Induction of labor versus expectant management in patients with idiopathic polyhydramnios.

OBJECTIVE: To evaluate whether induction of labor is associated with lower risk of cesarean section compared to expectant management in patients with isolated polyhydramnios. STUDY DESIGN: This is a single-center, retrospective cohort study of patients with pregnancies complicated by idiopathic polyhydramnios, documented between 34 and 38 weeks gestation, who were delivered between July 2012 and February 2020. The primary outcome was cesarean delivery. Secondary outcomes included chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, and composite neonatal morbidity. RESULTS: There were 194 patients included with idiopathic polyhydramnios - 115 underwent induction and 79 patients were expectantly managed. Planned induction was associated with a lower rate of CD compared with expectant management but did not meet statistical significance (19.1 % vs 30.4 %, aOR 0.51, 95 % CI 0.24, 1.05). A similar effect was seen when stratifying for parity: both nulliparous (9.1 % vs 16.3 %, aOR 0.59, 95 % CI 0.17, 1.98) and multiparous (32.7 % vs 47.2 %, aOR 0.45, 95 % CI 0.18, 1.15) patients had a lower CD rate when there was a planned induction, though neither group met statistical significance. No differences in maternal or fetal secondary outcomes were identified (chorioamnionitis, endometritis, postpartum hemorrhage, preeclampsia/gestational hypertension, composite neonatal morbidity). CONCLUSION: Lower rates of cesarean section were associated with labor induction for patients with isolated polyhydramnios, but confidence intervals did not reach statistical significance.

Death among patients hospitalized with symptomatic COVID-19: Implications for high-risk patients.

BACKGROUND: We aimed to examine the role played by the COVID-19 infection in patients' death and to determine the proportion of patients for whom it was a major contributor to death. METHODS: We included patients ≥50 years old who were hospitalized with COVID-19 infection and died between March 1, 2020 and September 30, 2020 in a tertiary medical center. We considered COVID-19 infection to be a major cause for death if the patient had well-controlled medical conditions and death was improbable without coronavirus infection, and a minor cause for death if the patient had serious illnesses and had an indication for palliative care. RESULTS: Among 243 patients, median age was 80 (interquartile intervals: 72-86) and 40% were female. One in two had moderate or severe frailty and 41% had dementia. Nearly 60% of the patients were classified as having advanced, serious illnesses present prior to the hospitalization, with death being expected within 12 months, and among this group 39% were full code at admission. In the remaining 40% of patients, deaths were classified as unexpected based on patients' prior conditions, suggesting that COVID-19 infection complications were the primary contributor to death. CONCLUSIONS: For slightly less than half (40%) of patients who died of complications of COVID-19, death was an unexpected event. Among the 60% of patients for whom death was not a surprise, our findings identify opportunities to improve end-of-life discussions and implement shared decision-making in high-risk patients early on or prior to hospitalization.

Efficacy of models of palliative care delivered beyond the traditional physician-led, subspecialty consultation service model: a systematic review and meta-analysis.

OBJECTIVE: This meta-analysis aimed to determine the effectiveness of non-physician provider-led palliative care (PC) interventions in the management of adults with advanced illnesses on patient-reported outcomes and advance care planning (ACP). METHODS: We included randomised trials and cluster trials published in MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Register of Controlled Trials and ClinicalTrials.gov searched until July 2021 that examined individuals ≥18 years with a diagnosis of advanced, life-limiting illness and received a PC intervention led by a non-physician (nurse, advance practitioner or social worker). Our primary outcome was quality of life (QOL), which was extracted as unadjusted or adjusted estimates and measures of variability. Secondary outcomes included anxiety, depression and ACP. RESULTS: Among the 21 studies (2370 subjects), 13 included patients with cancer, 3 with heart failure, 4 with chronic respiratory disease and 1 with chronic kidney disease. The interventions were diverse and varied with respect to team composition and services offered. For QOL, the standardised mean differences suggested null effects of PC interventions compared with usual care at 1-2 months (0.04; 95% CI=-0.14 to 0.23, n=10 randomised controlled trials (RCTs)) and 6-7 months (0.10; 95% CI=-0.15 to 0.34, n=6 RCTs). The results for anxiety and depression were not significant also. For the ACP, there was a strong benefit for the PC intervention (absolute increase of 0.32% (95% CI=0.06 to 0.57). CONCLUSIONS: In this meta-analysis, PC interventions delivered by non-physician were not associated with improvement in QOL, anxiety or depression but demonstrated an impact on the ACP discussion and documentation.

Examining the "Repletion Reflex": The Association between Serum Potassium and Outcomes in Hospitalized Patients with Heart Failure.

BACKGROUND: In patients hospitalized with heart failure (HF) exacerbations, physicians routinely supplement potassium to maintain levels ≥4.0 mEq/L. The evidence basis for this practice is relatively weak. We aimed to evaluate the association between serum potassium levels and outcomes in patients hospitalized with HF. METHODS: We identified patients admitted with acute HF exacerbations to hospitals that contributed to an electronic health record-derived dataset. In a subset of patients with normal admission serum potassium (3.5-5.0 mEq/L), we averaged serum potassium values during a 72-hour exposure window and categorized as follows: <4.0 mEq/L (low normal), 4.0-4.5 mEq/L (medium normal), and >4.5 mEq/L (high normal). We created multivariable models examining associations between these categories and outcomes. RESULTS: We included 4,995 patients: 2,080 (41.6%), 2,326 (46.6%), and 589 (11.8%) in the <4.0, 4.0-4.5, and >4.5 mEq/L cohorts, respectively. After adjustment for demographics, comorbidities, and presenting severity, we observed no difference in outcomes between the low and medium normal groups. Compared to patients with levels <4.0 mEq/L, patients with a potassium level of >4.5 mEq/L had a longer length of stay (median of 0.6 days; 95% CI = 0.1 to 1.0) but did not have statistically significant increases in mortality (OR [odds ratio] = 1.51; 95% CI = 0.97 to 2.36) or transfers to the intensive care unit (OR = 1.78; 95% CI = 0.98 to 3.26). CONCLUSIONS: Inpatients with heart failure who had mean serum potassium levels of <4.0 showed similar outcomes to those with mean serum potassium values of 4.0-4.5. Compared with mean serum potassium level of <4.0, mean serum levels of >4.5 may be associated with increased risk of poor outcomes.

Supplemental thiamine for the treatment of acute heart failure syndrome: a randomized controlled trial.

BACKGROUND: The purpose of this pilot study was to determine if a definitive clinical trial of thiamine supplementation was warranted in patients with acute heart failure. We hypothesized that thiamine, when added to standard of care, would improve dyspnea (primary outcome) in hospitalized patients with acute heart failure. Peak expiratory flow rate, type B natriuretic peptide, free fatty acids, glucose, hospital length of stay, as well as 30-day rehospitalization and mortality were pre-planned secondary outcome measures. METHODS: This was a blinded experimental study at two urban academic hospitals. Consecutive patients admitted from the Emergency Department with a primary diagnosis of acute heart failure were recruited over 2 years. Patients on a daily dietary supplement were excluded. Randomization was stratified by type B natriuretic peptide and diabetes medication categories. Subjects received study drug (100 mg thiamine or placebo) in the evening of their first and second day. Outcome measures were obtained 8 h after study drug infusion. Dyspnea was measured on a 100-mm visual analog scale sitting up on oxygen, sitting up off oxygen, and lying supine off oxygen with 0 indicating no dyspnea. Data were analyzed using mixed-models as well as linear, negative binomial and logistic regression models to assess the impact of group on outcome measures. RESULTS: Of 130 subjects randomized, 118 had evaluable data (55 in the control and 63 in the treatment groups), 89% in both groups were adjudicated to have primarily AHF. Thiamine values increased significantly in the treatment group and were unchanged in the control group. One patient had thiamine deficiency. Only dyspnea measured sitting upright on oxygen differed significantly by group over time. No change was found for the other measures of dyspnea and all of the secondary measures. CONCLUSIONS: In mild-moderate acute heart failure patients without thiamine deficiency, a standard dosing regimen of thiamine did not improve dyspnea, biomarkers, or other clinical parameters. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00680706 , May 20, 2008 (retrospectively registered).

An Acute Care for Elders Quality Improvement Program for Complex, High-Cost Patients Yields Savings for the System.

BACKGROUND: Acute Care for Elders (ACE) programs improve outcomes for older adults; however, little is known about whether impact varies with comorbidity severity. OBJECTIVE: To describe differences in hospital-level outcomes between ACE and routine care across various levels of comorbidity burden. DESIGN: Cross-sectional quality improvement study. SETTING: A 716-bed teaching hospital. PARTICIPANTS: Medical inpatients aged ≥70 years hospitalized between September 2014 and August 2017. INTERVENTION: ACE care, including interprofessional rounds, geriatric syndromes screening, and care protocols, in an environment prepared for elders MEASUREMENTS: Total cost, length of stay (LOS), and 30-day readmissions. We calculated median differences for cost and LOS between ACE and usual care and explored variations across the distribution of outcomes at the 25th, 50th, 75th and 90th percentiles. Results were also stratified across quartiles of the combined comorbidity score. RESULTS: A total of 1,429 ACE and 10,159 non-ACE patients were included in this study. The mean age was 81 years, 57% were female, and 81% were white. ACE patients had lower costs associated with care ranging from $171 at the 25th percentile to $3,687 at the 90th percentile, as well as lower LOS ranging from 0 days at the 25th percentile to 1.9 days at the 90th percentile. After stratifying by comorbidity score, the greatest differences in outcomes were among those with higher scores. There was no difference in 30-day readmission between the groups. CONCLUSION: The greatest reductions in cost and LOS were in patients with greater comorbidity scores. Risk stratification may help hospitals prioritize admissions to ACE units to maximize the impact of the more intensive intervention.

Effect of Transient and Sustained Acute Kidney Injury on Readmissions in Acute Decompensated Heart Failure.

Although acute kidney injury (AKI) is common in heart failure, yet the impact of the onset, timing, and duration of AKI on short-term outcomes is not well studied. AKI was defined as an increase in serum creatinine SCr of ≥0.3 mg/dl or 1.5 times relative to the admission and further categorized as transient AKI (T-AKI: SCr returning to within 10% of baseline); sustained AKI (S-AKI: those with at least 72 hours of hospital stay and did not meet T-AKI); and unknown duration AKI (U-AKI: those with less than 72 hours stay and did not meet T-AKI). Reference category was no AKI (stable or <0.3 mg/dl change in SCr). The main outcome was 30-day all-cause hospital readmission. Unadjusted and adjusted association between AKI category of interest and main outcome was represented as percent and relative risks with 95% CIs. Statistical significance was set at an alpha of 0.05. From the Cerner Health Facts sample, 14,017 of 22,059 available subjects met the eligibility criteria. Approximately, 19.2% of our sample met the primary outcome. Compared with no AKI (readmission rate of 17.7%; 95% CI 16.4% to 18.9%), the adjusted rate of readmission was highest in patients with S-AKI (22.8%, 95% CI 20.8% to 24.8%; p <0.001), followed by 20.2% (95% CI 17.5% to 22.8%; p = 0.05) in T-AKI patients. Compared with no AKI, the adjusted relative risk of 30-day readmission was 1.29 (95% CI 1.17 to 1.42), 1.14 (95% CI 1.00 to 1.31), and 1.12 (95% CI, 1.01 to 1.26) in S-AKI, T-AKI, and U-AKI, respectively. In conclusion, both sustained AKI and patients with transient elevation still remain at a higher risk of readmission within 30 days. Future studies should focus on examining process-of-care after discharge in patients with different patterns of AKI.

Effects of an enhanced primary care program on diabetes outcomes.

OBJECTIVES: To evaluate the effectiveness of Buena Salud, a multidisciplinary enhanced primary care program for Medicaid Managed Care patients at a community health center serving a low-income Hispanic community. STUDY DESIGN: Controlled before-and-after observational study. METHODS: We extracted data from the electronic health record for patients aged 18 to 64 years with a) type 2 diabetes (T2D) enrolled in the Buena Salud program between August 2011 and January 2012 and b) randomly selected control patients with T2D who had been seen at the study health center during the same time frame. Outcomes included process measures (eg, number of glycosylated hemoglobin measures in a year), target lab and blood pressure values, and utilization measures (eg, emergency department visits). Demographics and other potential confounders were also extracted. We used a difference-in-differences (DID) analysis to estimate the effect of the intervention. RESULTS: A total of 72 Buena Salud patients with T2D and 247 control patients with T2D were included in the analysis. The Buena Salud group had a greater increase in the percentage of patients with guideline-concordant measurement of microalbumin/creatinine (DID = 22.2%; P = .008), a trend toward fewer hospitalizations than controls, and a mean rise in diastolic blood pressure. We did not find differences in other outcome or utilization measures. CONCLUSIONS: A recently implemented enhanced primary care program had minimal impact on T2D process, outcome, and utilization measures for patients in this study. However, there were some promising trends, and it is possible that the intervention may demonstrate more of an effect as the program matures.

Promoting high value inpatient care via a coaching model of structured, interdisciplinary team rounds.

The professional development of early career hospital physicians may be improved by embedding an experienced physician in a coaching role during structured, interdisciplinary team rounds. This article gives a descriptive report of such a model and discusses how it may promote delivery of high-value care to adult inpatients.

Antral follicle count in clinical practice: analyzing clinical relevance.

OBJECTIVE: To determine the clinical relevance of obtaining antral follicle counts (AFC) before ovarian stimulation in an IVF program. DESIGN: Retrospective cohort study. SETTING: An IVF program in a large academic teaching hospital. PATIENT(S): A total of 1,049 stimulated IVF cycles in 734 subjects between September 2003 and December 2007 selected from our program's database. INTERVENTION(S): Basal antral follicles (AFCs) (3 mm-10 mm) were counted via ultrasound scan on cycle day 3 in luteal leuprolide acetate stimulations, or after at least 2 weeks of oral contraceptives in microdose leuprolide acetate stimulations. Patients were grouped according to basal AFC, and outcome parameters compared for AFC groups within each stimulation protocol. MAIN OUTCOME MEASURE(S): Oocytes retrieved, ovarian response, implantation rate, cancellations, pregnancy, pregnancy loss, and live births per cycle start. RESULT(S): Antral follicle count grouping is predictive of threefold change in ovarian response to gonadotropins and oocytes retrieved. Low AFC did predict a higher cancellation rate. Antral follicle count did not predict implantation rate, pregnancy rate, or live birth rate per cycle start. CONCLUSION(S): Antral follicle count may be helpful in determining stimulation protocol, as it is the most reliable determinant of oocytes retrieved per starting FSH dose. Antral follicle count predicts ovarian response, not embryo quality or pregnancy.

Utility of fetal echocardiography after normal cardiac imaging findings on detailed fetal anatomic ultrasonography.

OBJECTIVE: The purpose of this study was to assess the utility of fetal echocardiography (FE) after normal fetal cardiac imaging findings during detailed fetal anatomic ultrasonography (FAU). METHODS: We conducted a retrospective cohort review of obstetric ultrasonographic studies from November 2001 through July 2005. We identified women with a singleton gestation with increased risk for congenital heart disease who received FAU performed by a maternal-fetal medicine specialist at 16 to 20 weeks' gestation with subsequent FE. These records were compared with newborn outcomes. RESULTS: Of 789 pregnancies that had FAU and FE, 481 had satisfactory cardiac imaging. Of those, only 1 fetus had abnormal FE findings. After delivery, 4 of the 480 neonates with normal FAU and FE findings had a diagnosis of a heart defect. CONCLUSIONS: Fetal echocardiography does not substantially increase the detection rate of major cardiac anomalies after normal findings on detailed FAU performed by a maternal-fetal medicine specialist.