Search

Background: Poor functional status is a key marker of morbidity, yet is not routinely captured in clinical encounters. We developed and evaluated the accuracy of a machine learning algorithm that leveraged electronic health record (EHR) data to provide a scalable process for identification of functional impairment. Methods: We identified a cohort of patients with an electronically captured screening measure of functional status (Older Americans Resources and Services ADL/IADL) between 2018 and 2020 (N = 6484). Patients were classified using unsupervised learning K means and t‐distributed Stochastic Neighbor Embedding into normal function (NF), mild to moderate functional impairment (MFI), and severe functional impairment (SFI) states. Using 11 EHR clinical variable domains (832 variable input features), we trained an Extreme Gradient Boosting supervised machine learning algorithm to distinguish functional status states, and measured prediction accuracies. Data were randomly split into training (80%) and test (20%) sets. The SHapley Additive Explanations (SHAP) feature importance analysis was used to list the EHR features in rank order of their contribution to the outcome. Results: Median age was 75.3 years, 62% female, 60% White. Patients were classified as 53% NF (n = 3453), 30% MFI (n = 1947), and 17% SFI (n = 1084). Summary of model performance for identifying functional status state (NF, MFI, SFI) was AUROC (area under the receiving operating characteristic curve) 0.92, 0.89, and 0.87, respectively. Age, falls, hospitalization, home health use, labs (e.g., albumin), comorbidities (e.g., dementia, heart failure, chronic kidney disease, chronic pain), and social determinants of health (e.g., alcohol use) were highly ranked features in predicting functional status states. Conclusion: A machine learning algorithm run on EHR clinical data has potential utility for differentiating functional status in the clinical setting. Through further validation and refinement, such algorithms can complement traditional screening methods and result in a population‐based strategy for identifying patients with poor functional status who need additional health resources. [ABSTRACT FROM AUTHOR]

In this article, the author focuses on the teaching hospital in the U.S. He states that academic medical service provides students and house staff to present the subjective and objective data about their patients and they learn about the importance of clinical data. He mentions that one can learn diagnostic testing and other methods from the presentations showed during medical teaching. He further states that physicians use slow physical examination methods to know the exact problem with a patient and then suggest proper treatment methods according to the symptoms they have found in the patient.

Objectives: Sepsis remains a leading and preventable cause of hospital utilization and mortality in the United States. Despite updated guidelines, the optimal definition of sepsis as well as optimal timing of bundled treatment remain uncertain. Identifying patients with infection who benefit from early treatment is a necessary step for tailored interventions. In this study, we aimed to illustrate clinical predictors of time-to-antibiotics among patients with severe bacterial infection and model the effect of delay on risk-adjusted outcomes across different sepsis definitions.Design: A multicenter retrospective observational study.Setting: A seven-hospital network including academic tertiary care center.Patients: Eighteen thousand three hundred fifteen patients admitted with severe bacterial illness with or without sepsis by either acute organ dysfunction (AOD) or systemic inflammatory response syndrome positivity.Measurements and Main Results: The primary exposure was time to antibiotics. We identified patient predictors of time-to-antibiotics including demographics, chronic diagnoses, vitals, and laboratory results and determined the impact of delay on a composite of inhospital death or length of stay over 10 days. Distribution of time-to-antibiotics was similar across patients with and without sepsis. For all patients, a J-curve relationship between time-to-antibiotics and outcomes was observed, primarily driven by length of stay among patients without AOD. Patient characteristics provided good to excellent prediction of time-to-antibiotics irrespective of the presence of sepsis. Reduced time-to-antibiotics was associated with improved outcomes for all time points beyond 2.5 hours from presentation across sepsis definitions.Conclusions: Antibiotic timing is a function of patient factors regardless of sepsis criteria. Similarly, we show that early administration of antibiotics is associated with improved outcomes in all patients with severe bacterial illness. Our findings suggest identifying infection is a rate-limiting and actionable step that can improve outcomes in septic and nonseptic patients. [ABSTRACT FROM AUTHOR]

Context: Palliative care improves patient and family outcomes and may reduce the cost of care, but this service is underutilized among Medicare beneficiaries.Objectives: To describe enrollment patterns and outcomes associated with the Center for Medicare and Medicaid Innovation expansion of a multisetting community palliative care program in North and South Carolina.Methods: This observational study characterizes the Center for Medicare and Medicaid Innovation cohort's care and cost trajectories after enrollment. Program participants were age-eligible Medicare fee-for-service beneficiaries living in Western North Carolina and South Carolina who enrolled in a palliative care program from September 1, 2014, to August 31, 2017. End-of-life costs were compared between enrolled and nonenrolled decedents. Program administrative data and 100% Medicare claims data were used.Results: A total of 5243 Medicare beneficiaries enrolled in the program from community (19%), facility (21%), small hospital (27%), or large hospital (33%) settings. Changes in Medicare expenditures in the 30 days after enrollment varied by setting. Adjusted odds of hospice use were 60% higher (OR = 1.60; CI = 1.47, 1.75) for enrolled decedents relative to nonenrolled decedents. Participants discharged to hospice vs. participants not had 17% (OR = 0.83 CI = 0.72, 0.94) lower costs. Among enrolled decedents those enrolled for at least 30 days vs. <30 days had 42% (OR = 0.58, CI = 0.49, 0.69) lower costs in the last 30 days of life.Conclusions: Expansion of community palliative care programs into multiple enrollment settings is feasible. It may improve hospice utilization among enrollees. Heterogeneous program participation by program setting pose challenges to a standardizing reimbursement policy. [ABSTRACT FROM AUTHOR]

Background: Despite diagnostic errors impacting an estimated 12 million people yearly in the United States, educational strategies that foster diagnostic performance among nurse practitioner (NP) students remain elusive. One possible solution is to focus explicitly on competencies fundamental for diagnostic excellence. Currently, no educational tools were found that comprehensively address individual diagnostic reasoning competencies during simulated-based learning experiences., Purpose: Our research team developed and explored psychometric properties of the "Diagnostic Competency During Simulation-based (DCDS) Learning Tool.", Method: Items and domains were developed based on existing frameworks. Content validity was determined by a convenience sample of eight experts. Inter-rater reliability was determined by four faculty rating eight simulation scenarios., Results: Final individual competency domain scale content validity index (CVI) scores ranged between 0.9175 and 1.0; total scale CVI score was 0.98. The intra-class correlation coefficient (ICC) for the tool was 0.548 (p < 0.0001, 95 % confidence interval CI [0.482-0.612])., Conclusions: Results suggest that the DCDS Learning Tool is relevant to diagnostic reasoning competencies and may be implemented with moderate reliability across varied simulation scenarios and performance levels. The DCDS tool expands the landscape of diagnostic reasoning assessment by providing NP educators with granular, actionable, competency-specific assessment measures to foster improvement., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Abstract: Sepsis carries a high mortality in the United States. Hospitals across the country are working to find new ways to recognize, treat, and streamline care for patients with sepsis. At an academic medical center in the Midwest, a quality improvement project was developed using a sepsis rapid response team with physician associates/assistants (PAs) and NPs. This improved hospital adherence to sepsis evaluation and order set use from 48% to 86%. The added evaluation of the patient by a PA or NP, along with ensuring adherence to the sepsis order set, made an effective first step to improve care of patients with sepsis in this hospital., (Copyright © 2022 American Academy of Physician Associates.)

We administered a standardized 41-item questionnaire to a convenience sample of graduates of five residency programs with formal global health pathways and compared findings to a national cohort of practicing physicians to evaluate the comparative effectiveness of an overarching global health pathway on residency program graduates. Compared with the national cohort database, global health pathway graduates self-reported that they felt better prepared to treat immigrants, refugees, patients with limited English proficiency (LEP), racial/ethnic minorities, those with non-Western health beliefs, international travelers, and military veterans (P < 0.05). They were more likely to report using best practices when working with lesbian, gay, bisexual, transgender, queer/questioning patients, immigrant and refugee patients, patients with non-Western health beliefs, patients with LEP, and patients communicating via American Sign Language (P < 0.05). They also reported being more familiar with 11 of 14 high-impact or common infections encountered in travelers, immigrants, and military personnel (P < 0.05). Our findings suggest that formal postgraduate training focused on global health improves knowledge, attitudes, and self-reported medical practices when caring for diverse and marginalized populations in the United States.

Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background Miscommunication amongst providers is a major factor contributing to diagnostic errors. There is a need to explore the current state of communications between clinicians and diagnostic radiologists. We compare and contrast the perceptions, experiences, and other factors that influence communication behaviors about diagnostic errors between clinicians and radiologists. Methods A survey with questions addressing (1) communication around diagnostic error, (2) types of feedback observed, (3) the manner by which the feedback is reported, and (4) length of time between the discovery of the diagnostic error and disclosing it was created and distributed through two large academic health centers and through listservs of professional societies of radiologists and clinicians. Results A total of 240 individuals responded, of whom 58% were clinicians and 42% diagnostic radiologists. Both groups of providers frequently discover diagnostic errors, although radiologists encounter them more frequently. From the qualitative analysis, feedback around diagnostic error included (1) timeliness of error, (2) specificity in description or terminology, (3) collegial in delivery, and (4) of educational value through means such as quality improvement. Conclusions Clinicians and radiologists discover diagnostic errors surrounding the interpretation of radiology images, although radiologists discover them more frequently. There is significant opportunity for improvement in education and practice regarding how radiologists and clinicians communicate as a team and, importantly, how feedback is given when an error is discovered. Educators and clinical leaders should consider designing, implementing, and evaluating strategies for improvement.

Background: Hospital referral regions (HRRs) are often used to characterize inpatient referral patterns, but it is unknown how well these geographic regions are aligned with variation in Medicare-financed hospice care, which is largely provided at home. Objective: Our objective was to characterize the variability in hospice use rates among elderly Medicare decedents by HRR and county. Methods: Using 2014 Master Beneficiary File for decedents 65 and older from North and South Carolina, we applied Bayesian mixed models to quantify variation in hospice use rates explained by HRR fixed effects, county random effects, and residual error among Medicare decedents. Results: We found HRRs and county indicators are significant predictors of hospice use in NC and SC; however, the relative variation within HRRs and associated residual variation is substantial. On average, HRR fixed effects explained more variation in hospice use rates than county indicators with a standard deviation (SD) of 10.0 versus 5.1 percentage points. The SD of the residual error is 5.7 percentage points. On average, variation within HRRs is about half the variation between regions (52%). Conclusions: The magnitude of unexplained residual variation in hospice use for NC and SC suggests that novel, end-of-life-specific service areas should be developed and tested to better capture geographic differences and inform research, health systems, and policy.

The American Association of Colleges of Pharmacy, the Accreditation Council for Pharmacy Education, and the Center for the Advancement of Pharmacy Education frame patient safety from the perspective of medication management, which is also the current focus of pharmacy education and training. With the growing appreciation that diagnostic errors represent an urgent and actionable patient safety concern, the National Academy of Medicine has recommended diagnostic safety training for all health care professions. The Society to Improve Diagnosis in Medicine has worked with an interprofessional consensus group to identify a set of 12 key competencies necessary to achieve diagnostic quality and safety that focuses on individual, team-based, and system-related competencies. Much of this already exists in pharmacy education, but pharmacy training programs need to give graduates more guidance on how they contribute to the diagnostic process and the prevention and detection of diagnostic errors. We describe the current state of progress in this regard, and what steps are needed by training programs to provide content and assessment so that graduates achieve the requisite competencies. Governing and advisory bodies need to expand the expectations around patient safety to include diagnostic safety.

Background: Studying diagnostic error at the population level requires an understanding of how diagnoses change over time., Objective: To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy., Design: Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality., Participants: Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013., Main Measures: We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality., Key Results: Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10-1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89-0.99, p < 0.001)., Conclusions: Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.

Background: On January 1, 2016, Medicare implemented a new "two-tiered" model for hospice services, with per diem rates increased for days 1 through 60, decreased for days 61 and greater, and service intensity add-on payments made retrospectively for the last seven days of life., Objective: To estimate whether the Medicare hospice benefit's potential for cost savings will change as a result of the January 2016 change in payment structure., Design: Analysis of decedents' claims records using propensity score matching, logistic regression, and sensitivity analysis., Setting/subjects: All age-eligible Medicare decedents who received care and died in North Carolina in calendar years 2009 and 2010., Measurements: Costs to Medicare for hospice and other healthcare services., Results: Medicare costs were reduced from hospice election until death using both 2009-2010 and new 2016 payment structures and rates. Mean cost savings were $1,527 with actual payment rates, and would have been $2,105 with the new payment rates (p < 0.001). Cost savings were confirmed by reducing the number of days used for cost comparison by three days for those with hospice stays of at least four days ($4,318 using 2009-2010 rates, $3,138 for 2016 rates: p < 0.001). Cost savings were greater for males ($3,393) versus females ($1,051) and greatest in cancer ($6,706) followed by debility and failure to thrive ($5,636) and congestive heart failure ($1,309); dementia patients had higher costs (+$1,880) (p < 0.001). When adding 3 days to the comparison period, hospice increased costs to Medicare., Conclusions: Medicare savings could continue with the 2016 payment rate change. Cost savings were found for all primary diagnoses analyzed except dementia.

In the United States, the medical education community has begun a shift from the Flexnerian time-based model to a competency-based medical education model. The graduate medical education (GME) community is substantially farther along in this transition than is the undergraduate medical education (UME) community.GME has largely adopted the use of competencies and their attendant milestones and increasingly is employing the framework of entrustable professional activities (EPAs) to assess trainee competence. The UME community faces several challenges to successfully navigating a similar transition. First is the reliance on norm-based reference standards in the UME-GME transition, comparing students' performance versus their peers' with grades, United States Medical Licensing Examination Step 1 and Step 2 score interpretation, and the structured Medical School Performance Evaluation, or dean's letter. Second is the reliance on proxy assessments rather than direct observation of learners. Third is the emphasis on summative rather than formative assessments.Educators have overcome a major barrier to change by establishing UME outcomes assessment criteria with the advent and general acceptance of the physician competency reference set and the Core EPAs for Entering Residency in UME. Now is the time for the hard work of developing assessments steeped in direct observation that can be accepted by learners and faculty across the educational continuum and can be shown to predict clinical performance in a much more meaningful way than the current measures of grades and examinations. The acceptance of such assessments will facilitate the UME transition toward competency-based medical education.