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There is an inherent tension between the training needs of inexperienced clinicians and the safety of the patients for whom they are responsible. Our society has accepted this tension as a necessary trade-off to maintain a competent workforce of physicians year after year. However, recent trends in medical education have diminished resident autonomy in favor of the safety of current patients. One dramatic example is the rapid increase in the number of academic ICUs that provide coverage by attending physicians at all hours. The potential benefits of this staffing model have strong face validity: improved quality and efficiency from the constant involvement of experienced intensivists, increased family and staff satisfaction from the immediate availability of attending physicians, and reduced burn-out among intensivists from reduced on-call responsibilities. Thus, many hospitals have moved toward 24-h coverage by attending intensivist physicians without evidence that these benefits actually accrue and perhaps without full consideration of possible unintended consequences. In this article, we discuss the potential benefits and risks of nocturnal intensivist staffing, considering the needs of current and future patients. Furthermore, we suggest that there remains sufficient uncertainty about these benefits and risks that it is both necessary and ethical to study the effects in earnest. [ABSTRACT FROM AUTHOR]

Background: The successful incorporation of research into the future careers of residents provides tremendous potential for increasing scientific orthopaedic inquiry and improving musculoskeletal care. Therefore, we sought to assess resident opinions regarding plans and incentives for future research and the opinions of academic chairs who must support them.Methods: Residents from sixteen departments were surveyed with a twenty-four-question online survey. Similar surveys were sent to chairs of all residency-sponsoring departments.Results: The response rate was 44% (183) for the residents and 60% (eighty-six) for the chairs. Forty-two percent of the residents felt certain or likely that they would perform research during their careers, and 28% were undecided. Ninety-nine percent thought that orthopaedic surgeons performing research is important to clinical orthopaedics. Ninety-three percent of the residents expressed the need for monetary incentives for research, but only 40% would help to provide it. Chairs similarly noted the importance of research subsidization (92%) and a willingness to support it (70%). Residents indicated that increased funding and protected time would provide the greatest incentives for research during residency; chairs agreed. After training, debt relief and salary support were most important for residents; chairs chose protected time and a chair who is supportive of research as most important. Primary authorship on a prior manuscript and past research experience were found to be associated with greater future research interest in univariate analyses; primary authorship maintained an independent association in multivariate analysis. Younger residents and women were more likely to be unsure of their research interest.Conclusions: Many orthopaedic residents in training have interest in integrating research into their future practice and support the research mission of orthopaedic surgeons. Our results may aid in identifying residents with high research interest (and those unsure) and help to guide the provision of incentives to actuate those interests. [ABSTRACT FROM AUTHOR]

Representativeness in randomized clinical trials remains a critical concern, affecting the external validity of trial results, equitable access to the risks and benefits of research participation, and public trust in clinical research. Although representative participation by members of groups traditionally underrepresented in clinical trials is just a surrogate for true diversity, equity, inclusion, and belonging in clinical trials, it can be quantified, allowing stakeholders to add empirical rigor to diversity, equity, inclusion, and belonging efforts. Multiple ways to measure representativeness have been proposed, including the participation-to-prevalence ratio, raw participation proportions or numbers for relevant subgroups, and enrollment fraction for relevant subgroups. These methods have strengths and weaknesses and may be appropriate to report in certain circumstances, depending on why stakeholders seek to assess representativeness. Stakeholders-including regulatory agencies, journal editors, clinical trial investigators, and trial sponsors-may use quantitative measures of representativeness to establish trial enrollment standards, monitor equitable participation in ongoing trials, and condition funding or drug or device approval on achieving specific representativeness targets. However, using quantitative measures of representativeness in this way could have unintended consequences, including researchers "gaming" recruitment strategies to meet target numbers, overlooking nuanced variations within communities, and potentially incentivizing problematic and exploitative recruitment strategies. Although no single method of measuring representativeness offers a comprehensive solution for increasing diversity, equity, inclusion, and belonging in all randomized clinical trials, a carefully designed, multifaceted approach to measuring representativeness may provide stakeholders with useful perspectives for measuring progress in increasing the diversity of clinical trial participation. For stakeholders seeking a single number to assess the representativeness of a trial enrolling patients with a disease state with well-delineated demographics, the participation-to-prevalence ratio is ideal; however, for a more nuanced view of representativeness, the combination of enrollment fraction in subgroups of relevance plus a full report of the demographics of patients approached for enrollment may be more appropriate., Competing Interests: Dr Jacobson has received institutional support from the American Heart Association, the Abdul Latif Jameel Poverty Action Lab North America, the National Institute for Health Care Management Research, the National Institute on Aging, the Agency for Healthcare Research and Quality, and the Moore Foundation; has provided paid expert witness testimony for various hospitals in ongoing litigation against opioid manufacturers; and has served on the Agency for Healthcare Research and Quality’s National Advisory Council. Dr Ogunniyi has received institutional research grant support from AstraZeneca, Boehringer Ingelheim, and Pfizer and serves on a clinical trial steering committee for Novartis. Dr Morris is an employee of Bayer. Dr Dickert has received institutional research funding from the National Institutes of Health, the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Institute, the American Heart Association, Abiomed, and Merck, and has consulted for Abiomed. Dr Lane-Fall has consulted for Janssen Pharmaceuticals and Medtronic. Dr Fanaroff has received institutional research support from the American Heart Association, National Institutes of Health, Society for Cardiovascular Angiography and Intervention, and Abbott; has consulted for Anthos Therapeutics, Novartis, Abbott, Intercept Pharmaceuticals, and Areteia Therapeutics; and has consulted (unpaid) for the Centers for Medicare and Medicaid Services. The other authors report no conflicts.

Background: Though European Respiratory Society and American Thoracic Society (ERS/ATS) guidelines for pulmonary function test (PFT) interpretation recommend the use of the forced vital capacity (FVC) lower limit of normal (LLN) to exclude restriction, recent data suggest that the negative predictive value (NPV) of the FVC LLN is lower than has been accepted, particularly among non-Hispanic Black patients. We sought to develop and externally validate a machine learning (ML) model to predict restriction from spirometry and determine whether its use may improve the accuracy and equity of PFT interpretation., Methods: We included PFTs with both static and dynamic lung volume measurements for patients between 18 and 80 years of age who were tested at pulmonary diagnostic labs within two health systems. We used PFTs from one health system to train logistic regression, random forest, and boosted tree models to predict restriction using demographic, anthropometric, and spirometric data. We used PFTs from the second health system to externally validate these models. The primary measure of model performance was the NPV. Racial equity was assessed by comparing the NPV among non-Hispanic Black and non-Hispanic White patients., Findings: A total of 42 462 PFTs were used for model development and 24 524 for external validation. The prevalence of restriction was 29.8% in the development dataset and 39.6% in the validation dataset. All three ML models outperformed the FVC LLN by a wide margin, both overall and among all demographic subgroups. The overall NPV of the random forest model (88.3%, 95% confidence interval [CI] 87.8% to 88.9%) was significantly greater than that of the FVC LLN (72.7%, 95% CI 72.1% to 73.3%). The NPV of the random forest model was greater than that of the FVC LLN among both non-Hispanic Black (74.6% [95% CI 72.5% to 76.6%] versus 49.5% [95% CI 47.8% to 51.2%]) and non-Hispanic White (90.9% [95% CI 90.3% to 91.5%] versus 79.6% [95% CI 78.9% to 80.3%]) patients., Interpretation: ML models to exclude restriction from spirometry improve the accuracy and equity of PFT interpretation but do not fully eliminate racial differences., Competing Interests: Conflicts of Interest: ATM, AB, JA, LHU, SDH, and GEW have no financial disclosures to report relevant to this manuscript. MCM has received royalties from UpToDate, and consulting income from GlaxoSmithKline, Boehringer Ingelheim, Aridis, MCG Diagnostics and NDD Medical Technologies.

Rationale: Patients with sepsis and/or acute respiratory failure are at high risk for death or long hospital stays, yet limited evidence exists to guide triage to intensive care units (ICUs) or general medical wards for the majority of these patients who do not initially require life support., Objectives: To identify factors that influence how hospitals triage patients with capacity-sensitive conditions and those factors that may account for observed ICU relative to ward, or ward relative to ICU, benefits for such patients., Methods: We conducted an explanatory sequential mixed-methods study. As part of a 27-hospital, two-health system retrospective cohort study, we calculated hospital-specific measurements of ICU net benefit for patients with sepsis and/or acute respiratory failure. Hospitals among the highest ICU net benefit and lowest ICU net benefit (or highest ward net benefit) from each study health system were selected for in-depth qualitative study. At each hospital interviews were conducted with emergency department (ED), ward, and ICU clinicians and administrators. Interview transcripts were analyzed using flexible coding and the framework method., Results: Interviews were conducted with 118 respondents (46 physicians, 43 nurses, 5 advanced practice providers, and 24 administrators) from four hospitals. Respondents across hospitals agreed that the prediction of patient trajectory is central to triage decisions, but there was variation in opinion across work locations about optimal pre-triage ED interventions in terms of intensity, repetition, clinical reassessment, and observation duration. The main difference observed between high and low ICU net benefit hospitals related to the way respondents working in the ICU and ward described their responses to patients who experience rapid clinical deviations from triage-expected trajectories including sustained lack of critical care needs after admission to the ICU and acute critical care needs after admission to the ward. Hospitals with low ICU net benefit (or high ward net benefit) had particularly robust and proactive rapid response and clinical decompensation surveillance practices for ward-admitted patients., Conclusions: Particularly proactive rapid response programs that deliver on-location critical care may quantitatively increase ward net benefit by bringing ICU benefits without ICU-associated harms to ward patients who become critically ill.

Background: Guideline-directed medical therapy for heart failure (HF) with reduced ejection fraction can entail high out-of-pocket (OOP) costs, prompting concerns about financial toxicity and access. OOP costs are generally unavailable during encounters. This trial assessed the impact of providing patient-specific OOP costs to patients and clinicians., Methods: This trial was conducted between June 2021 and August 2023 at 6 clinics in 2 health systems using a stepped-wedge, clinic-level cluster-randomized design. Adult patients with HF with reduced ejection fraction (left ventricular ejection fraction ≤40%) were enrolled. The intervention was built upon the EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) checklist of approved HF with reduced ejection fraction medications. Patients and clinicians received this checklist with (intervention) or without (control) patient-specific OOP cost estimates for higher-cost medications at the time of encounter. Estimates were obtained by providing pharmacy benefit information to a financial navigation firm. Encounters were audio-recorded, and patients were surveyed 2 weeks later. The primary outcome was cost-informed decision-making, defined by mentioning HF medication cost during the encounter. The primary analysis used a generalized linear mixed model. Secondary outcomes were assessed via transcript subcoding and analysis of survey responses., Results: Demographic characteristics of 247 patients (mean age, 62.9 years; 29.5% female; 26.3% Black; and 3.2% Hispanic/LatinX) treated by 39 clinicians in intervention and control periods were similar. In the primary model, the rate of cost-informed decision-making was higher in the intervention group than the control group (68% versus 49%; P =0.021). Baseline rates of cost discussions and the impact of the intervention varied across sites. When cost discussions were present, fewer discussions in the intervention group involved contingency plans to address potential costs (16.5% versus 31.9%; P =0.028). Most other secondary outcomes were not significantly different., Conclusions: Disclosing comprehensive OOP medication costs to patients with HF with reduced ejection fraction increased cost-informed decision-making. Further work is needed to optimize implementation and assess the impact on medication choices and adherence., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04793880., Competing Interests: Dr Dickert reports research support and consulting activity from Abiomed, Inc and Merck. Dr Morris reports research support from American Heart Association, Merck, and the Association of Black Cardiologists, consulting activity for Abbott, Eli Lilly, Cytokinetics, Edwards Lifesciences, Ionis, Merck, Novo Nordisk, and Regeneron, and ownership interest in Gilead Sciences. Dr Allen has received consulting fees from ACI Clinical/WCG Clinical, American Heart Association, Boston Scientific, Cytokinetics, Medscape, Novartis, Story Health, and UpToDate. The other authors report no conflicts.

Background: Promoting options for aging in place (AIP) has broad appeal to policymakers and professionals providing services to persons living with dementia (PWD). However, the benefits or burdens of AIP likely vary among individuals and families. We sought to describe factors influencing decision-making to age in place versus seek a higher level of residential care for PWD., Methods: A qualitative study was undertaken as part of a larger mixed-methods study utilizing semi-structured interviews with PWD, family care partners, and dementia clinicians. Interview transcripts were analyzed using qualitative content analysis with constant comparison. Sample size was determined by thematic saturation within subgroups., Results: We conducted 74 interviews among 14 PWD, 36 care partners, and 24 clinicians. Preferences for AIP were driven by (1) desire to preserve independence, (2) a sense that the "best care" is delivered by loved ones and in a familiar environment, (3) distrust and fear of care facilities, and (4) caregiver guilt. PWD and care partners frequently considered moving from home as a "last resort" and wanted to avoid planning for future care needs. Many decisions to move were reactive and triggered by patient safety events, physical dependency, or the loss of caregiver. Proactive decision-making was facilitated by (1) prior experience witnessing the challenges of caring for a person with advanced dementia in the home; and (2) having substantial financial resources such that participants could seek major home adaptations or avoid "lower quality" institutions., Conclusions: Decisions regarding care setting for PWD frequently do not feel like a choice and are made under imperfect conditions. Programs using AIP as an outcome measure should recognize the various patient-centered and non-patient-centered factors that influence such choices, and interventions should be designed to promote more informed and equitable decision-making for care setting in dementia., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: European Respiratory Society and American Thoracic Society (ERS/ATS) guidelines for pulmonary function test (PFT) interpretation recommend the use of a normal forced vital capacity (FVC) to exclude restriction. However, this recommendation is based upon a single study from 1999, which was limited to White patients, and used race-specific reference equations that are no longer recommended by ERS/ATS. We sought to reassess the support for this recommendation by calculating the negative predictive value (NPV) of a normal FVC in a diverse, multicenter cohort using race-neutral reference equations., Methods: We interpreted PFTs performed between 2000 and 2023 in two academic medical systems and in a national electronic health record (EHR) database. We calculated the NPV of a normal FVC to exclude restriction overall and among pre-specified racial and ethnic groups., Results: We included PFTs from 85990 patients. The prevalence of restriction was 35.1%. The overall NPV of a normal FVC to exclude restriction was 80.5% (95% CI 80.1% to 80.8%), compared to an NPV of 97.6% cited in support of ERS/ATS guidelines. The NPV ranged from 65.2% (95% CI 64.4% to 66.0%) among non-Hispanic Black patients to 85.9% (95% CI 85.6% to 86.3%) among non-Hispanic White patients. This difference was largely attributable to lower FVC z-scores among non-Hispanic Black patients., Conclusions: The NPV of a normal FVC is lower than has been previously reported and varies by race and ethnicity. The approach to PFT interpretation recommended by ERS/ATS guidelines results in the under-recognition of restriction, particularly among non-Hispanic Black patients.

Background: Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the diagnosis of chronic obstructive pulmonary disease (COPD) only in patients with a post-bronchodilator forced expiratory volume in 1 second to forced vital capacity ratio (FEV 1 /FVC) less than 0.7. However the impact of this recommendation on clinical practice is unknown., Research Question: What is the effect of a documented post-bronchodilator FEV 1 /FVC < 0.7 on the diagnosis and treatment of COPD?, Study Design and Methods: We used a national electronic health record database to identify clinical encounters between 2007 to 2022 with patients 18 years of age and older in which a post-bronchodilator FEV 1 /FVC value was documented. An encounter was associated with a COPD diagnosis if a diagnostic code for COPD was assigned, and was associated with COPD treatment if a prescription for a medication commonly used to treat COPD was filled within 90 days. We used a regression discontinuity design to measure the effect of a post-bronchodilator FEV 1 /FVC < 0.7 on COPD diagnosis and treatment., Results: Among 27 817 clinical encounters, involving 18 991 patients, a post-bronchodilator FEV 1 /FVC < 0.7 was present in 14 876 (53.4%). The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 had a small effect on the probability of a COPD diagnosis, increasing by 6.0% (95% confidence interval [CI] 1.1% to 10.9%) from 38.0% just above the 0.7 cutoff to 44.0% just below this cutoff. The presence of a documented post-bronchodilator FEV 1 /FVC had no effect on the probability of COPD treatment (-2.1%, 95% CI -7.2% to 3.0%)., Interpretation: The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 has only a small effect on the probability that a clinician will make a guideline-concordant diagnosis of COPD and has no effect on corresponding treatment decisions., Competing Interests: Conflicts of Interest: ATM, SDH, and GEW declare no relevant financial conflicts of interest.

Background: In the US, 1.2 million people live with HIV (PWH). Despite having near-normal life expectancies due to antiretroviral therapy (ART), many PWH seek an HIV cure, even if it means risking their lives. This willingness to take risks for a cure raises questions about "affective forecasting biases," where people tend to overestimate the positive impact of future events on their well-being. We conducted a study to test two interventions to mitigate affective forecasting in the decisions of PWH about taking HIV cure medication., Methods: We recruited PWH to complete a 30-minute survey about their current quality of life (QoL) and the QoL they anticipate after being cured of HIV, and assigned them to either no additional intervention, to one of two interventions intended to reduce affective forecasting bias, or to both interventions: (1) a defocusing intervention designed to broaden the number of life domains people consider when imagining life changes associated with new circumstances (e.g. HIV cure); and (2) an adaptation intervention to help them gauge fading of strong emotions over time. The study design included a 2 × 2 design: defocusing (yes/no) x adaptation (yes/no) intervention. We assessed PWH's willingness to take hypothetical HIV sterilizing cure medication using the Time Trade-Off (TTO) and their quality of life predictions with WHOQOL-HIV., Results: 296 PWH participated. Counter to what we had hypothesized, neither intervention significantly reduced PWH's willingness to trade time for a cure. Instead, the defocusing intervention increased their willingness to trade time (IRR 1.77, p = 0.03). Exploratory analysis revealed that PWH with lower current quality of life who received the defocusing intervention were more willing to trade time for a cure., Conclusion: These negative findings suggest that either these biases are difficult to overcome in the settings of HIV curative medication or other factors beyond affective forecasting biases influence willingness to participate in HIV curative studies, such as respondents' current quality of life., (© 2024. The Author(s).)

Distracted driving is responsible for nearly 1 million crashes each year in the United States alone, and a major source of driver distraction is handheld phone use. We conducted a randomized, controlled trial to compare the effectiveness of interventions designed to create sustained reductions in handheld use while driving (NCT04587609). Participants were 1,653 consenting Progressive® Snapshot® usage-based auto insurance customers ages 18 to 77 who averaged at least 2 min/h of handheld use while driving in the month prior to study invitation. They were randomly assigned to one of five arms for a 10-wk intervention period. Arm 1 (control) got education about the risks of handheld phone use, as did the other arms. Arm 2 got a free phone mount to facilitate hands-free use. Arm 3 got the mount plus a commitment exercise and tips for hands-free use. Arm 4 got the mount, commitment, and tips plus weekly goal gamification and social competition. Arm 5 was the same as Arm 4, plus offered behaviorally designed financial incentives. Postintervention, participants were monitored until the end of their insurance rating period, 25 to 65 d more. Outcome differences were measured using fractional logistic regression. Arm 4 participants, who received gamification and competition, reduced their handheld use by 20.5% relative to control ( P < 0.001); Arm 5 participants, who additionally received financial incentives, reduced their use by 27.6% ( P < 0.001). Both groups sustained these reductions through the end of their insurance rating period., Competing Interests: Competing interests statement:While involved with this research, W.J.F., K.L.G., and W.C.E. were employed by The Progressive Corporation. As employees of the company, W.J.F., K.L.G., and W.C.E. owned stock in The Progressive Corporation. K.G.V. is part owner of a consulting company, VALHealth. F.K.W. has an intellectual property and financial interest in Diagnostic Driving, Inc. The Children’s Hospital of Philadelphia (CHOP) has an institutional interest in Diagnostic Driving, Inc. Diagnostic Driving, Inc., created a virtual driving assessment system that is used in Ohio as an assessment at licensing centers and in driving schools to assess driver training programs but not used in this study. Flaura K. Winston serves as the chief scientific advisor of Diagnostic Driving, Inc. This potential conflict of interest is managed under a conflict-of-interest management plan from CHOP and the University of Pennsylvania.

Background: The ability to classify patients' goals of care (GOC) from clinical documentation would facilitate serious illness communication quality improvement efforts and pragmatic measurement of goal-concordant care. Feasibility of this approach remains unknown., Objective: To evaluate the feasibility of classifying patients' GOC from clinical documentation in the electronic health record (EHR), describe the frequency and patterns of changes in patients' goals over time, and identify barriers to reliable goal classification., Design: Retrospective, mixed-methods chart review study., Participants: Adults with high (50-74%) and very high (≥ 75%) 6-month mortality risk admitted to three urban hospitals., Main Measures: Two physician coders independently reviewed EHR notes from 6 months before through 6 months after admission to identify documented GOC discussions and classify GOC. GOC were classified into one of four prespecified categories: (1) comfort-focused, (2) maintain or improve function, (3) life extension, or (4) unclear. Coder interrater reliability was assessed using kappa statistics. Barriers to classifying GOC were assessed using qualitative content analysis., Key Results: Among 85 of 109 (78%) patients, 338 GOC discussions were documented. Inter-rater reliability was substantial (75% interrater agreement; Cohen's kappa = 0.67; 95% CI, 0.60-0.73). Patients' initial documented goal was most frequently "life extension" (N = 37, 44%), followed by "maintain or improve function" (N = 28, 33%), "unclear" (N = 17, 20%), and "comfort-focused" (N = 3, 4%). Among the 66 patients whose goals' classification changed over time, most changed to "comfort-focused" goals (N = 49, 74%). Primary reasons for unclear goals were the observation of concurrently held or conditional goals, patient and family uncertainty, and limited documentation., Conclusions: Clinical notes in the EHR can be used to reliably classify patients' GOC into discrete, clinically germane categories. This work motivates future research to use natural language models to promote scalability of the approach in clinical care and serious illness research., (© 2024. The Author(s).)

Background: Women are more likely than men to report delays in the diagnosis of chronic obstructive pulmonary disease (COPD), though the etiology of these delays is unknown. We sought to test whether delays in COPD diagnosis persist after the performance of spirometry., Methods: We used the Optum Labs Data Warehouse to identify patients 18 years of age and older without a prior diagnosis of COPD, with a post-bronchodilator forced expiratory volume in 1 second (FEV 1 ) to forced vital capacity (FVC) ratio of less than 0.7 on spirometry. We used a Cox proportional hazards model to compare the time to diagnosis after spirometry in men and women, adjusting for age, race, ethnicity, tobacco use, and post-bronchodilator FEV 1 /FVC., Results: The probability of receiving a COPD diagnosis after the performance of spirometry was lower among women than men (adjusted hazard ratio [aHR] 0.66, 95% confidence interval [CI] 0.50 to 0.88)., Conclusion: In this retrospective cohort study of patients with spirometric evidence of obstruction, the time to diagnosis of COPD was greater among women than men. While previous vignette-based studies have found that gender differences in the diagnosis of COPD resolve with the performance of spirometry, we found that gender differences persist after spirometry has been performed. Clinicians were less likely to diagnose COPD in women even when spirometry supported this diagnosis.

Estimands can help clarify the interpretation of treatment effects and ensure that estimators are aligned with the study's objectives. Cluster-randomised trials require additional attributes to be defined within the estimand compared to individually randomised trials, including whether treatment effects are marginal or cluster-specific , and whether they are participant- or cluster-average . In this paper, we provide formal definitions of estimands encompassing both these attributes using potential outcomes notation and describe differences between them. We then provide an overview of estimators for each estimand, describe their assumptions, and show consistency (i.e. asymptotically unbiased estimation) for a series of analyses based on cluster-level summaries. Then, through a re-analysis of a published cluster-randomised trial, we demonstrate that the choice of both estimand and estimator can affect interpretation. For instance, the estimated odds ratio ranged from 1.38 ( p  = 0.17) to 1.83 ( p  = 0.03) depending on the target estimand, and for some estimands, the choice of estimator affected the conclusions by leading to smaller treatment effect estimates. We conclude that careful specification of the estimand, along with an appropriate choice of estimator, is essential to ensuring that cluster-randomised trials address the right question., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Handheld phone use while driving is a major factor in vehicle crashes. Scalable interventions are needed to encourage drivers not to use their phones., Objective: To test whether interventions involving social comparison feedback and/or financial incentives can reduce drivers' handheld phone use., Design, Setting, and Participants: In a randomized clinical trial, interventions were administered nationwide in the US via a mobile application in the context of a usage-based insurance program (Snapshot Mobile application). Customers were eligible to be invited to participate in the study if enrolled in the usage-based insurance program for 30 to 70 days. The study was conducted from May 13 to June 30, 2019. Analysis was completed December 22, 2023., Interventions: Participants were randomly assigned to 1 of 6 trial arms for a 7-week intervention period: (1) control; (2) feedback, with weekly push notification about their handheld phone use compared with that of similar others; (3) standard incentive, with a maximum $50 award at the end of the intervention based on how their handheld phone use compared with similar others; (4) standard incentive plus feedback, combining interventions of arms 2 and 3; (5) reframed incentive plus feedback, with a maximum $7.15 award each week, framed as participant's to lose; and (6) doubled reframed incentive plus feedback, a maximum $14.29 weekly loss-framed award., Main Outcome and Measure: Proportion of drive time engaged in handheld phone use in seconds per hour (s/h) of driving. Analyses were conducted with the intention-to-treat approach., Results: Of 17 663 customers invited by email to participate, 2109 opted in and were randomized. A total of 2020 drivers finished the intervention period (68.0% female; median age, 30 [IQR, 25-39] years). Median baseline handheld phone use was 216 (IQR, 72-480) s/h. Relative to control, feedback and standard incentive participants did not reduce their handheld phone use. Standard incentive plus feedback participants reduced their use by -38 (95% CI, -69 to -8) s/h (P = .045); reframed incentive plus feedback participants reduced their use by -56 (95% CI, -87 to -26) s/h (P < .001); and doubled reframed incentive plus feedback participants reduced their use by -42 s/h (95% CI, -72 to -13 s/h; P = .007). The 5 active treatment arms did not differ significantly from each other., Conclusions and Relevance: In this randomized clinical trial, providing social comparison feedback plus incentives reduced handheld phone use while individuals were driving., Trial Registration: ClinicalTrials.gov Identifier: NCT03833219.

Rationale: Hospital-free days (HFDs), a measure of the number of days alive spent outside the hospital, is increasingly used as an endpoint in studies of patients with acute respiratory failure (ARF) or other critical and serious illnesses. Current approaches to measuring HFDs do not account for decrements in functional status or quality of life that ARF survivors and family members value. Objectives: To develop an acceptable approach to measure quality-weighted HFDs using patient-reported outcomes. Methods: We conducted a four-round modified Delphi process among ARF experts: those with lived or professional experience. Experts rated survivorship domains, instrument and data collection characteristics, and methods to translate responses into quality-weighted HFDs. The consensus threshold was that ⩾70% of respondents rated an item "totally acceptable" or "acceptable" and ⩽15% of respondents rated the item "totally unacceptable," "unacceptable," or "slightly unacceptable." Results: Fifty-seven experts participated in round 1. Response rates were 82-93% for subsequent rounds. Priority survivorship domains were physical function and health-related quality of life. Participants reached a consensus that data collection during ARF recovery should take less than 15 minutes per assessment, allow surrogate completion when patients are unable, and continue for at least 24 months of follow-up. Using the EuroQol-5 Dimensions (EQ-5D) questionnaire to quality weight HFDs met consensus criteria for acceptability. A majority of panelists preferred quality-weighted HFDs to unweighted HFDs or survival for use in future ARF studies. Conclusions: Quality-weighting HFDs using patient and/or surrogate responses to the EQ-5D captured stakeholder priorities and was acceptable to this Delphi panel.

Despite the growing need for surrogate decision-making for older adults, little is known about how surrogates make decisions and whether advance directives would change decision-making. We conducted a nationally representative experimental survey that cross-randomized cognitive impairment, gender, and characteristics of advance care planning among hospitalized older adults through a series of vignettes. Our study yielded three main findings: first, respondents were much less likely to recommend life-sustaining treatments for patients with dementia, especially after personal exposure. Second, respondents were more likely to ignore patient preferences for life-extending treatment when the patient had dementia, and choose unwanted life-extending treatments for patients without dementia. Third, in scenarios where the patient's wishes were unclear, respondents were more likely to choose treatments that matched their own preferences. These findings underscore the need for improved communication and decision-making processes for patients with cognitive impairment and highlight the importance of choosing a surrogate decision-maker with similar treatment preferences., (© 2024 John Wiley & Sons Ltd.)

Understanding whether and how treatment effects vary across subgroups is crucial to inform clinical practice and recommendations. Accordingly, the assessment of heterogeneous treatment effects based on pre-specified potential effect modifiers has become a common goal in modern randomized trials. However, when one or more potential effect modifiers are missing, complete-case analysis may lead to bias and under-coverage. While statistical methods for handling missing data have been proposed and compared for individually randomized trials with missing effect modifier data, few guidelines exist for the cluster-randomized setting, where intracluster correlations in the effect modifiers, outcomes, or even missingness mechanisms may introduce further threats to accurate assessment of heterogeneous treatment effect. In this article, the performance of several missing data methods are compared through a simulation study of cluster-randomized trials with continuous outcome and missing binary effect modifier data, and further illustrated using real data from the Work, Family, and Health Study. Our results suggest that multilevel multiple imputation and Bayesian multilevel multiple imputation have better performance than other available methods, and that Bayesian multilevel multiple imputation has lower bias and closer to nominal coverage than standard multilevel multiple imputation when there are model specification or compatibility issues., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Topic Importance: Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps., Review Findings: We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies., Summary: Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: J. M. K.’s spouse receives honoraria for lectures and speakers bureaus from Astra Zeneca and for consulting from Radialogica. None declared (N. R. N., E. M. V., J. T. C., K. E. S., S. D. H.)., (Copyright © 2024. Published by Elsevier Inc.)

Background: Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) often entails substantial out-of-pocket costs that can vary appreciably between patients. This has raised concerns regarding financial toxicity, equity, and adherence to medical therapy. In spite of these concerns, cost discussions in the HFrEF population appear to be rare, partly because out-of-pocket costs are generally unavailable during clinical encounters. In this trial, out-of-pocket cost information is given to patients and clinicians during outpatient encounters with the aim to assess the impact of providing this information on medication discussions and decisions., Hypothesis: Cost-informed decision-making will be facilitated by providing access to patient-specific out-of-pocket cost estimates at the time of clinical encounter., Design: Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF) is a multicenter trial based at Emory Healthcare and University of Colorado Health. Adapting an existing patient activation tool from the EPIC-HF trial, patients and clinicians are presented a checklist with medications approved for treatment of HFrEF with or without patient-specific out-of-pocket costs (obtained from a financial navigation firm). Clinical encounters are audio-recorded, and patients are surveyed about their experience. The trial utilizes a stepped-wedge cluster randomized design, allowing for each site to enroll control and intervention group patients while minimizing contamination of the control arm., Discussion: This trial will elucidate the potential impact of robust cost disclosure efforts and key information regarding patient and clinician perspectives related to cost and cost communication. It also will reveal important challenges associated with providing out-of-pocket costs for medications during clinical encounters. Acquiring medication costs for this trial requires an involved process and outsourcing of work. In addition, costs may change throughout the year, raising questions regarding what specific information is most valuable. These data will represent an important step towards understanding the role of integrating cost discussions into heart failure care., Gov Identifier: NCT04793880., Competing Interests: Disclosures Dr Rao reports receiving research funding from NIH grant #UL1TR002378, #TL1TR002382, AHRQ grant #1F32HS028558-01 and from the Byron Williams Jr, MD Fellowship Fund. Dr Allen reports receiving research funding from AHA, NIH, and PCORI; and consulting fees from ACI Clinical, Amgen, Boston Scientific, Cytokinetics, and Novartis. Dr Dickert reports receiving research funding from AHRQ, NIH, PCORI, and the Greenwall Foundation. Dr Moore reports receiving research funding from AHRQ and HRSA., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking., Objective: To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes., Design, Setting, and Participants: A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019., Intervention: Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care., Main Outcomes and Measures: The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality., Results: Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08])., Conclusions and Relevance: Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes., Trial Registration: ClinicalTrials.gov Identifier: NCT02505035.

In many medical studies, the outcome measure (such as quality of life, QOL) for some study participants becomes informatively truncated (censored, missing, or unobserved) due to death or other forms of dropout, creating a nonignorable missing data problem. In such cases, the use of a composite outcome or imputation methods that fill in unmeasurable QOL values for those who died rely on strong and untestable assumptions and may be conceptually unappealing to certain stakeholders when estimating a treatment effect. The survivor average causal effect (SACE) is an alternative causal estimand that surmounts some of these issues. While principal stratification has been applied to estimate the SACE in individually randomized trials, methods for estimating the SACE in cluster-randomized trials are currently limited. To address this gap, we develop a mixed model approach along with an expectation-maximization algorithm to estimate the SACE in cluster-randomized trials. We model the continuous outcome measure with a random intercept to account for intracluster correlations due to cluster-level randomization, and model the principal strata membership both with and without a random intercept. In simulations, we compare the performance of our approaches with an existing fixed-effects approach to illustrate the importance of accounting for clustering in cluster-randomized trials. The methodology is then illustrated using a cluster-randomized trial of telecare and assistive technology on health-related QOL in the elderly., (© 2023 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd.)

Importance: Patients' expectations for future health guide their decisions and enable them to prepare, adapt, and cope. However, little is known about how inaccurate expectations may affect patients' illness outcomes., Objective: To assess the association between patients' expectation inaccuracies and health-related quality of life., Design, Setting, and Participants: This cohort study of patients with severe chronic obstructive pulmonary disease (COPD) was conducted from 2017 to 2021, which included a 24-month follow-up period. Eligible participants received outpatient primary care at pulmonary clinics of a single large US health system. Data were analyzed between 2021 and 2023., Exposure: Expectation accuracy, measured by comparing patients' self-reported expectations of their symptom burden with their actual physical and emotional symptoms 3, 12, and 24 months in the future., Main Outcome and Measure: Health-related quality of life, measured by the St George's Respiratory Questionnaire-COPD at 3, 12, and 24 months., Results: A total of 207 participants were included (median age, 65.5 years [range, 42.0-86.0 years]; 120 women [58.0%]; 118 Black [57.0%], 79 White [38.2%]). The consent rate among approached patients was 80.0%. Most patients reported no or only limited discussions of future health and symptom burdens with their clinicians. Across physical and emotional symptoms and all 3 time points, patients' expectations were more optimistic than their experiences. There were no consistent patterns of measured demographic or behavioral characteristics associated with expectation accuracy. Regression models revealed that overoptimistic expectations of future burdens of dyspnea (linear regression estimate, 4.68; 95% CI, 2.68 to 6.68) and negative emotions (linear regression estimate, -3.04; 95% CI, -4.78 to 1.29) were associated with lower health-related quality of life at 3 months after adjustment for baseline health-related quality of life, forced expiratory volume over 1 second, and interval clinical events (P < .001 for both). Similar patterns were observed at 12 months (dyspnea: linear regression estimate, 2.41; 95% CI, 0.45 to 4.37) and 24 months (negative emotions: linear regression estimate, -2.39; 95% CI, -4.67 to 0.12; dyspnea: linear regression estimate, 3.21; 95% CI, 0.82 to 5.60), although there was no statistically significant association between expectation of negative emotions and quality of life at 12 months., Conclusions and Relevance: In this cohort study of patients with COPD, we found that patients are overoptimistic in their expectations about future negative symptom burdens, and such inaccuracies were independently associated with worse well-being over time. Developing and implementing strategies to improve patients' symptom expectations may improve patient-centered outcomes.

ChatGPT is a large language model trained on text corpora and reinforced with human supervision. Because ChatGPT can provide human-like responses to complex questions, it could become an easily accessible source of medical advice for patients. However, its ability to answer medical questions appropriately and equitably remains unknown. We presented ChatGPT with 96 advice-seeking vignettes that varied across clinical contexts, medical histories, and social characteristics. We analyzed responses for clinical appropriateness by concordance with guidelines, recommendation type, and consideration of social factors. Ninety-three (97%) responses were appropriate and did not explicitly violate clinical guidelines. Recommendations in response to advice-seeking questions were completely absent (N = 34, 35%), general (N = 18, 18%), or specific (N = 44, 46%). 53 (55%) explicitly considered social factors like race or insurance status, which in some cases changed clinical recommendations. ChatGPT consistently provided background information in response to medical questions but did not reliably offer appropriate and personalized medical advice., (© 2023. Springer Nature Limited.)

Objective: To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions., Background: EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity., Methods: Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions., Results: Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients., Conclusions: The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Evaluate predictive performance of an electronic health record (EHR)-based, inpatient 6-month mortality risk model developed to trigger palliative care consultation among patient groups stratified by age, race, ethnicity, insurance and socioeconomic status (SES), which may vary due to social forces (eg, racism) that shape health, healthcare and health data., Design: Retrospective evaluation of prediction model., Setting: Three urban hospitals within a single health system., Participants: All patients ≥18 years admitted between 1 January and 31 December 2017, excluding observation, obstetric, rehabilitation and hospice (n=58 464 encounters, 41 327 patients)., Main Outcome Measures: General performance metrics (c-statistic, integrated calibration index (ICI), Brier Score) and additional measures relevant to health equity (accuracy, false positive rate (FPR), false negative rate (FNR))., Results: For black versus non-Hispanic white patients, the model's accuracy was higher (0.051, 95% CI 0.044 to 0.059), FPR lower (-0.060, 95% CI -0.067 to -0.052) and FNR higher (0.049, 95% CI 0.023 to 0.078). A similar pattern was observed among patients who were Hispanic, younger, with Medicaid/missing insurance, or living in low SES zip codes. No consistent differences emerged in c-statistic, ICI or Brier Score. Younger age had the second-largest effect size in the mortality prediction model, and there were large standardised group differences in age (eg, 0.32 for non-Hispanic white versus black patients), suggesting age may contribute to systematic differences in the predicted probabilities between groups., Conclusions: An EHR-based mortality risk model was less likely to identify some marginalised patients as potentially benefiting from palliative care, with younger age pinpointed as a possible mechanism. Evaluating predictive performance is a critical preliminary step in addressing algorithmic inequities in healthcare, which must also include evaluating clinical impact, and governance and regulatory structures for oversight, monitoring and accountability., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Supply-demand mismatch of ward resources ("ward capacity strain") alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors. In a retrospective cohort of ARF survivors transferred from intensive care units (ICUs) to wards in five hospitals from 4/2017-12/2019, we applied 11 machine learning (ML) models to identify ward strain measures during the first 24 hours after transfer most predictive of outcomes. Measures spanned patient volume (census, admissions, discharges), staff workload (medications administered, off-ward transports, transfusions, isolation precautions, patients per respiratory therapist and nurse), and average patient acuity (Laboratory Acute Physiology Score version 2, ICU transfers) domains. The cohort included 5,052 visits in 43 wards. Median age was 65 years (IQR 56-73); 2,865 (57%) were male; and 2,865 (57%) were white. 770 (15%) patients died in the hospital or had hospice discharges, and 2,628 (61%) were discharged home and 964 (23%) to skilled nursing facilities (SNFs). Ward admissions, isolation precautions, and hospital admissions most consistently predicted in-hospital mortality across ML models. Patients per nurse most consistently predicted discharge to home and SNF, and medications administered predicted SNF discharge. In this hypothesis-generating analysis of candidate ward strain variables' prediction of outcomes among ARF survivors, several variables emerged as consistently predictive of key outcomes across ML models. These findings suggest targets for future inferential studies to elucidate mechanisms of ward strain's adverse effects., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Mortality prediction for intensive care unit (ICU) patients frequently relies on single ICU admission acuity measures without accounting for subsequent clinical changes., Objective: Evaluate novel models incorporating modified admission and daily, time-updating Laboratory-based Acute Physiology Score, version 2 (LAPS2) to predict in-hospital mortality among ICU patients., Research Design: Retrospective cohort study., Patients: ICU patients in 5 hospitals from October 2017 through September 2019., Measures: We used logistic regression, penalized logistic regression, and random forest models to predict in-hospital mortality within 30 days of ICU admission using admission LAPS2 alone in patient-level and patient-day-level models, or admission and daily LAPS2 at the patient-day level. Multivariable models included patient and admission characteristics. We performed internal-external validation using 4 hospitals for training and the fifth for validation, repeating analyses for each hospital as the validation set. We assessed performance using scaled Brier scores (SBS), c -statistics, and calibration plots., Results: The cohort included 13,993 patients and 107,699 ICU days. Across validation hospitals, patient-day-level models including daily LAPS2 (SBS: 0.119-0.235; c -statistic: 0.772-0.878) consistently outperformed models with admission LAPS2 alone in patient-level (SBS: 0.109-0.175; c -statistic: 0.768-0.867) and patient-day-level (SBS: 0.064-0.153; c -statistic: 0.714-0.861) models. Across all predicted mortalities, daily models were better calibrated than models with admission LAPS2 alone., Conclusions: Patient-day-level models incorporating daily, time-updating LAPS2 to predict mortality among an ICU population performs as well or better than models incorporating modified admission LAPS2 alone. The use of daily LAPS2 may offer an improved tool for clinical prognostication and risk adjustment in research in this population., Competing Interests: R.K. is supported by NIH/NHLBI K23 HL146894. N.E.I. is supported by NIH/NHLBI T32 HL07741.G.L.A. is supported by NIH/NHLBI K23 HL161353. M.P.K. is supported by NIH/NHLBI R01 HL146386. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: The clinical progression of severe dementia frequently leads to situations where surrogate decision makers must quickly make choices about potentially burdensome treatments that offer limited clinical benefit. We examined whether the number of decision makers and their access to advance directives were related to treatment choice for patients with severe dementia in comparison to those with normal cognition., Research Design and Methods: We retrospectively linked survey responses about end-of-life treatment decisions to Medicare claims for Health and Retirement Study respondents dying between 2002 and 2015 whose next-of-kin reported a need for surrogate decision making. We estimated multivariable logistic regression models to study measures of aggressive care in the last 6 months of life; in-hospital death, burdensome transfers, and burdensome treatments., Results: Compared to patients who were cognitively normal near the end of life ( n = 1 198), patients with severe dementia ( n = 722) were less likely to experience burdensome treatments (18% [95% confidence interval {CI} 14-21] vs 32% [95% CI 29-35]), burdensome transfers (20% [95% CI 17-24] vs 30% [95% CI 27-33]), and in-hospital death (24% [95% CI 20-28] vs 30% [95% CI 26-33]) when surrogates were involved. Rates of burdensome treatments, transfers, or in-hospital death for decedents with severe dementia did not vary with single versus multiple decision makers or when decision makers were informed by advance directives. However, among decedents with normal cognition, a single decision maker informed by an advance directive was associated with the lowest rates of burdensome treatments and in-hospital death., Discussion and Implications: Surrogate decision makers made similar choices around end-of-life care for patients with severe dementia regardless of the number of decision makers and availability of advance directives. However, both advance directives and single decision makers were associated with less aggressive care for cognitively normal decedents., Competing Interests: None., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Rationale: Small trials and professional recommendations support mobilization interventions to improve recovery among critically ill patients, but their real-world effectiveness is unknown. Objective: To evaluate a low-cost, multifaceted mobilization intervention. Methods: We conducted a stepped-wedge cluster-randomized trial across 12 ICUs with diverse case mixes. The primary and secondary samples included patients mechanically ventilated for ⩾48 hours who were ambulatory before admission, and all patients with ICU stays ⩾48 hours, respectively. The mobilization intervention included 1 ) designation and posting of daily mobilization goals; 2 ) interprofessional closed-loop communication coordinated by each ICU's facilitator; and 3 ) performance feedback. Measurements and Main Results: From March 4, 2019 through March 15, 2020, 848 and 1,069 patients were enrolled in the usual care and intervention phases in the primary sample, respectively. The intervention did not increase the primary outcome, patient's maximal Intensive Care Mobility Scale (range, 0-10) score within 48 hours before ICU discharge (estimated mean difference, 0.16; 95% confidence interval, -0.31 to 0.63; P  = 0.51). More patients in the intervention (37.2%) than usual care (30.7%) groups achieved the prespecified secondary outcome of ability to stand before ICU discharge (odds ratio, 1.48; 95% confidence interval, 1.02 to 2.15; P  = 0.04). Similar results were observed among the 7,115 patients in the secondary sample. The percentage of days on which patients received physical therapy mediated 90.1% of the intervention effect on standing. ICU mortality (31.5% vs. 29.0%), falls (0.7% vs. 0.4%), and unplanned extubations (2.0% vs. 1.8%) were similar between groups (all P  > 0.3). Conclusions: A low-cost, multifaceted mobilization intervention did not improve overall mobility but improved patients' odds of standing and was safe. Clinical trial registered with www.clinicaltrials.gov (NCT03863470).

Importance: Race and ethnicity are routinely used to inform pulmonary function test (PFT) interpretation. However, there is no biological justification for such use, and it may reinforce health disparities., Objective: To compare the PFT interpretations produced with race-neutral and race-specific equations., Design, Setting, and Participants: In this cross-sectional study, race-neutral reference equations recently developed by the Global Lung Function Initiative (GLI) were used to interpret PFTs performed at an academic medical center between January 2010 and December 2020. The interpretations produced with these race-neutral reference equations were compared with those produced using the race and ethnicity-specific reference equations produced by GLI in 2012. The analysis was conducted from April to October 2022., Main Outcomes and Measures: The primary outcomes were differences in the percentage of obstructive, restrictive, mixed, and nonspecific lung function impairments identified using the 2 sets of reference equations. Secondary outcomes were differences in severity of these impairments., Results: PFTs were interpreted from 2722 Black (686 men [25.4%]; mean [SD] age, 51.8 [13.9] years) and 5709 White (2654 men [46.5%]; mean [SD] age, 56.4 [14.3] years) individuals. Among Black individuals, replacing the race-specific reference equations with the race-neutral reference equations was associated with an increase in the prevalence of restriction from 26.8% (95% CI, 25.2%-28.5%) to 37.5% (95% CI, 35.7%-39.3%) and of a nonspecific pattern of impairment from 3.2% (95% CI, 2.5%- 3.8%) to 6.5% (95% CI, 5.6%-7.4%) and no significant change in the prevalence of obstruction (19.9% [95% CI, 18.4%-21.4%] vs 19.5% [95% CI, 18.0%-21.0%]). Among White individuals, replacing the race-specific reference equations with the race-neutral reference equations was associated with a decrease in the prevalence of restriction from 22.6% (95% CI, 21.5%-23.6%) to 18.0% (95% CI, 17.0%-19.0%), a decrease in the prevalence of a nonspecific pattern of impairment from 8.7% (95% CI, 7.9%-9.4%) to 4.0% (95% CI, 3.5%-4.5%), and no significant change in the percentage with obstruction from 23.9% (95% CI, 22.8%-25.1%) to 25.1% (95% CI, 23.9%- 26.2%). The race-neutral reference equations were associated with an increase in severity in 22.8% (95% CI, 21.2%-24.4%) of Black individuals and a decrease in severity in 19.3% (95% CI, 18.2%-20.3%) of White individuals vs the race-specific reference equations., Conclusions and Relevance: In this cross-sectional study, the use of race-neutral reference equations to interpret PFTs resulted in a significant increase in the number of Black individuals with respiratory impairments along with a significant increase in the severity of the identified impairments. More work is needed to quantify the effect these reference equations would have on diagnosis, referral, and treatment patterns.

Importance: Although racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood., Objective: To measure disparities in hospital length of stay (LOS) among patients at high risk of adverse outcomes who present with sepsis and/or ARF and do not immediately require life support and to quantify associations with patient- and hospital-level factors., Design, Setting, and Participants: This matched retrospective cohort study used electronic health record data from 27 acute care teaching and community hospitals across the Philadelphia metropolitan and northern California areas between January 1, 2013, and December 31, 2018. Matching analyses were performed between June 1 and July 31, 2022. The study included 102 362 adult patients who met clinical criteria for sepsis (n = 84 685) or ARF (n = 42 008) with a high risk of death at the time of presentation to the emergency department but without an immediate requirement for invasive life support., Exposures: Racial or ethnic minority self-identification., Main Outcomes and Measures: Hospital LOS, defined as the time from hospital admission to the time of discharge or inpatient death. Matches were stratified by racial and ethnic minority patient identity, comparing Asian and Pacific Islander patients, Black patients, Hispanic patients, and multiracial patients with White patients in stratified analyses., Results: Among 102 362 patients, the median (IQR) age was 76 (65-85) years; 51.5% were male. A total of 10.2% of patients self-identified as Asian American or Pacific Islander, 13.7% as Black, 9.7% as Hispanic, 60.7% as White, and 5.7% as multiracial. After matching racial and ethnic minority patients to White patients on clinical presentation characteristics, hospital capacity strain, initial intensive care unit admission, and the occurrence of inpatient death, Black patients experienced longer LOS relative to White patients in fully adjusted matches (sepsis: 1.26 [95% CI, 0.68-1.84] days; ARF: 0.97 [95% CI, 0.05-1.89] days). Length of stay was shorter among Asian American and Pacific Islander patients with ARF (-0.61 [95% CI, -0.88 to -0.34] days) and Hispanic patients with sepsis (-0.22 [95% CI, -0.39 to -0.05] days) or ARF (-0.47 [-0.73 to -0.20] days)., Conclusions and Relevance: In this cohort study, Black patients with severe illness who presented with sepsis and/or ARF experienced longer LOS than White patients. Hispanic patients with sepsis and Asian American and Pacific Islander and Hispanic patients with ARF both experienced shorter LOS. Because matched differences were independent of commonly implicated clinical presentation-related factors associated with disparities, identification of additional mechanisms that underlie these disparities is warranted.

Rationale: We have previously shown that hospital strain is associated with intensive care unit (ICU) admission and that ICU admission, compared with ward admission, may benefit certain patients with acute respiratory failure (ARF). Objectives: To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. Methods: We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. Results: There was significant among-hospital variation in ICU admission rates, in hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF ( n  = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared with the ward, but among the 27 hospitals ( n  = 224-3,324), this effect varied from 5.85 days shorter (95% confidence interval [CI], -8.84 to -2.86; P  < 0.001) to 4.38 days longer (95% CI, 1.86-6.90; P  = 0.001). Corresponding ranges for in-hospital mortality with ICU compared with ward admission revealed odds ratios from 0.08 (95% CI, 0.01-0.56; P  < 0.007) to 8.89 (95% CI, 1.60-79.85; P  = 0.016) among patients with ARF (pooled odds ratio, 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. Conclusions: Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.