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BACKGROUND: Corticosteroids may be beneficial in a subset of patients with coronavirus disease 2019 (COVID-19), but predictors of therapeutic response remain unknown. C-reactive protein (CRP) is a routinely measured biomarker, and reduction in its levels after initiation of therapy may predict inpatient mortality. METHODS: In this retrospective cohort study, the charts of patients who were admitted to Montefiore Medical Center between March 10, 2020, and May 2, 2020 for the management of COVID-19 were examined. Of all patients who met inclusion criteria, patients who received corticosteroid treatment were categorized as CRP responders (≥50% CRP level reduction) and CRP nonresponders (

The efficacy of glucocorticoids in COVID-19 is unclear. This study was designed to determine whether systemic glucocorticoid treatment in COVID-19 patients is associated with reduced mortality or mechanical ventilation. This observational study included 1,806 hospitalized COVID-19 patients; 140 were treated with glucocorticoids within 48 hours of admission. Early use of glucocorticoids was not associated with mortality or mechanical ventilation. However, glucocorticoid treatment of patients with initial C-reactive protein (CRP) ≥20 mg/dL was associated with significantly reduced risk of mortality or mechanical ventilation (odds ratio, 0.23; 95% CI, 0.08- 0.70), while glucocorticoid treatment of patients with CRP

BACKGROUND: High-flow nasal cannula (HFNC), a form of noninvasive respiratory support, is effective for the treatment of respiratory distress in ICUs. Although HFNC has been used outside of the ICU, there is little research that examines its safety in this less-monitored setting. METHODS: Children ≤ 24 months old admitted with bronchiolitis to a pediatric floor at a tertiary care center from April 1 2013, to March 31 2015, were identified by using standard diagnostic codes. Exclusion criteria were concomitant pneumonia or complex comorbidities. Demographic and clinical characteristics were abstracted. Outcomes included transfer to the ICU, higher levels of respiratory support, intubation, pneumothorax, or aspiration events. RESULTS: Eighty children admitted with bronchiolitis who were treated with HFNC while on the pediatric floor were examined. The median age was 4.6 months, 45% were girls, and the majority were either Hispanic (41%) or black (36%). Flow ranged from 3 to 10 L/min. Thirty-three subjects (41% of the sample) required subsequent transfer to the ICU. No children were intubated or developed a pneumothorax. Eighty-three percent were fed while on HFNC. No children had an aspiration event. CONCLUSIONS: HFNC may be a safe modality of respiratory support outside of the ICU for children ages ≤ 24 months with bronchiolitis and without comorbidities up to a maximum flow of 10 L/min. There were no adverse events among the subjects who were fed while on HFNC.

BACKGROUND: Although most children with bronchiolitis only require supportive care, some decompensate and require ventilatory support. We examined predictors of respiratory decompensation among hospitalized children to identify which patients may benefit from expectant monitoring. METHODS: We examined children ≤24 months old with bronchiolitis admitted to the general infant and toddler floor. Children with pneumonia or comorbidities were excluded. Demographic and clinical characteristics were abstracted from a clinical database and medical records. Respiratory decompensation was defined as the need for initiating high-flow nasal cannula oxygen, continuous positive airway pressure, nasal intermittent mandatory ventilation, bilevel positive airway pressure, or intubation. A multivariable logistic regression model was constructed to identify independent predictors of respiratory decompensation. RESULTS: A total of 1217 children were included. The median age was 6.9 months, 41% were girls, 49% were Hispanic, 21% were black, and 18% were premature. Significant independent predictors of respiratory decompensation were age ≤3 months (odds ratio [OR]: 3.25; 95% confidence interval [CI]: 2.09–5.07), age 3 to 6 months (OR: 1.76; 95% CI: 1.04–3.0), black race (OR: 1.94; 95% CI: 1.27–2.95), emergency department hypoxemia (OR: 2.34; 95% CI: 1.30–4.21), and retractions or accessory muscle use (OR: 2.26; 95% CI: 1.48–3.46). Children with 0 of 4 predictors were found to have a low risk of decompensation (3%). CONCLUSIONS: Young age, black race, emergency department hypoxemia, and retractions or accessory muscle use were associated with respiratory decompensation in children with bronchiolitis. These factors should be considered at presentation, as they identify children who require a higher level of respiratory monitoring and support and others who may not benefit.

OBJECTIVE: Efforts to reduce C. difficile infections have targeted transmission from patients with symptomatic C. difficile. However, many patients with the C. difficile organism are carriers without symptoms who may serve as reservoirs for spread of infection and may be at risk for progression to symptomatic C. difficile. To estimate the prevalence of C. difficile carriage and determine the risk and speed of progression to symptomatic C. difficile among carriers, we established a pilot screening program in a large urban hospital. DESIGN: Prospective cohort study SETTING: An 800-bed, tertiary-care, academic medical center in the Bronx, NY PARTICIPANTS: A sample of admitted adults without diarrhea, with oversampling of nursing facility patients METHODS: Perirectal swabs were tested by Polymerase Chain Reaction for C. difficile within 24 hours of admission, and patients were followed for progression to symptomatic C. difficile. Development of symptomatic C. difficile was compared among C. difficile carriers and non-carriers using a Cox proportional hazards model. RESULTS: Of the 220 subjects, 21 (9.6%) were C. difficile carriers, including 10.2% of the nursing facility residents and 7.7% of the community residents (p=0.60). Among the 21 C. difficile carriers, 8 (38.1%) progressed to symptomatic C. difficile while only 4 (2.0%) of the 199 non-carriers progressed to symptomatic C. difficile (p

Hyponatremia is a common electrolyte disorder and is associated with mortality. We examined the frequency of appropriate testing in response to an episode of inpatient hyponatremia in a large urban hospital to better inform our educational intervention. We then evaluated the impact of a live CME activity with a focus on CKD- and ESRD-associated hyponatremia physiology, on diagnostic practices of audience hospitalist attendings. We performed a retrospective database analysis of all patients admitted to Montefiore Medical Center in 2014 to examine the performance of hospital staff in response to hyponatremia across all CKD stages. We then did a comparative analysis of diagnostic workup orders for hyponatremic patients admitted to audience members of a live CME activity in the 4 months prior as compared to the 4 months after the activity. The prevalence of hyponatremia was 27% in a cohort of hospitalized patients: 41% of these hyponatremia inpatients had CKD, and 11.4% had ESRD. Overall less than 10% of patients had orders written for serum and urine osmolality without a differential pattern based on CKD or ESRD diagnosis. Among the patients admitted to the CME audience hospitalists, urine/serum osmolality and urine sodium orders occurred infrequently overall and did not differ after vs. before the lecture. The frequency of appropriate diagnostic orders written in response to an episode of hyponatremia was very low and did not vary based on degree of CKD. A CME activity with an emphasis on the role of CKD/ESRD in diagnostic accuracy did not improve the order quality in a group of audience hospitalists. Efforts to improve the diagnostic workup of hyponatremia with concomitant kidney disease are crucial to proper management of these patients.

BACKGROUND Risk adjustment for mortality is increasingly important in an era when hospitals and health care systems are being compared with respect to health outcomes and quality. A powerful predictive model has been developed to risk-adjust for 30-day mortality among inpatients, but it is complex and not widely used. OBJECTIVE To develop and validate a simpler model, with predictive power similar to more complex models. RESEARCH DESIGN This was a retrospective split-validation study. In a derivation cohort, a predictive model for 30-day mortality was developed using logistic regression with the Charlson comorbidity score, Laboratory-Based Acute Physiology Score, and age as the predictor variables. In the validation cohort, the performance and calibration of the model to predict 30-day mortality was examined. SUBJECTS All admissions to the medical service of 2 urban university-based teaching hospitals located in Bronx, New York, between July 1, 2002, and April 30, 2008. MEASURES All-cause mortality was taken from the social security death registry. Predictor variables were constructed from demographic characteristics, laboratory and billing data extracted from a clinical data repository. RESULTS The study sample included 147 991 admissions and overall 30-day mortality was 5.4%. The model had excellent discrimination, with a c-statistics of 0.8585 in the derivation cohort and 0.8484 in the validation cohort. The model accurately predicts 30-day mortality in all risk deciles. CONCLUSIONS This simple and powerful predictive model can be used by hospitals and health care systems as a risk-adjustment tool for quality and research purposes.

Although cocaine is a well-recognized risk factor for coronary disease, detailed information is lacking regarding related behavioral and clinical features of cocaine-associated ST-segment elevation myocardial infarction (STEMI), particularly in socioeconomically disadvantaged urban settings. Nor are systematic or extended follow-up data available on outcomes for cocaine-associated STEMI in the contemporary era of percutaneous coronary intervention. We leveraged a prospective STEMI registry from a large health system serving an inner-city community to characterize the clinical features, acute management, and middle-term outcomes of cocaine-related versus cocaine-unrelated STEMI. Of the 1,003 patients included, 60% were black or Hispanic. Compared with cocaine-unrelated STEMI, cocaine-related STEMI (n = 58) was associated with younger age, male gender, lower socioeconomic score, current smoking, high alcohol consumption, and human immunodeficiency virus seropositivity but less commonly with diabetes or hypertension. Cocaine users less often received drug-eluting stents or β blockers at discharge. During median follow-up of 2.7 years, rates of death, death or any rehospitalization, and death or cardiovascular rehospitalization did not differ significantly between cocaine users and nonusers but were especially high for death or any hospitalization in the 2 groups (31.4 vs 32.4 per 100 person-years, p = 0.887). Adjusted hazard ratios for outcomes were likewise not significantly different. In conclusion, in this low-income community, cocaine use occurred in a substantial fraction of STEMI cases, who were younger than their nonuser counterparts but had more prevalent high-risk habits and exhibited similarly high rates of adverse outcomes. These data suggest that programs targeting cocaine abuse and related behaviors could contribute importantly to disease prevention in disadvantaged communities.

Purpose The traditional technique of placing a peripheral intravenous (IV) catheter is successful in most cases on inpatient wards. However, when the traditional method fails, a central venous catheter may be placed to maintain IV access. These catheters are associated with risks including central line-associated bloodstream infection. Methods We evaluated the effectiveness and acceptability of an ultrasound-guided peripheral IV service to reduce the number of newly placed central venous catheters on an inpatient ward. Central venous catheters were counted daily on intervention and control wards using a standard protocol, and rates of newly placed catheters were compared using a Poisson regression model. Nurses were surveyed to assess acceptability and perceived benefit. Results We found a reduction in the rate of newly placed central venous catheters on the intervention unit compared with the control unit at 90 days: mean 0.47 versus 0.67 newly placed central venous catheters/day, but the difference was not significant (P = .08). Nurses were in favor of the ultrasound-guided IV service, with perceived benefit to their patients. Conclusion Ultrasound-guided peripheral IV might reduce unnecessary central venous catheters on general inpatient wards. A portable ultrasound used for this purpose was found to be acceptable by nursing staff.

Using serial measurements of brain natriuretic peptide (BNP) has been proposed as a method to guide therapy for patients treated for acute decompensated heart failure. However, 20-47% of patients do not achieve the target BNP thresholds despite treatment. We hypothesised that "BNP unresponsive" patients represent a distinct group at high risk for poor outcomes and sought to examine the characteristics and outcomes of this group.In a retrospective study using electronic health record (EHR) data, we examined the outcomes of patients admitted with acute decompensated heart failure. Patients were divided into two groups based on their pro-BNP response to treatment: (1) pro-BNP responsive to treatment (decrease by at least 30%) and (2) pro-BNP unresponsive to treatment (decrease by less than 30%). The primary outcomes of interest were 180-day mortality and 180-day readmission. Univariate and multivariate Cox proportional hazard models were used to assess the independent association between pro-BNP response to treatment and 180-day mortality and readmission. Adjustment variables included age, gender, Charlson co-morbidity score, admission creatinine, admission haematocrit, ejection fraction, preserved ejection fraction, and LV end-diastolic dimension.The total study population included 819 patients with 455 (55.6%) in the pro-BNP responsive group and 364 (44.4%) in the pro-BNP unresponsive group. Admissions whose BNP was unresponsive to treatment had significantly increased risk for 180-day mortality, compared with BNP-responsive admissions (26.4% vs. 13.2%, p 0.001). Brain natriuretic peptide unresponsiveness remained significantly associated with increased 180-day mortality after adjustment for demographic and clinical characteristics (HRPatients whose pro-BNP did not improve by30% were at increased risk for 180-day mortality, but not 180-day readmission. Thus, BNP-unresponsiveness provides meaningful prognostic information, and it may define a patient population that would benefit from specific therapies to reduce the risk.

BACKGROUND: Because there can be no delay in providing identification wristbands to newborns, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs. To determine the level of risk associated with nondistinct naming conventions, we performed an intervention study to evaluate if assigning distinct first names at birth would result in a reduction in wrong-patient errors. METHODS: We conducted a 2-year before/after implementation study to examine the effect of a distinct naming convention that incorporates the mother’s first name into the newborn’s first name (eg, Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient within the next 10 minutes. RESULTS: The reduction in RAR events post- versus preintervention was 36.3%. After accounting for clusters of orders within order sessions, the odds ratio of an RAR event post- versus preintervention was 0.64 (95% confidence interval: 0.42–0.97). CONCLUSIONS: The study results suggest that nondistinct naming conventions are associated with an increased risk of wrong-patient errors and that this risk can be mitigated by changing to a more distinct naming convention.

Low molecular weight heparins (LMWHs) have been cautiously used in patients with chronic kidney disease (CKD) due to fear of accumulation. Dalteparin, however, has shown minimal tendency to accumulate in patients with CKD and may be safe to use in this patient population.We compared the incidence of clinically significant bleeding in patients with CKD receiving therapeutic doses of dalteparin to that of patients with CKD receiving therapeutic doses of UFH.This was a retrospective cohort study.Inpatients with CKD (GFR 60 ml/min) who were treated with therapeutic dalteparin or UFH were included in the studyPrimary outcome was major bleeding within 10 days of anticoagulation, identified by ICD-9 code and confirmed by chart review. Demographic characteristics, laboratory values, comorbidities, prior bleeding history and inpatient medications were extracted for each admission from the electronic medical record. Logistic regression models were created to examine the association between choice of anticoagulant and bleeding rates, after adjustment for demographic and clinical characteristics.Dalteparin-treated patients were significantly less likely to experience a major bleed than patients treated with UFH (1.14 % vs. 3.49 %, p 0.001). The reduced likelihood of bleeding associated with dalteparin treatment remained significant after adjustment for patient characteristics (HR 0.39, 95 % CI: 0.21-0.70, p 0.0001). A stratified analysis for subgroups with GFR30 mL/min and with GFR between 30 and 60 mL/min showed that dalteparin was still associated with lower odds of bleeding compared to treatment with unfractionated heparin, but the difference was nonsignificant for GFR30 (HR 0.35, 95 % CI: 0.11-1.15), even after adjustment (OR 0.37, 95 % CI: 0.11-1.22).In patients with CKD, treatment with therapeutic dose dalteparin was associated with lower rates of bleeding than treatment with unfractionated heparin. For patients with severe CKD (GFR30), dalteparin was shown to be at least as safe as unfractionated heparin.

Background End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis. Methods One thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis. Results Patients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43–4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16–1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01–2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46–0.91) and 0.71(95%CI:0.66–0.77) respectively). Conclusions Patients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.

BACKGROUND: NICU patients have characteristics believed to increase their risk for wrong-patient errors; however, little is known about the frequency of wrong-patient errors in the NICU or about effective interventions for preventing these errors. We conducted a quality improvement study to evaluate the frequency of wrong-patient orders in the NICU and to assess the effectiveness of an ID reentry intervention and a distinct naming convention (eg, “Wendysgirl”) for reducing these errors, using non-NICU pediatric units as a comparator. METHODS: Using a validated measure, we examined the rate of wrong-patient orders in NICU and non-NICU pediatric units during 3 periods: baseline (before implementing interventions), ID reentry intervention (reentry of patient identifiers before placing orders), and combined intervention (addition of a distinct naming convention for newborns). RESULTS: We reviewed >850 000 NICU orders and >3.5 million non-NICU pediatric orders during the 7-year study period. At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100 000 orders, respectively; odds ratio 1.56; 95% confidence interval, 1.34–1.82). The ID reentry intervention reduced the frequency of errors in the NICU to 60.2 per 100 000 (48.7% reduction; P < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; P < .001). CONCLUSIONS: The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.

Background Testing for patients at risk for hepatitis C virus (HCV) infection is recommended, but it is unclear whether providers adhere to testing guidelines. We aimed to measure adherence to an HCV screening protocol during a multifaceted continuous intervention. Subjects and methods Prospective cohort design to examine the associations between patient-level, physician-level, and visit-level characteristics and adherence to an HCV screening protocol. Study participants included all patients with a visit to 1 of the 3 study clinics and the physicians who cared for them. Adherence to the HCV screening protocol and patient-level, physician-level, and visit-level predictors of adherence were measured. Results A total of 8981 patients and 154 physicians were examined. Overall protocol adherence rate was 36.1%. In multivariate analysis, patient male sex (odds ratio [OR] = 1.18), new patient (OR = 1.23), morning visit (OR = 1.32), and patients' preferred language being non-English (OR = 0.87) were significantly associated with screening adherence. There was a wide variation in overall adherence among physicians (range, 0%-92.4%). Screening adherence continuously declined from 59.1% in week 1 of the study to 13.7% in week 15 (final week). When implementing complex clinical practice guidelines, planners should address physician attitudinal barriers as well as gaps in knowledge to maximize adherence.

Little research has been performed on the impact of race/ethnicity and obesity on the course of diverticulitis.To determine whether patients of different racial/ethnic backgrounds and patients who are obese have disparate courses of disease with regard to complications, recurrence rates, and need for surgery.We conducted a retrospective review of the charts of 347 patients with confirmed diverticulitis in 2 university teaching hospitals at Bronx, NY.African Americans were more likely [odds ratio (OR), 2.28, 95% confidence interval (CI), 1.04-5.00, P = 0.04] and Hispanics were less likely than other racial/ethnic groups (OR, 0.47; 95% CI, 0.22-0.97; P = 0.04) to require surgery for recurrent diverticulitis after at least 1 medically managed hospital admission for diverticulitis. Caucasians were less likely than other racial/ethnic groups to suffer a recurrence of diverticulitis (OR, 0.48; 95% CI, 0.27-0.86; P = 0.01). Obese patients [ body mass index (BMI)30] were more likely than nonobese patients to experience a recurrent episode of diverticulitis (OR, 1.69; 95% CI, 1.08-2.64; P = 0.02). The odds of requiring surgery on the initial presentation of diverticulitis were not significantly different among the various races/ethnicities nor was the likelihood of surgery influenced by BMI. Complication rates did not differ significantly when patients were stratified by age, sex, race, BMI, or number of prior episodes of diverticulitis.Surgery for diverticulitis after at least 1 medically managed hospital admission for diverticulitis is more frequently needed in African Americans and less frequently needed in Hispanics. Caucasians are less likely than other races/ethnicities to suffer a recurrence of diverticulitis. Finally, obesity is a risk factor for recurrent diverticulitis, but not for surgical therapy of diverticulitis.

Objectives. We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers. Methods. A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ2 test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener. Results. Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified. Conclusions. A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.

Background Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown. Methods We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges. Results Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR] adj 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR matched 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR adj 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR matched 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P Conclusions Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.

Elevated alkaline phosphatase (AlkPhos) and phosphate levels are associated with cardiovascular morbidity and mortality in patients receiving dialysis. A retrospective cohort study was conducted to test these associations in outpatients with an estimated GFRor =60 ml/min/1.73 m(2).Patients with serum AlkPhos and phosphate levels measured between 2000 and 2002 (n = 10,743) at Montefiore Medical Center (MMC) clinics were followed through September 11, 2008 (median 6.8 years). Mortality data were obtained via Social Security Administration records (n = 949 deaths). Hospitalization data were obtained from MMC records.The mean age was 51 years, 64% were women, 22% were white, 26% were non-Hispanic black, 16% were Hispanic, 13% had a diagnosis of hypertension, 9% had diabetes mellitus, and 8% had cardiovascular disease at baseline. AlkPhos and phosphate were independently associated with mortality and cardiovascular-related hospitalization after multivariable adjustment. Comparing patients in the highest (or =104 U/L) versus lowest quartile of AlkPhos (or =66 U/L), the adjusted hazard ratio (HR) for mortality was 1.65 (P trend across quartiles0.001). For the highest compared with the lowest quartile of serum phosphate (or =3.8 mg/dl versusor =3.0 mg/dl), the adjusted HR for mortality was 1.29 (P trend across quartiles = 0.008). High AlkPhos but not phosphate levels were also associated with all-cause, infection-related, and fracture-related hospitalization.Higher levels of serum AlkPhos and phosphate were associated with increased mortality and cardiovascular-related hospitalization in an inner-city clinic population. Further studies are needed to elucidate mechanisms underlying these associations.

In general, ischemic colitis has a very good prognosis, but there is concern that when ischemia affects the right side of the colon in an isolated fashion, the prognosis may not be so favorable.The aim of this study was to compare the clinical features and outcomes of ischemia isolated to the right side of the colon with those of ischemia involving other areas of the colon.A retrospective study was undertaken of patients with colon ischemia hospitalized at the Moses and Weiler Divisions of the Montefiore Medical Center during the interval 1998-2005. Patients were identified using computerized searches of ICD-9 codes for colon ischemia and were divided into two groups: those with isolated right colon ischemia (IRCI) and those with colon ischemia not involving the right colon in an isolated fashion (non-IRCI). Only patients with biopsy-proven ischemic colitis were entered into our study.A total of 273 cases of biopsy-proven ischemic colitis were identified, of which 71 (26.0%) were isolated to the right side. Of these IRCI cases, 59.2% had an unfavorable outcome compared with 17.3% of cases of non-ICRI: 54.9% of IRCI patients required surgery compared with 10.9% of non-IRCI patients; mortality in patients with IRCI was 22.5% compared with 11.9% in patients with non-IRCI.A total of 273 cases of biopsy-proven ischemic colitis were identified of which 71 (26.0%) involved only the right side. Patients with IRCI had a worse outcome than those with colon ischemia involving other colon regions, including a fivefold need for surgery and a twofold mortality.

Background & Aims National hepatitis C virus (HCV) screening guidelines recommended 1-time testing of persons born between 1945 and 1965. Methods We performed a retrospective study to compare care milestones achieved by HCV-infected patients identified by birth cohort versus risk-based screens. Results We determined the proportions of patients newly identified with HCV infection who met care milestones (viral load, referral to and evaluation by a specialist, offer of treatment, initiation of treatment, and sustained viral response) and the time it took to reach them. We found no differences in HCV care milestones for patients identified via birth cohort testing versus risk-based screening. Overall, only 43% of HCV antibody-positive patients were referred to care, and less than 4% started treatment. The time to each care milestone was lengthy and varied greatly; treatment was initiated in a median of 308 days. Conclusions Although birth cohort testing will likely increase identification of patients with HCV infection, it does not seem to increase the number of patients that meet management milestones. New methods are needed to increase access to care and establish efficient models of health care delivery.

Since the introduction of the prospective payment system in 1983, U.S. hospitals have been financially incentivized to reduce inpatient length of stay, and average length of stay has shortened dramatically.The purpose of this study was to determine whether short length of stay is associated with worse patient outcomes.We used a quasi-experimental design to compare the outcomes of admissions assigned to physicians with short versus long length-of-stay tendencies. We used each physician's mean length of stay to define their length of stay tendency. We then compared the outcomes of admissions assigned to physicians with short versus long length-of-stay tendencies in propensity score-matched and adjusted analyses using mixed-effects and conditional logistic regression models.The study included all admissions for 10 common diagnoses among patients admitted to the medical teaching service of an urban academic hospital from 7/1/2002 through 6/30/2008.The primary outcome was 30-day mortality.We examined 12,341 admissions among 79 physicians. After propensity score matching, admission groups were similar with respect to all demographic and clinical characteristics. Admissions of patients receiving care from short length-of-stay physicians were associated with significantly increased risk of 30-day mortality in adjusted (OR 1.43, 95 % CI: 1.11-1.85), propensity score-matched (OR 1.33, 95 % CI: 1.08-1.63), and matched and adjusted analyses (OR 1.36, 95 % CI: 0.98-1.90).Policies that incentivize short length of stay may lead to worse patient outcomes. The financial benefits of shortening inpatient length of stay should be weighed against the potential harm to patients.

Objective To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study. Materials and methods In phase 1, from May to August 2010, the effectiveness of a ‘retract-and-reorder’ measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an ‘ID-verify alert’, and an ‘ID-reentry function’. Results The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71). Discussion and conclusion Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.

Objective Although tight glucose control is used widely in hospitalized patients, there is concern that medication-induced hypoglycemia may worsen patient outcomes. We sought to determine if the mortality risk associated with hypoglycemia in hospitalized noncritically ill patients is linked to glucose-lowering medications (drug-associated hypoglycemia) or merely an association mediated by comorbidities (spontaneous hypoglycemia). Methods A retrospective cohort of patients admitted to the general wards of an academic center during 2007 was studied. The in-hospital mortality risk of a hypoglycemic group (at least 1 blood glucose≤70 mg/dL) was compared with that of a normoglycemic group using survival analysis. Stratification by subgroups of patients with spontaneous and drug-associated hypoglycemia was performed. Results Among 31,970 patients, 3349 (10.5%) had at least 1 episode of hypoglycemia. Patients with hypoglycemia were older, had more comorbidities, and received more antidiabetic agents. Hypoglycemia was associated with increased in-hospital mortality (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.33-2.09; P 001). However, this greater risk was limited to patients with spontaneous hypoglycemia (HR, 2.62; 95% CI, 1.97-3.47; P 001) and not to patients with drug-associated hypoglycemia (HR, 1.06; 95% CI, 0.74-1.52; P=. 749). After adjustment for patient comorbidities, the association between spontaneous hypoglycemia and mortality was eliminated (HR, 1.11; 95% CI, 0.76-1.64; P=. 582). Conclusion Drug-associated hypoglycemia was not associated with increased mortality risk in patients admitted to the general wards. The association between spontaneous hypoglycemia and mortality was eliminated after adjustment for comorbidities, suggesting that hypoglycemia may be a marker of disease burden rather than a direct cause of death.

Background An estimated 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S. Effective treatment is available, but approximately 50% of patients are not aware that they are infected. Optimal testing strategies have not been described. Methods The Hepatitis C Assessment and Testing Project (HepCAT) was a serial cross-sectional evaluation of two community-based interventions designed to increase HCV testing in urban primary care clinics in comparison with a baseline period. The first intervention (risk-based screener) prompted physicians to order HCV tests based on the presence of HCV-related risks. The second intervention (birth cohort) prompted physicians to order HCV tests on all patients born within a high-prevalence birth cohort (1945–1964). The study was conducted at three primary care clinics in the Bronx, New York. Results Both interventions were associated with an increased proportion of patients tested for HCV from 6.0% at baseline to 13.1% during the risk-based screener period (P Conclusions Two simple clinical reminder interventions were associated with significantly increased HCV testing rates. Our findings suggest that HCV screening programs, using either a risk-based or birth cohort strategy, should be adopted in primary care settings so that HCV-infected patients may benefit from antiviral treatment.

Background More physician years in practice have been associated with less frequent guideline adherence, but it is unknown whether years in practice are associated with patient outcomes. Methods We examined all inpatients on the teaching service of an urban hospital from July 1, 2002 through June 30, 2004. Admissions were assigned to attending physicians quasi-randomly. Years in practice was defined as the number of years the attending physician held a medical license. We divided physicians into 4 groups (0-5, 6-10, 11-20, and >20 years in practice), and used negative binomial and logistic regression to adjust for patient characteristics and estimate associations between years in practice and length-of-stay, readmission, and mortality. Results Fifty-nine physicians and 6572 admissions were examined. Although the 4 inpatient groups had similar demographic and clinical characteristics, physicians with more years in practice had longer mean lengths of stay (4.77, 5.29, 5.42, and 5.31 days for physicians with 0-5, 6-10, 11-20, and >20 years in practice, respectively, P =.001). After adjustment, inpatients of physicians with more than 20 years in practice had higher risk for both in-hospital mortality (odds ratio 1.71; 95% confidence interval, 1.06-2.76) and 30-day mortality (odds ratio 1.51, 95% confidence interval, 1.06-2.16) than inpatients of physicians with 0-5 years in practice. Conclusion Inpatient care by physicians with more years in practice is associated with higher risk of mortality. Quality-of-care interventions should be developed to maintain inpatient skills for physicians.

Approximately 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S.; most are not aware of their infection. Our objectives were to examine HCV testing practices to determine which patient characteristics are associated with HCV testing and positivity, and to estimate the prevalence of HCV infection in a high-risk urban population. The study subjects were all patients included in the baseline phase of the Hepatitis C Assessment and Testing Project (HepCAT), a serial cross-sectional study of HCV screening strategies. We examined all patients with a clinic visit to Montefiore Medical Center from 1/1/08 to 2/29/08. Demographic information, laboratory data and ICD-9 diagnostic codes from 3/1/97-2/29/08 were extracted from the electronic medical record. Risk factors for HCV were defined based on birth date, ICD-9 codes and laboratory data. The prevalence of HCV infection was estimated assuming that untested subjects would test positive at the same rate as tested subjects, based on risk-factors. Of 9579 subjects examined, 3803 (39.7%) had been tested for HCV and 438 (11.5%) were positive. The overall prevalence of HCV infection was estimated to be 7.7%. Risk factors associated with being tested and anti-HCV positivity included: born in the high-prevalence birth-cohort (1945-64), substance abuse, HIV infection, alcohol abuse, diagnosis of cirrhosis, end-stage renal disease, and alanine transaminase elevation. In a high-risk urban population, a significant proportion of patients were tested for HCV and the prevalence of HCV infection was high. Physicians appear to use a risk-based screening strategy to identify HCV infection.

Background: Academic medical centers are increasingly employing hospitalists to staff teaching wards. Although studies have demonstrated reduced lengths of stay (LOSs) associated with hospitalist care, it is unclear which patients are most likely to benefit. We sought to determine whether patients with specific diagnoses or discharge needs account for the association between hospitalist care and reduced LOS. Methods: Hospital admissions were divided into the following 2 groups based on type of attending physician: teaching hospitalist (full-time faculty hospitalist with no outpatient responsibilities) vs nonhospitalist (full-time or voluntary faculty contributing 1 or 2 months of teaching service per year). We included all patients discharged from an academic teaching service for a 2-year period. Data were extracted from the Montefiore Medical Center’s clinical information system and the Social Security Death Registry. Results: Mean LOS was lower for teaching hospitalists than for nonhospitalists (5.01 vs 5.87 days [P.02]). The reduction in LOS was greatest for patients requiring close clinical monitoring (patients with congestive heart failure, stroke, asthma, or pneumonia) and for those requiring complex discharge planning. There were no significant differences between the groups in readmission, in-hospital mortality, or 30-day mortality. Conclusion: Teaching hospitalist care was associated with shorter LOS in patients requiring close clinical monitoring and complex discharge planning, without adversely affecting readmission or mortality rates. Arch Intern Med. 2007;167(17):1869-1874

Background International guidelines and U.S. guidelines prior to 2012 only recommended testing for hepatitis C virus (HCV) infection among patients at risk, but adherence to guidelines is poor, and the majority of those infected remain undiagnosed. A strategy to perform one-time testing of all patients born during 1945–1965, birth cohort testing, may diagnose HCV infection among patients whose risk remains unknown. We sought to determine if a birth-cohort testing intervention for HCV antibody positivity helped identify patients with fewer documented risk factors or medical indications than a pre-intervention, risk-based testing strategy. Methods We used a cross-sectional design with retrospective electronic medical record review to examine patients identified with HCV antibody positivity (Ab+) during a pre-intervention (risk-based) phase, the standard of care at the time, vs. a birth-cohort testing intervention phase. We compared demographic and clinical characteristics and HCV risk-associated factors among patients whose HCV Ab + was identified during the pre-intervention (risk-based testing) vs. post birth-cohort intervention phases. Study subjects were patients identified as HCV-Ab + in the baseline (risk-based) and birth-cohort testing phases of the Hepatitis C Assessment and Testing (HepCAT) Project. Results Compared to the risk-based phase, patients newly diagnosed with HCV Ab + after the birth-cohort intervention were significantly less likely to have a history of any substance abuse (30.5 % vs. 49.5 %, p = 0.02), elevated alanine transaminase levels of > 40 U/L (22.0 % vs. 46.7 %, p = 0.002), or the composite any risk-associated factor (55.9 % vs. 79.0 %, p = 0.002). Conclusions Birth-cohort testing is an useful strategy for identifying previously undiagnosed HCV Ab + because it does not require providers ask risk-based questions, or patients to disclose risk behaviors, and appears to identify HCV Ab + in patients who would not have been identified using a risk-based testing strategy.