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Patients admitted via interhospital transfer (IHT) experience increased risk-adjusted mortality, adverse events, length of stay, and discharge to facility; however, the etiology is not well understood. We hypothesize that IHTs are more likely to experience in-hospital delirium as compared with admissions to the hospital via the emergency department (ED) and clinic. This is a cross-sectional study of all adult admissions to medical, surgical, neurological, and obstetrics and gynecology services at an academic medical center who were screened for delirium between August 2018 and January 2020. Unit of analysis was admission source (IHT vs ED vs clinic) as the independent variable and the primary outcome was in-hospital delirium, assessed with initial brief confusion assessment method (bCAM) screening. 30,100 hospitalizations were included in this study with 3925 admissions (13.0%) screening positive for delirium at the initial bCAM assessment. The prevalence of delirium was much higher in IHTs at 22.3% (1334/5971) when compared with clinic at 5.8% (244/4214) and ED at 11.8% (2347/19,915) admissions. Multivariable logistic regression adjusting for demographics and comorbidities showed that IHT admissions had higher odds (OR 1.91, 95% CI 1.74 to 2.10) and clinic admissions had lower odds (OR 0.56, 95% CI 0.48 to 0.64) of in-hospital delirium compared with ED admissions. Increased odds of delirium in IHT admissions may contribute to the observed increased length of stay, discharge to facility, and mortality. These results emphasize the importance of routine screening and possible intervention prior to patient transfer.

Identifying disparities in surgical outcomes among patient populations may help hospitals target patients at highest risk for complications. The South Carolina Surgical Quality Collaborative (SCSQC) is a regional collaborative made up of eight facilities whose goal is to improve the quality and value of general surgical care in South Carolina. Using SCSQC data, we reviewed colon surgery outcomes to determine whether disparities exist between specific patient populations. SCSQC colon surgery data were reviewed from August 2015 to August 2017. SSI, length of stay, return to the ED, and reoperation rates were used as outcome measures. They were evaluated in patient populations stratified by gender, race (white, black, and other), and age (50, 50-70, and70 years). A total of 2611 patients were included in this study. Statistically significant differences in outcomes were identified between white and black patients in length of stay (6.0 vs 7.5 days, P0.0001) and return to the ED (8.1% vs 14.7%, P0.0001), but not in SSI (6.4% vs 6.8%, P = 0.8839) or reoperation rates (6.4% vs 8.4%, P = 0.1886). Length of stay increased with increasing age (4.1 vs 7.1 vs 8.8, P0.0001). SSI varied by age (4.0% vs 8.2% vs 6.4%, P = 0.0005), as did return to the ED (11.2% vs 9.7% vs 769%, P = 0.0987) and reoperation rates (4.5% vs 8.1% vs 8.2%, P = 0.0034). SCSQC data indicate that race and age may place patients at risk for negative outcomes after colorectal surgery.

Tertiary referral centers have created inpatient units to meet the needs of specific patient populations but sometimes are forced to place patients on other units that, although having the basic necessary skillsets for treating the patient, are not focused on that diagnosis area. The objective of this study was to look at outcomes of patients admitted to these different inpatient settings.Retrospective review of patient data from a single tertiary academic medical center from August 1, 2014, to June 30, 2015, comparing patients admitted to primary versus secondary inpatient services. Patients admitted to the inpatient children's hospital, psychiatric hospital, labor and delivery unit, or subacute transitional care unit were excluded.Demographics of patients in the primary versus secondary units were compared to look for systematic differences between the 2 patient populations. To control for confounding variables, a gamma regression analysis was conducted for length of stay (LOS) and total cost, whereas a logistic regression was conducted for mortality.Admitting to the primary unit resulted in 5.5% lower observed LOS, controlling for other patient variables, but it came at a 17.8% higher total cost of care provided compared with secondary units. Mortality was also found to be lower on primary units (odds ratio, 0.864) but did not cross the threshold of statistical significance (P = .101).Patients admitted to the primary unit had a lower LOS with higher costs of care. There was a trend toward improved mortality, although it was not statistically significant.

Characterize patterns of referral from a patient-centered medical home (PCMH) and observe the association of provider experience, patient chronic disease burden, and risk of utilization on referral placement.Descriptive analysis of referral patterns in an academic, internal medicine PCMH.We examined referrals (eg, specialist visit, testing, ancillary services) placed between July and December of 2014 in an academic PCMH caring for a total of 12,000 patients. All referrals originated from the outpatient PCMH clinic and were divided into resident or faculty clinic based on the assigned primary care provider. Patients with a referral during the 6-month study period served as the unit of analysis, and we developed a generalized linear model to identify variables associated with referral placement. We estimated the association of the patients' risk of healthcare utilization using a risk stratification tool.The faculty placed 1709 referrals for 3055 unique patients seen compared with 2388 referrals for 2434 unique patients seen by residents. For those patients receiving referral, a mean of 1.72 referrals were placed, with residents having significantly more referrals per patient (1.9 ± 1.3 vs 1.5 ± 0.9; P.0001). For patients at highest risk of utilization, residents were referred at a rate of 0.327 compared with 0.226 (P = .0035) in the faculty clinic.In an academic setting, provider and patient factors play a role in referral patterns. Residents refer highest-risk patients more often than their faculty counterparts, while there is no difference for lower-risk patients.

Importance Optimizing assessments of rate of progression in Parkinson disease (PD) is important in designing clinical trials, especially of potential disease-modifying agents. Objective To examine the value of measures of impairment, disability, and quality of life in assessing progression in early PD. Design, Setting, and Participants Inception cohort analysis of data from 413 patients with early, untreated PD who were enrolled in 2 multicenter, randomized, double-blind clinical trials. Interventions Participants were randomly assigned to 1 of 5 treatments (67 received creatine, 66 received minocycline, 71 received coenzyme Q10, 71 received GPI-1485, and 138 received placebo). We assessed the association between the rates of change in measures of impairment, disability, and quality of life and time to initiation of symptomatic treatment. Main Outcomes and Measures Time between baseline assessment and need for the initiation of symptomatic pharmaceutical treatment for PD was the primary indicator of disease progression. Results After adjusting for baseline confounding variables with regard to the Unified Parkinson’s Disease Rating Scale (UPDRS) Part II score, the UPDRS Part III score, the modified Rankin Scale score, level of education, and treatment group, we assessed the rate of change for the following measurements: the UPDRS Part II score; the UPDRS Part III score; the Schwab and England Independence Scale score (which measures activities of daily living); the Total Functional Capacity scale; the 39-item Parkinson’s Disease Questionnaire, summary index, and activities of daily living subscale; and version 2 of the 12-item Short Form Health Survey Physical Summary and Mental Summary. Variables reaching the statistical threshold in univariate analysis were entered into a multivariable Cox proportional hazards model using time to symptomatic treatment as the dependent variable. More rapid change (ie, worsening) in the UPDRS Part II score (hazard ratio, 1.15 [95% CI, 1.08-1.22] for 1 scale unit change per 6 months), the UPDRS Part III score (hazard ratio, 1.09 [95% CI, 1.06-1.13] for 1 scale unit change per 6 months), and the Schwab and England Independence Scale score (hazard ratio, 1.29 [95% CI, 1.12-1.48] for 5 percentage point change per 6 months) was associated with earlier need for symptomatic therapy. Conclusions and Relevance In early PD, the UPDRS Part II score and Part III score and the Schwab and England Independence Scale score can be used to measure disease progression, whereas the 39-item Parkinson’s Disease Questionnaire and summary index, Total Functional Capacity scale, and the 12-item Short Form Health Survey Physical Summary and Mental Summary are not sensitive to change. Trial Registration clinicaltrials.gov Identifiers:NCT00063193andNCT00076492