Avi Baehr

Racial and Ethnic Disparities in Adverse Drug Events: A Systematic Review of the Literature

The 2014 National Action Plan for Adverse Drug Event Prevention has recognized adverse drug events (ADEs) as a national priority in order to facilitate a nationwide reduction in patient harms from these events. Throughout this effort, it will be integral to identify populations that may be at particular risk in order to improve care for these patients. We have undertaken a systematic review to evaluate the evidence regarding racial or ethnic disparities in ADEs with particular emphasis on anticoagulants, diabetes agents, and opioids due to the clinical significance and preventability of ADEs associated with these medication classes. From an initial search yielding 3302 studies, we identified 40 eligible studies. Twenty-seven of these included studies demonstrated the presence of a racial or ethnic disparity. There was no consistent evidence for racial or ethnic disparities in the eight studies of ADEs in general. Asians were most frequently determined to be at higher risk of anticoagulant-related ADEs, and black patients were most frequently determined to be at higher risk for diabetes agents-related ADEs. Whites were most frequently identified as at increased risk for opioid-related ADEs. However, few of these studies were specifically designed to evaluate racial or ethnic disparities, lacking a standardized approach to racial/ethnic categorization as well as control for potential confounders. We suggest the need for targeted interventions to reduce ADEs in populations that may be at increased risk, and we suggest strategies for future research.

Hospital Emergency Care as a Public Good and Community Health Benefit

The community benefit that nonprofit hospitals are required to demonstrate represents an enormous financial resource. Although these funds have historically been allocated in the form of charity care or other direct patient care, an increasing proportion of the US population with health insurance coverage has resulted in decreased need for uncompensated care. Furthermore, both a legal mandate and public demand for transparency and accountability have led to critique of the existing structure of nonprofit community benefit efforts. A historical overrepresentation of care delivery for individuals with advanced conditions requiring hospitalization is evolving toward a focus on more broad-based efforts to support community and population health. Emergency care’s involvement in hospital community benefit activities has largely been limited to provision of uncompensated care; there is room for recognition of other ways in which the emergency care system serves the public good. We propose 3 key themes that should be incorporated into the hospital community benefit framework to support the care of sick, injured, and vulnerable patients: systems building for critical illness, continuous provision of health care, and community preparedness and resilience. There are nearly 3,000 nonprofit hospitals in the United States that are legally exempt from paying federal, state, and local taxes in exchange for their commitment to provide a benefit to their surrounding community. The total value of this tax break was estimated at

Adverse Drug Event Prevention 2014 Action Plan Conference

24.6 billion in 2011, and hospitals reported an estimated

Racial and ethnic disparities in health care–associated Clostridium difficile infections in the United States: State of the science

36.7 billion in community benefit spending the following year. As a matter of perspective, per-capita hospital community benefit spending exceeds combined state and local investments in public health. Hospitals already have a tremendous monetary investment in population health, but the landscape of hospital community benefit is changing. Historically, community benefit expenditures overwhelmingly focused on direct patient care for those sick enough to require hospital admission, including the

Measuring Emergency Care Survival: The Implications of Risk-Adjusting for Race and Poverty.

Adverse drug events (ADEs) have been highlighted as a national patient safety and public health challenge by the National Action Plan for Adverse Drug Event Prevention (ADE Action Plan), which was released by the Office of Disease Prevention and Health Promotion in August 2014. The following October, the ADE Prevention: 2014 Action Plan Conference provided an opportunity for federal agencies, national experts, and stakeholders to coordinate and collaborate in the initiative to reduce preventable ADEs. The single-day conference included morning plenary sessions focused on the surveillance, evidence-based prevention, incentives and oversights, and additional research needs of the drug classes highlighted in the ADE Action Plan: anticoagulants, diabetes agents, and opioids. Afternoon breakout sessions allowed for facilitated discussions on measures for tracking national progress in ADE prevention and the identification of opportunities to ensure safe and high-quality health care and medication use.

A Note to Self: From an Emergency Department Boarder to a Future Emergency Physician

BACKGROUND Among health care-associated infections (HAIs), Clostridium difficile infections (CDIs) are a major cause of morbidity and mortality in the United States. As national progress toward CDI prevention continues, it will be critical to ensure that the benefits from CDI prevention are realized across different patient demographic groups, including any targeted interventions. METHODS Through a comprehensive review of existing evidence for racial/ethnic and other disparities in CDIs, we identified a few general trends, but the results were heterogeneous and highlight significant gaps in the literature. RESULTS The majority of analyzed studies identified white patients as at increased risk of CDIs, although there is a very limited literature base, and many studies had significant methodological limitations. CONCLUSION Key recommendations for future research are provided to address antimicrobial stewardship programs and populations that may be at increased risk for CDIs.

Describing Total Population Health: A Review and Critique of Existing Units

OBJECTIVES We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of non-white, Hispanic, or poor patients. METHODS We performed a cross-sectional analysis patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or non-white patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models. RESULTS The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for non-white and Hispanic patients (adjusted odds ratio [aOR] 1.27, 95%CI 1.19-1.36) and poor patients (aOR 1.21, 95%CI 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, P=0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals which moved out of the lowest-performing decile, relative to other hospitals, had significantly more non-white and Hispanic patients (68% vs. 11%, P<0.001) and poor patients (56% vs. 10%, P<0.001). CONCLUSIONS Sociodemographic risk-adjustment of emergency care sensitive mortality improves apparent performance of some hospitals treating a large number of non-white, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs. This article is protected by copyright. All rights reserved.

Hospital Community Benefit: What is it, why is it important, and how could it be more effective?

This winter, for the first time since starting medical school, I rushed into the emergency department (ED) as family of a patient, not as a physician-in-training. Familiar sights: harsh fluorescent lighting, no windows, patients on gurneys crammed into crowded hallways, the bustle of constant motion. Unfamiliar sight: Grandma lying in the bed with a crooked grimace, unable to move her left side, slurring a greeting because her tongue could not cooperate in the complex motions of speech. What did the CT scan show, I asked my uncle. I don’t think they did one, yet. What did the doctor say, I asked. The doc hasn’t been in, yet. Have they given any medications? Have they done an ECG? What were her lab results? I don’t know. No one has said. Three hours post–symptom onset, two-and-one-half hours in the ED, and a physician had not yet been in to explain the assessment or plan to my family. I asked the nurse to walk me through the chart, reviewing Grandma’s orders and test results. With the understanding of a fourthyear medical student, I explained what I could. Hours later, the emergency physician stood for a moment just inside the doorway. She looked ready to turn and rush off at the drop of a hat, and I could see that her mind was elsewhere even as she listened to my questions. Answer: She’s having a stroke; we will admit her to the hospital. Anything else? No? OK. That was the only time during my grandmother’s 21-hour ED stay that the physician came into the room. Despite the lapses in communication, Grandma’s evaluation and treatment were appropriate and in line with current stroke guidelines. The CT scan was promptly performed: no bleeding, no swelling, ordered for MRI in the morning. ECG and laboratory tests done: AFib, otherwise within normal limits. Medication review showed regular use of a blood thinner: tPA contraindicated. Aspirin administered, bed ordered for admission, neurology consulted.