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Bhasin A, Griffey RT, Ruhnke GW. Many (un)happy returns: Challenges and opportunities for potentially avoidable ED visits after discharge to a skilled nursing facility. J Hosp Med 2024; 19:77-78. [PMID: 37997187 DOI: 10.1002/jhm.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/04/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Ajay Bhasin
- Department of Medicine, Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Pediatrics, Division of Hospital-Based Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard T Griffey
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gregory W Ruhnke
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, Illinois, USA
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Linker AS, Jones CD, Ruhnke GW. Can we build the plane while flying? Creative approaches to expand the research community in hospital medicine. J Hosp Med 2023. [PMID: 37129425 DOI: 10.1002/jhm.13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/03/2023]
Affiliation(s)
- Anne S Linker
- Icahn School of Medicine at Mount Sinai, Division of Hospital Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Christine D Jones
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Geriatrics and Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Gregory W Ruhnke
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, Illinois, USA
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Hwang YJ, Ruhnke GW. Necessary hospitalizations, unnecessarily long stays: The problem of timely discharge. J Hosp Med 2023; 18:369-370. [PMID: 36935554 DOI: 10.1002/jhm.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/21/2023]
Affiliation(s)
- Yoseob Joseph Hwang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gregory W Ruhnke
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, Illinois, USA
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4
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Chen T, O'Donnell PH, Middlestadt M, Ruhnke GW, Danahey K, van Wijk XMR, Choksi A, Knoebel R, Hartman S, Yeo KTJ, Friedman PN, Ratain MJ, Nutescu EA, O'Leary KJ, Perera MA, Meltzer DO. Implementation of pharmacogenomics into inpatient general medicine. Pharmacogenet Genomics 2023; 33:19-23. [PMID: 36729768 DOI: 10.1097/fpc.0000000000000487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pharmacogenomics is a crucial piece of personalized medicine. Preemptive pharmacogenomic testing is only used sparsely in the inpatient setting and there are few models to date for fostering the adoption of pharmacogenomic treatment in the inpatient setting. We created a multi-institutional project in Chicago to enable the translation of pharmacogenomics into inpatient practice. We are reporting our implementation process and barriers we encountered with solutions. This study, 'Implementation of Point-of-Care Pharmacogenomic Decision Support Accounting for Minority Disparities', sought to implement pharmacogenomics into inpatient practice at three sites: The University of Chicago, Northwestern Memorial Hospital, and the University of Illinois at Chicago. This study involved enrolling African American adult patients for preemptive genotyping across a panel of actionable germline variants predicting drug response or toxicity risk. We report our approach to implementation and the barriers we encountered engaging hospitalists and general medical providers in the inpatient pharmacogenomic intervention. Our strategies included: a streamlined delivery system for pharmacogenomic information, attendance at hospital medicine section meetings, use of physician and pharmacist champions, focus on hospitalists' care and optimizing system function to fit their workflow, hand-offs, and dealing with hospitalists turnover. Our work provides insights into strategies for the initial engagement of inpatient general medicine providers that we hope will benefit other institutions seeking to implement pharmacogenomics in the inpatient setting.
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Affiliation(s)
- Thomas Chen
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Peter H O'Donnell
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | - Gregory W Ruhnke
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, Illinois, USA
| | | | - Anish Choksi
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | - Randall Knoebel
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | - Seth Hartman
- Department of Pharmacy, The University of Chicago, Chicago, Illinois, USA
| | | | - Paula N Friedman
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA
| | - Mark J Ratain
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kevin J O'Leary
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Northwestern University, Chicago, Illinois, USA
| | - David O Meltzer
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
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Ruhnke GW, Metlay JP. Hospital medicine: It's gotten bigger, but can we make it better? J Hosp Med 2022; 17:940-941. [PMID: 36205324 DOI: 10.1002/jhm.12978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Joshua P Metlay
- Department of Medicine, Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ruhnke GW, Lindenauer PK, Lyttle CS, Meltzer DO. The Impact of Principal Diagnosis on Readmission Risk among Patients Hospitalized for Community-Acquired Pneumonia. Am J Med Qual 2022; 37:307-313. [PMID: 35026784 PMCID: PMC9246841 DOI: 10.1097/jmq.0000000000000042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Coding variation distorts performance/outcome statistics not eliminated by risk adjustment. Among 1596 community-acquired pneumonia patients hospitalized from 1998 to 2012 identified using an evidence-based algorithm, the authors measured the association of principal diagnosis (PD) with 30-day readmission, stratified by Pneumonia Severity Index risk class. The 152 readmitted patients were more ill (Pneumonia Severity Index class V 38.8% versus 25.8%) and less likely to have a pneumonia PD (52.6% versus 69.9%). Among patients with PDs of pneumonia, respiratory failure, sepsis, and aspiration, mortality/readmission rates were 3.9/8.5%, 28.8/14.0%, 24.7/19.6%, and 9.0/15.0%, respectively. The nonpneumonia PDs were associated with a greater risk of adjusted 30-day readmission: respiratory failure odds ratio (OR) 1.89 (95% confidence interval [CI], 1.13-3.15), sepsis OR 2.54 (95% CI, 1.52-4.26), and possibly aspiration OR 1.73 (95% CI, 0.88-3.41). With increasing use of alternative PDs among pneumonia patients, quality reporting must account for variations in condition coding practices. Rigorous risk adjustment does not eliminate the need for accurate, consistent case definition in producing valid quality measures.
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Affiliation(s)
- Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
| | | | - David O. Meltzer
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
- Center for Health and the Social Sciences, University of Chicago, Chicago, IL
- Harris School of Public Policy, University of Chicago, Chicago, IL
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Ruhnke GW, Detsky AS. Should medical residents who care for COVID-19 patients receive hazard pay? J Hosp Med 2022; 17:140-141. [PMID: 35504530 PMCID: PMC9088306 DOI: 10.1002/jhm.2779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Gregory W. Ruhnke
- Section of Hospital Medicine, Department of MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Allan S. Detsky
- Department of Medicine, Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
- Department of MedicineSinai Health System and University Health NetworkTorontoOntarioCanada
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Saulsberry L, Danahey K, Middlestadt M, O’Leary KJ, Nutescu EA, Chen T, Lee JC, Ruhnke GW, George D, House L, van Wijk XMR, Yeo KTJ, Choksi A, Hartman SW, Knoebel RW, Friedman PN, Rasmussen LV, Ratain MJ, Perera MA, Meltzer DO, O’Donnell PH. Applicability of Pharmacogenomically Guided Medication Treatment during Hospitalization of At-Risk Minority Patients. J Pers Med 2021; 11:1343. [PMID: 34945816 PMCID: PMC8709436 DOI: 10.3390/jpm11121343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/17/2022] Open
Abstract
Known disparities exist in the availability of pharmacogenomic information for minority populations, amplifying uncertainty around clinical utility for these groups. We conducted a multi-site inpatient pharmacogenomic implementation program among self-identified African-Americans (AA; n = 135) with numerous rehospitalizations (n = 341) from 2017 to 2020 (NIH-funded ACCOuNT project/clinicaltrials.gov#NCT03225820). We evaluated the point-of-care availability of patient pharmacogenomic results to healthcare providers via an electronic clinical decision support tool. Among newly added medications during hospitalizations and at discharge, we examined the most frequently utilized medications with associated pharmacogenomic results. The population was predominantly female (61%) with a mean age of 53 years (range 19-86). On average, six medications were newly prescribed during each individual hospital admission. For 48% of all hospitalizations, clinical pharmacogenomic information was applicable to at least one newly prescribed medication. Most results indicated genomic favorability, although nearly 29% of newly prescribed medications indicated increased genomic caution (increase in toxicity risk/suboptimal response). More than one of every five medications prescribed to AA patients at hospital discharge were associated with cautionary pharmacogenomic results (most commonly pantoprazole/suboptimal antacid effect). Notably, high-risk pharmacogenomic results (genomic contraindication) were exceedingly rare. We conclude that the applicability of pharmacogenomic information during hospitalizations for vulnerable populations at-risk for experiencing health disparities is substantial and warrants continued prospective investigation.
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Affiliation(s)
- Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, IL 60637, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Center for Research Informatics, The University of Chicago, Chicago, IL 60637, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
| | - Kevin J. O’Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Edith A. Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, IL 60612, USA;
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Thomas Chen
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL 60612, USA;
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - David George
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
| | - Larry House
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
| | - Xander M. R. van Wijk
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Kiang-Teck J. Yeo
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Anish Choksi
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Seth W. Hartman
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Randall W. Knoebel
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Paula N. Friedman
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - Luke V. Rasmussen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Mark J. Ratain
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Minoli A. Perera
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - David O. Meltzer
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - Peter H. O’Donnell
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
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Molloy MJ, Ruhnke GW. Goal-Concordant Care After Hospitalization for Serious Acute Illness: A Key Opportunity for Hospitalists in Patient-Centered Outcomes. J Hosp Med 2021; 16:703. [PMID: 34752215 DOI: 10.12788/jhm.3723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Matthew J Molloy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Ruhnke GW, Richterman A. Predictors of COVID-19 Seropositivity Among Healthcare Workers: An Important Piece of an Incomplete Puzzle. J Hosp Med 2021; 16:320. [PMID: 33929955 DOI: 10.12788/jhm.3632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aaron Richterman
- Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Ruhnke GW, Bhatia RS. Physician-Driven Discretionary Utilization: Measuring Overuse and Choosing Wisely. J Hosp Med 2021; 16:125. [PMID: 33523796 DOI: 10.12788/jhm.3559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Illinois
| | - R Sacha Bhatia
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
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Affiliation(s)
- Gregory W Ruhnke
- Assistant Professor, Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
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Murakami H, Hotta D, Ruhnke GW. Paradoxical doppler echocardiographic parameters during recovery of left atrial contractility after spontaneous conversion from paroxysmal atrial fibrillation to sinus rhythm. J Cardiol Cases 2020; 22:302-304. [DOI: 10.1016/j.jccase.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/17/2020] [Accepted: 08/03/2020] [Indexed: 11/25/2022] Open
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Abstract
IMPORTANCE The association of patient desire to participate in health care decisions with care satisfaction is poorly understood. The contributions of such desire, expectations of care, and quality of care in assessing patient satisfaction are not known. OBJECTIVE To investigate the association of hospitalized patients' desire to delegate decisions to their physician with care dissatisfaction. DESIGN, SETTING, AND PARTICIPANTS Survey study in an academic research setting. As part of The University of Chicago Hospitalist Study, data were collected on 13 902 hospitalized patients admitted to the general internal medicine service of The University of Chicago Medical Center between July 1, 2004, and September 30, 2012, who answered an inpatient survey administered soon after the time of admission and a 30-day follow-up survey. The dates of analysis were January 2014 to June 2015. EXPOSURE Patient-reported preference to leave medical decisions to their physician (definitely agree or somewhat agree vs somewhat disagree or definitely disagree). MAIN OUTCOMES AND MEASURES The main outcomes were patient-reported dissatisfaction with overall service, dissatisfaction with physician care, and lack of confidence and trust in the physicians providing treatment, which were obtained from the 30-day follow-up survey. RESULTS The sample population included 13 902 patients (mean [SD] age, 56.7 [19.1] years; 60.4% female [n = 8397] and 74.2% African American [n = 10 310]) who completed both surveys. Overall, 53.2% had no higher educational attainment, 22.7% were insured by Medicaid, and 51.1% reported a general self-assessed health status of fair or poor. The proportions of respondents who agreed and disagreed with delegating decisions to the responsible physician were 71.1% and 28.9%, respectively. A statistically significantly higher proportion of those who agreed rated their overall care as excellent or very good compared with those who disagreed (68.0% vs 62.5%; P < .001). Similarly, a statistically significantly higher proportion of those who agreed were extremely satisfied with the physician care received (67.8% vs 62.5%; P < .001). In the multivariable logistic regression models, compared with those patients who definitely agreed with delegation, patients who definitely disagreed were more likely to be dissatisfied with overall service (odds ratio [OR], 1.86; 95% CI, 1.54-2.24) and the physician care received (OR, 1.78; 95% CI, 1.42-2.22) and lack confidence and trust in the physicians providing treatment (OR, 2.05; 95% CI, 1.62-2.59). CONCLUSIONS AND RELEVANCE The findings suggest that patient preferences to participate in medical decision-making are statistically significantly associated with dissatisfaction of hospitalized patients. Clinicians should individualize their encouragement of patient participation in diagnostic and management decisions to maximize patient satisfaction.
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Affiliation(s)
- Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Hyo Jung Tak
- Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha
| | - David O. Meltzer
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois
- Center for Health and the Social Sciences, Harris School of Public Policy, The University of Chicago, Chicago, Illinois
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Auerbach A, O’Leary KJ, Greysen SR, Harrison JD, Kripalani S, Ruhnke GW, Vasilevskis EE, Maselli J, Fang MC, Herzig SJ, Lee T, Schnipper J. Hospital Ward Adaptation During the COVID-19 Pandemic: A National Survey of Academic Medical Centers. J Hosp Med 2020; 15:483-488. [PMID: 32804610 PMCID: PMC7518133 DOI: 10.12788/jhm.3476] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/21/2020] [Indexed: 11/20/2022]
Abstract
IMPORTANCE Although intensive care unit (ICU) adaptations to the coronavirus disease of 2019 (COVID-19) pandemic have received substantial attention , most patients hospitalized with COVID-19 have been in general medical units. OBJECTIVE To characterize inpatient adaptations to care for non-ICU COVID-19 patients. DESIGN Cross-sectional survey. SETTING A network of 72 hospital medicine groups at US academic centers. MAIN OUTCOME MEASURES COVID-19 testing, approaches to personal protective equipment (PPE), and features of respiratory isolation units (RIUs). RESULTS Fifty-one of 72 sites responded (71%) between April 3 and April 5, 2020. At the time of our survey, only 15 (30%) reported COVID-19 test results being available in less than 6 hours. Half of sites with PPE data available reported PPE stockpiles of 2 weeks or less. Nearly all sites (90%) reported implementation of RIUs. RIUs primarily utilized attending physicians, with few incorporating residents and none incorporating students. Isolation and room-entry policies focused on grouping care activities and utilizing technology (such as video visits) to communicate with and evaluate patients. The vast majority of sites reported decreases in frequency of in-room encounters across provider or team types. Forty-six percent of respondents reported initially unrecognized non-COVID-19 diagnoses in patients admitted for COVID-19 evaluation; a similar number reported delayed identification of COVID-19 in patients admitted for other reasons. CONCLUSION The COVID-19 pandemic has required medical wards to rapidly adapt with expanding use of RIUs and use of technology emerging as critical approaches. Reports of unrecognized or delayed diagnoses highlight how such adaptations may produce potential adverse effects on care.
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Affiliation(s)
- Andrew Auerbach
- University of California, San Francisco School of Medicine, San Francisco, California
- Corresponding Author: Andrew Auerbach, MD, MPH; Twitter: @ADAuerbach
| | - Kevin J O’Leary
- Northwestern University Medical Center, Feinberg School of Medicine, Chicago, Illinois
| | - S Ryan Greysen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Harrison
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Sunil Kripalani
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Judith Maselli
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Margaret C Fang
- University of California, San Francisco School of Medicine, San Francisco, California
| | | | - Tiffany Lee
- University of California, San Francisco School of Medicine, San Francisco, California
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17
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Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA.
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Anderson ML, Turbow S, Willgerodt MA, Ruhnke GW. Education in a Crisis: The Opportunity of Our Lives. J Hosp Med 2020; 15:287-289. [PMID: 32379031 DOI: 10.12788/jhm.3431] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Mel L Anderson
- Primary and Specialty Care Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Sara Turbow
- Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Division of Preventive Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mayumi A Willgerodt
- Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Murakami H, Tahara S, Shibata M, Hotta D, Ruhnke GW. Anomalous Origin of the Left Circumflex Artery ― Role of Echocardiography ―. Circ Rep 2019; 1:153. [PMID: 33693131 PMCID: PMC7890295 DOI: 10.1253/circrep.cr-19-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Shizuka Tahara
- Department of Clinical Laboratory Medicine, Hokkaido Cardiovascular Hospital
| | - Masayoshi Shibata
- Department of Clinical Laboratory Medicine, Hokkaido Cardiovascular Hospital
| | - Daisuke Hotta
- Department of Cardiology, Hokkaido Cardiovascular Hospital
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Abstract
To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.
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Affiliation(s)
- Kiran Raj Pandey
- The Center for Health and the Social Sciences, University of Chicago, IL
| | - Fan Yang
- Department of Biostatistics and Informatics, University of Colorado Denver, Aurora, CO
| | | | | | - David O. Meltzer
- The Center for Health and the Social Sciences, University of Chicago, IL
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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Abstract
RATIONALE Few cases of autoimmune pancreatitis (AIP) complicated by gastric varices, in the absence of splenic vein obstruction, have been described in the medical literature. The findings in this case parallel those of 3 previously described cases from Japan and support a pathologic explanation for the evolution of gastric varices in relation to early splenomegaly and the role of steroid therapy for AIP. PATIENT CONCERNS A 50-year-old male with a history of transfusion-requiring erosive gastritis and recently diagnosed AIP on steroid therapy for 2 weeks presented with a 2-day history of lightheadedness, abdominal pain, and melena. DIAGNOSIS Esophagogastroduodenoscopy (EGD) revealed prominent varices in the gastric fundus. An abdominal ultrasound with Doppler demonstrated patency of the splenic, hepatic, and portal veins. Review of previous imaging revealed that the splenic vein and the superior mesenteric vein (SMV) were occluded prior to the diagnosis of AIP and steroid therapy initiation. OUTCOME Following resolution of hemodynamic instability through fluid resuscitation and blood transfusion, the remainder of his hospital course was uneventful. Subsequent to discontinuation of steroid therapy, he developed near total reocclusion of both the splenic vein and SMV. LESSON Early steroid treatment should be considered in patients with uncomplicated AIP to prevent the occlusive vascular complications that are frequently associated with the pathophysiology of this disease process.
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Affiliation(s)
| | - Roop R. Gupta
- Gastroenterology, Department of Internal Medicine, Mercy Hospital and Medical Center
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
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Graham KL, Auerbach AD, Schnipper JL, Flanders SA, Kim CS, Robinson EJ, Ruhnke GW, Thomas LR, Kripalani S, Vasilevskis EE, Fletcher GS, Sehgal NJ, Lindenauer PK, Williams MV, Metlay JP, Davis RB, Yang J, Marcantonio ER, Herzig SJ. Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients. Ann Intern Med 2018; 168:766-774. [PMID: 29710243 PMCID: PMC6247894 DOI: 10.7326/m17-1724] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design Prospective cohort study. Setting 10 academic medical centers in the United States. Patients 822 adults readmitted to a general medicine service. Measurements For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source Association of American Medical Colleges.
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Affiliation(s)
- Kelly L. Graham
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Andrew D. Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA
| | - Jeffrey L. Schnipper
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
| | - Scott A. Flanders
- Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI
| | | | - Edmondo J. Robinson
- Value Institute and Department of Medicine, Christiana Care Health System, Wilmington, DE
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Larissa R. Thomas
- Division of Hospital Medicine, University of California San Francisco at Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN
| | - Eduard E. Vasilevskis
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Grant S. Fletcher
- Division of General Internal Medicine, Department of Medicine, Harvorview Medical Center, University of Washington, Seattle, WA
| | - Neil J. Sehgal
- Division of General Medicine, University of Washington, Seattle, WA
| | | | - Mark V. Williams
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Roger B. Davis
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Julius Yang
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Edward R. Marcantonio
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Shoshana J. Herzig
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Tada S, Shibata M, Ohno S, Haruki Y, Murakami H, Hotta D, Nojima M, Ruhnke GW. Investigation on the optimal implantation site and setting of Reveal LINQ ® avoiding interference with performance of transthoracic echocardiography. J Arrhythm 2018; 34:261-266. [PMID: 29951141 PMCID: PMC6009771 DOI: 10.1002/joa3.12037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/15/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The optimal implantation site of a new implantable cardiac monitor (ICM) named Reveal LINQ® may be limited based on a sufficient amplitude of R wave potential (AEP) acquisition because it is the same anatomic area used for transthoracic echocardiography (TTE). METHODS Among 18 healthy volunteers, we assessed AEPs in 3 combinations through parasternal placement of 2 electrodes, (i) in the 4th intercostal space (ICS; site A/setting a; A/a), (ii) the same setting in the 5th ICS (site B/setting a; B/a), and (iii) in a sagittal plane relative to the left sternal border at the 4th ICS (site A/setting b; A/b), and further measured AFPs in several body positions in all site-setting combinations: supine, left and right lateral decubitus, sitting, and standing. The degree of interference with TTE performance was assessed by placement of an imitation ICM in setting a at both sites A and B. RESULTS Only the AEPs in A/a and B/a met the criteria (AEP ≥ 0.3 mV) in all positions. The AEPs in the supine position with all combinations were higher than those achieved in other positions (P < .001). The imitation interfered with TTE performance at site A among 78% of subjects, but only 17% at site B (P = .0006). The end-diastolic dimension of the left ventricle at site A was decreased after the imitation placement (P = .028). At site B, all female subjects complained of discomfort because their brassieres overlaid the imitation. CONCLUSION The B/a combination is optimal; however, the personal discomfort related to brassieres should be considered.
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Affiliation(s)
- Shizuka Tada
- Department of Clinical Laboratory MedicineHokkaido Cardiovascular HospitalSapporoJapan
| | - Masayoshi Shibata
- Department of Clinical Laboratory MedicineHokkaido Cardiovascular HospitalSapporoJapan
| | - Seiko Ohno
- Department of Clinical Laboratory MedicineHokkaido Cardiovascular HospitalSapporoJapan
| | - Yasunobu Haruki
- Department of Clinical Laboratory MedicineHokkaido Cardiovascular HospitalSapporoJapan
| | - Hironori Murakami
- Department of CardiologyHokkaido Cardiovascular HospitalSapporoJapan
| | - Daisuke Hotta
- Department of CardiologyHokkaido Cardiovascular HospitalSapporoJapan
| | - Masanori Nojima
- Center for Translational ResearchThe Institute of Medical Science HospitalThe University of TokyoTokyoJapan
| | - Gregory W. Ruhnke
- Section of Hospital MedicineDepartment of MedicineUniversity of ChicagoChicagoILUSA
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24
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Ruhnke GW, Manning WG, Rubin DT, Meltzer DO. The Drivers of Discretionary Utilization: Clinical History Versus Physician Supply. Acad Med 2017; 92:703-708. [PMID: 28441679 PMCID: PMC5407298 DOI: 10.1097/acm.0000000000001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Because the effect of physician supply on utilization remains controversial, literature based on non-Medicare populations is sparse, and a physician supply expansion is under way, the potential for physician-induced demand across diverse populations is important to understand. A substantial proportion of gastrointestinal endoscopies may be inappropriate. The authors analyzed the impact of physician supply, practice patterns, and clinical history on esophagogastroduodenoscopy (EGD, defined as discretionary) among patients hospitalized with lower gastrointestinal bleeding (LGIB). METHOD Among 34,344 patients hospitalized for LGIB from 2004 to 2009, 43.1% and 21.3% had a colonoscopy or EGD, respectively, during the index hospitalization or within 6 months after. Linking to the Dartmouth Atlas via patients' hospital referral region, gastroenterologist density and hospital care intensity (HCI) index were ascertained. Adjusting for age, gender, comorbidities, and race/education indicators, the association of gastroenterologist density, HCI index, and history of upper gastrointestinal disease with EGD was estimated using logistic regression. RESULTS EGD was not associated with gastroenterologist density or HCI index, but was associated with a history of upper gastrointestinal disease (OR 2.30; 95% CI 2.17-2.43), peptic ulcer disease (OR 4.82; 95% CI 4.26-5.45), and liver disease (OR 1.34; 95% CI 1.18-1.54). CONCLUSIONS Among patients hospitalized with LGIB, large variation in gastroenterologist density did not predict EGD, but relevant clinical history did, with association strengths commensurate with risk for upper gastrointestinal bleeding. In the scenario studied, no evidence was found that specialty physician supply increases will result in more discretionary care within commercially insured populations.
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Affiliation(s)
- Gregory W Ruhnke
- G.W. Ruhnke is assistant professor, Section of Hospital Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois.W.G. Manning was professor, Department of Health Studies, and professor, Public Policy Studies and Public Health Sciences, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois.D.T. Rubin is professor of medicine and section chief, Gastroenterology, Hepatology and Nutrition, Department of Medicine, Pritzker School of Medicine, University of Chicago Medicine, Chicago, Illinois.D.O. Meltzer is section chief, Hospital Medicine, Fanny L. Pritzker Professor of Medicine, and director, Center for Health and the Social Sciences, Pritzker School of Medicine, and professor, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois
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25
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Dong T, Cursio JF, Qadir S, Lindenauer PK, Ruhnke GW. Discharge disposition as an independent predictor of readmission among patients hospitalised for community-acquired pneumonia. Int J Clin Pract 2017; 71. [PMID: 28371024 DOI: 10.1111/ijcp.12935] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 02/12/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is the most common non-obstetrical reason for hospital admission, the leading infectious cause of death, and a target for public reporting. CAP has thus become a target of quality improvement and pay-for-performance efforts. However, the relationship between discharge disposition and readmission risk has not been investigated. METHODS We studied CAP patients admitted to the University of Chicago from 11/2011 to 04/2015. We collected demographic information, comorbidities, laboratory values, vital signs, a modified pneumonia severity index (PSI), length of stay (LOS), clinical instabilities before discharge, discharge disposition and 30-day all-cause readmission. A multivariate logistic regression was performed, specifying readmission as the dependent variable, including as independent variables gender, ethnicity, insurance status, discharge disposition, PSI tertile, the number of clinical instabilities, LOS and comorbidities. RESULTS Of the 2892 CAP patients identified, 14.9% were readmitted. The distribution of discharge disposition was: 43.0% home without services, 26.1% home with home health care (HHC), 16.2% to a skilled nursing or subacute rehabilitation facility and 14.8% to an acute rehabilitation or long-term acute care facility. Of patients discharged home with HHC, 20.1% were readmitted, compared to 11.5% discharged home without services. In the multivariate regression model, being discharged home with HHC was associated with a markedly greater risk of readmission (Odds ratio 1.58 [95% confidence interval 1.21-2.07]). CONCLUSIONS Discharge home with HHC is an independent predictor of readmission risk among hospitalised CAP patients. Discharging providers should carefully consider follow-up care and social factors that may impact the risk of readmission among such patients.
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Affiliation(s)
- Tien Dong
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - John F Cursio
- Center for Quality, Quality Performance Improvement, The University of Chicago Medicine, Chicago, IL, USA
| | - Samira Qadir
- Center for Quality, Quality Performance Improvement, The University of Chicago Medicine, Chicago, IL, USA
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
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Greysen SR, Harrison JD, Kripalani S, Vasilevskis E, Robinson E, Metlay J, Schnipper JL, Meltzer D, Sehgal N, Ruhnke GW, Williams MV, Auerbach AD. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf 2017; 26:33-41. [PMID: 26769841 DOI: 10.1136/bmjqs-2015-004570] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 12/04/2015] [Accepted: 12/19/2015] [Indexed: 11/03/2022]
Abstract
IMPORTANCE Patient concerns at or before discharge inform many transitional care interventions; few studies examine patients' perceptions of self-care and other factors related to readmission. OBJECTIVES To characterise patient-reported or caregiver-reported factors contributing to readmission. DESIGN, SETTING AND PARTICIPANTS Cross-sectional, national study of general medicine patients readmitted within 30 days at 12 US hospitals. Interviews included multiple-choice survey and open-ended survey questions of patients or their caregivers. MEASUREMENTS Multiple-choice survey quantified post-discharge difficulty in seven domains of self-care: medication use, contacting providers, transportation, basic needs (eg, food and shelter), diet, social support and substance abuse. Open-ended responses were coded into themes that added depth to the domains above or captured additional patient-centred concerns. RESULTS We interviewed 1066 readmitted patients. 91% reported understanding their discharge plan; however, only 37% reported that providers asked about barriers to carrying out the plan. 52% reported experiencing difficulty in ≥1 self-care domains ranging in frequency from 22% (diet) to 7% (substance use); 26% experienced difficulty in two or more domains. Among 508 patients (48% overall) who reported no difficulties in these domains, two-thirds either could not attribute their readmission to any specific difficulty (34%) or attributed their readmission to progression or persistence of their disease despite following their discharge plan (31%). Only 20% attributed their readmission to early discharge (8%), poor-quality hospital care (6%) or issues such as inadequate discharge instructions or follow-up care (6%). LIMITATIONS The study population included only patients readmitted at academic medical centres and may not be representative of community-based care. CONCLUSION Patients readmitted within 30 days reported understanding their discharge plans, but frequent difficulties in self-care and low anticipatory guidance for resolving these issues after discharge.
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Affiliation(s)
- S Ryan Greysen
- Division of Hospital Medicine, University of California, San Francisco, CA, USA
| | - James D Harrison
- Division of Hospital Medicine, University of California, San Francisco, CA, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University, Nashville, TN, USA
| | | | | | - Joshua Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffery L Schnipper
- Division of General Internal Medicine, Brigham and Womens Hospital, Boston, MA, USA
| | - David Meltzer
- Section of Hospital Medicine, University of Chicago, IL, USA
| | - Neil Sehgal
- School of Public Health, University of California, Berkeley, CA, USA
| | | | - Mark V Williams
- Division of Hospital Medicine, University of Kentucky, Louisville, KY, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California, San Francisco, CA, USA
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Schram AW, Hougham GW, Meltzer DO, Ruhnke GW. Palliative Care in Critical Care Settings: A Systematic Review of Communication-Based Competencies Essential for Patient and Family Satisfaction. Am J Hosp Palliat Care 2016; 34:887-895. [PMID: 27582376 DOI: 10.1177/1049909116667071] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is an emerging literature on the physician competencies most meaningful to patients and their families. However, there has been no systematic review on physician competency domains outside direct clinical care most important for patient- and family-centered outcomes in critical care settings at the end of life (EOL). Physician competencies are an essential component of palliative care (PC) provided at the EOL, but the literature on those competencies relevant for patient and family satisfaction is limited. A systematic review of this important topic can inform future research and assist in curricular development. METHODS Review of qualitative and quantitative empirical studies of the impact of physician competencies on patient- and family-reported outcomes conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews. The data sources used were PubMed, MEDLINE, Web of Science, and Google Scholar. RESULTS Fifteen studies (5 qualitative and 10 quantitative) meeting inclusion and exclusion criteria were identified. The competencies identified as critical for the delivery of high-quality PC in critical care settings are prognostication, conflict mediation, empathic communication, and family-centered aspects of care, the latter being the competency most frequently acknowledged in the literature identified. CONCLUSION Prognostication, conflict mediation, empathic communication, and family-centered aspects of care are the most important identified competencies for patient- and family-centered PC in critical care settings. Incorporation of education on these competencies is likely to improve patient and family satisfaction with EOL care.
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Affiliation(s)
- Andrew W Schram
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - David O Meltzer
- 3 Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA.,4 Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Gregory W Ruhnke
- 3 Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
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Auerbach AD, Kripalani S, Vasilevskis EE, Sehgal N, Lindenauer PK, Metlay JP, Fletcher G, Ruhnke GW, Flanders SA, Kim C, Williams MV, Thomas L, Giang V, Herzig SJ, Patel K, Boscardin WJ, Robinson EJ, Schnipper JL. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med 2016; 176:484-93. [PMID: 26954564 PMCID: PMC6900926 DOI: 10.1001/jamainternmed.2015.7863] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement. OBJECTIVES To determine preventability of readmissions and to use these estimates to prioritize areas for improvement. DESIGN, SETTING, AND PARTICIPANTS An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors. MAIN OUTCOME AND MEASURE Likelihood that a readmission could have been prevented. RESULTS The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%). CONCLUSIONS AND RELEVANCE Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.
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Affiliation(s)
- Andrew D Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Sunil Kripalani
- Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Neil Sehgal
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Joshua P Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Grant Fletcher
- Division of General Internal Medicine, Harborview Medical Center, Seattle, Washington
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Christopher Kim
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mark V Williams
- Center for Health Services Research, University of Kentucky College of Medicine, Louisville
| | - Larissa Thomas
- Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California
| | - Vernon Giang
- Department of Medicine, California Pacific Medical Center, San Francisco
| | - Shoshana J Herzig
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - W John Boscardin
- Department of Medicine, University of California, San Francisco15Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Edmondo J Robinson
- Value Institute and Department of Medicine, Christiana Care Health System, Wilmington, Delaware
| | - Jeffrey L Schnipper
- Hospital Medicine Service, Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Siddique J, Ruhnke GW, Flores A, Prochaska MT, Paesch E, Meltzer DO, Whelan CT. Applying Classification Trees to Hospital Administrative Data to Identify Patients with Lower Gastrointestinal Bleeding. PLoS One 2015; 10:e0138987. [PMID: 26406318 PMCID: PMC4583289 DOI: 10.1371/journal.pone.0138987] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 09/07/2015] [Indexed: 01/17/2023] Open
Abstract
Background Lower gastrointestinal bleeding (LGIB) is a common cause of acute hospitalization. Currently, there is no accepted standard for identifying patients with LGIB in hospital administrative data. The objective of this study was to develop and validate a set of classification algorithms that use hospital administrative data to identify LGIB. Methods Our sample consists of patients admitted between July 1, 2001 and June 30, 2003 (derivation cohort) and July 1, 2003 and June 30, 2005 (validation cohort) to the general medicine inpatient service of the University of Chicago Hospital, a large urban academic medical center. Confirmed cases of LGIB in both cohorts were determined by reviewing the charts of those patients who had at least 1 of 36 principal or secondary International Classification of Diseases, Ninth revision, Clinical Modification (ICD-9-CM) diagnosis codes associated with LGIB. Classification trees were used on the data of the derivation cohort to develop a set of decision rules for identifying patients with LGIB. These rules were then applied to the validation cohort to assess their performance. Results Three classification algorithms were identified and validated: a high specificity rule with 80.1% sensitivity and 95.8% specificity, a rule that balances sensitivity and specificity (87.8% sensitivity, 90.9% specificity), and a high sensitivity rule with 100% sensitivity and 91.0% specificity. Conclusion These classification algorithms can be used in future studies to evaluate resource utilization and assess outcomes associated with LGIB without the use of chart review.
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Affiliation(s)
- Juned Siddique
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- * E-mail:
| | - Gregory W. Ruhnke
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Andrea Flores
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Micah T. Prochaska
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Elizabeth Paesch
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - David O. Meltzer
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Chad T. Whelan
- Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois, United States of America
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Meltzer DO, Ruhnke GW. Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model. Health Aff (Millwood) 2015; 33:770-7. [PMID: 24799573 DOI: 10.1377/hlthaff.2014.0072] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Patients who have been hospitalized often experience care coordination problems that worsen outcomes and increase costs. One reason is that hospital care and ambulatory care are often provided by different physicians. However, interventions to improve care coordination for hospitalized patients have not consistently improved outcomes and generally have not reduced costs. We describe the rationale for the Comprehensive Care Physician model, in which physicians focus their practice on patients at increased risk of hospitalization so that they can provide both inpatient and outpatient care to their patients. We also describe the design and implementation of a study supported by the Center for Medicare and Medicaid Innovation to assess the model's effects on costs and outcomes. Evidence concerning the effectiveness of the program is expected by 2016. If the program is found to be effective, the next steps will be to assess the durability of its benefits and the model's potential for dissemination; evidence to the contrary will provide insights into how to alter the program to address sources of failure.
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Ruhnke GW, Meltzer DO. Constipation during acute hospitalisation: vigilance critical for all patients at high risk. Int J Clin Pract 2015; 69:388-9. [PMID: 25816906 DOI: 10.1111/ijcp.12585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- G W Ruhnke
- Section of Hospital Medicine, Department of Medicine, Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA.
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Abstract
The Nationwide Inpatient Sample aggregated data from approximately 20% of US hospital admissions from 1993 to 2011. Prior literature found that pneumonia admissions decreased following the introduction of the pneumococcal vaccine in 2000. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes provide information regarding pneumonia pathogens, but no studies, to our knowledge, have used these codes to analyze longitudinal trends in the pathogens documented during hospitalizations for pneumonia.
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Affiliation(s)
- Sean B Smith
- Department of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, Illinois
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Curtis H Weiss
- Department of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, Illinois
| | - Grant W Waterer
- School of Medicine and Pharmacology, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Richard G Wunderink
- Department of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, Illinois
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Tak HJ, Hougham GW, Ruhnke A, Ruhnke GW. The effect of in-office waiting time on physician visit frequency among working-age adults. Soc Sci Med 2014; 118:43-51. [PMID: 25089963 DOI: 10.1016/j.socscimed.2014.07.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 07/16/2014] [Accepted: 07/23/2014] [Indexed: 10/25/2022]
Abstract
Disparities in unmet health care demand resulting from socioeconomic, racial, and financial factors have received a great deal of attention in the United States. However, out-of-pocket costs alone do not fully reflect the total opportunity cost that patients must consider as they seek medical attention. While there is an extensive literature on the price elasticity of demand for health care, empirical evidence regarding the effect of waiting time on utilization is sparse. Using the nationally representative 2003 Community Tracking Study Household Survey, the most recent iteration containing respondents' physician office visit frequency and estimated in-office waiting time in the United States (N = 23,484), we investigated the association between waiting time and calculated time cost with the number of physician visits among a sample of working-age adults. To avoid the bias that literature suggests would result from excluding respondents with zero physician visits, we imputed waiting time for the essential inclusion of such individuals. On average, respondents visited physician offices 3.55 times, during which time they waited 28.7 min. The estimates from a negative binomial model indicated that a doubling of waiting time was associated with a 7.7 percent decrease (p-value < 0.001) in physician visit frequency. For women and unemployed respondents, who visited physicians more frequently, the decrease was even larger, suggesting a stronger response to greater waiting times. We believe this finding reflects the discretionary nature of incremental visits in these groups, and a consequent lower perceived marginal benefit of additional visits. The results suggest that in-office waiting time may have a substantial influence on patients' propensity to seek medical attention. Although there is a belief that expansions in health insurance coverage increase health care utilization by reducing financial barriers to access, our results suggest that unintended consequences may arise if in-office waiting time increases.
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Affiliation(s)
- Hyo Jung Tak
- Department of Health Management and Policy, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, EAD 601R, Fort Worth, TX 76107, USA.
| | - Gavin W Hougham
- Section of Hospital Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 5000, Chicago, IL 60637, USA; The Center for Health and the Social Sciences, University of Chicago, 5841 South Maryland Avenue, MC 1000, Chicago, IL 60637, USA.
| | | | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 5000, Chicago, IL 60637, USA.
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Meltzer DO, Ruhnke GW, Tak HJ. Actual involvement vs preference for involvement as an indicator of shared decision making-reply. JAMA Intern Med 2014; 174:644. [PMID: 24711194 DOI: 10.1001/jamainternmed.2013.12840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David O Meltzer
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Hyo Jung Tak
- School of Public Health, University of North Texas Health Science Center, Ft Worth
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Ruhnke GW, Coca Perraillon M, Cutler DM. The reply. Am J Med 2013; 126:e25. [PMID: 24157297 DOI: 10.1016/j.amjmed.2013.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/02/2013] [Indexed: 10/26/2022]
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Ruhnke GW, Doukas DJ. In reply-professional responsibility and certifying examinations. Mayo Clin Proc 2013; 88:1035-6. [PMID: 24001497 DOI: 10.1016/j.mayocp.2013.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
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Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med 2013; 173:1195-205. [PMID: 23712712 PMCID: PMC4390034 DOI: 10.1001/jamainternmed.2013.6048] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Patient participation in medical decision making has been associated with improved patient satisfaction and health outcomes. However, there is little evidence concerning its effects on resource utilization. Patient participation in medical decision making has been hypothesized to decrease excess utilization but might be expected to increase utilization when other decision makers have incentives to reduce utilization, as under prospective payment systems for hospital care. OBJECTIVE To examine the relationship between patient preferences for participation in medical decision making and health care utilization among hospitalized patients. DESIGN AND SETTING Survey study in an academic research setting. PARTICIPANTS A survey that included questions about preferences to receive medical information and to participate in medical decision making was administered to all patients admitted to the University of Chicago Medical Center general internal medicine service between July 1, 2003, and August 31, 2011, and completed by 21,754 (69.6%) of admitted patients. MAIN OUTCOMES AND MEASURES The survey data were linked with administrative data, including length of stay and total hospitalization costs. We used generalized linear models to measure the association of patient preference for participation in decision making with length of stay and costs. RESULTS The mean length of stay was 5.34 days, and the mean hospitalization costs were $14,576. While 96.3% of patients expressed a desire to receive information about their illnesses and treatment options, 71.1% of patients preferred to leave medical decision making to their physician. Preference to participate in decision making increased with educational level and with private health insurance. Compared with patients who had a strong desire to delegate decisions to their physician, patients who preferred to participate in decision making concerning their care had a 0.26-day (95% CI, 0.06-0.47 day) longer length of stay (P = .01) and $865 (95% CI, $155-$1575) higher total hospitalization costs (P = .02). CONCLUSIONS AND RELEVANCE Patient preference to participate in decision making concerning their care may be associated with increased resource utilization among hospitalized patients. Variation in patient preference to participate in medical decision making and its effects on costs and outcomes in the presence of varying physician incentives deserve further examination.
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Affiliation(s)
- Hyo Jung Tak
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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Ruhnke GW, Doukas DJ. Trust in residents and board examinations: when sharing crosses the boundary. Mayo Clin Proc 2013; 88:438-41. [PMID: 23639496 PMCID: PMC4862587 DOI: 10.1016/j.mayocp.2013.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/24/2013] [Accepted: 02/04/2013] [Indexed: 11/23/2022]
Affiliation(s)
- Gregory W Ruhnke
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA.
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Ruhnke GW, Coca-Perraillon M, Kitch BT, Cutler DM. Marked reduction in 30-day mortality among elderly patients with community-acquired pneumonia. Am J Med 2011; 124:171-178.e1. [PMID: 21295197 PMCID: PMC3064506 DOI: 10.1016/j.amjmed.2010.08.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 08/26/2010] [Accepted: 08/31/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Community-acquired pneumonia is the most common infectious cause of death in the US. Over the last 2 decades, patient characteristics and clinical care have changed. To understand the impact of these changes, we quantified incidence and mortality trends among elderly adults. METHODS We used Medicare claims to identify episodes of pneumonia, based on a validated combination of diagnosis codes. Comorbidities were ascertained using the diagnosis codes located on a 1-year look back. Trends in patient characteristics and site of care were compared. The association between year of pneumonia episode and 30-day mortality was then evaluated by logistic regression, with adjustment for age, sex, and comorbidities. RESULTS We identified 2,654,955 cases of pneumonia from 1987-2005. During this period, the proportion treated as inpatients decreased, the proportion aged ≥80 years increased, and the frequency of many comorbidities rose. Adjusted incidence increased to 3096 episodes per 100,000 population in 1999, with some decrease thereafter. Age/sex-adjusted mortality decreased from 13.5% to 9.7%, a relative reduction of 28.1%. Compared with 1987, the risk of mortality decreased through 2005 (adjusted odds ratio, 0.46; 95% confidence interval, 0.44-0.47). This result was robust to a restriction on comorbid diagnoses assessing for the results' sensitivity to increased coding. CONCLUSIONS These findings show a marked mortality reduction over time in community-acquired pneumonia patients. We hypothesize that increased pneumococcal and influenza vaccination rates as well as wider use of guideline-concordant antibiotics explain a large portion of this trend.
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Affiliation(s)
- Gregory W Ruhnke
- Section of Hospital Medicine, University of Chicago, IL 60637, USA.
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Ando S, Maemori M, Sakai H, Ando S, Shiraishi H, Sakai K, Ruhnke GW. Constitutional trisomy 8 mosaicism with myelodysplastic syndrome complicated by intestinal Behcet disease and antithrombin III deficiency. ACTA ACUST UNITED AC 2005; 162:172-5. [PMID: 16213367 DOI: 10.1016/j.cancergencyto.2005.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Accepted: 01/13/2005] [Indexed: 11/18/2022]
Abstract
Trisomy 8 is the most common acquired chromosomal abnormality associated with myeloid malignancy. As a constitutional trisomy 8 mosaicism (T8M), it exhibits an extremely variable phenotype. In addition, Behcet disease (BD) has been reported as an unusual complication of myelodysplastic syndrome (MDS). To our knowledge, 12 case reports of various hematologic malignancies in patients with T8M and 18 case reports of MDS with acquired trisomy 8 complicated by BD have been published to date. We report a case of constitutional T8M with MDS complicated by intestinal BD and antithrombin III deficiency.
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Affiliation(s)
- Sachiko Ando
- Department of Hematology, Teine Keijinkai Hospital, Hokkaido, Japan.
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Ruhnke GW, Wilson SR, Akamatsu T, Kinoue T, Takashima Y, Goldstein MK, Koenig BA, Hornberger JC, Raffin TA. Ethical decision making and patient autonomy: a comparison of physicians and patients in Japan and the United States. Chest 2000; 118:1172-82. [PMID: 11035693 DOI: 10.1378/chest.118.4.1172] [Citation(s) in RCA: 170] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patient-centered decision making, which in the United States is typically considered to be appropriate, may not be universally endorsed, thereby harboring the potential to complicate the care of patients from other cultural backgrounds in potentially unrecognized ways. This study compares the attitudes toward ethical decision making and autonomy issues among academic and community physicians and patients of medical center outpatient clinics in Japan and the United States. METHODS A questionnaire requesting judgments about seven clinical vignettes was distributed (in English or Japanese) to sample groups of Japanese physicians (n = 400) and patients (n = 65) as well as US physicians (n = 120) and patients (n = 60) that were selected randomly from academic institutions and community settings in Japan (Tokyo and the surrounding area) and the United States (the Stanford/Palo Alto, CA, area). Responses were obtained from 273 Japanese physicians (68%), 58 Japanese patients (89%), 98 US physicians (82%), and 55 US patients (92%). Physician and patient sample groups were compared on individual items, and composite scores were derived from subsets of items relevant to patient autonomy, family authority, and physician authority. RESULTS A majority of both US physicians and patients, but only a minority of Japanese physicians and patients, agreed that a patient should be informed of an incurable cancer diagnosis before their family is informed and that a terminally ill patient wishing to die immediately should not be ventilated, even if both the doctor and the patient's family want the patient ventilated (Japanese physicians and patients vs US physicians and patients, p < 0.001). A majority of respondents in both Japanese sample groups, but only a minority in both US sample groups, agreed that a patient's family should be informed of an incurable cancer diagnosis before the patient is informed and that the family of an HIV-positive patient should be informed of this disease status despite the patient's opposition to such disclosure (Japanese physicians and patients vs US physicians and patients, p < 0.001). Physicians in both Japan and the United States were less likely than patients in their respective countries to agree with physician assistance in the suicide of a terminally ill patient (Japanese physicians and patients vs US physicians and patients, p < 0.05). Across various clinical scenarios, all four respondent groups accorded greatest authority to the patient, less to the family, and still less to the physician when the views of these persons conflicted. Japanese physicians and patients, however, relied more on family and physician authority and placed less emphasis on patient autonomy than the US physicians and patients sampled. Younger respondents placed less emphasis on family and physician authority. CONCLUSIONS Family and physician opinions are accorded a larger role in clinical decision making by the Japanese physicians and patients sampled than by those in the United States, although both cultures place a greater emphasis on patient preferences than on the preferences of the family or physician. Our results are consistent with the view that cultural context shapes the relationship of the patient, the physician, and the patient's family in medical decision making. The results emphasize the need for clinicians to be aware of these issues that may affect patient and family responses in different clinical situations, potentially affecting patient satisfaction and compliance with therapy.
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Affiliation(s)
- G W Ruhnke
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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