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Petrosyan R, Endres P, Ufere NN, St Hillien SA, Krinsky S, Kalim S, Nigwekar SU, Ouyang T, Allegretti AS. Healthcare Resource Utilization and Goals of Care Discussions in Patients with Cirrhosis and Acute Kidney Injury. Dig Dis Sci 2024:10.1007/s10620-024-08317-9. [PMID: 38451428 DOI: 10.1007/s10620-024-08317-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/25/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Patients with cirrhosis and acute kidney injury (AKI) are critically ill and have high health care resource utilization (HCRU). The impact and timing of goals of care discussions on HCRU are not well described. METHODS 221 patients enrolled in a prospective cohort study of patients admitted with AKI and cirrhosis were reviewed. Documentation and timing of a goals of care discussions were analyzed as predictors of HCRU, defined as a composite outcome of intubation, initiation of renal replacement therapy, and/or admission to the intensive care unit. RESULTS Median MELD score was 26 [IQR 19, 33]. 29% patients were listed for liver transplant. 90-day mortality was 61%. 51% patients had at least one HCRU episode. Code status changed from admission to discharge from 91%/7%/0% to 68%/14%18% (full code/do not resuscitate/comfort measures, p < 0.001). 28% patients underwent goals of care discussions, with change in code status at a median of 16 [9, 22] days into admission. Only 18% of discussions were within 7 days of admission and all were after an HCRU event. Being listed for liver transplant was not associated with whether goals of care discussions occurred (23% listed vs. 31% non-listed, p = 0.24) but was associated with higher HCRU (69% vs. 43%; p < 0.001). CONCLUSION Goals of care discussions occurred late into the hospital course, after episodes of HCRU. Efforts should be made to engage in these discussions earlier in the hospital stay, which may decrease HCRU rates in this critically ill population and align with patients' goals of care.
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Affiliation(s)
- Romela Petrosyan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Paul Endres
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Nneka N Ufere
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Shelsea A St Hillien
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Scott Krinsky
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA.
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St-Pierre F, Petrosyan R, Gupta A, Hughes S, Trickett J, Read S, Van Doren V, Zeveney A, Shoushtari C. Impact of the COVID-19 pandemic on internal medicine training in the United States: results from a national survey. BMC Health Serv Res 2023; 23:1285. [PMID: 37993947 PMCID: PMC10666403 DOI: 10.1186/s12913-023-10237-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 10/28/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Internal medicine (IM) residency is a notoriously challenging time generally characterized by long work hours and adjustment to new roles and responsibilities. The COVID-19 pandemic has led to multiple emergent adjustments in training schedules to accommodate increasing needs in patient care. The physician training period, in itself, has been consistently shown to be associated with vulnerability with respect to mental well-being. The impact of the COVID-19 pandemic on the experience of IM trainees is not well established. OBJECTIVE Characterize the impact of the COVID-19 pandemic on trainee clinical education, finances, and well-being. METHODS We developed a survey composed of 25 multiple choice questions, 6 of which had an optional short-answer component. The survey was distributed by the American College of Physicians (ACP) to 23,289 IM residents and subspecialty fellows. We received 1,128 complete surveys and an additional 269 partially completed surveys. RESULTS The majority of respondents reported a disruption in their clinical schedule (76%) and a decrease in both didactic conferences (71%) and protected time for education (56%). A majority of respondents (81%) reported an impact on their well-being with an increase in their level of burnout and 41% of respondents reported a decrease in level of direct supervision. Despite these changes, the majority of trainee respondents (78%) felt well prepared for clinical practice after graduation. CONCLUSIONS These results outline the vulnerable position of internal medicine physicians in training. Preserving educational experiences, adequate supervision, and humane work hours are essential in protecting trainees from mental illness and burnout during global emergencies.
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Affiliation(s)
- Frederique St-Pierre
- Department of Internal Medicine, Division of Hematology/Oncology, Northwestern University, 676 N St Clair St (Suite 850), Chicago, IL, 60611, USA.
| | - Romela Petrosyan
- Combined Brigham and Women's Hospital and Massachusetts General Hospital Department of Medicine, Division of Nephrology, Harvard University, Boston, MA, USA
| | - Arjun Gupta
- Department of Cardiology, The Mount Sinai Hospital, New York, NY, USA
| | - Stephen Hughes
- Department of Pulmonary, Critical Care, and Sleep Medicine, Naval Medical Center San Diego, San Diego, CA, USA
| | - John Trickett
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Susan Read
- Research Center, American College of Physicians, Philadelphia, PA, USA
| | - Vanessa Van Doren
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew Zeveney
- Research Center, American College of Physicians, Philadelphia, PA, USA
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Charilaou P, Devani K, Petrosyan R, Reddy C, Pyrsopoulos N. Inpatient Mortality Benefit with Transjugular Intrahepatic Portosystemic Shunt for Hospitalized Hepatorenal Syndrome Patients. Dig Dis Sci 2020; 65:3378-3388. [PMID: 32062714 DOI: 10.1007/s10620-020-06136-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND It has been reported that transjugular intrahepatic portosystemic shunting (TIPS) might be utilized as a salvage option for hepatorenal syndrome (HRS), while randomized controlled trials are pending and real-world contemporary data on inpatient mortality is lacking. METHODS We conducted an observational retrospective cohort study from the National Inpatient Sample from 2005 to 2014. We included all adult patients admitted with HRS and cirrhosis, using ICD 9-CM codes. We excluded cases with variceal bleeding, Budd-Chiari, end-stage renal disease, liver transplant and transfers to acute-care facilities. TIPS' association with inpatient mortality was assessed using multivariable mixed-effects logistic regression, as well as exact-matching, thus mitigating for TIPS selection bias. The exact-matched analysis was repeated among TIPS-only versus dialysis-only patients. RESULTS A total of 79,354 patients were included. Nine hundred eighteen (1.2%) underwent TIPS. Between TIPS and non-TIPS groups, mean age (58 years) and gender (65% males) were similar. Overall mortality was 18% in TIPS and 48% in dialysis-only cases (n = 10,379; 13.1%). Ninety six (10.5%) TIPS patients underwent dialysis. In-hospital mortality in TIPS patients was twice less likely than in non-TIPS patients (adjusted odds ratio [aOR] = 0.43, 95% CI 0.30-0.62; p < 0.001), with similar results in matched analysis [exact-matched (em) OR = 0.39, 95% CI 0.17-0.89; p < 0.024; groups = 96; unweighted n = 463]. Head-to-head comparison showed that TIPS-only patients were 3.3 times less likely to succumb inpatient versus dialysis-only patients (contrast aOR = 0.31, 95% CI 0.20-0.46; p < 0.001), with similar findings post-matching (emOR = 0.22, 95% CI 0.15-0.33; p < 0.001; groups = 54, unweighted n = 1457). CONCLUSIONS Contemporary, real-world data reveal that TIPS on its own, and when compared to dialysis, is associated with decreased inpatient mortality when utilized in non-bleeders-HRS patients. Further randomized studies are needed to establish the long-term benefit of TIPS in these patients.
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Affiliation(s)
- Paris Charilaou
- Division of Gastroenterology & Hepatology, Saint Peter's University Hospital/Rutgers - RWJ Medical School, New Brunswick, NJ, USA.
| | - Kalpit Devani
- Division of Gastroenterology, East Tennessee State University, Johnson City, TN, USA
| | - Romela Petrosyan
- Department of Internal Medicine, Greenville Memorial Hospital, Greenville, SC, USA
| | - Chakradhar Reddy
- Division of Gastroenterology, East Tennessee State University, Johnson City, TN, USA
| | - Nikolaos Pyrsopoulos
- Division of Gastroenterology and Hepatology, Newark University Hospital/Rutgers - New Jersey Medical School, Newark, NJ, USA
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