID-19 who have recovered from symptoms but might have persistently positive NAT tests. Our experience emphasizes the opportunities of telemedicine in the management of kidney transplant recipients with COVID-19 and in the maintenance of uninterrupted follow-up care for such immunosuppressed patients with prolonged viral shedding. Telemedicine may help increase access to care for kidney transplant recipients during and beyond the pandemic as it offers a prompt, safe, and convenient platform in the delivery of care for these patients. Yet in order to advance the practice of telemedicine in the field of kidney transplantation, barriers to increasing the widespread implementation of telemedicine should be removed, and research studies to assess the effectiveness of telemedicine in the care kidney transplant recipients are needed., Highlights • Telemedicine helped diagnose, triage, and manage transplant patients with COVID-19 • Practical workflow process for COVID-19 test and surveillance • Telemedicine aid from home to inpatient settings, while avoiding ER or clinic visit • Telemedicine provides prompt, safe, and convenient approach to COVID-19 patients • Care delivery for immunosuppressed patients with prolonged COVID-19 shedding • Uninterrupted follow-up care for kidney transplant recipients with COVID-19
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- 2020
17. Improving patient selection for use of consumer grade physical activity monitors in the hospital
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Stephanie Hiser, Jacek Urbanek, Daniel L. Young, Kevin H. McLaughlin, Elizabeth Colantuoni, Daniel J Brotman, Dale M. Needham, and Erik Hoyer
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Adult ,Patient Selection ,Rehabilitation ,Activities of Daily Living ,Humans ,Orthopedics and Sports Medicine ,Physical Therapy, Sports Therapy and Rehabilitation ,Walking ,Exercise ,Hospitals ,Original Research - Abstract
BACKGROUND: Bedrest is toxic for inpatients and consumer grade physical activity monitors offer an economical solution to monitor patient ambulation. But these devices may not be accurate in debilitated hospitalized patients who frequently ambulate very slowly. OBJECTIVE: To determine whether measures of physical capacity can help identify inpatients for whom wearable physical activity monitors may accurately measure step count. METHODS: Prospective observational study of 54 adult inpatients with acute neurological diagnoses. Patients were assessed using 2 physical capacity assessments (Activity Measure for Post-Acute Care Inpatient Mobility Short Form [AM-PAC IMSF] and Katz Activities of Daily Living [ADL] scale). They also completed a 2-minute walk test (2MWT) wearing a consumer grade physical activity monitor. RESULTS: The wearable activity monitor recorded steps (initiated) in 33 (61%) of the inpatients, and for 94% of inpatients with gait speeds >0.43 m/s. Physical capacity assessments correlated well with gait speed, AM-PAC IMSF r = 0.7, and Katz ADL r = 0.6, p 45) and Katz ADL (>5) cutoff scores identified inpatients for whom physical activity monitors initiated with a sensitivity of 94 and 91%, respectively. CONCLUSIONS: Physical capacity assessments, such as AM-PAC, and Katz ADL, may be a useful and feasible screening strategy to help identify inpatients where wearable physical activity monitors can measure their mobility.
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- 2022
18. Association between ambulatory status and call bell use in hospitalized patients—A retrospective cohort study
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Elys Bhatia, Carmen E. Capo-Lugo, Erik H. Hoyer, Andre Cassell, Annette Lavezza, Lisa M. Klein, Daniel L. Young, Michael Friedman, Kara Shumock, Daniel J. Brotman, and Maria Cvach
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Adult ,Male ,medicine.medical_specialty ,Leadership and Management ,Hospitalized patients ,Nurses ,Walking ,Workload ,03 medical and health sciences ,Help-Seeking Behavior ,Mobility status ,Humans ,Medicine ,Association (psychology) ,Nursing management ,Aged ,Retrospective Studies ,030504 nursing ,business.industry ,030503 health policy & services ,Ambulatory Status ,Retrospective cohort study ,Length of Stay ,Middle Aged ,stomatognathic diseases ,Ambulatory ,Emergency medicine ,Female ,Nurse-Patient Relations ,0305 other medical science ,business - Abstract
Aim Characterize the relationship between patient ambulatory status and in-hospital call bell use. Background Although call bells are frequently used by patients to request help, the relationship between physical functioning and call bell use has not been evaluated. Methods Retrospective cohort study of 944 neuroscience patients hospitalized in a large academic urban medical centre between April 1, 2014 and August 1, 2014. We conducted multiple linear regression analyses with number of daily call bells from each patient as the primary outcome and patients' average ambulation status as the primary exposure variable. Results The mean number of daily call bell requests for all patients was 6.9 (6.1), for ambulatory patients 5.6 (4.8), and for non-ambulatory patients, it was 7.7 (6.6). Compared with non-ambulatory patients, ambulatory patients had a mean reduction in call bell use by 1.7 (95% CI 2.5 to -0.93, p 250 feet had 5 fewer daily call bells than patients who were able to perform in-bed mobility. Conclusion Ambulatory patients use their call bells less frequently than non-ambulatory patients. Implications for nursing management Frequent use of call bells by non-ambulatory patients can place additional demands on nursing staff; patient mobility status should be considered in nurse workload/patient assignment.
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- 2019
19. Venous thromboembolism (VTE) prevention and diagnosis in COVID-19: Practice patterns and outcomes at 33 hospitals
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Anna L, Parks, Andrew D, Auerbach, Jeffrey L, Schnipper, Amanda, Bertram, Sun Y, Jeon, Bridget, Boyle, Margaret C, Fang, Shrirang M, Gadrey, Zishan K, Siddiqui, and Daniel J, Brotman
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Adult ,Male ,Multidisciplinary ,SARS-CoV-2 ,Anticoagulants ,COVID-19 ,Hemorrhage ,Venous Thromboembolism ,Middle Aged ,Hospitals ,Cross-Sectional Studies ,Humans ,Female ,Pulmonary Embolism ,Aged ,Retrospective Studies - Abstract
Background Early reports of increased thrombosis risk with SARS-CoV-2 infection led to changes in venous thromboembolism (VTE) management. Real-world data on the prevalence, efficacy and harms of these changes informs best practices. Objective Define practice patterns and clinical outcomes related to VTE diagnosis, prevention, and management in hospitalized patients with coronavirus disease-19 (COVID-19) using a multi-hospital US sample. Methods In this retrospective cross-sectional study of 1121 patients admitted to 33 hospitals, exposure was dose of anticoagulant prescribed for VTE prophylaxis (standard, intensified, therapeutic), and primary outcome was VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]); secondary outcomes were PE, DVT, arterial thromboembolism (ATE), and bleeding events. Multivariable logistic regression models accounting for clustering by site and adjusted for risk factors were used to estimate odds ratios (ORs). Inverse probability weighting was used to account for confounding by indication. Results 1121 patients (mean age 60 ± 18, 47% female) admitted with COVID-19 between February 2, 2020 and December 31, 2020 to 33 US hospitals were included. Pharmacologic VTE prophylaxis was prescribed in 86%. Forty-seven patients (4.2%) had PE, 51 (4.6%) had DVT, and 23 (2.1%) had ATE. Forty-six patients (4.1%) had major bleeding and 46 (4.1%) had clinically relevant non-major bleeding. Compared to standard prophylaxis, adjusted odds of VTE were 0.67 (95% CI 0.21–2.1) with no prophylaxis, 1.0 (95% CI 0.06–17) with intensified, and 3.0 (95% CI 0.89–10) with therapeutic. Adjusted odds of bleeding with no prophylaxis were 5.6 (95% CI 3.0–11) and 5.3 (95% CI 3.0–10) with therapeutic (no events on intensified dosing). Conclusions Therapeutic anticoagulation was associated with a 3-fold increased odds of VTE and 5-fold increased odds of bleeding. While higher bleeding rates with high-intensity prophylaxis were likely due to full-dose anticoagulation, we conclude that high thrombosis rates were due to clinical concern for thrombosis before formal diagnosis.
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- 2021
20. Characterizing the relationship between diagnostic intensity and quality of care
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Laura Prichett, Michael I. Ellenbogen, Daniel J. Brotman, and David E. Newman-Toker
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medicine.medical_specialty ,Index (economics) ,Hospital bed ,media_common.quotation_subject ,Clinical Biochemistry ,Medicine (miscellaneous) ,01 natural sciences ,Patient Readmission ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,Quality (business) ,030212 general & internal medicine ,0101 mathematics ,Quality of care ,media_common ,Quality of Health Care ,business.industry ,Health Policy ,Mortality rate ,010102 general mathematics ,Biochemistry (medical) ,Public Health, Environmental and Occupational Health ,Hospital level ,Random effects model ,Hospitals ,Intensity (physics) ,Emergency medicine ,business - Abstract
Objectives The relationship between diagnostic intensity and quality of care has not been well-characterized at the hospital level. We performed an exploratory analysis to better delineate this relationship using a hospital-level diagnostic overuse index and accepted hospital quality metrics (readmissions and mortality). Methods We previously developed and published a hospital-level diagnostic overuse index. A hospital’s overuse index value (which ranges from 0 to 0.986, with larger numbers indicating more overuse) was our predictor variable of interest. The outcome variables were excess readmission ratios and mortality rates for common medical conditions, which CMS publicly reports. The model controlled for Elixhauser comorbidity score, hospital bed size, hospital teaching status, and random effects that vary by state. Results We did not find a statistically significant relationship between our overuse index and the quality measures we evaluated. Conclusions The lack of a significant relationship between diagnostic intensity and quality, at least as measured by our overuse index and the tested quality metrics, suggests that well-targeted efforts to reduce diagnostic overuse in hospitals may not adversely impact quality of care.
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- 2021
21. Infective endocarditis: Beyond the usual tests
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Nkemdilim Mgbojikwe, Steven R. Jones, Daniel J. Brotman, and Thorsten M. Leucker
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Prosthetic valve ,medicine.medical_specialty ,Four-Dimensional Computed Tomography ,medicine.diagnostic_test ,business.industry ,Magnetic resonance imaging ,Computed tomography ,General Medicine ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Neuroimaging ,Positron emission tomography ,Clinical diagnosis ,Infective endocarditis ,medicine ,030212 general & internal medicine ,Radiology ,business - Abstract
Infective endocarditis remains a diagnostic challenge. Although echocardiography is still the mainstay imaging test, it misses up to 30% of cases. Newer imaging tests--4-dimensional computed tomography (4D CT), fluorodeoxy-glucose positron emission tomography (FDG-PET), and leukocyte scintigraphy--are increasingly used as alternative or adjunct tests for select patients. They improve the sensitivity of clinical diagnosis of infective endocarditis when appropriately used, especially in the setting of a prosthetic valve.
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- 2019
22. Heart failure guidelines: What you need to know about the 2017 focused update
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Ilan S. Wittstein, Daniel J. Brotman, and Lee Rodney Haselhuhn
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medicine.medical_specialty ,Acute decompensated heart failure ,Cardiology ,Blood Pressure ,03 medical and health sciences ,0302 clinical medicine ,Natriuretic Peptide, Brain ,medicine ,Humans ,030212 general & internal medicine ,Disease management (health) ,Intensive care medicine ,Referral and Consultation ,Mineralocorticoid Receptor Antagonists ,Heart Failure ,business.industry ,Disease Management ,Stroke Volume ,General Medicine ,Stroke volume ,Guideline ,medicine.disease ,Blood pressure ,Heart failure ,Practice Guidelines as Topic ,Biomarker (medicine) ,Heart failure with preserved ejection fraction ,business ,Biomarkers - Abstract
The 2017 focused update of the 2013 ACC/AHA guideline on heart failure contains new and important recommendations on prevention, novel biomarker uses, heart failure with preserved ejection fraction (HFpEF), and comorbidities such as hypertension, iron deficiency, and sleep-disordered breathing. Potential implications for management of acute decompensated heart failure will also be explored.
- Published
- 2019
23. Supine-Related Pseudoanemia in Hospitalized Patients
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Thomas S. Kickler, Bennett A Peterson, Reza Manesh, Arsalan Derakhshan, Daniel J. Brotman, and Bibhu D. Mohanty
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Male ,Time Factors ,Supine position ,Leadership and Management ,Hospitalized patients ,Anemia ,030204 cardiovascular system & hematology ,Assessment and Diagnosis ,Hemoglobin levels ,Sitting ,Hemoglobins ,03 medical and health sciences ,0302 clinical medicine ,Sitting upright ,Supine Position ,medicine ,Humans ,030212 general & internal medicine ,Hemoglobin measurement ,Care Planning ,business.industry ,Health Policy ,General Medicine ,medicine.disease ,Anesthesia ,Female ,Fundamentals and skills ,Hemoglobin ,business - Abstract
A patient’s supine posture redistributes plasma into the vascular space, leading to dilution of blood constituents. The extent to which posture may influence identification of hospital-acquired anemia is unknown. Patients in this quasi-experimental study had blood obtained for hemoglobin measurement while recumbent for at least 6 hours, and then again after sitting upright for at least 1 hour. Of the 35 patients who completed the study, 13 were women (37%). Patients had a median increase in hemoglobin of 0.60 g/dL (range, –0.6 to 1.4 g/dL) with sitting, a 5.2% (range, (–4.5% to 15.1%) relative change (P < .001). Ten of 35 patients (29%) exhibited an increase in hemoglobin of 1.0 g/dL or more. Posture influences hemoglobin levels in hospitalized patients on general medicine wards; this knowledge may help curb unnecessary testing to evaluate small changes in hemoglobin concentration.
- Published
- 2021
24. Venous thromboembolism prophylaxis in patients with traumatic brain injury: a systematic review [version 1; referees: 2 approved]
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Yohalakshmi Chelladurai, Kent A Stevens, Elliott R Haut, Daniel J Brotman, Ritu Sharma, Kenneth M Shermock, Sosena Kebede, Sonal Singh, and Jodi B Segal
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Systematic Review ,Articles ,Hypertension ,Neurorehabilitation & CNS Trauma - Abstract
Objective: There is considerable practice variation and clinical uncertainty about the choice of prophylaxis for preventing venous thromboembolism in patients with traumatic brain injury. We performed a systematic review to assess both the effectiveness and safety of pharmacologic and mechanical prophylaxis, and the optimal time to initiate pharmacologic prophylaxis in hospitalized patients with traumatic brain injury. Data sources and study selection: MEDLINE®, EMBASE®, SCOPUS, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library were searched in July 2012 to identify randomized controlled trials and observational studies reporting on the effectiveness or safety of venous thromboembolism prevention in traumatic brain injury patients. Data extraction: Paired reviewers extracted detailed information from included articles on standardized forms and assessed the risk of bias in each article. Data synthesis: Twelve studies (2 randomized controlled trials and 10 cohort studies) evaluated the effectiveness and safety of venous thromboembolism prophylaxis in patients with traumatic brain injury. Five of the included studies assessed the optimal timing of initiation of pharmacological prophylaxis. Low grade evidence supports the effectiveness of enoxaparin over control in reducing deep vein thrombosis. Low grade evidence also supports the safety of unfractionated heparin over control in reducing mortality in patients with traumatic brain injury. Evidence was insufficient for remaining comparisons and outcomes including the optimal timing of initiation of pharmacoprophylaxis. Conclusion: There is some evidence that pharmacoprophylaxis improves deep vein thromboses and mortality outcomes in patients hospitalized with traumatic brain injury. Additional studies are required to strengthen this evidence base.
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- 2013
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25. Venous thromboembolism in hospitalized patients with COVID-19 receiving prophylactic anticoagulation
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Daniel J. Brotman, Gigi Liu, Vivek K. Murthy, Rodney Omron, Michael B. Streiff, Romsai T. Boonyasai, and Brian T. Garibaldi
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medicine.medical_specialty ,RAM, risk assessment model ,biology ,Coronavirus disease 2019 (COVID-19) ,business.industry ,MEDLINE ,VTE, venous thromboembolism ,General Medicine ,biology.organism_classification ,Article ,COVID-19, infection with SAR-CoV-2 ,PCR, polymerase chain reaction ,Internal medicine ,Severity of illness ,Pandemic ,DVT, deep venous thrombus ,Medicine ,Premedication ,ECG, electrocardiogram ,business ,Risk assessment ,Venous thromboembolism ,Betacoronavirus - Published
- 2020
26. Evaluation of Bedside Delivery of Medications Before Discharge: Effect on 30-Day Readmission
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Ariella Apfel, Kenneth M. Shermock, Jeanne M. Clark, Daniel J. Brotman, and Jodi B Segal
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Male ,medicine.medical_specialty ,Medication Systems, Hospital ,MEDLINE ,Pharmaceutical Science ,Medication adherence ,Pharmacy ,Patient Readmission ,Medication Adherence ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Intervention (counseling) ,Odds Ratio ,Medicine ,Humans ,030212 general & internal medicine ,Aged ,Retrospective Studies ,Patient discharge ,Maryland ,business.industry ,030503 health policy & services ,Health Policy ,Retrospective cohort study ,Odds ratio ,Middle Aged ,Patient Discharge ,Multicenter study ,Emergency medicine ,Female ,0305 other medical science ,business ,Cohort study - Abstract
This study is an evaluation of a discharge intervention that occurred in multiple hospitals across Maryland. In this program, patients received medications at their bedside before discharge with the goal of reducing the risk of primary nonadherence to prescribed medications.To test if the intervention reduced the risk of 30-day readmission for the patients who received bedside medication delivery relative to comparable patients who did not receive bedside medication delivery.This was a retrospective cohort study. Patients who received the intervention were linked to their claims data in the Maryland Health Information Exchange. These patients were matched on age, sex, diagnosis-related group, and hospital to a set of patients who did not receive the intervention. We used propensity score matching, as well as inverse-probability weighting, to account for residual differences between the treated and comparison patients. With robust Poisson regression, adjusting for hospital, we generated risk ratios for 30-day readmission and explored risk ratios in key subgroups.The cohort included 6,167 inpatients who received medications at bedside and 28,546 who did not from 10 Maryland hospitals. They were 60% female, 61% white, and 31% African American; the average age was 56 years. The risk ratio for readmission, comparing the intervention group to the propensity score-matched comparison group, was 1.21 (95% CI = 0.96-1.5). Inverse-probability weighting yielded a similar result (1.19 [95% CI = 0.98-1.45]).In this study, the isolated intervention of bedside medication delivery did not reduce 30-day readmission risk. We expect it may have favorable outcomes on other metrics such as primary nonadherence and patient satisfaction. It may also have a favorable effect when bundled with other care transition activities. As an isolated intervention, however, bedside medication delivery is unlikely to affect 30-day readmission rates.This study was funded by Walgreen Co. through unrestricted funds to Johns Hopkins University, which has received fees from Walgreens for providing consultation as an institution to Walgreens. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. Segal received a grant from the National Institute on Aging during the conduct of this study. The other authors have nothing to disclose.
- Published
- 2020
27. Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department
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Veena G. Billioux, Daniel J. Brotman, Kimiyoshi Kobayashi, Benjamin E. Bodnar, Linda Huffman, Ashley Pleiss, Hetal Rupani, Erin Kane, Carrie Herzke, Rohit Toteja, and Henry J. Michtalik
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Downtime ,Inpatients ,Quality management ,business.industry ,Six Sigma ,Psychological intervention ,General Medicine ,Emergency department ,Guideline ,Length of Stay ,Critical Care and Intensive Care Medicine ,medicine.disease ,Patient Admission ,Multidisciplinary approach ,Emergency Medicine ,medicine ,Humans ,Medical emergency ,Metric (unit) ,business ,Emergency Service, Hospital ,Retrospective Studies - Abstract
BackgroundEmergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time.MethodsAfter initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric ‘bed downtime’—the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre.InterventionsInterventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures.ResultsThis package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit.ConclusionUse of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.
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- 2020
28. New frontiers in High-Value Care Education and Innovation: When Less is Not More
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Pamela T. Johnson, Amit K. Pahwa, and Daniel J. Brotman
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Leadership and Management ,business.industry ,Health Policy ,Medicine ,Fundamentals and skills ,General Medicine ,Assessment and Diagnosis ,Marketing ,business ,Care Planning ,Value (mathematics) - Published
- 2019
29. Implementation of a comprehensive program to improve coordination of care in an urban academic health care system
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Albert W. Wu, Constantine G. Lyketsos, Daniel J. Brotman, Amy Deutschendorf, Anita Everett, Scott A. Berkowitz, Debra Hickman, Leon Purnell, Melissa Richardson, Michele Bellantoni, Raymond Zollinger, Carol Sylvester, Eric B Bass, Linda Dunbar, Eric E. Howell, and Ya Luan Hsiao
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medicine.medical_specialty ,Psychological intervention ,Efficiency, Organizational ,03 medical and health sciences ,Hospitals, Urban ,0302 clinical medicine ,Ambulatory care ,Nursing ,Multidisciplinary approach ,Acute care ,Health care ,medicine ,030212 general & internal medicine ,Skilled Nursing Facilities ,Chronic care ,Academic Medical Centers ,Primary Health Care ,business.industry ,030503 health policy & services ,Health Policy ,Continuity of Patient Care ,Quality Improvement ,Community health ,Business, Management and Accounting (miscellaneous) ,0305 other medical science ,Psychology ,business ,Delivery of Health Care ,Medicaid - Abstract
Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.
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- 2018
30. Geographically Localized Medicine House-Staff Teams and Patient Satisfaction
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Stephen A. Berry, Amanda Bertram, Leonard Feldman, Peter J. Pronovost, Daniel J. Brotman, Rehan Qayyum, Timothy Niessen, Carrie Herzke, Zishan K. Siddiqui, Lisa Allen, and Nowella Durkin
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lcsh:R5-920 ,Health (social science) ,patient satisfaction ,Leadership and Management ,Health Policy ,clinician–patient relationship ,HCAHPS ,Patient satisfaction ,Nursing ,Psychology ,lcsh:Medicine (General) ,Research Articles ,House staff ,interprofessional communication - Abstract
Background: Geographically localized care teams may demonstrate improved communication between team members and patients, potentially enhancing coordination of care. However, the impact of geographically localized team on patient experience scores is not well understood. Objective: To compare experience scores of patients on resident teams home clinical units with patients assigned to them off of their home units over a 10-year period. Participants: Patients admitted to any of the 4 chief resident staffed internal medicine inpatient service were included. Patients admitted to the house-staff teams’ home clinical unit comprised the exposure group and their patients off of their home units comprised the control patients. Measurement: Top-box experience scores calculated from the physician Hospital Consumer Assessment of Healthcare and Provider Systems (HCAHPS) and Press Ganey patient satisfaction surveys. Results: There were 3012 patients included in the study. There were no significant differences in experience scores with physician communication, nursing communication, pain, or discharge planning between the 2 groups. Patients did not report satisfaction more often with the time physicians spent with them on localized teams (48.6% vs 47.5%; P = .54) or that staff were better at working together (63.2% vs 61.3%; P = .29). This did not change during a 45-month period when the proportion of patients on home units exceeded 75% and multidisciplinary rounds were started. Conclusion: Patients cared for by geographically localized teams did not have better patient experience. Other factors such as physician communication skills or limited time spent in direct care may overshadow the impact of having localized teams. Further research is needed to better understand organizational, team, and individual factors impacting patient experience.
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- 2018
31. A Method for Attributing Patient-Level Metrics to Rotating Providers in an Inpatient Setting
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Curtis Leung, Henry J. Michtalik, Daniel J. Brotman, Nowella Durkin, Carrie Herzke, Jason Miller, Amy Deutschendorf, and Joseph Finkelstein
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Percentile ,Leadership and Management ,Dashboard (business) ,MEDLINE ,Assessment and Diagnosis ,01 natural sciences ,Patient care ,03 medical and health sciences ,0302 clinical medicine ,Patient satisfaction ,Humans ,Medicine ,030212 general & internal medicine ,0101 mathematics ,Care Planning ,Inpatients ,Operationalization ,business.industry ,Health Policy ,010102 general mathematics ,General Medicine ,Inpatient setting ,medicine.disease ,Hospitalization ,Hospitalists ,Patient Satisfaction ,Fundamentals and skills ,Patient Care ,Medical emergency ,business ,Attribution - Abstract
BACKGROUND: Individual provider performance drives group metrics, and increasingly, individual providers are held accountable for these metrics. However, appropriate attribution can be challenging, particularly when multiple providers care for a single patient. OBJECTIVE: We sought to develop and operationalize individual provider scorecards that fairly attribute patient-level metrics, such as length of stay and patient satisfaction, to individual hospitalists involved in each patient’s care. DESIGN: Using patients cared for by hospitalists from July 2010 through June 2014, we linked billing data across each hospitalization to assign “ownership” of patient care based on the type, timing, and number of charges associated with each hospitalization (referred to as “provider day weighted”). These metrics were presented to providers via a dashboard that was updated quarterly with their performance (relative to their peers). For the purposes of this article, we compared the method we used to the traditional method of attribution, in which an entire hospitalization is attributed to 1 provider, based on the attending of record as labeled in the administrative data. RESULTS: Provider performance in the 2 methods was concordant 56% to 75% of the time for top half versus bottom half performance (which would be expected to occur by chance 50% of the time). While provider percentile differences between the 2 methods were modest for most providers, there were some providers for whom the methods yielded dramatically different results for 1 or more metrics. CONCLUSION: We found potentially meaningful discrepancies in how well providers scored (relative to their peers) based on the method used for attribution. We demonstrate that it is possible to generate meaningful provider-level metrics from administrative data by using billing data even when multiple providers care for 1 patient over the course of a hospitalization.
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- 2017
32. Improving Outcomes After Hospitalization: A Prospective Observational Multicenter Evaluation of Care Coordination Strategies for Reducing 30-Day Readmissions to Maryland Hospitals
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Diane Lepley, Romsai T. Boonyasai, Amy Deutschendorf, Curtis Leung, Erik H. Hoyer, Melissa Richardson, Daniel J. Brotman, and Ariella Apfel
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Adult ,Male ,medicine.medical_specialty ,Psychological intervention ,030204 cardiovascular system & hematology ,Patient Readmission ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Outcome Assessment, Health Care ,Health care ,Internal Medicine ,Humans ,Medicine ,Prospective Studies ,030212 general & internal medicine ,Prospective cohort study ,Aged ,Quality Indicators, Health Care ,Maryland ,business.industry ,Case-control study ,Odds ratio ,Middle Aged ,Patient Discharge ,Confidence interval ,Editorial ,Case-Control Studies ,Emergency medicine ,Female ,Observational study ,business ,Risk assessment - Abstract
Patients frequently experience suboptimal transitions from the hospital to the community, which can increase the likelihood of readmission. It is not known which care coordination services can lead to improvements in readmission rates. To evaluate the effects of two care coordination interventions on 30-day readmission rates. Prospective multicenter observational study of hospitalized patients eligible for two care coordination services between January 1, 2013, and October 31, 2015. Readmission rates were compared for patients who received each care coordination intervention versus those who did not using multivariable generalized estimating equation logistic regression models. A total of 25,628 patients hospitalized in medicine, neurosciences, or surgical sciences units. Patients discharged home and deemed to be at high risk for readmission were assigned a nurse Transition Guide (TG) for 30 days post-discharge. All other patients were assigned the Patient Access Line (PAL) intervention, which provided a post-discharge phone call from a registered nurse. Two large academic hospitals in Baltimore, MD. Thirty-day all-cause readmission to any Maryland hospital. Among all patients, 14.2% (2409/16,993) of those referred for the PAL intervention and 22.8% (1973/8635) of those referred for the TG intervention were readmitted. PAL-referred patients who did not receive the intervention had an adjusted odds ratio (aOR) for readmission of 1.27 (95% confidence interval [95% CI] 1.12–1.44, p
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- 2017
33. A Concise Tool for Measuring Care Coordination from the Provider's Perspective in the Hospital Setting
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Albert W. Wu, Eric E. Howell, Christine Weston, Daniel J. Brotman, Eric B Bass, Sehyo Yune, Scott A. Berkowitz, Amy Deutschendorf, Melissa Richardson, and Carol Sylvester
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Male ,Patient Transfer ,Leadership and Management ,Health Personnel ,media_common.quotation_subject ,Assessment and Diagnosis ,03 medical and health sciences ,0302 clinical medicine ,Cronbach's alpha ,Nursing ,Surveys and Questionnaires ,Humans ,Medicine ,Care Planning ,Patient transfer ,media_common ,Response rate (survey) ,Teamwork ,Inpatient care ,business.industry ,Communication ,Health Policy ,Patient Handoff ,Reproducibility of Results ,Construct validity ,General Medicine ,Continuity of Patient Care ,Hospitals ,Exploratory factor analysis ,030220 oncology & carcinogenesis ,Female ,030211 gastroenterology & hepatology ,Fundamentals and skills ,business - Abstract
Background To support hospital efforts to improve coordination of care, a tool is needed to evaluate care coordination from the perspective of inpatient healthcare professionals. Objectives To develop a concise tool for assessing care coordination in hospital units from the perspective of healthcare professionals, and to assess the performance of the tool in measuring dimensions of care coordination in 2 hospitals after implementation of a care coordination initiative. Methods We developed a survey consisting of 12 specific items and 1 global item to measure provider perceptions of care coordination across a variety of domains, including teamwork and communication, handoffs, transitions, and patient engagement. The questionnaire was distributed online between October 2015 and January 2016 to nurses, physicians, social workers, case managers, and other professionals in 2 tertiary care hospitals. Results A total of 841 inpatient care professionals completed the survey (response rate = 56.6%). Among respondents, 590 (75%) were nurses and 37 (4.7%) were physicians. Exploratory factor analysis revealed 4 subscales: (1) Teamwork, (2) Patient Engagement, (3) Handoffs, and (4) Transitions (Cronbach's alpha 0.84-0.90). Scores were fairly consistent for 3 subscales but were lower for patient engagement. There were minor differences in scores by profession, department, and hospital. Conclusions The new tool measures 4 important aspects of inpatient care coordination with evidence for internal consistency and construct validity, indicating that the tool can be used in monitoring, evaluating, and planning care coordination activities in hospital settings.
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- 2017
34. Impact of Displaying Inpatient Pharmaceutical Costs at the Time of Order Entry: Lessons From a Tertiary Care Center
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Sarah J. Conway, Kenneth M. Shermock, Leonard Feldman, David Merola, BL Pinto, Redonda G. Miller, and Daniel J. Brotman
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Pediatrics ,medicine.medical_specialty ,Leadership and Management ,MEDLINE ,Assessment and Diagnosis ,030226 pharmacology & pharmacy ,Tertiary care ,Drug Costs ,Medical Order Entry Systems ,Tertiary Care Centers ,Order entry ,03 medical and health sciences ,0302 clinical medicine ,Health care ,medicine ,Humans ,030212 general & internal medicine ,Practice Patterns, Physicians' ,Care Planning ,Retrospective Studies ,Pantoprazole ,Voriconazole ,Academic Medical Centers ,Inpatients ,business.industry ,Health Policy ,Retrospective cohort study ,General Medicine ,Emergency medicine ,Female ,Fundamentals and skills ,Levetiracetam ,business ,medicine.drug - Abstract
BACKGROUND A lack of cost-conscious medication use is a major contributor to excessive healthcare expenditures in the inpatient setting. Expensive medicines are often utilized when there are comparable alternatives available at a lower cost. Increasing prescriber awareness of medication cost at the time of ordering may help promote cost-conscious use of medications in the hospital. OBJECTIVE To evaluate the impact of cost messaging on the ordering of 9 expensive medications. DESIGN Retrospective analysis of an institutional cost-transparency initiative. SETTING A 1145-bed, tertiary care, academic medical center. PARTICIPANTS Prescribers who ordered medications through the computerized provider order entry system at the Johns Hopkins Hospital. METHODS Interrupted time series and segmented regression models were used to examine prescriber ordering before and after implementation of cost messaging for 9 highcost medications. RESULTS Following the implementation of cost messaging, no significant changes were observed in the number of orders or ordering trends for intravenous (IV) formulations of eculizumab, calcitonin, levetiracetam, linezolid, mycophenolate, ribavirin, and levothyroxine. An immediate and sustained reduction in medication utilization was seen in 2 drugs that underwent a policy change during our study, IV pantoprazole and oral voriconazole. IV pantoprazole became restricted at our facility due to a national shortage (-985 orders per 10,000 patient days; 𝑃 < 0.001), and oral voriconazole was replaced with an alternative antifungal in oncology order sets (-110 orders per 10,000 patient days; 𝑃 = 0.001). CONCLUSIONS Prescriber cost transparency alone did not significantly influence medication utilization at our institution. Active strategies to reduce ordering resulted in dramatic reductions in ordering.
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- 2017
35. Does Provider Self‐Reporting of Etiquette Behaviors Improve Patient Experience? A Randomized Controlled Trial
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Zishan K. Siddiqui, Amanda Bertram, Rehan Qayyum, Daniel J. Brotman, Sosena Kebede, Lisa Allen, Ibironke Oduyebo, Lucia Ponor, and Nowella Durkin
- Subjects
Male ,Self-assessment ,Self-Assessment ,medicine.medical_specialty ,Leadership and Management ,Interprofessional Relations ,media_common.quotation_subject ,Assessment and Diagnosis ,law.invention ,Etiquette ,03 medical and health sciences ,0302 clinical medicine ,Patient satisfaction ,Randomized controlled trial ,law ,Intervention (counseling) ,Acute care ,Patient experience ,Humans ,Medicine ,030212 general & internal medicine ,Care Planning ,media_common ,Physician-Patient Relations ,business.industry ,030503 health policy & services ,Health Policy ,General Medicine ,Hospital medicine ,Hospitalists ,Patient Satisfaction ,Physical therapy ,Female ,Fundamentals and skills ,Self Report ,0305 other medical science ,business - Abstract
Background There is a glaring lack of published evidence-based strategies to improve the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores on the physician domain. Strategies that have been used are resource intensive and difficult to sustain. Objective We hypothesized that prompting providers to assess their own etiquette-based practices every 2 weeks over the course of 1 year would improve patient experience on the physician domain. Design Randomized controlled trial. Setting 4 acute care hospitals. Participants Hospitalists. Intervention Hospitalists were randomized to the study or the control arm. The study arm was prompted every 2 weeks for 12 months to report how frequently they engaged in 7 best-practice bedside etiquette behaviors. Control arm participants received similarly worded questions on quality improvement behaviors. Measurement Provider experience scores were calculated from the physician HCAHPS and Press Ganey survey provider items. Results Physicians reported high rates of etiquette-based behavior at baseline, and this changed modestly over the study period. Self-reported etiquette behaviors were not associated with experience scores. The difference in difference analysis of the baseline and postintervention physician experience scores between the intervention arm and the control arm was not statistically significant (P = 0.71). Conclusion In this 12-month study, biweekly reflection and reporting of best-practice bedside etiquette behaviors did not result in significant improvement on physician domain experience scores. It is likely that hospitalists' self-assessment of their bedside etiquette may not reflect patient perception of these behaviors. Furthermore, hospitalists may be resistant to improvement in this area since they rate themselves highly at baseline. Journal of Hospital Medicine 2017;12:402-406.
- Published
- 2017
36. Prediction of Disposition Within 48 Hours of Hospital Admission Using Patient Mobility Scores
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Erik H. Hoyer, Jason Seltzer, Elizabeth Colantuoni, Lisa Aronson Friedman, Daniel J. Brotman, Bingqing Ye, Kelly N. Daley, and Daniel L. Young
- Subjects
medicine.medical_specialty ,Leadership and Management ,Hospitalized patients ,medicine.medical_treatment ,Assessment and Diagnosis ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,030212 general & internal medicine ,Mobility Limitation ,Care Planning ,Early discharge ,Retrospective Studies ,Rehabilitation ,business.industry ,Health Policy ,General Medicine ,Disposition ,Middle Aged ,Functional recovery ,Hospitals ,Patient Discharge ,Hospitalization ,Systematic measurement ,Hospital admission ,Emergency medicine ,Fundamentals and skills ,Discharge location ,business ,030217 neurology & neurosurgery ,Subacute Care - Abstract
Delayed hospital discharges for patients needing rehabilitation in a postacute setting can exacerbate hospital-acquired mobility loss, prolong functional recovery, and increase costs. Systematic measurement of patient mobility by nurses early during hospitalization has the potential to help identify which patients are likely to be discharged to a postacute care facility versus home. To test the predictive ability of this approach, a machine learning classification tree method was applied retrospectively to a diverse sample of hospitalized patients (N = 805) using training and validation sets. Compared with patients discharged to home, patients discharged to a postacute facility were older (median, 64 vs 56 years old) and had lower mobility scores at hospital admission (median, 32 vs 41). The final decision tree accurately classified the discharge location for 73% (95%CI:67%-78%) of patients. This study emphasizes the value of systematically measuring mobility in the hospital and provides a simple decision tree to facilitate early discharge planning.
- Published
- 2019
37. Academic Hospital Medicine 2.0: If You Aren't Teaching Residents, Are You Still Academic?
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Daniel J. Brotman, Carrie Herzke, and Daniel P. Hunt
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Medical education ,Hospital Medicine ,Leadership and Management ,business.industry ,Health Policy ,Medicine ,Humans ,Fundamentals and skills ,General Medicine ,Assessment and Diagnosis ,business ,Care Planning ,Hospital medicine - Published
- 2019
38. Characteristics of Syncope Admissions Among Hospitals of Varying Teaching Intensity
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Michael I. Ellenbogen, Julia Lee, Daniel J. Brotman, Kevin J. O'Leary, and Kimberly Koloms
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Male ,medicine.medical_specialty ,Cardiac Catheterization ,medicine.medical_treatment ,education ,MEDLINE ,Myocardial Ischemia ,01 natural sciences ,Syncope ,03 medical and health sciences ,0302 clinical medicine ,Odds Ratio ,Medicine ,Humans ,030212 general & internal medicine ,0101 mathematics ,Disease management (health) ,Hospitals, Teaching ,Cardiac catheterization ,Aged ,Aged, 80 and over ,biology ,business.industry ,010102 general mathematics ,Health services research ,Syncope (genus) ,Disease Management ,General Medicine ,Odds ratio ,Middle Aged ,biology.organism_classification ,Confidence interval ,Hospitals ,Hospitalization ,Emergency medicine ,Etiology ,Exercise Test ,Female ,business - Abstract
Objectives Previous work suggests that hospitals' teaching status is correlated with readmission rates, cost of care, and mortality. The degree to which teaching status is associated with the management of syncope has not been studied extensively. We sought to characterize the relation between teaching status and inpatient syncope management. Methods We created regression models to characterize the relation between teaching status and cardiac ischemic evaluations (cardiac catheterization and/or stress test) during syncope admissions. Admissions with a primary diagnosis of syncope in Maryland and Kentucky between 2007 and 2014 were included. Results The dataset included 71,341 syncope admissions at 151 hospitals. Overall, 15% of patients had an ischemic evaluation. There was a significantly lower likelihood of an ischemic evaluation at major teaching hospitals relative to nonteaching hospitals (adjusted odds ratio 0.75, 95% confidence interval 0.71-0.79), but a higher likelihood of an ischemic evaluation at minor teaching hospitals (adjusted odds ratio 1.21, 95% confidence interval 1.16-1.25). Conclusions By definition, the syncope admissions included were unexplained or idiopathic cases, and thus likely to be lower-risk syncope cases. Those with a known etiology are coded by the cause of syncope, as dictated by coding guidelines. It is likely that many of these ischemic evaluations represent low-value care. Financial incentives and processes of care at major teaching hospitals may be driving this trend, and efforts should be made to better understand and replicate these at minor teaching and nonteaching hospitals.
- Published
- 2019
39. Recommendations on the use of ultrasound guidance for adult lumbar puncture: a position statement of the Society of Hospital Medicine
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Jeff Bates, Nitin Puri, Venkat Kalidindi, Benji Matthews, Nilam J. Soni, Kreegan Reierson, Joshua D. Lenchus, Satyen Nichani, Loretta Grikis, Joel Cho, Elizabeth K. Haro, Vicki E. Noble, Martin G Perez, Richard Hoppmann, Anjali Bhagra, Michael Mader, Nick Marzano, Vivek S. Tayal, David M. Tierney, Sophia Chu Rodgers, Ketino Kobaidze, Josh Lenchus, Michael Blaivas, Kirk T. Spencer, Robert Arntfield, Daniel J. Brotman, Mahmoud El Barbary, Susan Hunt, Ria Dancel, Saaid Abdel-Ghani, Trevor Jensen, Brian P. Lucas, P. Trevor, Ricardo Franco-Sadud, Aliaksei Pustavoitau, Ricardo Franco, Gerard Salame, Daniel Schnobrich, and Paul H. Mayo
- Subjects
medicine.medical_specialty ,Inservice Training ,Leadership and Management ,medicine.medical_treatment ,Radiography ,Thoracentesis ,Assessment and Diagnosis ,Spinal Puncture ,Asymptomatic ,Hospital Medicine ,medicine ,Humans ,Care Planning ,Societies, Medical ,Ultrasonography, Interventional ,Lumbar Vertebrae ,medicine.diagnostic_test ,business.industry ,Lumbar puncture ,Health Policy ,Ultrasound ,General Medicine ,medicine.disease ,Diaphragm (structural system) ,Hospital medicine ,Knowledge ,Pneumothorax ,Practice Guidelines as Topic ,Fundamentals and skills ,Clinical Competence ,Radiology ,medicine.symptom ,business - Abstract
Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.
- Published
- 2019
40. Patient isolation for infection control and patient experience
- Author
-
Albert W. Wu, Mohammed S. Abusamaan, Sarah J. Conway, Junya Zhu, Ariella Apfel, Stephen A. Berry, Holley Farley, Zishan K. Siddiqui, Amanda Bertram, Daniel J. Brotman, and Lisa Allen
- Subjects
Microbiology (medical) ,medicine.medical_specialty ,education.field_of_study ,Isolation (health care) ,Epidemiology ,business.industry ,Population ,Loneliness ,Odds ratio ,Infectious Diseases ,Patient experience ,Emergency medicine ,Severity of illness ,Toileting ,Medicine ,Anxiety ,medicine.symptom ,business ,education - Abstract
ObjectiveHospitalized patients placed in isolation due to a carrier state or infection with resistant or highly communicable organisms report higher rates of anxiety and loneliness and have fewer physician encounters, room entries, and vital sign records. We hypothesized that isolation status might adversely impact patient experience as reported through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, particularly regarding communication.DesignRetrospective analysis of HCAHPS survey results over 5 years.SettingA 1,165-bed, tertiary-care, academic medical center.PatientsPatients on any type of isolation for at least 50% of their stay were the exposure group. Those never in isolation served as controls.MethodsMultivariable logistic regression, adjusting for age, race, gender, payer, severity of illness, length of stay and clinical service were used to examine associations between isolation status and “top-box” experience scores. Dose response to increasing percentage of days in isolation was also analyzed.ResultsPatients in isolation reported worse experience, primarily with staff responsiveness (help toileting 63% vs 51%; adjusted odds ratio [aOR], 0.77; P = .0009) and overall care (rate hospital 80% vs 73%; aOR, 0.78; P < .0001), but they reported similar experience in other domains. No dose-response effect was observed.ConclusionIsolated patients do not report adverse experience for most aspects of provider communication regarded to be among the most important elements for safety and quality of care. However, patients in isolation had worse experiences with staff responsiveness for time-sensitive needs. The absence of a dose-response effect suggests that isolation status may be a marker for other factors, such as illness severity. Regardless, hospitals should emphasize timely staff response for this population.
- Published
- 2018
41. Inpatient Mobility Technicians: One Step Forward?
- Author
-
Daniel J. Brotman, Erik H. Hoyer, and Daniel L. Young
- Subjects
Inpatients ,Leadership and Management ,business.industry ,Health Policy ,MEDLINE ,General Medicine ,Walking ,Assessment and Diagnosis ,medicine.disease ,Text mining ,Physical Therapist Assistants ,Early ambulation ,medicine ,Humans ,Fundamentals and skills ,Medical emergency ,business ,Care Planning ,Early Ambulation - Published
- 2018
42. Routine Inpatient Mobility Assessment and Hospital Discharge Planning
- Author
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Daniel L. Young, Daniel J. Brotman, Michael Friedman, Erik H. Hoyer, Lisa M. Klein, Lisa Aronson Friedman, and Dale M. Needham
- Subjects
Male ,medicine.medical_specialty ,Hospitalized patients ,MEDLINE ,01 natural sciences ,03 medical and health sciences ,Disability Evaluation ,0302 clinical medicine ,Internal Medicine ,Hospital discharge ,medicine ,Research Letter ,Humans ,030212 general & internal medicine ,0101 mathematics ,Mobility Limitation ,Retrospective Studies ,Patient discharge ,business.industry ,010102 general mathematics ,Retrospective cohort study ,Patient Discharge ,Impaired mobility ,Emergency medicine ,Baltimore ,Female ,business ,Cohort study - Abstract
This cohort study examines whether use of a mobility assessment tool in hospitalized patients with impaired mobility is associated with discharge to a postacute facility.
- Published
- 2018
43. Going Beyond Clinical Care to Reduce Health Care Spending: Findings From the J-CHiP Community-based Population Health Management Program Evaluation: Erratum
- Author
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Patricia M. Brown, Sarah Kachur, Debra Hickman, Constantine G. Lyketsos, Stephanie Reel, Diane Lepley, Lisa Filbert, Daniel J. Brotman, Lindsay Andon, Hunter Young, Romsai T. Boonyasai, Anita Everett, Mary Lee Myers, Anne Langley, William A. Baumgartner, Edward Beranek, Michael Fingerhood, Melissa Richardson, Peter S. Greene, Michele Bellantoni, Michelle Petinga, David Parker, Stuart Erdman, Leon Purnell, David B. Hellmann, Curtis Leung, Lindsay Hebert Proctor, Jenny Bailey, John Colmers, Steven J. Kravet, Paul B. Rothman, Tracy Novak, Samuel C. Durso, Judy Reitz, Robert W. Blum, Steven Mandell, Daniel E. Ford, Eric E. Howell, Amy Deutschendorf, Carol Sylvester, Dalal Haldeman, and Vince Truant
- Subjects
Program evaluation ,Community based ,business.industry ,030503 health policy & services ,Public Health, Environmental and Occupational Health ,Medical care ,03 medical and health sciences ,0302 clinical medicine ,Nursing ,Health care ,Medicine ,030212 general & internal medicine ,Clinical care ,0305 other medical science ,business ,Population Health Management - Published
- 2018
44. Physicians’ Perceptions of Radiation Dose Quantity Depend on the Language in Which It Is Expressed
- Author
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Mahadevappa Mahesh, Anand K. Narayan, Leonard Feldman, Jonathan S. Lewin, Daniel J. Brotman, and Daniel J. Durand
- Subjects
Health Knowledge, Attitudes, Practice ,medicine.medical_specialty ,Demographics ,Attitude of Health Personnel ,Radiation Dosage ,Pediatrics ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Terminology as Topic ,Internal medicine ,Internal Medicine ,medicine ,Radiology, Nuclear Medicine and imaging ,Medical physics ,030212 general & internal medicine ,Language ,Response rate (survey) ,business.industry ,Radiation dose ,Word choice ,Internship and Residency ,Radiation Exposure ,Standard methods ,United States ,Confidence interval ,Radiation risk ,Health Care Surveys ,Clinical Competence ,Cancer risk ,business ,Attitude to Health - Abstract
Radiation dose information is increasingly requested by nonradiology providers, but there are no standard methods for communicating dose. The aim of this study was to compare physicians' perceptions of the amount of radiation associated with similar dose quantities expressed using different dose terms to evaluate the impact of word choice on physicians' understanding of radiation dose.Internal medicine and pediatric residents were surveyed online for 42 days. After obtaining demographics and training levels, respondents were asked to rank five different radiation dose quantities, each corresponding to one of the five ACR relative radiation levels (RRLs) expressed using different dose terms. Respondents ranked the choices from least to greatest (ie, from 1 to 5) or indicated if all five were equal. For the final question, the same dose quantity was expressed five different ways.Fifty-one medicine and 45 pediatric residents responded (a 44% response rate). Mean differences in rankings were as follows: for chest x-rays, 0.109 (95% confidence interval [CI], -0.018 to 0.236); for cross-country flights, 0.462 (95% CI, 0.338 to 0.585); for natural background radiation, -0.672 (95% CI, -0.793 to -0.551); for cancer risk, -0.294 (95% CI, -0.409 to -0.178); and for ACR RRL, 0.239 (95% CI, 0.148 to 0.329). Statistically significant differences were found in the distributions of rankings (P.001) and percentage of correct rankings across each radiation dose term (P.001), with the ACR RRL having the highest percentage of correct rankings (61.2%).Adult and pediatric physicians consistently over- or underestimated radiation dose quantities using different terms to express radiation dose. These results suggest that radiation dose information should be communicated using standard terminology such as the ACR RRL scale to foster consistency and improve the accuracy of physicians' radiation risk perceptions.
- Published
- 2016
45. Features of successful academic hospitalist programs: Insights from the SCHOLAR (SuCcessful HOspitaLists in academics and research) project
- Author
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Rebecca A. Harrison, Vikas I. Parekh, Bradley A. Sharpe, James C. Pile, Luci K. Leykum, Alfred Burger, Daniel P. Hunt, Daniel J. Brotman, Gregory B. Seymann, William Southern, and Chayan Chakraborti
- Subjects
medicine.medical_specialty ,Biomedical Research ,Faculty, Medical ,Leadership and Management ,media_common.quotation_subject ,Alternative medicine ,MEDLINE ,Sample (statistics) ,Assessment and Diagnosis ,01 natural sciences ,03 medical and health sciences ,0302 clinical medicine ,Promotion (rank) ,Humans ,Medicine ,030212 general & internal medicine ,0101 mathematics ,Care Planning ,media_common ,Academic Medical Centers ,Medical education ,business.industry ,Health Policy ,Financing, Organized ,010102 general mathematics ,General Medicine ,Maturity (finance) ,Hospital medicine ,Scholarship ,Hospitalists ,Cohort ,Fundamentals and skills ,business - Abstract
BACKGROUND As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important. OBJECTIVE To develop and validate a quantifiable definition of academic success for AHPs. METHODS A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey. RESULTS Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6–18 years) and mean size of 36 faculty (range, 18–95). The mean total grant funding/program was $4 million (range, $0–$15 million), with mean funding/FTE of $364,000 (range, $0–$1.4 million); both were significantly higher than the comparison sample. The majority of SCHOLAR faculty (82%) were junior, a lower percentage than the comparison sample. The mean number of research abstracts presented over 2 years was 10.8 (range, 9–23). DISCUSSION Our approach effectively identified a subset of successful AHPs. Despite the relative maturity and large size of the programs in the SCHOLAR cohort, they were comprised of relatively few senior faculty members and varied widely in the quantity of funded research and scholarship. Journal of Hospital Medicine 2016;11:708–713. © 2016 Society of Hospital Medicine
- Published
- 2016
46. Snowflakes in August: Leptospirosis Hemorrhagic Pneumonitis
- Author
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Vasanth Sathiyakumar, Daniel J. Brotman, Jessica Tao, Ashwini Niranjan-Azadi, Nishant P. Shah, Isabella W. Martin, Allison L. Tsao, and Annukka A.R. Antar
- Subjects
Adult ,medicine.medical_specialty ,030231 tropical medicine ,Hemorrhage ,03 medical and health sciences ,0302 clinical medicine ,Pneumonia, Bacterial ,Humans ,Medicine ,Leptospirosis ,030212 general & internal medicine ,Snowflake ,Pneumonitis ,Leptospira ,business.industry ,General Medicine ,medicine.disease ,Dermatology ,Anti-Bacterial Agents ,Treatment Outcome ,Drug Therapy, Combination ,Female ,Tomography, X-Ray Computed ,business ,Follow-Up Studies - Published
- 2017
47. In reply: Infective endocarditis: Don’t forget the ICE
- Author
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Thorsten M. Leucker, Nkemdilim Mgbojikwe, Steven R. Jones, and Daniel J. Brotman
- Subjects
medicine.medical_specialty ,Intracardiac echocardiography ,Endocarditis ,business.industry ,General surgery ,Infective endocarditis ,medicine ,Humans ,Endocarditis, Bacterial ,General Medicine ,medicine.disease ,business - Abstract
In reply : The letter from Drs. Araj and Luna regarding the utilization of intracardiac echocardiography (ICE) raises several interesting points. Indeed, for patients with infective endocarditis with inconclusive findings on transthoracic echocardiography (TTE) and contraindications to use of
- Published
- 2020
48. Does Patient Experience Predict 30-Day Readmission? A Patient-Level Analysis of HCAHPS Data
- Author
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Rehan Qayyum, Amanda Bertram, Nowella Durkin, Daniel J. Brotman, Peter J. Pronovost, Stephen A. Berry, Elizabeth C. Wick, Erik H. Hoyer, Zishan K. Siddiqui, and Lisa Allen
- Subjects
Adult ,Male ,medicine.medical_specialty ,Time Factors ,Leadership and Management ,MEDLINE ,Assessment and Diagnosis ,01 natural sciences ,Tertiary care ,Patient Readmission ,03 medical and health sciences ,0302 clinical medicine ,Exposure group ,Risk Factors ,Patient experience ,medicine ,Humans ,030212 general & internal medicine ,0101 mathematics ,Care Planning ,Aged ,Retrospective Studies ,Academic Medical Centers ,business.industry ,Health Policy ,010102 general mathematics ,Retrospective cohort study ,General Medicine ,Middle Aged ,Logistic Models ,Patient Satisfaction ,Health Care Surveys ,Emergency medicine ,Fundamentals and skills ,Observational study ,Female ,Index hospitalization ,business ,Healthcare providers - Abstract
BACKGROUND Hospital-level studies have found an inverse relationship between patient experience and readmissions. However, based on typical survey response time, it is unclear if patients are able to respond to surveys before they get readmitted and whether being readmitted might be a driver of poor experience scores (reverse causation). OBJECTIVE Using patient-level Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS) and Press Ganey data to examine the relationship between readmissions and experience scores and to distinguish between patients who responded before or after a subsequent readmission. DESIGN Retrospective analysis of 10-year HCAHPS data. SETTING Single tertiary care academic hospital. PARTICIPANTS Patients readmitted within 30 days of an index hospitalization who received an HCAHPS survey linked to index admission comprised the exposure group. This group was divided into those who responded prior to readmission and those who responded after readmission. Nonreadmitted patients comprised the control group. ANALYSIS Multivariable-logistic regression to analyze the association between HCHAPS and Press Ganey scores and 30-readmission status, adjusted for patient factors. RESULTS Only 15.8% of the readmitted patients responded to the survey prior to readmission, and their scores were not significantly different from the nonreadmitted patients. The patients who responded after readmission were significantly more dissatisfied with physicians (doctors listened 73.0% vs 79.2%, aOR 0.75, P < .0001), staff responsiveness, (call button 50.0% vs 59.1%, aOR 0.71, P < .0001) pain control, discharge plan, noise, and cleanliness of the hospital. CONCLUSIONS Our findings suggest that poor patient experience may be due to being readmitted, rather than being predictive of readmission.
- Published
- 2018
49. The Virtual Hospitalist: The Future is Now
- Author
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Daniel J. Brotman and Michael K. Ong
- Subjects
Physician-Patient Relations ,Leadership and Management ,business.industry ,Health Policy ,MEDLINE ,General Medicine ,Assessment and Diagnosis ,medicine.disease ,Hospitalists ,Medicine ,Humans ,Fundamentals and skills ,Medical emergency ,business ,Care Planning ,Quality of Health Care - Published
- 2018
50. Contemporary Rates of Preoperative Cardiac Testing Prior to Inpatient Hip Fracture Surgery
- Author
-
Laura Prichett, Leonard Feldman, Daniel J. Brotman, Ximin Li, and Michael I. Ellenbogen
- Subjects
Male ,medicine.medical_specialty ,Quality management ,Leadership and Management ,Stress testing ,MEDLINE ,Hip fracture surgery ,Assessment and Diagnosis ,Unnecessary Procedures ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,Preoperative Care ,medicine ,Humans ,030212 general & internal medicine ,Care Planning ,Aged ,Hip fracture ,Inpatients ,business.industry ,Hip Fractures ,Health Policy ,General Medicine ,medicine.disease ,Quality Improvement ,United States ,Echocardiography ,Emergency medicine ,Exercise Test ,Fundamentals and skills ,Female ,Risk assessment ,business - Abstract
Hip fracture is a common reason for urgent inpatient surgery. In the past few years, several professional societies have identified preoperative echocardiography and stress testing for noncardiac surgeries as low-value diagnostics. We utilized data on hospitalizations with a primary diagnosis of hip fracture surgery between 2011 and 2015 from the State Inpatient Databases (SID) of Maryland, New Jersey, and Washington, combined with data on hospital characteristics from the American Hospital Association (AHA). We found that the rate of preoperative ischemic testing is surprisingly but encouragingly low (stress tests 1.1% and cardiac catheterizations 0.5%), which is consistent with studies evaluating the outpatient utilization of these tests for low-and intermediate-risk surgeries. The rate of echocardiograms was 12.6%, which was higher than other published reports. Our findings emphasize the importance of ensuring that quality improvement efforts are directed toward areas where quality improvement is, in fact, needed.
- Published
- 2018
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