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Schafer KR, Heincelman M, Adams W, Abraham RA, Kwan B, Sebasky M, Foster JG, Fitz M. Internal Medicine Applicants' Experiences with Program Signaling and Second Looks: A Multi-institutional Survey. Am J Med 2024:S0002-9343(24)00267-5. [PMID: 38697591 DOI: 10.1016/j.amjmed.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/09/2024] [Accepted: 04/26/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Katherine R Schafer
- K. Schafer is an Associate Professor and inpatient Clerkship Director in the Department of Internal Medicine, Wake Forest University School of Medicine
| | - Marc Heincelman
- M. Heincelman is an Associate Professor, Interim Director of the Division of Hospital Medicine, and the Clerkship Director in the Department of Medicine, Medical University of South Carolina
| | - William Adams
- William Adams is an Assistant Professor, Department of Medicine, Loyola University Chicago Stritch School of Medicine
| | - Reeni A Abraham
- R. Abraham is an Associate Professor and the Associate Vice Chair of Undergraduate Medical Education in the Department of Internal Medicine, University of Texas Southwestern Medical School
| | - Brian Kwan
- B. Kwan is a Clinical Professor and Internal Medicine Clerkship Co-Director in the Department of Medicine, University of California, San Diego
| | - Meghan Sebasky
- M. Sebasky is a Clinical Professor and Internal Medicine Clerkship Co-Director in the Department of Medicine, University of California, San Diego
| | - Jennifer G Foster
- J. Foster is an Associate Professor and Assistant Dean for Clinical Curriculum in the Department of Medicine, Florida Atlantic University
| | - Matthew Fitz
- M. Fitz is a Professor in the Department of Internal Medicine, Loyola University Chicago Stritch School of Medicine.
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Nielsen EM, Zhang J, Marsden J, Bays C, Moran WP, Mauldin PD, Lenert LA, Toll BA, Schreiner AD, Heincelman M. Hospitalization as an opportunity to improve lung cancer screening in high-risk patients. Cancer Epidemiol 2024; 90:102553. [PMID: 38460398 DOI: 10.1016/j.canep.2024.102553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/28/2023] [Revised: 02/15/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Lung cancer screening with annual low-dose computed tomography (LDCT) in high-risk patients with exposure to smoking reduces lung cancer-related mortality, yet the screening rate of eligible adults is low. As hospitalization is an opportune moment to engage patients in their overall health, it may be an opportunity to improve rates of lung cancer screening. Prior to implementing a hospital-based lung cancer screening referral program, this study assesses the association between hospitalization and completion of lung cancer screening. METHODS A retrospective cohort study of evaluated completion of at least one LDCT from 2014 to 2021 using electronic health record data using hospitalization as the primary exposure. Patients aged 55-80 who received care from a university-based internal medicine clinic and reported cigarette use were included. Univariate analysis and logistic regression evaluated the association of hospitalization and completion of LDCT. Cox proportional hazard model examined the time relationship between hospitalization and LDCT. RESULTS Of the 1935 current smokers identified, 47% had at least one hospitalization, and 21% completed a LDCT during the study period. While a higher proportion of patients with a hospitalization had a LDCT (24%) compared to patients without a hospitalization (18%, p<0.001), there was no association between hospitalization and completion of a LDCT after adjusting for potentially confounding covariates (95%CI 0.680 - 1.149). There was an association between hospitalization time to event and LDCT completion, with hospitalized patients having a lower probability of competing LDCT compared to non-hospitalized patients (HR 0.747; 95% CI 0.611 - 0.914). CONCLUSIONS In a cohort of patients at risk for lung cancer and established within a primary care clinic, only 1 in 4 patients who had been hospitalized completed lung cancer screening with LDCT. Hospitalization events were associated with a lower probability of LDCT completion. Hospitalization is a missed opportunity to refer at-risk patients to lung cancer screening.
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Affiliation(s)
- Ellen M Nielsen
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States.
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
| | - Chloe Bays
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
| | - Leslie A Lenert
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
| | - Benjamin A Toll
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Charleston, SC 29425, United States; MUSC Hollings Cancer Center, 86 Jonathan Lucas Street, Charleston, SC 29425, United States
| | - Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
| | - Marc Heincelman
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, United States
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Nielsen EM, Zhang J, Marsden J, Bays C, Moran WP, Mauldin PD, Lenert LA, Toll BA, Schreiner AD, Heincelman M. Is hospitalization a missed opportunity to intervene on tobacco cessation? Am J Med Sci 2024; 367:89-94. [PMID: 38043793 DOI: 10.1016/j.amjms.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 04/24/2023] [Revised: 10/11/2023] [Accepted: 11/21/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Although tobacco use is associated with elevated morbidity and mortality, its use remains widespread among adults within the United States. Nicotine Replacement Therapy (NRT) products are effective aids that improve rates of tobacco cessation. Many smokers interact with the medical system, such as during hospitalization, without their tobacco use addressed. Hospitalization is a teachable moment for patients to make health-related changes, including tobacco cessation. METHODS Retrospective cohort study of adult patients in a university-based patient-centered medical home from 2012 to 2021 evaluating the proportion of adults who smoke who received at least one prescription for NRT. Logistic regression models were used to analyze the association of being hospitalized and receipt of a NRT prescription. RESULTS Of the 4,072 current smokers identified, 1,182 (29%) received at least one prescription for NRT during the study period. Hospitalization was associated with increased odds of receiving a NRT prescription (OR 1.68). Of 1,844 current smokers with a hospitalization during the study period, 1,078 (58%) never received a prescription for NRT at any point. Only 87 (5%) of the smokers received a prescription for NRT during hospitalization or at the time of hospital discharge. CONCLUSIONS Despite hospitalization being associated with NRT prescribing, most patients who use tobacco and are hospitalized are not prescribed NRT. Hospitalization is an underutilized opportunity for both hospitalists and primary care physicians to intervene on smoking cessation through education and prescription of tobacco cessation aids.
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Affiliation(s)
- Ellen M Nielsen
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Chloe Bays
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Leslie A Lenert
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Benjamin A Toll
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Marc Heincelman
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
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Thomas MK, Kalivas B, Zhang J, Marsden J, Mauldin PD, Moran WP, Hunt K, Heincelman M. Effect of Delirium on Interhospital Transfer Outcomes. South Med J 2024; 117:108-114. [PMID: 38307509 DOI: 10.14423/smj.0000000000001653] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
OBJECTIVES Interhospital transfer (IHT) and in-hospital delirium are both independently associated with increased length of stay (LOS), mortality, and discharge to facility. Our objective was to investigate the joint effects between IHT and the presence of in-hospital delirium on the outcomes of LOS, discharge to a facility, and in-hospital mortality. METHODS This was a single-center retrospective cohort study of 25,886 adult hospital admissions at a tertiary-care academic medical center. Staged multivariable logistic and linear regression models were used to evaluate the association between IHT status and the outcomes of discharge to a facility, LOS, and mortality while considering the joint impact of delirium. The joint effects of IHT status and delirium were evaluated by categorizing patients into one of four categories: emergency department (ED) admissions without delirium, ED admissions with delirium, IHT admissions without delirium, and IHT admissions with delirium. The primary outcomes were LOS, in-hospital mortality, and discharge disposition. RESULTS The odds of discharge to a facility were 4.48 times higher in admissions through IHT with delirium when compared with ED admissions without delirium. IHT admissions with delirium had a 1.97-fold (95% confidence interval 1.88-2.06) longer LOS when compared with admission through the ED without delirium. Finally, admissions through IHT with delirium had 3.60 (95% confidence interval 2.36-5.49) times the odds of mortality when compared with admissions through the ED without delirium. CONCLUSIONS The relationship between IHT and delirium is complex, and patients with IHT combined with in-hospital delirium are at high risk of longer LOS, discharge to a facility, and mortality.
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Kalivas B, Zhang J, Harper K, Dulin J, Heincelman M, Marsden J, Hunt KJ, Mauldin PD, Moran WP, Thomas MK. The Combined Effect of Delirium and Falls on Length of Stay and Discharge. J Healthc Qual 2023; 45:177-190. [PMID: 37141572 DOI: 10.1097/jhq.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Delirium or a fall are associated with many negative outcomes including increased length of stay (LOS) and discharge to a facility; however, this relationship is incompletely understood. METHODS A cross-sectional study of all hospitalizations in a large, tertiary care hospital evaluated the effect of delirium and a fall on the outcomes of LOS and risk of being discharged to a facility. RESULTS The study included 29,655 hospital admissions. A total of 3,707 (12.5%) patients screened positive for delirium and 286 (0.96%) had a reported fall. After adjustment for covariates, relative to patients without delirium or a fall, patients with delirium only had a 1.64-fold longer LOS; patients with fall only had a 1.96-fold longer LOS; and patients who had delirium and fall had a 2.84-fold longer LOS. The adjusted odds of discharge to a facility, relative to those without delirium or a fall, was 8.98 times higher in those with delirium and a fall. CONCLUSIONS Delirium and falls influence LOS and likelihood of being discharged to a facility. The joint impact of falls and delirium on LOS and facility discharge was more than additive. Hospitals should consider the integrated management of delirium and falls.
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Hagood NL, Heincelman M, Thomas MK. Use of point-of-care ultrasound by internists to rapidly diagnose acute decompensated heart failure. Respir Med Case Rep 2023; 41:101789. [DOI: 10.1016/j.rmcr.2022.101789] [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: 11/01/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
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Thomas M, Keck C, Schreiner AD, Heincelman M. Longitudinal, Spaced-learning POCUS Curriculum for Internal Medicine Residents to Improve Knowledge and Skills. Am J Med Sci 2022; 363:399-402. [PMID: 35300977 DOI: 10.1016/j.amjms.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/07/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Meghan Thomas
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425.
| | - Carson Keck
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425
| | - Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425
| | - Marc Heincelman
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425
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Abstract
Infections due to nontuberculous mycobacterium (NTM) are important in chronically immunosuppressed populations and are a particular threat to solid organ transplant recipients (SOT). However, they are not a common occurrence and have protean manifestations, making it important that clinicians maintain a high degree of suspicion in the correct patient population. Mycobacterium avium complex (MAC) usually presents with pulmonary involvement in immunocompetent population and disseminated disease in SOT patients with fever of unknown origin, lymphadenopathy, and cutaneous lesions being part of the well-known presentation. It is not commonly described as causing severe diarrhea. Here, we present an interesting case of a patient with a kidney and pancreas transplant who presented with debilitating wasting and chronic diarrhea. Biopsies and cultures confirmed MAC. To our knowledge, this is the first case report of MAC causing severe wasting diarrhea in renal transplant patients. The patient was treated with a multidrug regimen. Given the rare presentation of MAC presenting as chronic diarrhea, the treatment regimen is not standardized and infectious disease specialists should be involved early on. Up to 30% of renal transplant patients infected with NTM lose graft function and 20% die. Unfortunately, our patient suffered both these outcomes.
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Affiliation(s)
- Manasi Singh
- Medical University of South Carolina, Charleston, USA
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Barbina S, Kavin U, Sutton MM, Heincelman M, Thomas MK. Ascitic Fluid Analysis Leading to the Diagnosis of Constrictive Pericarditis in 2 Patients. J Investig Med High Impact Case Rep 2022; 10:23247096221097530. [PMID: 35546528 PMCID: PMC9112309 DOI: 10.1177/23247096221097530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 11/26/2022] Open
Abstract
Although well documented, constrictive pericarditis is a rare entity and an uncommon cause of heart failure. A stiff and noncompliant pericardium creates the disease's unique hemodynamics and leads to elevated venous pressures, hepatic sinusoidal congestion, and draining of protein-rich fluid into the peritoneal cavity presenting as ascites. The low incidence in addition to its varied and subtle clinical presentations can often lead to a delay in diagnosis. Here, we present 2 clinical cases of constrictive pericarditis in which ascitic fluid analysis was important-one patient who presented with new-onset ascites with concern for cirrhosis and another patient who presented with symptoms concerning for heart failure with ascites. Through their hospital course and workup, we highlight the importance of diagnostic sampling of ascitic fluid to prompt the consideration of constrictive pericarditis followed by utilizing advanced diagnostics, such as echocardiogram and cardiac catheterization to reach the correct diagnosis in an otherwise often overlooked pathology.
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Affiliation(s)
- Sarah Barbina
- Department of Medicine, Medical
University of South Carolina, Charleston, USA
| | - Umakanthan Kavin
- Department of Medicine, Medical
University of South Carolina, Charleston, USA
| | - Michael M. Sutton
- Department of Medicine, Medical
University of South Carolina, Charleston, USA
| | - Marc Heincelman
- Department of Medicine, Medical
University of South Carolina, Charleston, USA
| | - Meghan K. Thomas
- Department of Medicine, Medical
University of South Carolina, Charleston, USA
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Kirkland E, Schumann SO, Schreiner A, Heincelman M, Zhang J, Marsden J, Mauldin P, Moran WP. Patient Demographics and Clinic Type Are Associated With Patient Engagement Within a Remote Monitoring Program. Telemed J E Health 2021; 27:843-850. [PMID: 34115942 DOI: 10.1089/tmj.2020.0535] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 12/26/2022] Open
Abstract
Background: Remote physiological monitoring (RPM) is accessible, convenient, relatively inexpensive, and can improve clinical outcomes. Yet, it is unclear in which clinical setting or target population RPM is maximally effective. Objective: To determine whether patients' demographic characteristics or clinical settings are associated with data transmission and engagement. Methods: This is a prospective cohort study of adults enrolled in a diabetes RPM program for a minimum of 12 months as of April 2020. We developed a multivariable logistic regression model for engagement with age, gender, race, income, and primary care clinic type as variables and a second model to include first-order interactions for all demographic variables by time. The participants included 549 adults (mean age 53 years, 63% female, 54% Black, and 75% very low income) with baseline hemoglobin A1c ≥8.0% and enrolled in a statewide diabetes RPM program. The main measure was the transmission engagement over time, where engagement is defined as a minimum of three distinct days per week in which remote data are transmitted. Results: Significant predictors of transmission engagement included increasing age, academic clinic type, higher annual household income, and shorter time-in-program (p < 0.001 for each). Self-identified race and gender were not significantly associated with transmission engagement (p = 0.729 and 0.237, respectively). Conclusions: RPM appears to be an accessible tool for minority racial groups and for the aging population, yet engagement is impacted by primary care location setting and socioeconomic status. These results should inform implementation of future RPM studies, guide advocacy efforts, and highlight the need to focus efforts on maintaining engagement over time.
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Affiliation(s)
- Elizabeth Kirkland
- Center for Health Disparities Research, Medical University of South Carolina, Charleston, South Carolina, USA.,Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Samuel O Schumann
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrew Schreiner
- Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Marc Heincelman
- Division of Hospital Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jingwen Zhang
- Section of Health Systems Research and Policy, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Justin Marsden
- Section of Health Systems Research and Policy, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick Mauldin
- Section of Health Systems Research and Policy, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William P Moran
- Center for Health Disparities Research, Medical University of South Carolina, Charleston, South Carolina, USA.,Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Walthall L, Heincelman M. Pyometra: An Atypical Cause of Abdominal Pain. J Investig Med High Impact Case Rep 2021; 9:23247096211022481. [PMID: 34105423 PMCID: PMC8193658 DOI: 10.1177/23247096211022481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/23/2022] Open
Abstract
Pyometra, a purulent infection of the uterus, is a rare cause of a very common complaint—abdominal pain. Risk factors include gynecologic malignancy and postmenopausal status. The classically described presentation includes abdominal pain, fever, and vaginal discharge. In this article, we present an atypical presentation of nonperforated pyometra in an 80-year-old female who was admitted to the internal medicine inpatient service. She initially presented with nonspecific subacute right lower quadrant abdominal pain. Physical examination did not demonstrate vaginal discharge. Laboratory evaluation failed to identify an underlying etiology. Computed tomography scan of the abdomen and pelvis with oral and intravenous contrast demonstrated a 6.5 × 6.1 cm cystic containing structure within the uterine fundus, concerning for a gynecologic malignancy. Pelvis ultrasound confirmed the mass. Endometrial biopsy did not reveal underlying malignancy, but instead showed frank pus, leading to the diagnosis of pyometra. This report illustrates that pyometra should be considered in the differential diagnosis of lower abdominal pain in elderly women.
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Heincelman M, Gebregziabher M, Kirkland E, Schumann SO, Schreiner A, Warr P, Zhang J, Mauldin PD, Moran WP, Rockey DC. Impact of Patient-Level Characteristics on In-hospital Mortality After Interhospital Transfer to Medicine Services: an Observational Study. J Gen Intern Med 2020; 35:1127-1134. [PMID: 31965521 PMCID: PMC7174524 DOI: 10.1007/s11606-020-05659-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 12/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND National administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED). OBJECTIVE To investigate the impact of patient-level data not available in larger administrative datasets on the association between IHT status and in-hospital mortality. DESIGN Retrospective cohort study with logistic regression analyses to examine the association between IHT status and in-hospital mortality, controlling for covariates that were potential confounders. Model 1: IHT status, admit service. Model 2: model 1 and patient demographics. Model 3: model 2 and disease-specific conditions. Model 4: model 3 and vital signs and laboratory data. PARTICIPANTS Nine thousand three hundred twenty-eight adults admitted to Medicine services. MAIN MEASURES Interhospital transfer status, coded as an unordered categorical variable (IHT vs ED vs clinic), was the independent variable. The primary outcome was in-hospital mortality. Secondary outcomes included unadjusted length of stay and total cost. KEY RESULTS IHT patients accounted for 180 out of 484 (37%) in-hospital deaths, despite accounting for only 17% of total admissions. Unadjusted mean length of stay was 8.4 days vs 5.6 days (p < 0.0001) and mean total cost was $22,647 vs $12,968 (p < 0.0001) for patients admitted via IHT vs ED respectively. The odds ratios (OR) for in-hospital mortality for patients admitted via IHT compared to the ED were as follows: model 1 OR, 2.06 (95% CI 1.66-2.56, p < 0.0001); model 2 OR, 2.07 (95% CI 1.66-2.58, p < 0.0001); model 3 OR, 2.07 (95% CI 1.63-2.61, p < 0.0001); model 4 OR, 1.70 (95% CI 1.31-2.19, p < 0.0001). The AUCs of the models were as follows: model 1, 0.74; model 2, 0.76; model 3, 0.83; model 4, 0.88, consistent with a good prediction model. CONCLUSIONS Patient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.
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Affiliation(s)
- Marc Heincelman
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA.
| | - Mulugeta Gebregziabher
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Elizabeth Kirkland
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Samuel O Schumann
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Andrew Schreiner
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Phillip Warr
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Don C Rockey
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
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Bishu KG, Lekoubou A, Kirkland E, Schumann SO, Schreiner A, Heincelman M, Moran WP, Mauldin PD. Estimating the Economic Burden of Acute Myocardial Infarction in the US: 12 Year National Data. Am J Med Sci 2020; 359:257-265. [PMID: 32265010 DOI: 10.1016/j.amjms.2020.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 08/25/2019] [Revised: 12/21/2019] [Accepted: 02/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute myocardial infarction (AMI) carries a substantial mortality and morbidity burden. The purpose of this study is to provide annual mean cost per patient and national level estimates of direct and indirect costs (lost productivity from morbidity and premature mortality) associated with AMI. METHODS Nationally representative data spanning 12 years (2003-2014) with a sample of 324,869 patients with AMI from the Medical Expenditure Panel Survey (MEPS) were analyzed. A novel 2-part model was used to examine the excess direct cost associated with AMI, controlling for covariates. To estimate lost productivity from morbidity, an adjusted Generalized Linear Model was used for the differential in wage earnings between participants with and without AMI. Lost productivity from premature mortality was estimated based on published data. RESULTS The total annual cost of AMI in 2016 dollars was estimated to be $84.9 billion, including $29.8 billion in excess direct medical expenditures, $14.6 billion in lost productivity from morbidity and $40.5 billion in lost productivity from premature mortality between 2003 and 2014. In the adjusted regression, the overall excess direct medical expenditure of AMI was $7,076 (95% confidence interval [CI] $6,028-$8,125) higher than those without AMI. After adjustment, annual wages for patients with AMI were $10,166 (95% CI -$12,985 to -$7,347) lower and annual missed work days were 5.9 days (95% CI 3.57-8.27) higher than those without AMI. CONCLUSIONS The study finds that the economic burden of AMI is substantial, for which effective prevention could result in significant health and productivity cost savings.
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Affiliation(s)
- Kinfe G Bishu
- Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, South Carolina; Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina.
| | - Alain Lekoubou
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Kirkland
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Samuel O Schumann
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Andrew Schreiner
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Marc Heincelman
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - William P Moran
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Patrick D Mauldin
- Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, South Carolina; Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
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Singh M, Duckett A, Heincelman M. Porphyria Cutanea Tarda Associated With Acute Hemorrhagic Pancreatitis. J Investig Med High Impact Case Rep 2019; 7:2324709619852769. [PMID: 31155958 PMCID: PMC6547174 DOI: 10.1177/2324709619852769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/16/2022] Open
Abstract
Porphyria cutanea tarda (PCT) is a condition of dysregulated heme synthesis that
leads to accumulation of photosensitizing precursors with resultant fragility
and blistering of the skin. It can be hereditary or acquired and has been known
to be associated with hepatic C virus, alcohol, HIV, and estrogen. In this
article, we report an unusual presentation of PCT associated with acute
hemorrhagic pancreatitis in a 57-year-old man. He presented initially to a
community hospital with acute onset of epigastric abdominal pain and new-onset
ascites. Lipase was elevated. Diagnostic paracentesis was grossly bloody. He was
then transferred to our institution for concern for acute hemorrhagic
pancreatitis. On arrival, physical examination demonstrated vesicles and bullae
with erythematous bases, in different stages of healing seen over the dorsal
aspects of both hands with scaling, scarring, and hypopigmentation and
hyperpigmentation of the skin. Laboratory evaluation and skin biopsy confirmed
the diagnosis of PCT. Search for an underlying etiology failed to reveal typical
predisposing factors. This report illustrates that acute hemorrhagic
pancreatitis may be an underlying etiology for PCT.
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Affiliation(s)
- Manasi Singh
- 1 Medical University of South Carolina, Charleston, SC, USA
| | - Ashley Duckett
- 1 Medical University of South Carolina, Charleston, SC, USA
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15
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Kirkland EB, Heincelman M, Bishu KG, Schumann SO, Schreiner A, Axon RN, Mauldin PD, Moran WP. Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003-2014. J Am Heart Assoc 2018; 7:JAHA.118.008731. [PMID: 29848493 PMCID: PMC6015342 DOI: 10.1161/jaha.118.008731] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background One in 3 US adults has high blood pressure, or hypertension. As prior projections suggest hypertension is the costliest of all cardiovascular diseases, it is important to define the current state of healthcare expenditures related to hypertension. Methods and Results We used a nationally representative database, the Medical Expenditure Panel Survey, to calculate the estimated annual healthcare expenditure for patients with hypertension and to measure trends in expenditure longitudinally over a 12‐year period. A 2‐part model was used to estimate adjusted incremental expenditures for individuals with hypertension versus those without hypertension. Sex, race/ethnicity, education, insurance status, census region, income, marital status, Charlson Comorbidity Index, and year category were included as covariates. The 2003–2014 pooled data include a total sample of 224 920 adults, of whom 36.9% had hypertension. Unadjusted mean annual medical expenditure attributable to patients with hypertension was $9089. Relative to individuals without hypertension, individuals with hypertension had $1920 higher annual adjusted incremental expenditure, 2.5 times the inpatient cost, almost double the outpatient cost, and nearly triple the prescription medication expenditure. Based on the prevalence of hypertension in the United States, the estimated adjusted annual incremental cost is $131 billion per year higher for the hypertensive adult population compared with the nonhypertensive population. Conclusions Individuals with hypertension are estimated to face nearly $2000 higher annual healthcare expenditure compared with their nonhypertensive peers. This trend has been relatively stable over 12 years. Healthcare costs associated with hypertension account for about $131 billion. This warrants intense effort toward hypertension prevention and management.
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Affiliation(s)
- Elizabeth B Kirkland
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Marc Heincelman
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kinfe G Bishu
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC.,Section of Health Systems Research and Policy, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Samuel O Schumann
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Andrew Schreiner
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - R Neal Axon
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC.,Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Patrick D Mauldin
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC.,Section of Health Systems Research and Policy, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - William P Moran
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, SC
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16
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Heincelman M, Duckett A, Keith B, Schreiner A, Zhang J, Kilb E, Clyburn B. The Structure of Medical Intensive Care Units at Training Institutions. Am J Med Sci 2018; 355:396-401. [PMID: 29661355 DOI: 10.1016/j.amjms.2017.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/02/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND As a result of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour guideline implementation, the structure of intensive care unit (ICU) teams at training institutions has been affected. The impact these changes have had on the current work environment has not been well described. METHODS The authors conducted an online survey of internal medicine program directors in 2016. The survey investigated how training institutions structure their intensive care units in reference to volume, resident housestaff and alternative coverage options, with a focus on changes made after the implementation of the 2011 ACGME duty hour restrictions. RESULTS Notable differences were found in program director responses to coverage of patients in the ICUs. A total of 62 of the 132 (48%) responding program directors describe coverage of all patients solely by resident housestaff. Since 2011, 54 (41%) programs have increased the number of resident physicians rotating in the ICU per month and initiated or increased the use of nonresident coverage of patients. Use of non-resident providers is not associated with a decrease in the number of total ICU months per resident or a decrease in educational value. CONCLUSIONS Since the 2011 ACGME duty hour implementation, there is wide variability in the learning environment of medical intensive care units in training institutions.
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Affiliation(s)
- Marc Heincelman
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Ashley Duckett
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Brad Keith
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Andrew Schreiner
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jingwen Zhang
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Edward Kilb
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Benjamin Clyburn
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
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17
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Kirkland E, Zhang J, Brownfield E, Heincelman M, Schumann S, Schreiner A, Bishu K, Mauldin PD, Moran WP. Sustained Improvement in Blood Pressure Control for a Multiracial Cohort: Results of a Patient-centered Medical Home Quality Improvement Initiative. Qual Prim Care 2017; 25:297-302. [PMID: 31363347 PMCID: PMC6666407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Patient-centered medical homes incorporate strategies to increase healthcare access as a means of improving health at the patient and population level. We hypothesized that quality improvement initiatives based in a patient-centered medical home would improve hypertension control for adult patients, regardless of race. METHODS This prospective cohort study included patients of a hospital-based Internal Medicine practice in the southeastern U.S. whose systolic blood pressure was uncontrolled (criteria ≥140mmHg) prior to patient-centered medical home certification. Mean systolic blood pressure and hypertension control rates were calculated from the average of the four quarterly means prior to patient-centered medical home designation and again from the last 4 quarters of the five-year study period (final). Quality improvement interventions included patient identification, multidisciplinary team meetings, targeted outreach, and dedicated office visits for addressing hypertension. Primary outcomes included the change in systolic blood pressure and the change in the proportion of the cohort with hypertension control. Chi-square, two sample t-tests, and ANOVA were used for comparison (SAS 9.3). RESULTS The inception cohort had 1,702 patients (64% nonwhite, 36% white) with systolic blood pressure ≥140mmHg. Mean systolic blood pressure significantly decreased while hypertension control rates increased in both races after patient-centered medical home certification. White adults had lower mean systolic blood pressure and higher control rates at baseline and study conclusion compared to nonwhite adults. Similar trends persisted regardless of the number of office visits. CONCLUSIONS The analysis of blood pressure before and after designation of an Internal Medicine clinic as a patient-centered medical home reveals disparities in rates of chronic disease control. Team-based outreach improves hypertension control for patients regardless of race or visit number. These findings suggest that patient-centered medical homes and a multidisciplinary care approach, not limited to increased access, improve chronic disease control and should be considered for diverse outpatient clinics.
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Affiliation(s)
- Elizabeth Kirkland
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jingwen Zhang
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Elisha Brownfield
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Marc Heincelman
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Samuel Schumann
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew Schreiner
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kinfe Bishu
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D. Mauldin
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - William P. Moran
- Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
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18
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Heincelman M, Karakala N, Rockey DC. Acute Lymphoblastic Leukemia in a Young Adult Presenting as Hepatitis and Acute Kidney Injury. J Investig Med High Impact Case Rep 2016; 4:2324709616665866. [PMID: 27722178 PMCID: PMC5036134 DOI: 10.1177/2324709616665866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 06/13/2016] [Revised: 07/22/2016] [Accepted: 07/27/2016] [Indexed: 11/15/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) in adults is a relatively rare malignancy. The typical presentation includes signs and symptoms associated with bone marrow failure, including fevers, infections, fatigue, and excessive bruising. In this article, we report an unusual systemic presentation of ALL in a previously healthy 18-year-old man. He initially presented with several-day history of nausea and vomiting, 10-pound weight loss, and right upper quadrant abdominal pain with evidence of acute hepatocellular liver injury (elevations in aspartate aminotransferase/alanine aminotransferase) and elevation in serum creatinine. Further history revealed that he just joined the Marine Corp; in preparation, he had been lifting weights and taking protein and creatine supplements. A complete serological evaluation for liver disease was negative and creatine phosphokinase was normal. His aspartate aminotransferase and alanine aminotransferase declined, and he was discharged with expected improvement. However, he returned one week later with continued symptoms and greater elevation of aminotransferases. Liver biopsy was nondiagnostic, revealing scattered portal and lobular inflammatory cells (primarily lymphocytes) felt to be consistent with drug-induced liver injury or viral hepatitis. Given his elevated creatinine, unresponsive to aggressive volume expansion, a kidney biopsy was performed, revealing normal histology. He subsequently developed an extensive left lower extremity deep venous thrombosis. Given his deep venous thrombosis, his peripheral blood was sent for flow cytometry, which revealed lymphoblasts. Bone marrow biopsy revealed 78% blasts with markers consistent with acute B-cell lymphoblastic leukemia. This report emphasizes that right upper quadrant abdominal pain with liver test abnormalities may be the initial presentation of a systemic illness such as ALL.
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Affiliation(s)
| | | | - Don C Rockey
- Medical University of South Carolina, Charleston, SC, USA
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Heincelman M, Schumann SO, Riley J, Zhang J, Marsden JE, Mauldin PD, Rockey DC. Identification of High Utilization Inpatients on Internal Medicine Services. Am J Med Sci 2016; 352:63-70. [PMID: 27432036 DOI: 10.1016/j.amjms.2016.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 11/26/2022]
Abstract
BACKGROUND As healthcare reform moves toward value based care, hospitals must reduce costs. As a first step, here we developed a predictive model to identify high-cost patients on admission. METHODS We performed a retrospective observational study of 7,571 adults admitted to internal medicine services from July 1, 2013 to June 30, 2014. We compared the top 10% highest cost patients to other patients (controls) and identified clinical variables associated with high inpatient costs. Using logistic regression analyses, we developed a predictive model that could be used on admission to identify potential high utilization patients. RESULTS In the 757 high utilizer patients, the median total hospital cost was $53,430 ± 60,679 compared to $8,431 ± 7,245 in the control group (P < 0.0001). The median length of stay for high utilization patients was 19.5 ± 32.5 days compared to 3.8 ± 3.9 days in the control group (P < 0.001). Variables associated with high utilization included transfer from an outside hospital (odds ratio [OR] = 1.6), admission to the pulmonary or medical intensive care unit (OR = 2.4), admission to cardiology (OR = 1.8), coagulopathy (OR = 2.6) and fluid and electrolyte disorders (OR = 2.1). A multivariate logistic regression model was used to fit a predictive model for high utilizers. The receiver operating characteristics curve of this prediction model yielded an area under the curve of 0.80. CONCLUSIONS High resource utilization patients appear to have a specific phenotype that can be predicted with commonly available clinical variables. Our predictive formula holds promise as a tool that may help ultimately reduce hospital costs.
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Affiliation(s)
- Marc Heincelman
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Samuel O Schumann
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jenny Riley
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jingwen Zhang
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Justin E Marsden
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Patrick D Mauldin
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Don C Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
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