Characteristics, Treatment Patterns, and Clinical Outcomes After Heart Failure Hospitalizations During the COVID-19 Pandemic, March to October 2020.

OBJECTIVE: To compare clinical characteristics, treatment patterns, and 30-day all-cause readmission and mortality between patients hospitalized for heart failure (HF) before and during the coronavirus disease 2019 (COVID-19) pandemic. PATIENTS AND METHODS: The study was conducted at 16 hospitals across 3 geographically dispersed US states. The study included 6769 adults (mean age, 74 years; 56% [5033 of 8989] men) with cumulative 8989 HF hospitalizations: 2341 hospitalizations during the COVID-19 pandemic (March 1 through October 30, 2020) and 6648 in the pre-COVID-19 (October 1, 2018, through February 28, 2020) comparator group. We used Poisson regression, Kaplan-Meier estimates, multivariable logistic, and Cox regression analysis to determine whether prespecified study outcomes varied by time frames. RESULTS: The adjusted 30-day readmission rate decreased from 13.1% (872 of 6648) in the pre-COVID-19 period to 10.0% (234 of 2341) in the COVID-19 pandemic period (relative risk reduction, 23%; hazard ratio, 0.77; 95% CI, 0.66 to 0.89). Conversely, all-cause mortality increased from 9.7% (645 of 6648) in the pre-COVID-19 period to 11.3% (264 of 2341) in the COVID-19 pandemic period (relative risk increase, 16%; number of admissions needed for one additional death, 62.5; hazard ratio, 1.19; 95% CI, 1.02 to 1.39). Despite significant differences in rates of index hospitalization, readmission, and mortality across the study time frames, the disease severity, HF subtypes, and treatment patterns remained unchanged (P>0.05). CONCLUSION: The findings of this large tristate multicenter cohort study of HF hospitalizations suggest lower rates of index hospitalizations and 30-day readmissions but higher incidence of 30-day mortality with broadly similar use of HF medication, surgical interventions, and devices during the COVID-19 pandemic compared with the pre-COVID-19 time frame.

Post-discharge early assessment with remote video link (PEARL) initiative for patients discharged from hospital medicine services.

OBJECTIVES: The COVID-19 pandemic impacted the availability and accessibility of outpatient care following hospital discharge. Hospitalists (physicians) and hospital medicine advanced practice providers (HM-APPs) coordinate discharge care of hospitalized patients; however, it is unknown if they can deliver post-discharge virtual care and overcome barriers to outpatient care. The objective was to develop and provide post-discharge virtual care for patients discharged from hospital medicine services. METHODS: We developed the Post-discharge Early Assessment with Remote video Link (PEARL) initiative for HM-APPs to conduct a post-discharge video visit (to review recommendations) and telephone follow-up (to evaluate adherence) with patients 2-6 days following hospital discharge. Participants included patients discharged from hospital medicine services at an institution's hospitals in Rochester (May 2020-August 2020) and Austin (November 2020-February 2021) in Minnesota, US. HM-APPs also interviewed patients about their experience with the video visit and completed a survey on their experience with PEARL. RESULTS: Of 386 eligible patients, 61.4% were enrolled (n = 237/386) including 48.1% women (n = 114/237). In patients with complete video visit and telephone follow-up (n = 141/237), most were prescribed new medications (83.7%) and took them as prescribed (93.2%). Among five classes of chronic medications, patient-reported adherence ranged from 59.2% (narcotics) to 91.5% (anti-hypertensives). Patient-reported self-management of 12 discharge recommendations ranged from 40% (smoking cessation) to 100% (checking rashes). Patients reported benefit from the video visit (agree: 77.3%) with an equivocal preference for video visits over clinic visits. Among HM-APPs who responded to the survey (88.2%; n = 15/17), 73.3% reported benefit from visual contact with patients but were uncertain if video visits would reduce emergency department visits. CONCLUSION: In this novel initiative, HM-APPs used video visits to provide care beyond their hospital role, reinforce discharge recommendations for patients, and reduce barriers to outpatient care. The effect of this initiative is under evaluation in a randomized controlled trial.

Psychologic wellness of PA, NP, and physician hospitalists during the COVID-19 pandemic.

OBJECTIVES: Hospitalists, comprising PAs, NPs, and physicians, manage patients hospitalized with COVID-19. To guide the development of support programs, this study compared the psychologic wellness of hospitalist PAs, NPs, and physicians during the COVID-19 pandemic. METHODS: We surveyed hospitalists in 16 hospitals at Mayo Clinic, from May 4 to 25, 2020. We used PROMIS surveys for self-reported global well-being (two single-item measures), anxiety, social isolation, and emotional support, before and during the pandemic. Linear and logistic regression models were adjusted for personal and professional factors. RESULTS: The response rate was 52.2% (N = 154/295). In adjusted linear regression models, the change in scores (before minus during pandemic) for anxiety, social isolation, and emotional support was similar for PAs and NPs compared with physicians. In adjusted logistic regression models, physicians, compared with PAs and NPs, had a higher odds of top global well-being for mental health (adjusted odds ratio [95% confidence interval]: 2.82 [1.12, 7.13]; P = .03) and top global well-being for social activities and relationships (adjusted odds ratio 4.08 [1.38, 12.08]; P = .01). CONCLUSIONS: During the COVID-19 pandemic, global well-being was lower for PAs and NPs compared with physician hospitalists. These results can guide support programs for hospitalists.

Wellness of hospitalists and hospital medicine advanced practice providers during the COVID-19 pandemic, 2020-2021.

BACKGROUND: The early phase of the coronavirus disease 2019 (COVID-19) pandemic had a negative impact on the wellness of hospitalists and hospital medicine advanced practice providers (APPs). However, the burden of the pandemic has evolved and the change in hospitalist and hospital medicine APP wellness is unknown. OBJECTIVE: To evaluate the longitudinal trend in wellness of hospitalists and hospital medicine APPs during the COVID-19 pandemic and guide wellness interventions. DESIGN, SETTING AND PARTICIPANTS: Between May 4, 2020, and June 6, 2021, we administered three surveys to Internal Medicine hospitalists (physicians) and hospital medicine APPs (nurse practitioners and physician assistants) at 16 Mayo Clinic hospitals in four U.S. states. MEASUREMENTS: We evaluated the association of hospitalist and hospital medicine APP characteristics with PROMIS® measures of global wellbeing-mental health, global wellbeing-social activities and relationships, anxiety, social isolation, and emotional support, using logistic and linear regression models. RESULTS: The response rates were 52.2% (n=154/295; May 2020), 37.1% (n=111/299; October 2020) and 35.5% (n=114/321; May 2021). In mixed models that included hospitalist and hospital medicine APP characteristics and survey period, APPs, compared with physicians, had lower odds of top global wellbeing-social activities and relationships (adjusted odds ratio 0.42 [0.22-0.82]; p = .01), whereas survey period showed no association. The survey period showed an independent association with higher anxiety (May 2020 vs. others) and higher social isolation (October 2020 vs. others), whereas profession showed no association. Concern about contracting COVID-19 at work was significantly associated with lower odds of top global wellbeing-mental health and global wellbeing-social activities and relationships, and with higher anxiety and social isolation. Hospitalist and hospital medicine APP characteristics showed no association with levels of emotional support. CONCLUSIONS: In this longitudinal assessment of hospitalists and hospital medicine APPs, concern about contracting COVID-19 at work remained a determinant of wellness. The trend for global wellbeing, anxiety, and social isolation may guide wellness interventions.

Hospitalist perspectives on barriers to recommend and potential benefit of the COVID-19 vaccine.

Background: Hospitalists, comprised of nurse practitioners and physician assistants (collectively, advanced practice providers [APPs]) and physicians, have opportunities to counsel patients and reduce SARS-CoV-2 related coronavirus disease 2019 (COVID-19) vaccine hesitancy. However, hospitalist perspectives on the COVID-19 vaccine and potential differences between APPs and physicians are unknown. Understanding hospitalist perspectives could help to address vaccine hesitancy among patients.Methods: We conducted an online survey of hospitalists at Mayo Clinic sites in Arizona, Florida, Minnesota, and Wisconsin from 14 December 2020 through 4 January 2021. We collected demographic information and assessed perspectives on the COVID-19 vaccine and, for comparison, on the influenza vaccine. Descriptive statistics were used to compare responses between APPs and physicians.Results: The overall response rate was 42.7% (n = 128/300) and comprised of 53.9% women (n = 69/128) and 41.4% APPs (n = 53/128). Most hospitalists reported receiving or planning to receive vaccination against COVID-19 (93.7%; n = 119/128) and influenza (97.7%; n = 125/128). Most hospitalists reported they would advise 100% of patients to receive the COVID-19 vaccine (66% for APPs; 74.7% for physicians) and influenza vaccine (83% for APPs; 80% for physicians). Barriers to recommending the COVID-19 vaccine included patient health status and vaccine safety profile. Hospitalists reported that patients and coworkers receiving the COVID-19 vaccine would reduce their anxiety (~80% of hospitalists), social isolation (~64% of hospitalists), and improve their emotional support (~40% of hospitalists). APP and physician responses were similar. The possible reduction in social isolation was associated with higher odds of hospitalists advising all patients to receive the COVID-19 vaccine (adjusted odds ratio 2.95 [95% confidence interval, 1.32-6.59]; P< .008), whereas hospitalist age, gender, and profession showed no association.Conclusion: Most hospitalists would reportedly advise patients to receive the COVID-19 vaccine. Barriers to this recommendation included patient health status and vaccine safety. Hospitalists are an important resource to provide patient education and reduce COVID-19 vaccine hesitancy.

Burden and management of type 2 diabetes in rural United States.

In the United States, rural areas have a higher burden of type 2 diabetes (T2DM) compared to urban areas. However, there is limited information on risk factors and interventions that improve the primary prevention and management of T2DM in rural areas. To synthesize current knowledge on T2DM in rural areas and to guide healthcare providers and policy makers, we reviewed five scientific databases and the grey literature over the last decade (2010-2020). We described classification systems for rurality and the T2DM burden based on rurality and region (West, South, Midwest, and Northeast). We highlighted risk factors for T2DM in rural compared to urban areas, and summarized interventions to screen and manage T2DM based on opportunistic screening, T2DM self-management, community-based initiatives, as well as interventions targeting comorbidities and T2DM. Several studies identified the co-existence of T2DM and depression/psychological symptoms, which could reduce adherence to non-pharmacologic and pharmacologic management of T2DM. We highlighted the role of technology in education and counselling of patients with geographic and financial barriers to accessing care, which is exacerbated by the SARS-CoV-2 coronavirus disease-19 pandemic. We identified knowledge gaps and next steps in improving T2DM care in rural areas. There is an urgent need for interventions tailored to rural areas given that rural Americans currently experience a disproportionate burden of T2DM and are encumbered by its associated morbidity, mortality, and loss in economic productivity.

Psychological wellness of internal medicine hospitalists during the COVID-19 pandemic.

BACKGROUND: Patients with COVID-19 infection requiring in-hospital care are frequently managed by Internal Medicine hospitalists, comprised of physicians, nurse practitioners and physician assistants. There is sparse information on the psychological impact of the COVID-19 pandemic on Internal Medicine hospitalists. METHODS: We surveyed Internal Medicine hospitalists at Mayo Clinic sites in four states (Arizona, Florida, Minnesota, and Wisconsin). We collected demographic information, and used Patient-Reported Outcomes Measurement Information System (PROMIS®) measures to assess global well-being, anxiety, social isolation, and emotional support. Descriptive statistics were used to compare responses between two periods: prior to the pandemic (before March 15th, 2020), and during the pandemic (March 15 through 30 April 2020). The survey was conducted from May 4-25, 2020. RESULTS: Of 295 Internal Medicine hospitalists, 154 (52%) responded. Fifty-six percent were women (n = 85/154) and 54% were physicians (n = 84/154). Most hospitalists (75%; n = 115/154) reported concerns about contracting COVID-19 infection at work, and 5% (n = 8/154) reported changing where they lived during the pandemic. Most hospitalists (73%; n = 112/154) reported relying primarily on institutional resources for COVID-19 information. During the pandemic, the percentage of participants with excellent or very good global well-being decreased (90% prior to pandemic vs. 53% during pandemic), with increases in mean anxiety (-4.88 [95% confidence interval, - 5.61 to - 4.16]; P<.001) and social isolation (-3.91[95% confidence interval, - 4.68 to - 3.13]; P<.001). During the same period, there was a small decrease in mean emotional support (1.46 [95% confidence interval, 0.83 to 2.09]; P<.001). CONCLUSION: During the COVID-19 pandemic, Internal Medicine hospitalists reported lower global well-being, higher anxiety and social isolation, and a small decrease in emotional support. These results provide a framework to develop programs to support hospitalists and potentially mitigate long-term psychological sequelae including burnout.

80-year-old man with dyspnoea and bilateral groundglass infiltrates: an elusive case of COVID-19.

COVID-19 is a novel viral infection caused by severe acute respiratory syndrome-coronavirus-2 virus, first identified in Wuhan, China in December 2019. COVID-19 has spread rapidly and is now considered a global pandemic. We present a case of a patient with minimal respiratory symptoms but prominent bilateral groundglass opacities in a 'crazy paving' pattern on chest CT imaging and a negative initial infectious workup. However, given persistent dyspnoea and labs suggestive of COVID-19 infection, the patient remained hospitalised for further monitoring. Forty-eight hours after initial testing, the PCR test was repeated and returned positive for COVID-19. This case illustrates the importance of clinical vigilance to retest patients for COVID-19, particularly in the absence of another compelling aetiology. As COVID-19 testing improves to rapidly generate results, selective retesting of patients may uncover additional COVID-19 cases and strengthen measures to minimise the spread of COVID-19.