Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study

Comprehensive geriatric assessment as an essential tool to register or update DNR codes in a tertiary care hospital

PURPOSE

To investigate the prevalence of Do not Resuscitate (DNR) code registration in patients with a geriatric profile admitted to Antwerp University Hospital, a tertiary care hospital in Flanders, Belgium, and the impact of comprehensive geriatric assessment (CGA) on DNR code registration.

PATIENTS AND METHODS

Retrospective analysis of a population of 543 geriatric patients (mean age 82.4 ± 5.19 years, 46.4% males) admitted to Antwerp University Hospital from 2018 to 2020 who underwent a CGA during admission. An association between DNR code registration status before and at hospital admission and age, gender, ethnicity, type of residence, clinical frailty score (CFS), cognitive and oncological status, hospital ward and stay on intensive care was studied. Admissions before and during the first wave of the pandemic were compared.

RESULTS

At the time of hospital admission, a DNR code had been registered for 66.3% (360/543) of patients. Patients with a DNR code at hospital admission were older (82.7 ± 5.5 vs. 81.7 ± 4.6 years, p = 0.031), more frail (CFS 5.11 ± 1.63 vs. 4.70 ± 1.61, p = 0.006) and less likely to be admitted to intensive care. During the hospital stay, the proportion of patients with a DNR code increased to 77% before and to 85.3% after CGA (p < 0.0001). Patients were consulted about and agreed with the registered DNR code in 55.8% and 52.1% of cases, respectively. The proportion of patients with DNR codes at the time of admission or registered after CGA did not differ significantly before and after the start of the COVID-19 pandemic.

CONCLUSION

After CGA, a significant increase in DNR registration was observed in hospitalized patients with a geriatric profile.

Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

BACKGROUND

Racial and ethnic minority groups are less likely to have advance directives and living wills, despite the importance of advanced care planning (ACP) in end-of-life care. We aimed to understand the impact of an intervention to improve ACP documentation across race, ethnicity, and language on hospitalized patients at our institution.

METHODS

We launched an intervention to improve the rates of ACP documentation for hospitalized patients aged >75 or with advanced illness defined by the International Classification of Diseases 10th Revision codes. We analyzed ACP completion rates, preintervention, and intervention, and used interrupted time-series analyses to measure the differential impact of the intervention across race, ethnicity, and language.

KEY RESULTS

A total of 10,220 patients met the inclusion criteria. Overall rates of ACP documentation improved from 13.9% to 43.7% in the intervention period, with a 2.47% monthly increase in ACP documentation compared to baseline (p < .001). During the intervention period, the rate of ACP documentation increased by 2.72% per month for non-Hispanic White patients (p < .001), by 1.84% per month for Latinx patients (p < .001), and by 1.9% per month for Black patients (p < .001). Differences in the intervention trends between non-Hispanic White and Latinx patients (p = .04) and Black patients (p = .04) were significant.

CONCLUSIONS

An intervention designed to improve ACP documentation in hospitalized patients widened a disparity across race and ethnicity with Latinx and Black patients having lower rates of improvement. Our findings reinforce the need to measure the impact of quality improvement interventions on existing health disparities and to implement specific strategies to prevent worsening disparities.

Code status orders in hospitalized patients with COVID-19

Background

The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19.

Methods

A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020).

Results

Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80.

Conclusions

There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.

Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement

BACKGROUND

Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients.

METHODS

We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP.

RESULTS

Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001).

CONCLUSION

Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Improving Knowledge, Attitudes, and Skills of Medical Clinicians and Trainees in Clinical Medical Ethics

Purpose: There is limited data in the medical literature evaluating knowledge, attitudes, and skill in clinical medical ethics for clinicians or medical trainees. Our study aimed to evaluate baseline clinician knowledge, attitudes, and skills regarding clinical medical ethics and to implement and evaluate a curriculum designed with the intent to improve these measures. Method: Internal medicine residents, palliative fellows, medical and pre-medical students, social workers, advanced practice providers, and chaplains were surveyed at a large urban academic center to determine their baseline knowledge, attitudes, and skills regarding clinical medical ethics (64% response rate, n = 93/145). A one-hour discussion-based curriculum on clinical medical ethics topics was implemented, followed by another survey; χ2 and McNemar tests were used to compare pre- and post-surveys to evaluate the curriculum. Results: Baseline knowledge of all respondents (n = 93) in the four principles of bioethics (54%-89%), determining an alternate decision-maker (5%-50%), decision-making capacity (14%-71%), and in-hospital cardiac arrest survival (19%-77%) significantly increased (P < .0001) post-curriculum, as did baseline self-reported attitudes towards clinicians making medical recommendations to patients (27%-60%) and having had adequate education on code status discussions (42%-77%). Self-reported skills in determining an alternate decision-maker (40%-89%) and assessing decision-making capacity (40%-72%) also significantly increased post curriculum (P < .01 and P < .05). Conclusion: Implementation of a curriculum in medical ethics improved baseline knowledge, attitudes and self-reported skills of medical providers and trainees in clinical medical ethics.

Code status documentation at admission in COVID-19 patients: a descriptive cohort study

OBJECTIVES

The COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients.

SETTING

University Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands.

PARTICIPANTS

A total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018).

PRIMARY AND SECONDARY OUTCOME MEASURES

We described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status.

RESULTS

Frequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, 'no intensive care admission' (81% vs 51%) and 'no intubation' (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in 'other limitation' (17% vs 9%), while 'no resuscitation' (96% vs 92%) was comparable between both periods.

CONCLUSION

We observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially 'no intubation' and 'no intensive care admission'.

Code Status Documentation Availability and Accuracy Among Emergency Patients with End-stage Disease

INTRODUCTION

Some patients with end-stage disease who may neither want nor benefit from aggressive resuscitation receive such treatment if they cannot communicate in an emergency. Timely access to patients' current resuscitation wishes, or "code status," should be a key metric of electronic health records (EHR). We sought to determine what percentage of a cohort of patients with end-stage disease who present to the emergency department (ED) have accessible, code status documents, and for those who do, how quickly can this documentation be retrieved.

METHODS

In this cross-sectional study of ED patients with end-stage disease (eg, palliative care, metastatic malignancy, home oxygen, dialysis) conducted during purposefully sampled random accrual times we performed a standardized, timed review of available health records, including accompanying transfer documents. We also interviewed consenting patients and substitute decision makers to compare available code status documents to their current wishes.

RESULTS

Code status documentation was unavailable within 15 minutes of ED arrival in most cases (54/85, or 63%). Retrieval time was under five minutes in the rest, especially when "one click deep" in the EHR. When interviewed, 20/32 (63%) expressed "do not resuscitate" wishes, 10 of whom had no supporting documentation. Patients from assisted-living (odds ratio [OR] 6.7; 95% confidence interval [CI], 1.7-26) and long-term care facilities (OR 13; 95% CI, 2.5-65) were more likely to have a documented code status available compared to those living in the community.

CONCLUSION

The majority of patients with end-stage disease, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have code status documents readily available upon arrival to our tertiary care ED. Patients living in the community with advanced disease may be at higher risk for unwanted resuscitative efforts should they present to hospital in extremis. While easily retrievable code status documentation within the EHR shows promise, its accuracy and validity remain important considerations.

Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders

Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age >85 years (adjusted odd ratios (AOR) 1.700, 1.027–2.814), living in long-term care facilities (AOR 1.880, 1.066–3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039–4.358), “medical staff would not be surprised if the patient died within 12 months” (AOR 1.725, 1.193–2.496), and patients’ family requesting palliative care (AOR 2.420, 1.187–4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p < 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p < 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.

A STEEEP Hill to Climb: A Scoping Review of Assessments of Individual Hospitalist Performance

BACKGROUND

Although ensuring high-quality care requires assessment of individual hospitalist performance, current assessment approaches lack consistency and coherence. The Institute of Medicine's STEEEP framework for quality healthcare conceptualizes quality through domains of "Safe," "Timely," "Effective," "Efficient," "Equitable," and "Patient Centered." This framework may be applicable to assessing individual hospitalists.

OBJECTIVE

This scoping review sought to identify studies that describe variation in individual hospitalist performance and to code this data to the domains of the STEEEP framework.

METHODS

Via a systematic search of peer-reviewed literature that assessed the performance of individual hospitalists in the Medline database, we identified studies that described measurement of individual hospitalist performance. Forty-two studies were included in the final review and coded into one or more domains of the STEEEP framework.

RESULTS

Studies in the Safe domain focused on transitions of care, both at discharge and within the hospital. Many studies were coded to more than one domain, especially Timely, Effective, and Efficient. Examples include adherence to evidence-based guidelines or Choosing Wisely recommendations. The Patient Centered domain was most frequently coded, but approaches were heterogeneous. No included studies addressed the domain Equitable.

CONCLUSIONS

Applying the STEEEP framework to the published literature on assessment of individual hospitalist performance revealed strengths and weaknesses. Areas of strength were assessments of transitions of care and application of consensus guidelines. Other areas, such as equity and some components of safe practice, need development. All domains would benefit from more practical approaches. These findings should stimulate future work on feasibility of multidimensional assessment approaches.

Twelve tips for teaching oncology to non-oncologists

Background: Teaching subspecialty care to trainees who are not pursuing that subspecialty poses many challenges. These challenges are amplified in the teaching of oncology to non-oncologists because there are more new therapies emerging in oncology than in any other discipline, and there are few oncologic issues managed by generalists without consultation. Concurrently, there is an increasing need for generalists to manage many aspects of care for patients with cancer.Aim: To provide 12 tips for oncologists to use to educate trainees on their oncology rotations.Method: The tips provided are based upon the available literature and the authors' own experience.Results: The 12 tips presented offer specific strategies for oncologists to enhance their teaching by selection of appropriate content and enhancing delivery. Focus is placed on aspects of oncology that trainees are likely to encounter as a generalist or non-cancer subspecialist. While oncology is used as the case study, these strategies are adaptable to any subspecialty area.Conclusion: Oncologists and other subspecialists can be core medical educators.

Goals of care conversations and documentation in patients triggering medical emergency team calls

BACKGROUND

It is widely accepted that early discussions about goals of care (GOC) should occur during a hospital admission. Whilst rapid response systems such as Medical Emergency Team (MET) calls were designed to identify patients at risk of deterioration early enough in their illness to intervene, it is becoming apparent that these teams frequently diagnose the dying patient.

AIMS

To determine how frequently Launceston General Hospital MET doctors are involved in discussions surrounding GOC.

METHODS

A retrospective audit of all MET calls and Code Blues at the Launceston General Hospital over an 18 month period was performed.

RESULTS

50% of MET calls occurred in patients with no valid GOC form completed prior. At 3% of events, the GOC form was completed for the first time, and at 3% it was modified. At a further 3% the notes implied there had been a modification to the GOC but the form had not been completed.

CONCLUSIONS

This audit confirms that documentation surrounding GOC is inadequate, and that at 9% of MET calls, MET doctors are involved in discussions surrounding treatment limitations. This suggests that further education and training is required for doctors working in inpatient care, including those who staff the MET.

More than one in three proxies do not know their loved one's current code status: An observational study in a Maryland ICU

Rationale

The majority of ICU patients lack decision-making capacity at some point during their ICU stay. However the extent to which proxy decision-makers are engaged in decisions about their patient’s care is challenging to quantify.

Objectives

To assess 1)whether proxies know their patient’s actual code status as recorded in the electronic medical record (EMR), and 2)whether code status orders reflect ICU patient preferences as reported by proxy decision-makers.

Methods

We enrolled proxy decision-makers for 96 days starting January 4, 2016. Proxies were asked about the patient’s goals of care, preferred code status, and actual code status. Responses were compared to code status orders in the EMR at the time of interview. Characteristics of patients and proxies who correctly vs incorrectly identified actual code status were compared, as were characteristics of proxies who reported a preferred code status that did vs did not match actual code status.

Measurements and main results

Among 111 proxies, 42 (38%) were incorrect or unsure about the patient’s actual code status and those who were correct vs. incorrect or unsure were similar in age, race, and years of education (P>0.20 for all comparisons). Twenty-nine percent reported a preferred code status that did not match the patient’s code status in the EMR. Matching preferred and actual code status was not associated with a patient’s age, gender, income, admission diagnosis, or subsequent in-hospital mortality or with proxy age, gender, race, education level, or relation to the patient (P>0.20 for all comparisons).

Conclusions

More than 1 in 3 proxies is incorrect or unsure about their patient’s actual code status and more than 1 in 4 proxies reported that a preferred code status that did not match orders in the EMR. Proxy age, race, gender and education level were not associated with correctly identifying code status or code status concordance.

Effect of a do-not-resuscitate order on the quality of care in acute heart failure patients: a single-center cohort study

Background

A do-not-resuscitate (DNR) order is reportedly associated with a decrease in performance measures, but it should not be applied to noncardiopulmonary resuscitation procedures. Good performance measures are associated with improvement in heart failure outcomes.

Aim

To analyze the influence of DNR order on performance measures of heart failure at our hospital, where lectures on DNR order are held every 3 months.

Design

Retrospective cohort study.

Methods

The medical report of patients with acute heart failure who were admitted between April 2013 and March 2015 were retrospectively analyzed. We collected demographic data, information on the presence or absence of DNR order within 24 hours of admission, and inhospital mortality. Performance measures of heart failure, including assessment of cardiac function and discharge prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and beta-blocker for left ventricular systolic dysfunction and anticoagulant for atrial fibrillation, were collected and compared between groups with and without DNR orders.

Results

In 394 total patients and 183 patients with left ventricular systolic dysfunction, 114 (30%) and 44 (24%) patients, respectively, had a DNR order. Patients with a DNR order had higher inhospital mortality. There were no significant differences between the two groups in terms of the four quality measures (left ventricular function assessment, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, and anticoagulant).

Conclusion

DNR orders did not affect performance measures, but they were associated with higher inhospital mortality among acute heart failure patients.

Challenges to code status discussions for pediatric patients

Objectives

In the context of serious or life-limiting illness, pediatric patients and their families are faced with difficult decisions surrounding appropriate resuscitation efforts in the event of a cardiopulmonary arrest. Code status orders are one way to inform end-of-life medical decision making. The objectives of this study are to evaluate the extent to which pediatric providers have knowledge of code status options and explore the association of provider role with (1) knowledge of code status options, (2) perception of timing of code status discussions, (3) perception of family receptivity to code status discussions, and (4) comfort carrying out code status discussions.

Design

Nurses, trainees (residents and fellows), and attending physicians from pediatric units where code status discussions typically occur completed a short survey questionnaire regarding their knowledge of code status options and perceptions surrounding code status discussions.

Setting

Single center, quaternary care children’s hospital.

Measurements and main results

203 nurses, 31 trainees, and 29 attending physicians in 4 high-acuity pediatric units responded to the survey (N = 263, 90% response rate). Based on an objective knowledge measure, providers demonstrate poor understanding of available code status options, with only 22% of providers able to enumerate more than two of four available code status options. In contrast, provider groups self-report high levels of familiarity with available code status options, with attending physicians reporting significantly higher levels than nurses and trainees (p = 0.0125). Nurses and attending physicians show significantly different perception of code status discussion timing, with majority of nurses (63.4%) perceiving discussions as occurring “too late” or “much too late” and majority of attending physicians (55.6%) perceiving the timing as “about right” (p<0.0001). Attending physicians report significantly higher comfort having code status discussions with families than do nurses or trainees (p≤0.0001). Attending physicians and trainees perceive families as more receptive to code status discussions than nurses (p<0.0001 and p = 0.0018, respectively).

Conclusions

Providers have poor understanding of code status options and differ significantly in their comfort having code status discussions and their perceptions of these discussions. These findings may reflect inherent differences among providers, but may also reflect discordant visions of appropriate care and function as a potential source of moral distress. Lack of knowledge of code status options and differences in provider perceptions are likely barriers to quality communication surrounding end-of-life options.

Bereavement support for family caregivers: The gap between guidelines and practice in palliative care

Background

Standards for bereavement care propose that support should be matched to risk and need. However, studies in many countries demonstrate that palliative care services continue to adopt a generic approach in offering support to bereaved families.

Objective

To identify patterns of bereavement support in palliative care services based upon the experience of bereaved people from a population based survey and in relation to clinical practice guidelines.

Design

An anonymous postal survey collected information from clients of six funeral providers in four Australian states (2014–15), 6 to 24 months after the death of their family member or friend, with 1,139 responding. Responses from 506 bereaved relatives of people who had terminal illnesses were analysed. Of these, 298 had used palliative care services and 208 had not.

Results

More people with cancer (64%) had received palliative care in comparison to other illnesses such as heart disease, dementia and organ failure (4–10%). The support for family caregivers before and after their relative’s death was not considered optimal. Only 39.4% of the bereaved reported being specifically asked about their emotional/ psychological distress pre-bereavement, and just half of the bereaved perceived they had enough support from palliative care services. Half of the bereaved had a follow up contact from the service at 3–6 weeks, and a quarter had a follow-up at 6 months. Their qualitative feedback underlined the limited helpfulness of the blanket approach to bereavement support, which was often described as “not personal” or “generic”, or “just standard practice”.

Conclusions

Timeliness and consistency of relationship is crucial to building rapport and trust in the service’s ability to help at post-bereavement as well as a focus on the specific rather than the generic needs of the bereaved. In light of these limitations, palliative care services might do better investing their efforts principally in assessing and supporting family caregivers during the pre-bereavement period and developing community capacity and referral pathways for bereavement care. Our findings suggest that bereavement support in Australian palliative care services has only a tenuous relationship with guidelines and assessment tools, a conclusion also drawn in studies from other countries, emphasizing the international implications of our study.

Processes of code status transitions in hospitalized patients with advanced cancer

BACKGROUND

Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown.

METHODS

We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR.

RESULTS

In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005).

CONCLUSIONS

One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.

Association of code status discussion with invasive procedures among advanced-stage cancer and noncancer patients

Background

Code status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases.

Methods

We performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis.

Results

Among the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (P<0.001, odds ratio =0.03, 95% CI =0.004–0.21), which was found by using multivariate logistic regression analysis.

Conclusion

Code status discussion on admission is associated with a decrease in invasive procedures and CPR in cancer and noncancer patients. Physicians should be educated about code status discussion to improve end-of-life care.

Utilizing the Electronic Health Record to Improve Advance Care Planning: A Systematic Review

PURPOSE

Advance care planning may ensure care that is concordant with patient wishes. However, advance care plans are frequently absent when needed due to failure to engage patients in planning, inability to access prior documentation, or poor documentation quality. Interventions utilizing tools within the electronic health record (EHR) may address these barriers at the point of care. We aimed to identify EHR interventions previously utilized to improve advance care plans.

METHODS

We systematically searched 7 databases for observational and experimental studies of EHR interventions associated with advance care plans. We abstracted information on the study populations, EHR and non-EHR components of the interventions, and the efficacy for advance care plan-related outcomes.

RESULTS

We identified 16 articles that contained an EHR intervention to improve advance care plans. Study populations, study designs, and EHR components of the interventions were heterogeneous. Documentation templates were the most common EHR tool reported (n = 8), followed by automated prompts (n = 7) and electronic order sets (n = 5). The most common reported outcomes were documentation of an advance care planning conversation in the EHR (n = 7) and the placement of code status orders (n = 7). All studies reporting efficacy (n = 9) demonstrated an improvement in 1 or more advance care planning outcomes.

CONCLUSIONS

The use of EHR interventions may improve advance care plan completion and availability at the point of care. Further work should seek to develop and evaluate standardized EHR tools for advance care planning.

Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions: A systematic review

BACKGROUND

Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient's wishes or delayed physician-family communications on preference.

AIM

To determine whether advance care documentation encourages healthcare professional's timely engagement in end-of-life discussions.

DESIGN

Systematic review of the English language articles published from January 2000 to April 2015.

DATA SOURCES

EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists.

RESULTS

A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available.

CONCLUSION

Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff to perceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians' confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review.

Frequency and clinical relevance of inconsistent code status documentation

BACKGROUND

Accurate and complete documentation of hospitalized patients' code status is important to ensure that healthcare providers take appropriate action in the event of a cardiac arrest.

OBJECTIVE

Determine the frequency and clinical relevance of incomplete and inconsistent code status documentation.

DESIGN

Point-prevalence study.

SETTING

Academic medical centers.

PATIENTS

Patients admitted to general internal medicine wards.

MEASUREMENTS

Frequency and clinical relevance of inconsistent code status documentation across 5 documentation sources.

RESULTS

Thirty-eight (20%; 95% confidence interval [CI], 14%-26%) of 187 patients had complete and consistent code status documentation. Another 27 (14%; 95% CI, 9%-19%) patients had no code status documentation. The remaining 122 (65%; 95% CI, 58%-72%) patients had at least 1 code status documentation inconsistency. Of these, 38 (20%; 95% CI, 14%-26%) patients had a clinically relevant code status documentation inconsistency. Multivariate logistic regression analysis demonstrated that increased age (odds ratio [OR] = 1.07 [95% CI, 1.05-1.10] for every 1-year increase in age, P < 0.001) and patients receiving comfort measures (OR = 9.39 [95% CI, 1.35-65.19], P = 0.02) were independently associated with a clinically relevant code status documentation inconsistency.

CONCLUSIONS

Incomplete and inconsistent documentation of code status occurred frequently in hospitalized patients, especially elderly patients and patients receiving comfort measures. Having multiple, poorly integrated code status documentation sources leads to a significant number of concerning inconsistencies that create opportunities for healthcare providers to inappropriately deliver or withhold resuscitative measures that conflict with patients' expressed wishes. Institutions need to be aware of this potential documentation hazard and take steps to minimize code status documentation inconsistencies.

Mayo Registry for Telemetry Efficacy in Arrest (MR TEA) study: An analysis of code status change following cardiopulmonary arrest

INTRODUCTION

Code status discussions are important during a hospitalization, yet variation in its practice exists. No data have assessed the likelihood of patients to change code status following a cardiopulmonary arrest.

METHODS

A retrospective review of all patients that experienced a cardiopulmonary arrest between May 1, 2008 and June 30, 2014 at an academic medical center was performed. The proportion of code status modifications to do not resuscitate (DNR) from full code was assessed. Baseline clinical characteristics, resuscitation factors, and 24-h post-resuscitation, hospital, and overall survival rates were compared between the two subsets.

RESULTS

A total of 157 patients survived the index event and were included. One hundred and fifteen (73.2%) patients did not have a change in code status following the index event, while 42 (26.8%) changed code status to DNR. Clinical characteristics were similar between subsets, although patients in the change to DNR subset were older (average age 67.7 years) compared to the full code subset (average age 59.2 years; p = 0.005). Patients in the DNR subset had longer overall resuscitation efforts with less attempts at defibrillation. Compared to the DNR subset, patients that remained full code demonstrated higher 24-h post-resuscitation (n = 108, 93.9% versus n = 32, 76.2%; p = 0.001) and hospital (n = 50, 43.5% versus n = 6, 14.3%; p = 0.001) survival rates. Patients in the DNR subset were more likely to have neurologic deficits on discharge and shorter overall survival.

CONCLUSIONS

Patient code status wishes do tend to change during critical periods within a hospitalization, adding emphasis for continued code status evaluation.

Sequence patterns in the resolution of clinical instabilities in community-acquired pneumonia and association with outcomes

BACKGROUND

In patients hospitalized with community-acquired pneumonia (CAP), indicators of clinical instability at discharge (fever, tachycardia, tachypnea, hypotension, hypoxia, decreased oral intake and altered mental status) are associated with poor outcomes. It is not known whether the order of indicator stabilization is associated with outcomes.

OBJECTIVES

To describe variation in the sequences, including whether and in what order, indicators of clinical instability resolve among patients hospitalized with CAP, and to assess associations between patterns of stabilization and patient-level outcomes. DESIGN/PARTICIPANTS / MAIN MEASURES: Chart review ascertained whether and when indicators stabilized and other data for 1,326 adult CAP patients in six U.S. academic medical centers. The sequences of indicator stabilization were characterized using sequence analysis and grouped using cluster analysis. Associations between sequence patterns and 30-day mortality, length of stay (LOS), and total costs were modeled using regression analysis.

KEY RESULTS

We found 986 unique sequences of indicator stabilization. Sequence analysis identified eight clusters of sequences (patterns) derived by the order or speed in which instabilities resolved or remained at discharge and inpatient mortality. Two of the clusters (56% of patients) were characterized by almost complete stabilization prior to discharge alive, but differing in the rank orders of four indicators and time to maximum stabilization. Five other clusters (42% of patients) were characterized by one to three instabilities at discharge with variable orderings of indicator stabilization. In models with fast and almost complete stabilization as the referent, 30-day mortality was lowest in clusters with slow and almost complete stabilization or tachycardia or fever at discharge [OR = 0.73, 95% CI = (0.28-1.92)], and highest in those with hypoxia with instabilities in mental status or oral intake at discharge [OR = 3.99, 95% CI = (1.68-9.50)].

CONCLUSIONS

Sequences of clinical instability resolution exhibit great heterogeneity, yet certain sequence patterns may be associated with differences in days to maximum stabilization, mortality, LOS, and hospital costs.

Patient experiences after hospitalizations for elective surgery

BACKGROUND

Little is known from patients' perspective about the quality of postdischarge care and the causes of rehospitalization after elective surgery.

METHODS

A prospective observational cohort study was conducted.

RESULTS

Of 400 patient participants, 374 completed the 30-day follow-up questionnaire (completion rate, 94%). Half of all unplanned rehospitalizations (experienced by 13% of patients) and nonrehospitalization emergency department visits (experienced by 6%) occurred within 10 days of discharge. Patients used emergency departments and were rehospitalized at facilities near their homes (mean distance traveled, 12.1 mi). The most common primary reason for rehospitalization was postoperative complications, according to patient report, clinical records, and administrative data. Poor perceived care coordination was associated with higher readmission risk.

CONCLUSIONS

Patients perceive surgical complications as dominating the reasons for rehospitalizations after elective surgery. Strategies to improve care quality around elective surgery at referral centers should target the discharge process and the coordinated management of postoperative complications through care received at regional hospitals.

The impact of early do not resuscitate (DNR) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest

OBJECTIVES

Among patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) and admitted to California hospitals, we examined how the placement of a do not resuscitate (DNR) order in the first 24h after admission was associated with patient care, procedures and inhospital survival. We further analyzed hospital and patient demographic factors associated with early DNR placement among patients admitted following OHCA.

METHODS

We identified post-OHCA patients from a statewide California database of hospital admissions from 2002 to 2010. Documentation of patient and hospital demographics, hospital interventions, and patient outcome were analyzed by descriptive statistics and multiple regression models to calculate odds ratios and 95% confidence intervals.

RESULTS

Of 5212 patients admitted to California hospitals after resuscitation from OHCA, 1692 (32.5%) had a DNR order placed in the first 24h after admission. These patients had decreased frequency of cardiac catheterization (1.1% vs. 4.3%), blood transfusion (7.6% vs. 11.2%), ICD placement (0.1% vs. 1.1%), and survival to discharge (5.2% vs. 21.6%, all p-values<0.0001). There was wide intrahospital variability and significant racial differences in the adjusted odds of early DNR orders (Asian, OR 0.67, 95% CI 0.48-0.95; Black, OR 0.49, 95% CI 0.35-0.69).

CONCLUSIONS

Early DNR placement is associated with a decrease in potentially critical hospital interventions, procedures, and survival to discharge, and wide variability in practice patterns between hospitals. In the absence of prior patient wishes, DNR placement within 24h may be premature given the lack of early prognostic indicators after OHCA.

Relationships among advance directives, principal diagnoses, and discharge outcomes in critically ill older adults

OBJECTIVE

The purpose of this study was to determine the relationships among advance directive status, principal diagnoses, and the discharge outcomes in community-dwelling, critically ill older adults.

METHOD

Using administrative and clinical data (n = 1673), multinomial logit regressions were used to examine the relationships among advance directive status, principal diagnoses, and discharge outcomes (in-hospital deaths, hospice discharges, and transition to institutions).

RESULTS

In the overall sample, the adjusted probability of in-hospital deaths with advance directives (12%) was lower than that without advance directives (17%; odds ratio [OR] = 0.56; p = 0.007) and the adjusted probability of hospice discharges with advance directives (11%) was higher than that without advance directives (7%; OR = 1.96; p = 0.03). Subgroup analysis showed that the magnitude of the abovementioned changes was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of the abovementioned findings was diminished with other principal diagnoses. On the other hand, the presence of advance directives did not make a contribution to transition from communities to institutions.

SIGNIFICANCE OF RESULTS

Significantly fewer in-hospital deaths in addition to higher hospice discharges were observed with any advance directives in community-dwelling, critically ill older adults. The magnitude of these findings was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of these findings was diminished with other principal diagnoses.

Physician use of advance care planning discussions in a diverse hospitalized population

Two decades after the Patient Self Determination Act it is unknown how often physicians have advance care planning (ACP) discussions with hospitalized patients. The objective of this study is to investigate use of ACP discussions in a multi-ethnic, multi-lingual hospitalized population. Cross-sectional communication study of hospitalized patients. The Participants are 369 patients at one urban county hospital and one academic medical center. Interventions are not applicable. Participants were asked at baseline and a post-discharge interview whether hospital physicians had discussed either (a) what type of treatment they would want if they could not make decisions for themselves or (b) whether they would want cardiopulmonary resuscitation if needed. We compared patient characteristics for those who did and did not have an ACP discussion. Only 151 (41%) participants reported an ACP discussion. Rates of ACP were low across ethnic, language, education and age groups. In a multivariate model, scoring higher on a co-morbidity scale was associated with higher odds of reporting having had an ACP discussion during hospitalization; this finding remained after adjusting for time period and site of data collection. Multiethnic, multi-lingual hospitalized patients reported low rates of ACP discussions with their physicians regardless of ethnicity, English proficiency, education level or age.

Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker

OBJECTIVES

To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions.

DESIGN

Retrospective cohort study.

SETTING

Large, urban, public hospital.

PARTICIPANTS

Hospitalized adults aged 65 and older over a 3-year period (1/1/2004-12/31/2006) with a DNR order during their hospital stay.

MEASUREMENTS

Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders.

RESULTS

Of 668 patients, the ordering physician indicated that the DNR decision was made with the patient in 191 cases (28.9%), the surrogate in 389 (58.2%), and both in 88 (13.2%). Patients who required a surrogate were more likely to be in the intensive care unit (62.2% vs 39.8%, P<.001) but did not differ according to demographic characteristics. By hospital Day 3, 77.6% of patient decisions, 61.9% of surrogate decisions, and 58.0% of shared decisions had been made. In multivariable models, the number of days from admission to DNR order was higher for surrogate (odds ratio (OR)=1.97, P<.001) and shared decisions (OR=1.48, P=.009) than for patient decisions. The adjusted hazard ratio for hospital death was higher for patients with surrogate than patient decisions (2.61, 95% confidence interval (CI)=1.56-4.36). Patients whose DNR orders were written on Day 6 or later were twice as likely to die in the hospital (OR=2.20, 95% CI=1.45-3.36) than patients with earlier DNR orders.

CONCLUSION

For patients who have a DNR order entered during their hospital stay, order entry occurs later when a surrogate is involved. Surrogate decision-making may take longer because of the greater ethical, emotional, or communication complexity of making decisions with surrogates than with patients.

Resident sign-out and patient hand-offs: opportunities for improvement

BACKGROUND

Inpatient care is characterized by multiple transitions of patient care responsibilities. In most residency programs trainees manage transitions via verbal, written, or combined methods of communication termed "sign-out." Often sign-out occurs without standardization or supervision.

PURPOSE

The purpose was to assess daily sign-out with a goal of identifying aspects of this process most in need of improvement.

METHODS

This was a prospective, observational cohort study of interns' sign-out conducted by industrial engineering students. Daily sign-out was analyzed for inclusion of multiple criteria and scored on organization (on a scale of 0-4) based on how effectively written information was conveyed.

RESULTS

We observed 124 unique verbal and written sign-outs. We found that 99% of sign-outs included a general hospital course. Sign-outs were well organized with a mean of 3.1, though substantial variation was noted (SD = 0.8). Directions for anticipated patient events were included in only 42% of sign-outs. Do Not Resuscitate (DNR) or advanced directive discussions were reported in only 11% of sign-outs. Only 50% of successive daily sign-outs were updated.

CONCLUSIONS

We found variability in the content and organization of interns' sign-out, possibly reflecting a lack of instruction and supervision. Standardization of sign-out content, and education on good sign-out skills are increasingly important as patient hand-offs become more frequent.

Code status discussions between attending hospitalist physicians and medical patients at hospital admission

BACKGROUND

Bioethicists and professional associations give specific recommendations for discussing cardiopulmonary resuscitation (CPR).

OBJECTIVE

To determine whether attending hospitalist physicians' discussions meet these recommendations.

DESIGN

Cross-sectional observational study on the medical services at two hospitals within a university system between August 2008 and March 2009.

PARTICIPANTS

Attending hospitalist physicians and patients who were able to communicate verbally about their medical care.

MAIN MEASURES

We identified code status discussions in audio-recorded admission encounters via physician survey and review of encounter transcripts. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions; Cohen's kappa was 0.64-1 for all reported elements.

KEY RESULTS

Audio-recordings of 80 patients' admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2-14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2-8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients' preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.

CONCLUSIONS

Code status was not discussed with many seriously ill patients. Discussions were brief, and did not include elements that bioethicists and professional associations recommend to promote patient autonomy. Local and national guidelines, research, and clinical practice changes are needed to clarify and systematize with whom and how CPR is discussed at hospital admission.

Documentation of Information and Care Planning for Patients with Advanced Cancer

Objective: We evaluated the association between patient characteristics, utilization of care, and documentation of information and care planning. Methods: We abstracted chart documentation for 238 deceased patients with advanced cancer. Results: Do-not-resuscitate (DNR) orders were documented in 34% of charts, advance directives in 19%, hospice discussion in 49%, and hospice referral in 36%. Compared to white patients, black patients had a higher odds of hospice discussion (Adjusted Odds Ratio [AOR] 2.11; 95% CI 1.18 to 3.76) and hospice referral (AOR 2.18; 95% CI 1.21 to 3.93). Documentation of advance directive and DNR order was associated with higher utilization of care. Conclusion: Black race was associated with higher odds of hospice discussion and referral in a primarily Medicaid population. Additional research is needed to explore variations in physician–patient discussion about hospice among different patient populations.

Code Status Discussions at Hospital Admission Are Not Associated With Patient and Surrogate Satisfaction With Hospital Care: Results From the Multicenter Hospitalist Study

Background: Physicians may avoid code status discussions for fear of decreasing patient or surrogate satisfaction. Methods: Charts of patients admitted to medical services at 6 university hospitals were reviewed for documentation of a code status discussion in the first 24 hours of admission. Satisfaction with care provided during the hospitalization was assessed by telephone 1 month after discharge. Results: Of the 11 717 patients with 1-month follow-up, 1090 (9.3%) had a code status discussion documented. Patient or surrogate satisfaction did not differ by whether a discussion was documented. The lack of association persisted after adjusting for patient’s severity of illness and using propensity adjustment for likelihood of having a discussion. Conclusions: Discussing code status on admission to the inpatient setting did not affect patient or surrogate satisfaction.

Influence of language barriers on outcomes of hospital care for general medicine inpatients

BACKGROUND

Few studies have examined whether patients with language barriers receive worse hospital care in terms of quality or efficiency.

OBJECTIVE

: To examine whether patients' primary language influences hospital outcomes.

DESIGN AND SETTING

Observational cohort of urban university hospital general medical admissions between July 1, 2001 to June 30, 2003.

PATIENTS

Eighteen years old or older whose hospital data included information on their primary language, specifically English, Russian, Spanish or Chinese.

MEASUREMENTS

Hospital costs, length of stay (LOS), and odds for 30-day readmission or 30-day mortality.

RESULTS

Of 7023 admitted patients, 84% spoke English, 8% spoke Chinese, 4% Russian and 4% Spanish. In multivariable models, non-English and English speakers had statistically similar total cost, LOS, and odds for mortality. However, non-English speakers had higher adjusted odds of readmission (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.0-1.7). Higher odds for readmission persisted for Chinese and Spanish speakers when compared to all English speakers (OR, 1.7; 95% CI, 1.2-2.3 and OR, 1.5; 95% CI, 1.0-2.3 respectively).

CONCLUSIONS

After accounting for socioeconomic variables and comorbidities, non-English speaking Latino and Chinese patients have higher risk for readmission. Whether language barriers produce differences in readmission or are a marker for less access to post-hospital care remains unclear. Journal of Hospital Medicine 2010;5:276-282. (c) 2010 Society of Hospital Medicine.

Do hospitalists affect clinical outcomes and efficiency for patients with acute upper gastrointestinal hemorrhage (UGIH)?

BACKGROUND

Care by hospitalists has been associated with improved/similar clinical outcomes and efficiency. However, less is known about their effect on conditions dependent upon specialists for procedures/treatment plans. Our objective was to compare care for upper gastrointestinal hemorrhage (UGIH) patients attended by academic hospitalists and nonhospitalists.

METHODS

The study included 450 UGIH patients admitted to general medical services of 6 teaching hospitals. Outcomes included in-hospital mortality and complications (ie, recurrent bleeding, intensive care unit [ICU] transfer, decompensation, transfusion, reendoscopy, 30-day readmission). Efficiency was measured by hospital costs and length of stay (LOS).

RESULTS

Of 450 patients, 40% (177) were cared for by hospitalists with no differences between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy (EGD), Rockall risk score, or Charlson comorbidity index. Unadjusted clinical outcomes between hospitalists and nonhospitalists were similar except for 2 outcomes: patients cared for by hospitalists were more likely to receive a transfusion (74% vs. 63%; P = 0.02) or be readmitted within 30 days (7.3% vs. 3.3%; P = 0.05). However, differences in adverse outcomes between providers were not seen after multivariable adjustments. Median LOS was similar for hospitalists and nonhospitalists (4 days; P = 0.69), but patients cared for by hospitalists had higher median costs ($7,359 vs. $6,181; P < 0.01). In multivariable analyses, LOS was similar (5.2 vs. 4.7 days; P = 0.15) and costs remained higher for the hospitalist-led teams (P < 0.03).

CONCLUSIONS

Despite having similar overall outcomes and LOS, costs were higher in UGIH patients attended by hospitalists. These results suggest that the academic hospitalist model may be tempered in patients requiring specialists for procedures or management.