Publications by authors named "William N Southern"

34 Publications

Utility of D-dimer in predicting venous thromboembolism in non-mechanically ventilated COVID-19 survivors.

Thromb Res 2021 03 26;199:82-84. Epub 2020 Dec 26.

Albert Einstein College of Medicine and Montefiore Medical Center, Department of Medicine, Division of Hospital Medicine, Bronx, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.thromres.2020.12.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834437PMC
March 2021

Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York.

Metabolism 2020 07 16;108:154262. Epub 2020 May 16.

Section of Endocrinology, VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA.

Background & Aims: New York is the current epicenter of Coronavirus disease 2019 (COVID-19) pandemic. The underrepresented minorities, where the prevalence of obesity is higher, appear to be affected disproportionately. Our objectives were to assess the characteristics and early outcomes of patients hospitalized with COVID-19 in the Bronx and investigate whether obesity is associated with worse outcomes independently from age, gender and other comorbidities.

Methods: This retrospective study included the first 200 patients admitted to a tertiary medical center with COVID-19. The electronic medical records were reviewed at least three weeks after admission. The primary endpoint was in-hospital mortality.

Results: 200 patients were included (female sex: 102, African American: 102). The median BMI was 30 kg/m. The median age was 64 years. Hypertension (76%), hyperlipidemia (46.2%), and diabetes (39.5%) were the three most common comorbidities. Fever (86%), cough (76.5%), and dyspnea (68%) were the three most common symptoms. 24% died during hospitalization (BMI < 25 kg/m: 31.6%, BMI 25-34 kg/m: 17.2%, BMI ≥ 35 kg/m: 34.8%, p = 0.03). Increasing age (analyzed in quartiles), male sex, BMI ≥ 35 kg/m (reference: BMI 25-34 kg/m), heart failure, CAD, and CKD or ESRD were found to have a significant univariate association with mortality. The multivariate analysis demonstrated that BMI ≥ 35 kg/m (reference: BMI 25-34 kg/m, OR: 3.78; 95% CI: 1.45-9.83; p = 0.006), male sex (OR: 2.74; 95% CI: 1.25-5.98; p = 0.011) and increasing age (analyzed in quartiles, OR: 1.73; 95% CI: 1.13-2.63; p = 0.011) were independently associated with higher in-hospital mortality. Similarly, age, male sex, BMI ≥ 35 kg/m and current or prior smoking were significant predictors for increasing oxygenation requirements in the multivariate analysis, while male sex, age and BMI ≥ 35 kg/m were significant predictors in the multivariate analysis for the outcome of intubation.

Conclusions: In this cohort of hospitalized patients with COVID-19 in a minority-predominant population, severe obesity, increasing age, and male sex were independently associated with higher in-hospital mortality and in general worse in-hospital outcomes.
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http://dx.doi.org/10.1016/j.metabol.2020.154262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228874PMC
July 2020

Screening of carriers in an urban academic medical center: Understanding implications of disease.

Infect Control Hosp Epidemiol 2020 02;41(2):149-153

Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York.

Objective: Efforts to reduce Clostridioides difficile infection (CDI) 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, New York.

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 noncarriers 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 = .60). Among the 21 C. difficile carriers, 8 (38.1%) progressed to symptomatic C. difficile, but only 4 (2.0%) of the 199 noncarriers progressed to symptomatic C. difficile (hazard ratio, 23.9; 95% CI, 7.2-79.6; P < .0001).

Conclusions: Asymptomatic carriage of C. difficile is prevalent among admitted patients and confers a significant risk of progression to symptomatic CDI. Screening for asymptomatic carriers may represent an opportunity to reduce CDI.
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http://dx.doi.org/10.1017/ice.2019.309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7702293PMC
February 2020

Limiting the Number of Open Records in an Electronic Health Record-Reply.

JAMA 2019 10;322(13):1314-1315

Division of Hospital Medicine, Albert Einstein College of Medicine, Bronx, New York.

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http://dx.doi.org/10.1001/jama.2019.11501DOI Listing
October 2019

Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems.

JAMA Pediatr 2019 Aug 26. Epub 2019 Aug 26.

Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants.

Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors).

Design, Setting, And Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included.

Main Outcomes And Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes.

Results: A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P < .001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100 000 orders) was similar to that of singleton-birth infants (41.7 per 100 000 orders). The excess risk among multiple-birth infants (29.9 per 100 000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births.

Conclusions And Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.
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http://dx.doi.org/10.1001/jamapediatrics.2019.2733DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714004PMC
August 2019

Patient-controlled Analgesia For Vaso-Occlusive Crisis: A Cohort Study.

Clin J Pain 2019 08;35(8):686-690

Department of Medicine.

Background: Sickle cell disease (SCD) accounts for over 68,000 hospital admissions each year in the United States, with long inpatient length of stays (LOS) and frequent readmission common. Patient-controlled analgesia (PCA) has been used to treat patients admitted with vaso-occlusive crisis (VOC), but it is unknown if PCA is associated with shorter LOS and reduced risk of readmission.

Methods: We examined all admissions for acute VOC treated with parenteral opioids to an urban, academic health system over 3 years. We compared LOS, 30-day readmission, and discharges against medical advice between admissions treated with PCA versus standard therapy in unadjusted and adjusted analyses using generalized estimating equations to adjust for demographic and clinical characteristics.

Results: Of 823 admissions included, 536 (65.1%) were treated with PCA and 287 (34.9%) were treated with standard nurse-administered opioid therapy. Treatment with PCA was associated with significantly shorter LOS in the unadjusted analyses (7.46 vs. 9.42 d, P=0.001), but the difference was not significant after adjustment (adjusted difference: 1.47 d, P=0.06). Treatment with PCA was also associated with significantly decreased risk of 30-day readmission in unadjusted analysis (odds ratio [OR]unadj: 0.69; 95% confidence interval [CI]: 0.54-0.89, P=0.004), but after adjustment the association was no longer significant (ORadj: 0.76; 95% CI: 0.54-1.06, P=0.11). Finally, treatment with PCA was not associated with increased risk of discharge against medical advice in Generalized Estimating Equation modeled unadjusted (ORunadj: 1.10; 95% CI: 0.69-1.76, P=0.68), or adjusted analysis (ORadj: 1.19; 95% CI: 0.73-1.94, P=0.49).

Conclusions: Treatment with PCA may be associated with shorter LOS and may be considered as the primary modality for opioid-based pain control for patients with SCD who are admitted with painful VOC.
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http://dx.doi.org/10.1097/AJP.0000000000000726DOI Listing
August 2019

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

JAMA 2019 05;321(18):1780-1787

Division of Hospital Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York.

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation.

Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently.

Design, Setting, And Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings.

Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687).

Main Outcomes And Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient).

Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions.

Conclusions And Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors.

Trial Registration: clinicaltrials.gov Identifier: NCT02876588.
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http://dx.doi.org/10.1001/jama.2019.3698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518341PMC
May 2019

Safety of High-Flow Nasal Cannula Outside the ICU for Previously Healthy Children With Bronchiolitis.

Respir Care 2019 Nov 26;64(11):1410-1415. Epub 2019 Mar 26.

Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine Bronx, New York.

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.
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http://dx.doi.org/10.4187/respcare.06352DOI Listing
November 2019

BNP-Response to Acute Heart Failure Treatment Identifies High-Risk Population.

Heart Lung Circ 2020 Mar 26;29(3):354-360. Epub 2019 Feb 26.

Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA; Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA. Electronic address:

Background: 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.

Methods: 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.

Results: 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 (HR = 2.19, 95% CI: 1.52-3.14). BNP-unresponsiveness was not associated with significantly increased 180-day readmission rates (HR = 1.07, 95% CI: 0.92-1.25).

Conclusions: Patients whose pro-BNP did not improve by >30% 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.
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http://dx.doi.org/10.1016/j.hlc.2019.02.004DOI Listing
March 2020

Reducing the default dispense quantity for new opioid analgesic prescriptions: study protocol for a cluster randomised controlled trial.

BMJ Open 2018 04 20;8(4):e019559. Epub 2018 Apr 20.

Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, New York, USA.

Introduction: As opioid analgesic consumption has grown, so have opioid use disorder and opioid-related overdoses. Reducing the quantity of opioid analgesics prescribed for acute non-cancer pain can potentially reduce risks to the individual receiving the prescription and to others who might unintentionally or intentionally consume any leftover tablets. Reducing the default dispense quantity for new opioid analgesic prescriptions in the electronic health record (EHR) is a promising intervention to reduce prescribing.

Methods And Analysis: This study is a prospective cluster randomised controlled trial with two parallel arms. Primary care sites (n=32) and emergency departments (n=4) will be randomised in matched pairs to either a modification of the EHR so that new opioid analgesic prescriptions default to a dispense quantity of 10 tablets (intervention) or to no EHR change (control). The dispense quantity will remain fully modifiable by providers in both arms. From 6 months preintervention to 18 months postintervention, patient-level data will be analysed (ie, the patient is the unit of inference). Patient eligibility criteria are: (A) received a new opioid analgesic prescription, defined as no other opioid analgesic prescription in the prior 6 months; (B) age ≥18 years; and (C) no cancer diagnosis within 1 year prior to the new opioid analgesic prescription. The primary outcome will be the quantity of opioid analgesics prescribed in the initial prescription. Secondary outcomes will include opioid analgesic reorders and health service utilisation within 30 days after the initial prescription. Outcomes will be compared between study arms using a difference-in-differences analysis.

Ethics And Dissemination: This study has been approved by the Montefiore Medical Center/Albert Einstein College of Medicine Institutional Review Board with a waiver of informed consent (2016-6036) and is registered on ClinicalTrials.gov (NCT03003832, 6 December 2016). Findings will be disseminated through publication, conferences and meetings with health system leaders.

Trial Registration Number: NCT03003832; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2017-019559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914704PMC
April 2018

Ultrasound-Guided Peripheral Intravenous Catheters to Reduce Central Venous Catheter Use on the Inpatient Medical Ward.

Qual Manag Health Care 2018 Jan/Mar;27(1):30-32

Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York.

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.
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http://dx.doi.org/10.1097/QMH.0000000000000156DOI Listing
July 2019

Risk Factors for Respiratory Decompensation Among Healthy Infants With Bronchiolitis.

Hosp Pediatr 2017 09;7(9):530-535

Division of Hospital Medicine, Department of Medicine and

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.
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http://dx.doi.org/10.1542/hpeds.2017-0034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574668PMC
September 2017

Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU.

Pediatrics 2017 May;139(5)

Division of Hospital Medicine.

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; < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; < .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.
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http://dx.doi.org/10.1542/peds.2016-2863DOI Listing
May 2017

A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.

J Am Med Inform Assoc 2017 Sep;24(5):992-995

Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

To reduce the risk of wrong-patient errors, safety experts recommend limiting the number of patient records providers can open at once in electronic health records (EHRs). However, it is unknown whether health care organizations follow this recommendation or what rationales drive their decisions. To address this gap, we conducted an electronic survey via 2 national listservs. Among 167 inpatient and outpatient study facilities using EHR systems designed to open multiple records at once, 44.3% were configured to allow ≥3 records open at once (unrestricted), 38.3% allowed only 1 record open (restricted), and 17.4% allowed 2 records open (hedged). Decision-making centered on efforts to balance safety and efficiency, but there was disagreement among organizations about how to achieve that balance. Results demonstrate no consensus on the number of records to be allowed open at once in EHRs. Rigorous studies are needed to determine the optimal number of records that balances safety and efficiency.
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http://dx.doi.org/10.1093/jamia/ocx034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651980PMC
September 2017

A Simple and Powerful Risk-Adjustment Tool for 30-day Mortality Among Inpatients.

Qual Manag Health Care 2016 Jul-Sep;25(3):123-8

Department of Medicine, Mount Sinai School of Medicine, Mount Sinai Medical Center, New York, New York (Dr Tremblay); and Department of Medicine (Drs Arnsten and Southern), Division of General Internal Medicine (Dr Arnsten), and Division of Hospital Medicine (Dr Southern), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.

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.
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http://dx.doi.org/10.1097/QMH.0000000000000096DOI Listing
July 2017

No Differences in Achieving Hepatitis C Virus Care Milestones Between Patients Identified by Birth Cohort or Risk-Based Screening.

Clin Gastroenterol Hepatol 2016 09 19;14(9):1356-60. Epub 2016 Apr 19.

Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York; Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.

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.
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http://dx.doi.org/10.1016/j.cgh.2016.04.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5822431PMC
September 2016

A Birth-cohort testing intervention identified hepatitis c virus infection among patients with few identified risks: a cross-sectional study.

BMC Infect Dis 2015 Dec 1;15:553. Epub 2015 Dec 1.

Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA.

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.
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http://dx.doi.org/10.1186/s12879-015-1283-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4667399PMC
December 2015

Increased Risk of Mortality among Patients Cared for by Physicians with Short Length-of-Stay Tendencies.

J Gen Intern Med 2015 Jun 24;30(6):712-8. Epub 2015 Jan 24.

Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA,

Background: 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.

Objective: The purpose of this study was to determine whether short length of stay is associated with worse patient outcomes.

Design: 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.

Patients: 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.

Main Measure: The primary outcome was 30-day mortality.

Results: 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).

Conclusions: 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.
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http://dx.doi.org/10.1007/s11606-014-3155-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441656PMC
June 2015

Profiting and providing less care: comprehensive services at for-profit, nonprofit, and public opioid treatment programs in the United States.

Med Care 2014 May;52(5):428-34

*Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center †Robert Wood Johnson Foundation Clinical Scholars Program ‡Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA §Department of Medicine, Division of Hospital Medicine ∥Department of Medicine, Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY.

Background: Opioid use disorders are frequently associated with medical and psychiatric comorbidities (eg, HIV infection and depression), as well as social problems (eg, lack of health insurance). Comprehensive services addressing these conditions improve outcomes.

Objective: To compare the proportion of for-profit, nonprofit, and public opioid treatment programs offering comprehensive services, which are not mandated by government regulations.

Design, Setting, And Participants: Cross-sectional analysis of opioid treatment programs offering outpatient care in the United States (n=1036).

Main Outcome Measure: Self-reported offering of communicable disease (HIV, sexually transmitted infections, and viral hepatitis) testing, psychiatric services (screening, assessment and diagnostic evaluation, and pharmacotherapy), and social services support (assistance in applying for programs such as Medicaid). Mixed-effects logistic regression models were developed to adjust for several county-level factors.

Results: Of opioid treatment programs, 58.0% were for profit, 33.5% were nonprofit, and 8.5% were public. Nonprofit programs were more likely than for-profit programs to offer testing for all communicable diseases [adjusted odds ratios (AOR), 1.7; 95% confidence interval (CI), 1.2, 2.5], all psychiatric services (AOR, 8.0; 95% CI, 4.9, 13.1), and social services support (AOR, 3.3; 95% CI, 2.3, 4.8). Public programs were also more likely than for-profit programs to offer communicable disease testing (AOR, 6.4; 95% CI, 3.5, 11.7), all psychiatric services (AOR, 25.8; 95% CI, 12.6, 52.5), and social services support (AOR, 2.4; 95% CI, 1.4, 4.3).

Conclusions: For-profit programs were significantly less likely than nonprofit and public programs to offer comprehensive services. Interventions to increase the offering of comprehensive services are needed, particularly among for-profit programs.
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http://dx.doi.org/10.1097/MLR.0000000000000121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277871PMC
May 2014

Hospitalization rates of people living with HIV in the United States, 2009.

Public Health Rep 2014 Mar-Apr;129(2):178-86

Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine, Division of Hospital Medicine, Bronx, NY.

Objectives: We determined hospitalization rates and disparities among people with HIV, which may have been underestimated in previous studies, as only those in medical care were included.

Methods: We estimated the hospitalization rate of people with diagnosed HIV infection in the U.S. in 2009 using two nationally representative datasets. We took the number of hospitalizations from the Nationwide Inpatient Sample and searched each discharge for International Classification of Diseases, Ninth Revision codes for HIV infection and opportunistic infections (OIs). We divided the number of hospitalizations by the number of prevalent diagnosed HIV cases estimated by CDC to produce hospitalization rates, and then compared those rates using Z-tests.

Results: The estimated nationwide hospitalization rate was 26.6 per 100 population. Women had a 51% higher rate than men (35.5 vs. 23.5 per 100 population, p=0.002). Black people (31.2 per 100 population, p=0.01) had a 42% higher rate, and Hispanic people (18.2 per 100 population, p=0.23) had an 18% lower rate than white people (22.1 per 100 population) of hospitalization for any illness. Of hospitalizations with an OI, females with HIV had a 50% higher rate than males with HIV (5.0 vs. 3.4 per 100 population, p=0.003). Black people with HIV (4.7 per 100 population, p<0.001) had a 72% higher rate and Hispanic people with HIV (2.9 per 100 population, p=0.78) had a similar rate of hospitalization with an OI compared with white people with HIV (2.7 per 100 population).

Conclusions: Hospitalization rates among people living with HIV in the U.S. are higher than have been previously estimated. Substantial gender and racial/ethnic disparities in hospitalization rates exist, suggesting that the benefits of antiretroviral therapy have not been realized across all groups equally.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904898PMC
http://dx.doi.org/10.1177/003335491412900212DOI Listing
April 2014

Physician nonadherence with a hepatitis C screening program.

Qual Manag Health Care 2014 Jan-Mar;23(1):1-9

Department of Medicine (Drs Southern and Litwin), Division of Hospital Medicine (Dr Southern), Division of General Internal Medicine (Dr Litwin), and Department of Family and Social Medicine (Dr McKee), Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York; Department of Health Policy & Management, Boston University School of Public Health, Boston, Massachusetts (Drs Drainoni, Christiansen, and Gifford and Ms Koppelman); Department of Medicine (Drs Drainoni and Gifford), Division of General Internal Medicine (Dr Gifford), Section of Infectious Diseases (Dr Drainoni), Boston University School of Medicine, Boston, Massachusetts; Center for Health Quality, Outcomes and Economic Research, ENRM Veterans Administration Hospital, Bedford, Massachusetts (Drs Drainoni, Christiansen, and Gifford and Ms Koppelman); and Division of Viral Hepatitis, National Center for HIV/Viral Hepatitis/STD/TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (Drs Smith and Weinbaum).

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.
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http://dx.doi.org/10.1097/QMH.0000000000000007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5464610PMC
April 2015

Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting.

Am J Public Health 2012 Nov 20;102(11):e115-21. Epub 2012 Sep 20.

Department of Health and Policy Management, Boston University School of Public Health, Boston, MA, USA.

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, χ(2) 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.
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http://dx.doi.org/10.2105/AJPH.2012.300659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477946PMC
November 2012

The impact of ethnicity and obesity on the course of colonic diverticulitis.

J Clin Gastroenterol 2013 Feb;47(2):160-4

Department of Medicine, Division of Gastroenterology & Liver Diseases, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.

Background: Little research has been performed on the impact of race/ethnicity and obesity on the course of diverticulitis.

Purpose: 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.

Methods: We conducted a retrospective review of the charts of 347 patients with confirmed diverticulitis in 2 university teaching hospitals at Bronx, NY.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1097/MCG.0b013e318259e71cDOI Listing
February 2013

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

J Am Med Inform Assoc 2013 Mar-Apr;20(2):305-10. Epub 2012 Jun 29.

Departments of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.

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.
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http://dx.doi.org/10.1136/amiajnl-2012-001055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3638184PMC
August 2013

Increased risk of mortality and readmission among patients discharged against medical advice.

Am J Med 2012 Jun 17;125(6):594-602. Epub 2012 Apr 17.

Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.

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 <.001).

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.
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http://dx.doi.org/10.1016/j.amjmed.2011.12.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372411PMC
June 2012

Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk.

Dig Liver Dis 2012 Jun 18;44(6):497-503. Epub 2012 Feb 18.

Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.

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<0.001) and 9.9% during the birth cohort period (P<0.001).

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.
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http://dx.doi.org/10.1016/j.dld.2011.12.014DOI Listing
June 2012

Hypoglycemia-associated mortality is not drug-associated but linked to comorbidities.

Am J Med 2011 Nov;124(11):1028-35

Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.

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.
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http://dx.doi.org/10.1016/j.amjmed.2011.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200530PMC
November 2011

Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice.

Am J Med 2011 Sep 23;124(9):868-74. Epub 2011 Jul 23.

Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.

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.
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http://dx.doi.org/10.1016/j.amjmed.2011.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159750PMC
September 2011