Regina Landis

What happens to the medication regimens of older adults during and after an acute hospitalization

Background Hospitalized elderly patients are at risk for medication errors and nonadherence when discharged home. Objective To describe how older patients’ medications change during and after hospitalizations and what patients ultimately take after discharge. Methods We conducted an observational cohort study of 95 patients aged 65 years and older admitted to Johns Hopkins Bayview Medical Center in 2007. Inclusion criteria included admissions longer than 24 hours and discharge to home. Medication lists from three periods were recorded: prehospitalization, day of discharge, and 3 days after discharge. In comparing lists, we characterized: new and discontinued medications, changes in dosage, and changes in frequency. Results Before admission, patients were taking a total of 701 medications (mean, 7 per patient). Upon discharge, 192 new medicines were started (2.0 per patient), 76 discontinued (0.8 per patient), 67 changed in frequency, (0.7 per patient), and 45 changed in dosage (0.5 per patient). Antibiotics and antihypertensives were the most commonly prescribed new medications. Antihypertensives were also most likely to be discontinued. At day 3 after discharge, patients were adherent with 98% (763/778) of medications. However, 25% of antihypertensives and 88% analgesics discontinued by hospitalists on the day of discharge were reinitiated by patients upon their return home. Conclusions During hospitalizations, medications of older adults change substantially. Despite clear medication reconciliation efforts in the hospital environment, medication errors occur upon discharge to home. Because current standards are yielding suboptimal results, alternate methodologies for promoting medication adherence should also be considered, developed, and studied for effectiveness.

Addressing obesity in the hospitalized patient: a needs assessment.

Objective: To perform a needs assessment to determine the extent to which hospitalist providers recognize and intervene upon obese patients in the hospital setting. Methods: A chart review was performed for patients admitted to the hospitalist service at Johns Hopkins Bayview Medical Center between September 1 and October 1, 2008. Patient charts were reviewed for documentation of obesity and treatment plans were ordered and implemented. Demographic data for patients and hospitalist providers was also collected. Providers were also surveyed about their documentation practices related to obesity and any perceived barriers. Results: Forty-nine percent (136/276) of admitted patients were obese. Obesity was documented in 19% (26/136) of admission notes and a discrete plan was made to address obesity 7% (10/136) of the time. Hospitalist providers were more likely to document obesity in patients <60 years old (85% versus 55% respectively, P <0.007), and in patients with body mass indices (BMI) ≥ 35 (77% versus 44% respectively, P < 0.004). Provider survey results suggest that providers do not document obesity because it is not considered to be an acute issue (67%), and they elect not to address obesity because they lack the time (63%), skill (37%), and they believe that their efforts will be unsuccessful (33%). Conclusion: Documentation of obesity by hospitalist providers is poor. Because an inpatient admission has been characterized as a teachable moment when patients are willing to reflect on behavior change, this may be an ideal time to counsel and educate obese patients.

Breast cancer screening preferences among hospitalized women

BACKGROUND Efforts to increase mammographic screening for early detection of breast cancer among women of lower socioeconomic class and ethnic minorities have been largely unsuccessful. This study explores the receptivity of hospitalized women to inpatient mammography as a novel approach to enhance breast cancer screening. METHODS A cross-sectional study was conducted among 210 hospitalized women, aged 50-75 years, admitted to the medicine services at Johns Hopkins Bayview Medical Center in early 2012. Unpaired t-test and Chi-square tests were used to compare characteristics, barriers, and receptivity to inpatient mammography among women adherent and non-adherent to screening guidelines. RESULTS One-third of women enrolled were African American, and 60% of study participants reported an annual household income of <

Management of Cocaine-Induced Myocardial Infarction: 4-Year Experience at an Urban Medical Center.

20,000. Thirty-nine percent were overdue for screening, of which, 13% never had a mammogram and 28% were at high risk for breast cancer (Gail score ≥1.7%). The commonly reported barriers to screening mammograms were failure to remember appointments and lack of transportation. Most women (91%) believed that it is important for healthcare providers to discuss breast cancer screening while patients are in the hospital. Sixty-eight percent of non-adherent women would agree to have an inpatient screening mammogram if it was due and offered. CONCLUSIONS A significant number of hospitalized women from lower socioeconomic class are at high risk of developing breast cancer and non-adherent to mammographic screening. Inpatient hospital stay may be a feasible time for screening and education to ensure adequate breast care and promote screening among these women.

Receptivity to weight management interventions among hospitalized obese patients: an untapped opportunity.

Objectives In 2008, the American Heart Association and the American College of Cardiology released guidelines for the management of cocaine-induced myocardial infarction (CIMI). We hypothesized that CIMI patients are likely to receive less invasive and more conservative management than patients with MI without history of cocaine use. Methods We conducted a retrospective analysis on patients younger than 65 years presenting with acute MI between April 1, 2008 and December 31, 2012. Patients were classified as cocaine-negative MI or CIMI based on either urine toxicology results or self-reported cocaine use. Categorical and continuous variables were compared using &khgr;2 or t test as appropriate. The primary outcome was cardiac catheterization or stress testing. The secondary outcome was a 30-day readmission rate for major adverse cardiovascular events. Multiple logistic regression models calculated odds ratios (ORs) for the primary outcomes adjusting for patient demographics and comorbidities. Results Of 378 MI patients, 4.2 % had CIMI. CIMI patients were younger (50 vs 54 years; P < 0.01) predominantly African American (56% vs 16%, P < 0.01), and mostly active smokers (88% vs 58%, P = 0.02). They were more likely to receive stress testing (adjusted OR 3.61, 95% confidence interval 1.04–12.53) and less likely to undergo cardiac catheterization (adjusted OR 0.12, 95% confidence interval 0.03–0.45). The 30-day readmission rate for major adverse cardiovascular events was higher in CIMI compared with cocaine-negative MI patients (38% vs 13%; P = 0.03). Conclusions The use of cocaine in patients presenting with acute MI appears to impact management decisions of providers. Patient-centered postdischarge arrangements need better coordination for this patient group to optimize their follow-up care.

Learning needs of physician assistants working in hospital medicine

Objectives Hospitalized obese patients rarely receive counseling about weight loss. Specific patient preferences regarding inpatient weight loss interventions have not been systematically investigated. The objective of the study was to describe the preferences of hospitalized obese patients for weight loss interventions and to identify predictors of receptivity to such offerings. Methods A total of 204 individuals with a body mass index (BMI) ≥30 kg/m2 (mean BMI 38.1 kg/m2) admitted to the hospital medicine service in spring 2011 were surveyed at bedside for this cross-sectional study. The study population was predominantly white (67%) and women (62%), and their mean age was 55 years. Results Although 82% expressed a desire for providers to discuss weight loss during hospitalization, nearly all (92%) of the patients reported that providers did not address this subject. Logistic regression analysis tested demographic variables and obesity-related health beliefs as predictors of receptivity to inpatient weight loss interventions. The recognition of their own obesity and belief that weight loss would prolong life were significantly associated with receptivity to specific interventions, over and above objectively measured BMI in adjusted models. Conclusions Receptivity to inpatient weight loss interventions varies considerably among hospitalized obese patients. The most important determinants that predict the level of receptivity were related to weight-related beliefs and perceptions. Future inpatient weight loss interventions could be targeted to patients with truthful health beliefs and perceptions about obesity.

Association Between Radiologic Incidental Findings and Resource Utilization in Patients Admitted With Chest Pain in an Urban Medical Center

BACKGROUND Hospital Medicine is growing rapidly, and the number of physician assistants (PAs) in this field is expected to grow. However, there is no available data related to the learning needs of PA hospitalists. OBJECTIVE To conduct a needs assessment for PA hospitalists who may be embarking on a hospitalist career. DESIGN Cross-sectional survey based on the Core Competencies in Hospital Medicine. SETTING/PARTICIPANTS A sample of hospitalist PAs working in the United States. MEASUREMENTS Amount of experience with core diagnoses and procedures, preferences for additional training that would have prepared them to function as hospitalist PAs. RESULTS Sixty-nine PAs responded (response rate, 67%). Among the core clinical conditions, respondents had the most experience in managing diabetes and urinary tract infections and were least experienced with health care-associated pneumonias and sepsis syndrome. Over 90% rarely performed core competency procedures other than electrocardiogram and chest X-ray interpretations. The top 3 content areas that PA hospitalists believed would have helped to better prepare them to care for inpatients were palliative care (percent of PAs who agreed or strongly agreed: 85%), nutrition for hospitalized patients (84%), and consultations (64%). Almost all (91%) indicated that they would have been interested in formal postgraduate hospital medicine training even if it meant having a lower stipend during the first year on the job. CONCLUSIONS This is the first national data on self-perceived learning needs of PA hospitalists. The results may prove helpful for both PAs entering hospitalist careers and for the physician groups looking to hire them.

Communication of laboratory data and diagnostic test results to hospitalized patients: a study of preferences and recall.

BACKGROUND: Increasing use of testing among hospitalized patients has resulted in an increase in radiologic incidental findings (IFs), which challenge the provision of high‐value care in the hospital setting. OBJECTIVE: To understand impact of radiologic incidental findings on resource utilization in patients hospitalized with chest pain. DESIGN: Retrospective observational cross sectional study. SETTING: Academic medical center. PARTICIPANTS: Adult patients hospitalized with principal diagnosis of chest pain. MEASUREMENTS: Demographic, imaging, and length of stay (LOS) data were abstracted from the medical charts. We used multiple logistic regression to evaluate factors associated with radiologic IFs and negative binomial regression to evaluate the association between radiologic IFs and LOS. RESULTS: 1811 consecutive admissions with chest pain were analyzed retrospectively over a period of 24 months; 376 patients were included in the study after exclusion criteria were applied and readmissions removed. Of these, 197 patients (52%) had 364 new radiologic IFs on imaging; most IFs were of minor (50%) or moderate clinical significance (42%), with only 7% of major significance. Odds of finding radiologic IFs increased with age (adjusted odds ratio, 1.04; 95% confidence interval [CI], 1.01–1.06) and was associated with a 26% increase in LOS (adjusted incidence rate ratio, 1.26; 95% CI, 1.07–1.49). CONCLUSION: Radiologic IFs were very common among patients hospitalized with chest pain of suspected cardiac origin and independently associated with an increase in the LOS. Interventions to address radiologic IFs may reduce LOS and, thereby, support high‐value care.

Comportment and communication patterns among hospitalist physicians: Insight gleaned through observation

Objective To assess patients’ preferences with respect to different methods of receiving test results while they were hospitalized and to determine whether the different modes of communication of the test results were associated with better recall. Methods Five discrete test results were shared with adult inpatients on general medicine service (blood pressure, white blood cell count, hematocrit, creatinine, and chest X-ray). The information was delivered by a physician in one of three ways: 1) verbally, 2) explained with a print out of the results, or 3) described while showing results on a computer monitor (electronic). The same physician returned within 3 hours to assess recall and satisfaction with the way patients received their results. Results All the patients (100%) receiving their results in written format were satisfied with the mode of communication as compared to electronic format (86%) or verbally (79%) (P=0.02). Fifty percent of patients in the computer format group could recall four or more test results at the follow-up, as compared to 43% in printed group and 24% who were informed of their results verbally (P=0.35). Conclusion Patients most appreciated receiving test results in written form while in the hospital, and this delivery method was as good as any other method with respect to recall.

Development and validation of the tool to assess inpatient satisfaction with care from hospitalists.

Objectives By 2014, there were more than 40,000 hospitalists delivering the majority of inpatient care in US hospitals. No empiric research has characterized hospitalist comportment and communication patterns as they care for patients. Methods The chiefs of hospital medicine at five different hospitals were asked to identify their best hospitalists. These hospitalists were watched during their routine clinical care of patients. An observation tool was developed that focused on elements believed to be associated with excellent comportment and communication. One observer watched the physicians, taking detailed quantitative and qualitative field notes. Results A total of 26 hospitalists were shadowed. The mean age of the physicians was 38 years, and their average experience in hospital medicine was 6 years. The hospitalists were observed for a mean of 5 hours, during which time they saw an average of 7 patients (patient encounters observed N = 181). Physicians spent an average of 11 minutes with each patient. There was large variation in the extent to which desirable behaviors were performed. For example, most physicians (76%) started encounters with an open-ended question, and relatively few (30%) attempted to integrate nonmedical content into conversation with patients. Conclusions This study represents a first step in trying to characterize comportment and communication in hospital medicine. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication are clearly defined and established as a goal for every encounter.