COPD education, gender of leaders, and more

Research summaries from ACP Hospitalist Weekly.

Educational video at discharge after COPD exacerbation didn't improve rehab uptake

Watching an educational video at discharge about the value of pulmonary rehabilitation did not increase rates of participation, referral, or completion among patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD) in a recent trial.

Researchers in London designed an educational video as an adjunct to care for patients who were hospitalized for COPD exacerbations. Patients were assigned to receive usual care, defined as a COPD discharge bundle that included written information about pulmonary rehab, or usual care plus the video, which was viewed on a handheld tablet at discharge. Those in the intervention group also received a secure link and password that allowed them to access the video after discharge. Pulmonary rehab uptake within 28 days of discharge was the study's primary outcome. Secondary end points included referral to or completion of pulmonary rehab, and safety end points were readmission and death. In addition, 15 participants in the intervention group were interviewed about their perspectives within a week after the 90-day follow-up period ended. The study results were published March 17 by the American Journal of Respiratory and Critical Care Medicine and appeared in the June 15 issue.

Image by Getty Images
Image by Getty Images

Two hundred patients were recruited for the study between February 2015 and May 2018, and of these, 196 were randomly assigned, 98 to each group. Fifty-one percent of patients were women, and the median FEV1 was 36% of predicted. Overall, uptake of pulmonary rehab was 37%, and the difference in uptake between the usual care and intervention groups was not significant (41% vs. 34%; P=0.37). No between-group differences were seen in secondary end points or safety end points. Of the 15 patients interviewed, eight did not participate in pulmonary rehab and six completed the program. Six participants did not remember having seen the video. Mortality rates and all-cause readmission rates during the 90-day follow-up period were 2% and 15% in the control group and 1% and 22% in the intervention group, respectively. However, 42 patients in the intervention group and 38 in the control group were lost to follow-up.

The study was done at a single center, and patients were not formally evaluated for cognitive dysfunction, digital literacy, or internet availability, among other limitations. The researchers concluded that the educational video in this trial did not appear to affect rates of referral to or uptake of pulmonary rehab after a COPD-related hospitalization. “However, given the intervention is cheap, easily implementable and not associated with any known adverse effects, further studies could be considered to identify potential roles for this education video,” the authors wrote. They noted that the video may be able increase delivery of COPD discharge bundles in some settings.

Leadership, rank differ by gender in academic hospital medicine, survey finds

Gender inequities in leadership and rank are common in academic hospital medicine, according to a recent study.

Researchers conducted a national survey of academic hospital medicine programs that was developed using literature review and expert recommendations in association with the Society of Hospital Medicine. Program and faculty information were assessed, and the gender of program leaders was determined by website or by telephone call. Program leaders were included in the study if their program was associated with the American Association of Medical Colleges (AAMC). Programs were excluded if they were at a Veterans Affairs hospital, if they did not have a primary teaching hospital, or if they were not staffed by university-affiliated physicians.

An academic hospitalist was defined as a physician whose primary professional focus is the care of general medical hospitalized patients, who works at a hospital or hospitals associated with AAMC, and who is employed by either the health center or university. The study's main outcome measures were description and characteristics of programs and leaders, including multivariable analysis of the gender of hospitalist leaders and the proportion of female faculty. The results were published March 3 by the Journal of General Internal Medicine.

One hundred thirty-five programs were sent the survey by email, with email and paper reminders. Eighty programs responded, for a response rate of 59%. Responders and nonresponders did not differ significantly in NIH funding, type of institution, geographic region, or year the program was established. Programs reported an approximately equal number of female and male faculty. Of the 80 respondents, 66 (82.5%) said their title was “hospitalist director” or the equivalent, and nearly 80% of this group were men. Thirty-seven percent of male hospitalist leaders and 0% of female hospitalist leaders were full professors. The number of hospitals staffed was a significant predictor of having a female hospitalist leader in univariate and multivariate analysis, but no significant predictors of having fewer female faculty were found.

The authors concluded that although gender distribution among faculty in their study appeared equal, gender inequality was present in leadership and rank, since the majority of leaders and all full professors were men. “It is heartening that there are reported roughly equal number of men and women on faculty in AHM [academic hospital medicine],” the authors wrote. “However, our findings of gender inequity in leadership and academic rank suggest that research, faculty development, and interventions to reach gender equity are necessary to move AHM forward.” Possible solutions to promote gender equity include strategies to address implicit bias during the hiring and promotion process and development of mentorship programs for women, they said.

Moral distress common among physicians caring for inpatients without decisional capacity

Nearly half of physicians reported experiencing moral distress while caring for hospitalized older patients who lacked decision-making capacity in a recent prospective observational study.

As part of a secondary analysis of another study, researchers surveyed 154 attendings and trainees caring for 362 patients ages 65 years and older with surrogate decision makers at three hospitals in one Midwestern city. They used the Moral Distress Thermometer screening tool to measure moral distress, defined as an emotional experience in which one feels constrained from acting on deeply held beliefs, resulting in the sense of compromising professional integrity. Patients were admitted to medicine or medical intensive care services, hospitalized for at least 48 hours, lacked decisional capacity, and had an identified surrogate. Results were published Feb. 24 by the Journal of General Internal Medicine.

Physicians experienced moral distress in the care of 152 of 362 patients (42%) (ratings were missing for two patients). After adjustment for physician, patient, and surrogate characteristics, discordance in preferences between the physician and surrogate regarding the plan of care was not significantly associated with moral distress. However, there was increased moral distress when physicians perceived the plan of treatment as different from what they would prefer. Female physicians were less likely than male physicians to experience moral distress in the adjusted analysis (odds ratio [OR], 0.45; 95% CI, 0.21 to 0.93; P=0.0316).

Physicians were more likely to experience moral distress when caring for older patients (OR, 1.06; 95% CI, 1.02 to 1.10; P=0.0013) and when facing a decision about life-sustaining treatment (OR, 3.58; 95% CI, 1.54 to 8.32; P=0.0031). In contrast, physicians were less likely to experience moral distress when caring for patients who resided in nursing homes (OR, 0.40; 95% CI, 0.23 to 0.69; P=0.0010), had previously discussed care preferences with anyone (OR, 0.56; 95% CI, 0.35 to 0.90; P=0.0170), or had higher surrogate ratings of emotional support from clinicians (OR, 0.94; 95% CI, 0.89 to 0.99; P=0.0128). Physicians' internal discordance when they preferred a more comfort-focused plan than the patient was receiving was associated with significantly higher moral distress (OR, 2.22; 95% CI, 1.33 to 3.70; P=0.0022) after adjustment for patient, surrogate, and physician characteristics.

The study authors noted that they did not explore the particular causes of discordance or distress in each case and that there was potential for unmeasured confounders, among other limitations. An important finding of the study was that when physicians knew that patient preferences have been discussed, they were less likely to experience moral distress, the study authors said. “Future research could investigate whether advance care planning and emotional support of surrogates could reduce the levels of physician moral distress,” they concluded.

Incidence of several multidrug-resistant infections in U.S. inpatients declined in recent years

Hospitals are seeing reductions in the incidence of infections with several, but not all, multidrug-resistant pathogens, a recent study found.

Researchers used data from patients hospitalized in a cohort of 890 U.S. hospitals from 2012 through 2017 to generate national case counts for both hospital- and community-onset infections caused by multidrug-resistant bacteria. Such bacteria included methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum cephalosporin resistance in Enterobacteriaceae suggestive of extended-spectrum beta-lactamase (ESBL) production, carbapenem-resistant Enterobacteriaceae and Acinetobacter species, and multidrug-resistant Pseudomonas aeruginosa. Results of the CDC-funded study were published on April 2 by the New England Journal of Medicine.

Overall, the hospital cohort accounted for 41.6 million hospitalizations, representing more than 20% of U.S. hospitalizations annually. The overall rate of clinical cultures, which remained stable throughout the study period, was 292 cultures per 1,000 patient-days. In 2017, the multidrug-resistant pathogens caused an estimated 622,390 infections (95% CI, 579,125 to 665,655 infections) among hospitalized patients. Of these infections, 517,818 (83%) had their onset in the community and 104,572 (17%) had their onset in the hospital. MRSA and ESBL infections accounted for the majority of the infections (52% and 32%, respectively). From 2012 to 2017, the incidence decreased for MRSA infection (from 114.18 to 93.68 cases per 10,000 hospitalizations), VRE infection (from 24.15 to 15.76 per 10,000 hospitalizations), carbapenem-resistant Acinetobacter species infection (from 3.33 to 2.47 per 10,000 hospitalizations), and multidrug-resistant P. aeruginosa infection (from 13.10 to 9.43 per 10,000 hospitalizations), with decreases ranging from −20.5% to −39.2%. The incidence of ESBL infection increased by 53.3% (from 37.55 to 57.12 cases per 10,000 hospitalizations), a change driven by an increase in community-onset cases. The incidence of carbapenem-resistant Enterobacteriaceae infection did not change significantly (from 3.36 to 3.79 cases per 10,000 hospitalizations).

Limitations of the study include the fact that case identification and categorization were based on clinical microbiology test results, combined with test and admission dates, the authors noted, so they could not determine if an isolate represented a true infection. They added that data were derived from a large but not randomly selected sample of hospitals that may not have been nationally representative.

The results show encouraging signs that collective efforts to limit the transmission of multidrug-resistant pathogens in health care institutions have had beneficial effects, an accompanying editorial noted. However, the increase in incidence of ESBL infection suggests that these efforts have been offset by increasing rates of antimicrobial resistance in the community, the editorialists said.

“We cannot afford to be complacent about recent progress in the health care setting, because resistant pathogens are still too common in most institutions, and favorable trends can be readily reversed,” they wrote. “It will be more difficult to control antimicrobial resistance in the community, and innovative approaches are needed.”

Care disparities, barriers common in homeless patients hospitalized for acute MI

Patients with acute myocardial infarction (MI) who are homeless may receive less optimal in-hospital care and have higher rehospitalization rates than nonhomeless patients.

Researchers used the National Readmission Database to identify homeless and nonhomeless adults admitted to the hospital with acute MI between Jan. 1, 2015, and Dec. 31, 2016. The two cohorts were compared for baseline characteristics, rates of invasive assessment and revascularization, mortality rates, 30-day readmission rates, and readmission reasons. Results were published March 19 by Mayo Clinic Proceedings and appeared in the April 1 issue.

Image by Getty Images
Image by Getty Images

Of 1,100,241 index hospitalizations for acute MI, 3,938 (0.4%) were in patients who were homeless. Homeless patients were younger (mean age, 57 years vs. 68 years) and were less likely to have atherosclerotic risk factors such as hypertension, hyperlipidemia, and diabetes but more likely to have anxiety, depression, and substance abuse compared with nonhomeless patients. The homeless cohort included fewer women than the nonhomeless cohort (17.5% vs. 40.5%, respectively). Coronary angiography, percutaneous coronary intervention, and coronary artery bypass grafting were done less frequently in homeless patients, and homeless patients who did undergo percutaneous coronary intervention were more likely to receive bare-metal stents. Mortality rates were similar in homeless and nonhomeless patients after propensity score matching, but homeless patients were more likely to have acute kidney injury, to be discharged to an intermediate care facility or against medical advice, and to have longer hospital stays. Significantly higher 30-day readmission rates were seen in homeless versus nonhomeless patients (22.5% vs. 10.0%; P<0.001), and readmissions for psychiatric causes were also more common (18.0% vs. 2.0%; P<0.001).

The researchers noted that homelessness might have been underreported in National Readmission Database and that it does not include data on deaths outside the hospital, among other limitations. They concluded that homeless patients who are admitted to the hospital for acute MI have a different risk profile than nonhomeless patients, experience disparities in care, and have worse short-term outcomes and higher readmission rates. “Stakeholders need to collaborate on policies and interventions to improve the psychosocial profile, health care delivery, and outcomes in homeless patients,” the authors wrote. They called for additional research on the potential effects of a housing intervention in this cohort.

1 in 10 older inpatients with diabetes discharged with intensified medication regimen

For older inpatients with diabetes, discharging clinicians should consider long-term glucose control and life expectancy in addition to inpatient blood glucose readings to avoid excessive medication intensifications at discharge, a study suggested.

Researchers retrospectively looked at patients ages 65 years and older with diabetes not previously requiring insulin who were hospitalized in Veterans Health Administration hospitals for common medical conditions between 2012 and 2013. They assessed how often the patients were discharged with intensified diabetes medications, defined as a new or higher-dose medication at discharge than was being taken prior to hospitalization, as well as the likelihood of benefit associated with these intensifications. Results were published March 24 by JAMA Network Open.

Of 16,178 patients (mean age, 73 years; 98% men), 8,535 (53%) had a preadmission HbA1c level less than 7.0%, and 1,044 (6%) had an HbA1c level greater than 9.0%. Nearly 70% of patients were taking one or more diabetes medications prior to hospitalization, with metformin and sulfonylureas the most commonly used. Overall, 1,626 patients (10%) were discharged with intensified diabetes medications, including 781 (5%) with new insulin use and 557 (3%) with intensified sulfonylureas.

Nearly half of those receiving intensifications (n=791; 49%) were classified by the researchers as unlikely to benefit due to limited life expectancy or a preadmission HbA1c level less than 7.5%. Twenty percent (n=329) had potential benefit (i.e., preadmission HbA1c level greater than 9.0%). The remaining 31% were classified as indeterminate benefit (i.e., HbA1c level between 7.5% and 9.0% with a life expectancy of five years or more). Higher preadmission HbA1c levels and inpatient blood glucose levels were associated with intensified diabetes medications at discharge. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3% to 4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15% to 26%) for those with severely elevated inpatient blood glucose levels.

Among other limitations, pharmacy records allowed for identification of dose changes for oral medications but did not accurately reflect changes to insulin dosing; therefore, the study excluded patients taking insulin prior to hospitalization, the authors noted. “Improving diabetes care for hospitalized older adults will require efforts to move beyond treating elevated inpatient numbers and toward patient-centered decision-making that considers long-term benefits and the risks of potentially unnecessary medication intensifications,” they concluded.

The results demonstrate that inpatient clinicians “may be currently too focused on the numbers” and trying to reconcile outpatient and inpatient American Diabetes Association guidelines during acute care transitions, an accompanying editorial noted. They may be responding to outpatient guidelines for glucose control while also extrapolating inpatient treatment guidelines to the postdischarge period, possibly in an effort to continue control of hyperglycemia, the editorial said.

“Inpatient clinicians are appropriately concerned about outcomes among their patients with elevated HbA1c levels and ongoing hyperglycemia. However, preventing potentially unnecessary intensification will require new evidence and continued improvements during care transitions,” the editorialist wrote.