Lilia Cervantes

Prospective comparison of curbside versus formal consultations

BACKGROUND Curbside consultations are commonly requested during the care of hospitalized patients, but physicians perceive that the recommendations provided may be based on inaccurate or incomplete information. OBJECTIVE To compare the accuracy and completeness of the information received from providers requesting a curbside consultation of hospitalists with that obtained in a formal consultation on the same patients, and to examine whether the recommendations offered in the 2 consultations differed. DESIGN Prospective cohort. SETTING University-affiliated, urban safety net hospital. MAIN OUTCOME MEASURES Proportion of curbside consultations with inaccurate or incomplete information; frequency with which recommendations in the formal consultation differed from those in the curbside consultation. RESULTS Curbside consultations were requested for 50 patients, 47 of which were also evaluated in a formal consultation performed on the same day by a hospitalist other than the one performing the curbside consultation. Based on information collected in the formal consultation, information was either inaccurate or incomplete in 24/47 (51%) of the curbside consultations. Management advice after formal consultation differed from that given in the curbside consultation for 28/47 patients (60%). When inaccurate or incomplete information was received, the advice provided in the formal versus the curbside consultation differed in 22/24 patients (92%, P < 0.0001). CONCLUSIONS Information presented during inpatient curbside consultations of hospitalists is often inaccurate or incomplete, and this often results in inaccurate management advice.

Association of Emergency-Only vs Standard Hemodialysis With Mortality and Health Care Use Among Undocumented Immigrants With End-stage Renal Disease

Importance Undocumented immigrants with end-stage renal disease have variable access to hemodialysis in the United States despite evidence-based standards for frequency of dialysis care. Objective To determine whether mortality and health care use differs among undocumented immigrants who receive emergency-only hemodialysis vs standard hemodialysis (3 times weekly at a health care center). Design, Setting, and Participants A retrospective cohort study was conducted of undocumented immigrants with incident end-stage renal disease who initiated emergency-only hemodialysis (Denver Health, Denver, Colorado, and Harris Health, Houston, Texas) or standard (Zuckerberg San Francisco General Hospital, San Francisco, California) hemodialysis between January 1, 2007, and July 15, 2014. Exposures Access to emergency-only hemodialysis vs standard hemodialysis. Main Outcomes and Measures The primary outcome was mortality. Secondary outcomes were health care use (acute care days and ambulatory care visits) and rates of bacteremia. Outcomes were adjusted for propensity to undergo emergency hemodialysis vs standard hemodialysis. Results A total of 211 undocumented patients (86 women and 125 men; mean [SD] age, 46.5 [14.6] years; 42 from the standard hemodialysis group and 169 from the emergency-only hemodialysis group) initiated hemodialysis during the study period. Patients receiving standard hemodialysis were more likely to initiate hemodialysis with an arteriovenous fistula or graft and had higher albumin and hemoglobin levels than patients receiving emergency-only hemodialysis. Adjusting for propensity score, the mean 3-year relative hazard of mortality among patients who received emergency-only hemodialysis was nearly 5-fold (hazard ratio, 4.96; 95% CI, 0.93-26.45; P = .06) greater compared with patients who received standard hemodialysis. Mean 5-year relative hazard of mortality for patients who received emergency-only hemodialysis was more than 14-fold (hazard ratio, 14.13; 95% CI, 1.24-161.00; P = .03) higher than for those who received standard hemodialysis after adjustment for propensity score. The number of acute care days for patients who received emergency-only hemodialysis was 9.81 times (95% CI, 6.27-15.35; P < .001) the expected number of days for patients who had standard hemodialysis after adjustment for propensity score. Ambulatory care visits for patients who received emergency-only hemodialysis were 0.31 (95% CI, 0.21-0.46; P < .001) times less than the expected number of days for patients who received standard hemodialysis. Conclusions and Relevance Undocumented immigrants with end-stage renal disease treated with emergency-only hemodialysis have higher mortality and spend more days in the hospital than those receiving standard hemodialysis. States and cities should consider offering standard hemodialysis to undocumented immigrants.

Apoyo con Carino: RCT of Patient Navigation to Improve Palliative Care Outcomes (FR417-C)

Objectives 1. Recognize the need to assess and address symptoms and quality of life even among early stage lung cancer patients. 2. Identify the need for continued interdisciplinary palliative care for late stage lung cancer patients as they face the final stage of their cancer. 3. Describe the importance of educating the patient’s caregiver along the lung cancer trajectory. Background. Palliative cancer care addresses multiple issues that cause suffering for patients and caregivers, greatly impacting their quality of life. Research Objectives. This paper describes how symptoms, distress, and quality of life (QOL) data from the usual care phase of a NCI supported Program Project informed the development of an interdisciplinary, tailored palliative care intervention for patients with early (I-IIIB, n 1⁄4 103) and late (IV, n 1⁄4 114) stage lung cancer, and their caregivers (n 1⁄4 163). Method. Patient-reported outcomes were completed at baseline, 6, 12, and 24 weeks with Early Stage completing an additional 36 and 52 weeks. Caregivers completed outcome measures at baseline, 7, 12, 18, and 24 weeks. Result. Earlyd 55% female, 78% former smokers. IADLs, KPS, and Timed Up and Go fluctuated longitudinally, p 1⁄4.012, .044 and p 1⁄4.008 respectively. QOL decreased (FACT physical well-being subscale, p 32 hours/week. Caregivers were highly functional, experienced high levels of emotional stress, increased caregiver burden, decrease in perceived skills preparedness, and reported deterioration in psychological well being and overall QOL. Conclusion. Patients continue to experience high symptom burden, diminished physical well-being, and decreased QOL. Caregivers experience high levels of caregiver burden and report decreased psychological well being and overall QOL over time. Implications for Research, Policy, or Practice. There is a vital need for interdisciplinary palliative care interventions for patients with lung cancer and family caregivers. Phase II of this study is currently testing such an intervention based on Phase I results.