Nancy L. Dawson

Functional Health Literacy and Understanding of Medications at Discharge

The objective of this study was to evaluate patient knowledge of newly prescribed medication after hospital discharge. We reviewed the charts of 172 patients who were discharged from February 1, 2006, through April 25, 2006, from the internal medicine residency service at a community-based teaching hospital with prescriptions for 1 or more new medications. Between 4 and 18 days after discharge, patients were contacted by telephone and asked about the name, number, dosages, schedule, purpose, and adverse effects of the new medication(s) and whether they could name their medical contact person. We recorded the number of correct answers, patient age, and years of education. Of the survey respondents, 86% were aware that they had been prescribed new medications, but fewer could identify the name (64%) or number (74%) of new medications or their dosages (56%), schedule (68%), or purpose (64%). Only 11% could recall being told of any adverse effects, and only 22% could name at least 1 adverse effect. Older patients tended to answer fewer questions correctly (P=.02). We observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and survey (P=.17), or number of new medications (P=.65). Overall, we found that patients had limited knowledge about their medications after discharge from an internal medicine residency service, with age but not years of education significantly associated with level of knowledge.

Warfarin Dosing and Body Mass Index

Background: Warfarin is still the most commonly used anticoagulant for the treatment of venous thromboembolism and other hypercoagulable states. Warfarin metabolism is affected by multiple factors, including diet, medications, and individual patient characteristics. As both underdosing and overdosing can increase risks to patients, several studies have attempted to develop dosing protocols. However, few have investigated how patient weight and body mass index (BMI) affect warfarin dosing. Objective: The objective of this study was to determine the association between BMI and the total weekly dose (TWD) of warfarin. Methods: In this retrospective study, we identified patients taking warfarin who had an international normalized ratio (INR) within the therapeutic range to assess if there was a significant correlation between TWD, that is, maintenance warfarin dosing, and BMI in obese and nonobese patients. Results: A total of 831 patients were studied, with a BMI range between 13.4 and 63.1 kg/m2. We found that BMI is positively correlated with the total weekly warfarin dose. Our study showed that for each 1-point increase in BMI, the weekly warfarin dose increased by 0.69 mg. We found that the average warfarin weekly dose in this population can be estimated using the formula: 12.34 + 0.69 × BMI. Conclusion: There is an association between BMI and the TWD of warfarin. This could have dosing implications for both patients and prescribers, as patients with a high BMI will be expected to require higher doses of warfarin to maintain a therapeutic INR.

Left-sided Pseudomonas aeruginosa endocarditis in patients without injection drug use.

We aimed to determine the clinical features, predisposing factors, and outcome of left-sided Pseudomonas aeruginosa endocarditis in persons with no history of injection drug use. We performed a retrospective review of patient medical records from Mayo Clinic (Rochester, MN; Scottsdale, AZ; and Jacksonville, FL) for all cases of left-sided P. aeruginosa endocarditis. We identified 4 cases. We present these cases, as well as a review of the English-language medical literature. Data gathered included the year the case was reported; the valve involved; treatment, including valve replacement surgery; and outcome, if known. Left-sided P. aeruginosa endocarditis in persons without injection drug use is a rare but serious infection, with a history of instrumentation as a common predisposing condition. Valvular surgery is indicated, when possible, for the best chance of survival, along with extended therapy with combination antibiotics for complete recovery.

Reducing unnecessary testing: an intervention to improve resident ordering practices.

Purpose of the study To reduce the number of unnecessary laboratory tests ordered through a measurement of effects of education and cost awareness on laboratory ordering behaviour by internal medicine residents for common tests, including complete blood cell count (CBC) and renal profile (RP), and to evaluate effects of cost awareness on hospitalisation, 30-day readmission rate and mortality rate. Study design 567 patients admitted during February, March and April 2014 were reviewed as the control group. Total CBC, CBC with differential and RP tests were counted, along with readmission and mortality rates. Interventions were education and visual cost reminders. The same tests were reassessed for 629 patients treated during 12 months after intervention in 2015. Results Data showed a significant increase in CBCs ordered after the intervention (mean number per hospitalisation changed from 1.7 to 2.3 (p<0.001)), a decrease in CBCs with differential (mean number changed from 1.7 to 1.2 (p<0.001)) and no change in RPs ordered (mean number, 3.7 both before and after intervention (p=0.23)). No change was found in mortality rate, but the decrease in the readmission rate was significant (p=0.008). Conclusions Education in the form of cost reminders did not significantly reduce the overall ordering of the most common daily laboratory testing in our academic teaching service. We believe further research is needed to fully evaluate the effectiveness of other education forms on the redundant ordering of tests in the hospital setting.

Recurrent Candida tropicalis meningitis

Candida meningitis, a previously rare occurrence, has been increasing in prevalence and often is a result of complications of neurosurgery. We describe the case of a 49-year-old man who presented with headache, vertigo, intermittent blurred vision, and multiple episodes of nausea and vomiting. Computed tomography (CT) showed a left cerebellar hemorrhage with obliteration of the fourth ventricle causing hydrocephalus. He had an occipital craniotomy with transcondylar evacuation of the hemorrhage and placement of a temporary ventriculostomy. The hospital stay was prolonged because of postsurgical complications, and Candida tropicalis meningitis developed. Treatment was started with 400 mg of fluconazole administered intravenously every 12 h. In vitro susceptibility testing showed a minimum inhibitory concentration (MIC) to fluconazole of 1 microg/mL. Fluconazole was therefore continued orally for a total of 60 days, and the patient remained asymptomatic for 2 years. He then presented with increased vertigo and ataxia. Cerebrospinal fluid cultures grew C. tropicalis, which again showed susceptibility to fluconazole with a MIC of 1 microg/mL, identical to that in the previous infection. However, a second course of fluconazole failed to control the infection despite adequate cerebrospinal fluid levels.

Comparing performance of 30-day readmission risk classifiers among hospitalized primary care patients

RATIONALE, AIMS AND OBJECTIVES Hospital readmission within 30 days of discharge occurs in almost 20% of US Medicare patients and may be a marker of poor quality inpatient care, ineffective hospital to home transitions, or disease severity. Within a patient centered medical home, care transition interventions may only be practical from cost and staffing perspectives if targeted at patients with the greatest risk of readmission. Various scoring algorithms attempt to predict patients at risk for 30-day readmission, but head-to-head comparison of performance is lacking. Compare published scoring algorithms which use generally available electronic medical record data on the same set of hospitalized primary care patients. METHODS The LACE index, the LACE+ index, the HOSPITAL score, and the readmission risk score were computed on a consecutive cohort of 26,278 hospital admissions. Classifier performance was assessed by plotting receiver operating characteristic curves comparing the computed score with the actual outcome of death or readmission within 30 days. Statistical significance of differences in performance was assessed using bootstrapping techniques. RESULTS Correct readmission classification on this cohort was moderate with the following c-statistics: Readmission risk score 0.666; LACE 0.680; LACE+ 0.662; and HOSPITAL 0.675. There was no statistically significant difference in performance between classifiers. CONCLUSIONS Logistic regression based classifiers yield only moderate performance when utilized to predict 30-day readmissions. The task is difficult due to the variety of underlying causes for readmission, nonlinearity, and the arbitrary time period of concern. More sophisticated classification techniques may be necessary to increase performance and allow patient centered medical homes to effectively focus efforts to reduce readmissions.

Residents’ knowledge of quality improvement: the impact of using a group project curriculum

Background The Accreditation Council for Graduate Medical Education requires residents to learn and demonstrate proficiency in practice improvement. Quality improvement (QI) projects are a way to improve patient care as well as facilitate education on this core competency. There are inherent barriers to completing these goals in the structure of residency training including rigorous resident schedules and a limited number of projects and resources. Objectives We developed a QI programme using an experiential class project and incorporated it into our Internal Medicine Resident Core Curriculum to improve the residents’ knowledge of QI methods. We assessed the residents’ experience, knowledge and interest in practice and QI subject matter with a survey preimplementation and postimplementation. Methods In 2009, 24 residents in the Internal Medicine resident programme completed a survey measuring their experience, knowledge and interest in QI initiatives. They then completed a QI 1-year programme, with monthly, 1-hour sessions combining didactics and a resident-designed project. At the conclusion of the year, the residents completed the same survey, and the results were compared and analysed. Results Postcurriculum questionnaires revealed residents were more knowledgeable about QI methods, showing improvement in knowledge about institutional-wide QI projects, better preparation for implementing a QI project, and more likely to participate in QI in the future. The project completed was one which improved patients’ knowledge of their anticipated date of discharge from the hospital. Conclusions A class quality project can teach QI to residents incorporating both didactic and practical methods to maximise the experience and minimise the barriers. We found that this method improved residents experience, knowledge and interest in quality initiatives.

The use of passive visual stimuli to enhance compliance with handwashing in a perioperative setting.

BACKGROUND To encourage handwashing, we analyzed the effect that a passive visual stimulus in the form of a picture of a set of eyes had on self-directed hand hygiene among health care staff. METHODS This was a prospective, single-blind study using a repeated measure design. Four dispensers of alcohol foam located in positions identified as #1, #2, #3, and #4 were used to deliver a single uniform volume of alcohol foam in an automated fashion. Pictures of eyes were placed on dispensers #1 and #3 but not dispensers #2 and #4 for 1 time period. The visual stimulus was rotated with each study time period. At the end of each study period, the volumes dispensed were examined to determine if the visual stimulus had a statistically significant influence on the volume dispensed. RESULTS There were a total of 6 time periods. The average volume dispensed in stations with eyes was 279 cc versus that in the stations without eyes, which was 246 cc, and this was a statistically significant difference (P = .009). CONCLUSION The correct visual stimuli may enhance compliance with hand hygiene in health care settings.

Patient portal use and hospital outcomes

Objectives To determine whether use of a patient portal during hospitalization is associated with improvement in hospital outcomes, 30-day readmissions, inpatient mortality, and 30-day mortality. Materials and Methods We performed a retrospective propensity score-matched study that included all adult patients admitted to Mayo Clinic Hospital in Jacksonville, Florida, from August 1, 2012, to July 31, 2014, who had signed up for a patient portal account prior to hospitalization (N = 7538). Results Out of the admitted patients with a portal account, 1566 (20.8%) accessed the portal while in the hospital. Compared to patients who did not access the portal, patients who accessed the portal were younger (58.8 years vs 62.3 years), had fewer elective admissions (54.2% vs 64.1%), were more frequently admitted to medical services (45.8% vs 35.2%), and were more likely to have liver disease (21.9% vs 12.9%) and higher disease severity scores (0.653 vs 0.456). After propensity score matching, there was no statistically significant difference between the 2 cohorts with respect to 30-day readmission (P = .13), inpatient mortality (P = .82), or 30-day mortality (P = .082). Conclusion Use of the patient portal in the inpatient setting may not improve hospital outcomes. Future research should examine the association of portal use with more immediate inpatient health outcomes such as patient experience, patient engagement, medication reconciliation, and prevention of adverse events.

Opioid Use in Patients with Congestive Heart Failure

Objective To understand the relationship between opioid use in patients with congestive heart failure and outcomes, we compared length of stay (LOS), 30-day readmission rates, and 30- and 90-day mortality in patients discharged with a primary diagnosis of congestive heart failure (CHF) who were taking opioids. Design Retrospective study design. Setting Patients were seen at a 320-bed academic hospital. Subjects All patients not awaiting transplant who were discharged with a primary diagnosis of heart failure from January 1, 2011, through December 31, 2014. Methods Records were reviewed for demographic data, comorbidities, and opioid status at admission or discharge. The association of opioid use (at admission and discharge) with LOS, 30-day readmission, and 30- and 90-day mortality was examined. Results Six hundred eighty-two patients with a principle diagnosis of heart failure were admitted during the study period, with 168 (24.6%) taking opioids at admission. Opioid use at admission was not significantly associated with 30-day readmission (odds ratio [OR] = 1.24, 95% confidence interval [CI] = 0.80-1.93), 30-day mortality (hazard ratio [HR] = 0.91, 95% CI = 0.47-1.78), 90-day mortality (HR = 0.95, 95% CI = 0.58-1.54), or LOS (parameter estimate = -0.21, 95% CI = -0.91 to 0.48). One hundred ninety-three patients (28.3%) were prescribed opioids at discharge. No significant differences were observed between those who were and were not taking opioids at discharge for 30-day readmission (OR = 1.10, 95% CI = 0.72-1.69) or for 30- or 90-day mortality (HR = 0.51, 95% CI = 0.24-1.06, and HR = 0.67, 95% CI = 0.41-1.10, respectively). LOS was slightly shorter for patients not using opioids at discharge than for those who were (mean = 3.8 vs 4.6 days, respectively). Conclusions Opioid use at admission or discharge in patients with CHF did not appear to affect outcomes.