Howard Abrams

Predicting cardiac complications in patients undergoing non-cardiac surgery

The authors prospectively studied 455 consecutive patients referred to the general medical consultation service for cardiac risk assessment prior to non-cardiac surgery, in order to validate a previously derived multifactorial index in their clinical setting. They also tested a version of the index that they had modified to reflect factors they believed to be important. For patients undergoing major surgery, the original index performed less well in the validation data set than in the original derivation set (p<0.05), but still added predictive information to a statistically significant degree (p<0.05). The modified index also added predictive information for patients undergoing both major and minor surgery, demonstrating an area under the Receiver Operating Characteristic curve of 0.75 (95% confidence interval of 0.70 to 0.80). A simple nomogram is presented which will enable conversion of pretest probabilities into posttest probabilities using the likelihood ratios associated with each risk score. It is recommended that clinicians estimate local overall complication rates (pretest probabilities) for the clinically relevant populations in their settings before they apply the predictive properties (likelihood ratios) demonstrated in this study in order to calculate cardiac risks for individual patients (posttest probabilities).

The effect of English language proficiency on length of stay and in-hospital mortality

AbstractBACKGROUND: In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients. OBJECTIVE: To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality. DESIGN: Retrospective analysis of administrative data at 3 tertiary care teaching hospitals (University Health Network) in Toronto, Canada. PARTICIPANTS: Consecutive inpatient admissions from April 1993 to December 1999 were analyzed for LOS differences first by looking at 23 medical and surgical conditions (59,547 records) and then by a meta-analysis of 220 case mix groups (189,119 records). We performed a similar analysis for in-hospital mortality. MEASUREMENTS: LOS and odds of in-hospital death for limited English-proficient (LEP) patients relative to English-proficient (EP) patients. RESULTS: LEP patients stayed in hospital longer for 7 of 23 conditions (unstable coronary syndromes and chest pain, coronary artery bypass grafting, stroke, craniotomy procedures, diabetes mellitus, major intestinal and rectal procedures, and elective hip replacement), with LOS differences ranging from approximately 0.7 to 4.3 days. A meta-analysis using all admission data demonstrated that LEP patients stayed 6% (approximately 0.5 days) longer overall than EP patients (95% confidence interval, 0.04 to 0.07). LEP patients were not at increased risk of in-hospital death (relative odds, 1.0; 95% confidence interval, 0.9 to 1.1). CONCLUSIONS: Patients with limited English proficiency have longer hospital stays for some medical and surgical conditions. Limited English proficiency does not affect in-hospital mortality. The effect of communication barriers on outcomes of care in the inpatient setting requires further exploration, particularly for selected conditions in which length of stay is significantly prolonged.

Quality of life of patients on long-term total parenteral nutrition at home

Quality of life and quality-adjusted survival were measured for a cohort of 73 patients maintained on long-term parenteral nutrition at home (HPN) for periods ranging from six months to 12 years. Quality-adjusted survival was also modeled (although not directly observed) for this cohort under alternative therapeutic strategies (e.g., parenteral nutrition in hospital as needed). Using three utility assessment techniques (category scaling, time-tradeoff, direct questioning of objectives), quality of life was measured through interviews with 37 patients. The quality of life of the patients interviewed was good (mean value 0.73 where 0 represents death and 1.0 represents perfect health); for those who had experienced a period of chronic malnutrition before HPN, quality of life had improved. For the entire cohort, the estimate of quality-adjusted survival was four times greater with HPN than with the alternative therapeutic strategies (p<0.001). In comparison with alternative strategies, HPN significantly improves the quality of life of patients unable to sustain themselves with oral alimentation. Quality of life (utility) techniques can be used to evaluate the effectiveness of interventions for patients with chronic diseases.

A Cost-Utility Analysis of the Home Parenteral Nutrition Program at Toronto General Hospital: 1970-1982

We performed an economic evaluation of a home parenteral nutrition (HPN) program by measuring the incremental costs and health outcomes for a cohort of 73 patients treated at our institution from November 1970 to July 1982. Over a 12-year time frame, we estimate that HPN resulted in a net savings in health care cost of

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: Anemia, Biomarkers, and Recent Therapeutic Trial Implications

19,232 per patient and an increase in survival, adjusted for quality of life, of 3.3 years, compared with the alternative of treating these patients in hospital with intermittent nutritional support when needed. This result was sensitive to assumptions made about the cost of the alternative treatment strategy. When these assumptions were most unfavorable to the HPN program, we estimated that HPN resulted in incremental costs of

Electronic inpatient whiteboards: Improving multidisciplinary communication and coordination of care

48,180 over 12 years,

Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients: A Randomized Clinical Trial

14,600 per quality-adjusted life-year gained. We conclude that the cost-utility of HPN compares favorably with other health care programs, when HPN is used to treat patients with gut failure secondary to conditions such as Crohns disease or acute volvulus. Since only one patient with active malignancy was enrolled in our HPN program, these results should not be extrapolated to patients with active malignancy.

The Canadian Cardiovascular Society Heart Failure Companion: Bridging Guidelines to Your Practice

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart failure and anemia should be investigated for reversible causes of anemia. Second, patients with chronic stable heart failure should undergo natriuretic peptide testing. Third, considerations should be given to treat selected patients with heart failure and preserved systolic function with a mineralocorticoid receptor antagonist and to treat patients with heart failure and reduced ejection fraction with an angiotensin receptor/neprilysin inhibitor, when the drug is approved. As with updates in previous years, the topics were chosen in response to stakeholder feedback. The 2014 Update includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers to best manage patients with heart failure.

Medical Students and Personal Smartphones in the Clinical Environment: The Impact on Confidentiality of Personal Health Information and Professionalism

OBJECTIVES Effective and timely communication of information is essential for quality patient care. Information and communication technology tools have the potential to transform and enable health care processes to be more accurate, timely, and integrated. This study describes the development, implementation, and evaluation of an electronic whiteboard in a General Internal Medicine (GIM) inpatient unit of an acute care hospital. METHODS The development, implementation, and evaluation of the inpatient whiteboard included scope discussions, workflow analyses, communication and training, and issues and enhancement reporting, all managed through a central project team. Evaluation of the whiteboard was two-fold: a survey given to allied health, nursing and physician disciplines (n=120), and an audit performed on whiteboard usage. RESULTS The whiteboard displays relevant, real-time patient information, in a single, highly visible, user-friendly display. With a quick glance at the whiteboard, one can get an accurate snapshot view of the current patient activity in the unit. Approximately 71% of survey participants believed that the whiteboard improves and standardizes communication within the care team. Further, approximately 62% of the participants agreed that the whiteboard saves them time when searching for information on a patient and their care plan. In addition, the whiteboard has had an impact on the work practices of many GIM care providers, and it along with its users has acted together as agents for positive change. Whiteboard utilization has significantly increased since its implementation. CONCLUSIONS The success of the whiteboard is in part due to overall change management methodologies through collaborative development throughout the project development lifecycle and subsequent continuous improvement initiatives. The multidisciplinary care team embraced the tool, took ownership of it, and tailored it to meet their needs.

How much do operational processes affect hospital inpatient discharge rates

IMPORTANCE Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated. OBJECTIVE To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital. DESIGN, SETTING, AND PATIENTS High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014. INTERVENTIONS Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year. RESULTS There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups. CONCLUSIONS AND RELEVANCE In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01108172.