Understanding the Relationship Between Wealth and Cognitive Function by Race/Ethnicity Among Older United States Adults with Diabetes.

Background: The prevalence of type 2 diabetes is increasing with the burden disproportionately falling on older adults and racial/ethnic minorities. Older adults with diabetes show greater cognitive decline and there are disparities in cognitive function by race/ethnicity that can be explained by social determinants such as wealth. Objective: To understand whether there is a differential relationship between wealth and cognitive function by race/ethnicity among older U.S. adults with diabetes. Methods: Data on 9,006 adults aged 50+ with diabetes from the Health and Retirement Study (2006-2016) were analyzed. The primary outcome, cognitive function, was a score ranging from range 0-27 categorized as: normal [12-27], mild cognitive impairment (MCI) [7-11], and dementia including Alzheimer's disease [0-6]. Three modeled outcomes were: 1) normal versus MCI, 2) normal versus dementia, 3) MCI versus dementia. Wealth was log transformed and used as continuous and binary (≥median,

Understanding the relationship between social risk factors and functional limitation among stroke survivors in the US.

BACKGROUND: Stroke is the fifth leading cause of death and disability in the United States. Social risk factors contribute to recovery from stroke, however the relationship between social risk factors and functional limitation among stroke survivors remains unknown. METHODS: Data on 2,888 adults with stroke from the National Health Interview Survey from 2016-2018 was analyzed. The primary independent variables included six social risk factors: economic instability, lack of community, educational deficit, food insecurity, social isolation, and inadequate access to care. The outcome measure was functional limitation count. Negative binomial regression models were run to test the relationship between the independent and dependent variables adjusting for covariates. RESULTS: Overall, 56% of the study participants were aged 65+, 70% were Non-Hispanic White, and 95% had at least one comorbidity. The mean functional limitation count was 1.8. In the unadjusted model, each social risk factor was significantly associated with functional limitation. In the fully adjusted model, significant association with functional limitation was found in individuals reporting economic instability (Incidence rate ratio [IRR] 1.65, 95% CI 1.33, 2.06), food insecurity (IRR 1.28, 95% CI 1.15, 1.42), and social isolation (IRR 1.64, 95% CI 1.48, 1.82). CONCLUSIONS: Social risk factors such as economic instability, food insecurity and social isolation are significantly associated with functional limitation in adults with stroke. Interventions designed to address both social and medical needs have the potential to improve physical functioning and other clinical outcomes in stroke survivors.

State of research in adult Hospital Medicine: Updated results of a national survey and longitudinal analysis of national data.

We sought to understand the current state of research in adult Hospital Medicine by repeating a 2018 survey of leaders in Hospital Medicine with changes to improve the response rate of surveyed programs. We also analyzed the public sources of federal research funding and MEDLINE-indexed publications from 2010 through 2019 among members of the Society of Hospital Medicine (SHM). Of the 102 contacted leaders of Hospital Medicine groups across the country, 49 responded, for a total response rate of 48%. Among the 3397 faculty members represented in responding programs, 72 (2%) of faculty were identified as conducting research for more than 50% of their time. Respondents noted difficulties at every stage of the research development pipeline, from a lack of mentors to running a fellowship program to a lack of applicants seeking further research training. Improvements to our research training pipeline will be essential to the long-term improvement of our profession.

Dose response relationship between food insecurity and quality of life in United States adults: 2016-2017.

BACKGROUND: Food insecurity is associated with worse general health rating, but little research exists investigating whether there is a dose response relationship across levels of food security and mental and physical health domains at the population level. METHODS: Data from the Medical Expenditure Panel Survey (2016-2017) with US adults aged 18 years and older was used. The physical component score (PCS) and mental component score (MCS) of Quality of Life, served as the outcome measures. Four categories of food insecurity (high, marginal, low, very low food security) served as the primary independent variable. Linear regression was used to run unadjusted followed by adjusted models. Separate models were run for PCS and MCS. RESULTS: In a sample of US adults, 16.1% reported some degree of food insecurity. For PCS, marginal (ß = - 2.54 (p < 0.001), low (ß = - 3.41, (p < 0.001), and very low (ß = - 5.62, (p < 0.001) food security was associated with worse PCS scores, compared to adults with high food security. For MCS, marginal (ß = - 3.90 (p < 0.001), low (ß = - 4.79, (p < 0.001), and very low (ß = - 9.72, (p < 0.001) food security was associated with worse MCS scores, compared to adults with high food security. CONCLUSION: Increasing levels of food insecurity were associated with decreased physical and mental health quality of life scores. This relationship was not explained by demographic factors, socioeconomic factors, insurance, or comorbidity burden. This study suggests work is needed to mitigate the impact of social risk, such as food insecurity, on quality of life in adults, and understand pathways and mechanisms for this relationship.

Interventions to Reduce Hospital Readmissions in Older African Americans: A Systematic Review of Studies Including African American Patients.

OBJECTIVES: This systematic review aims to summarize interventions that effectively reduced hospital readmission rates for African Americans (AAs) aged 65 and older. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this review. Studies were identified by searching PubMed for clinical trials on reducing hospital readmission among older patients published between 1 January 1990 and 31 January 2020. Eligibility criteria for the included studies were mean or median age ≥ 65 years, AAs included in the study, randomized clinical trial or quasi-experimental design, presence of an intervention, and hospital readmission as an outcome. RESULTS: There were 5270 articles identified and 11 were included in the final review based on eligibility criteria. The majority of studies were conducted in academic centers, were multi-center trials, and included over 200 patients, and 6-90% of participants were older AAs. The length of intervention ranged from 1 week to over a year, with readmission assessed between 30 days and 1 year. Four studies which reported interventions that significantly reduced readmissions included both inpatient (e.g., discharge planning prior to discharge) and outpatient care components (e.g., follow-ups after discharge), and the majority used a multifaceted approach. CONCLUSION: Findings from the review suggest successful interventions to reduce readmissions among AAs aged 65 and older should include inpatient and outpatient care components at a minimum. This systematic review showed limited evidence of interventions successfully decreasing readmission in older AAs, suggesting a need for research in the area to reduce readmission disparities and improve overall health.

Perception of Burnout and Its Impact on Academic Hospitalists During COVID-19 and Institutional Strategies to Combat Burnout and Improve Wellness.

INTRODUCTION: Physician burnout has been alarmingly high, particularly among general internal medicine, which displays some of the highest rates. A recent study of academic hospitalists reported a higher level of burnout (62%) than the rates found in similar studies, but with agreement about factors leading to burnout, consequences of burnout, and importance of steps to prevent burnout. This study seeks to expand upon these results by investigating the impact of COVID-19 on burnout among hospitalists and uncovering the perspectives of frontline clinicians to formulate effective mitigation strategies. METHODS: Academic hospitalists were recruited to participate in a series of focus group interviews. The questions focused on contributors to burnout, the impact of COVID-19, and strategies to improve wellness and reduce burnout. The focus groups were audio-recorded, transcribed, and coded for emergent themes using Taguette, an open-source qualitative data analysis software. RESULTS: Burnout-inducing themes included workload, bureaucratic hurdles, and lack of control. COVID-19-specific themes included fear of exposing family and social isolation. The most common mitigation strategy was to increase social interactions to foster a sense of community. Additional solutions included adhering to a census cap of patients, streamlining clinical work, and providing avenues for two-way communication between leadership and clinicians to share concerns and elicit feedback. CONCLUSIONS: Streamlining clinical work allows more time for patient care. Enhancing community and fostering collaboration in decision-making allows clinicians to feel more empowered. A crucial first step to combat burnout is to encourage a work environment that values clinician well-being and proactively works to increase job satisfaction.

Relationship between food insecurity and housing instability on quality of care and quality of life in adults with diabetes.

OBJECTIVE: Examine the relationship between food and housing insecurities, quality of care and quality of life in adults with diabetes using a nationally representative data source. METHODS: Data from 39,604 adults with diabetes who indicated if they experienced food and/or housing insecurity in the Behavioral Risk Factor Surveillance System (2014, 2015, 2017) was analyzed. Outcomes included quality of care (HbA1c test, eye exam, diabetes education, foot check) and quality of life (general health status, poor physical and mental health days, poor overall health days). Logistic models were run for each quality of care measure and linear models were run for each quality of life measure adjusting for socio-demographics, insurance status, and comorbidity count. RESULTS: 35.6% of adults with diabetes reported housing insecurity, 31.8% reported food insecurity, and 23.4% reported both. After adjustment, food and housing insecurity was significantly associated with lower odds of having an eye exam (housing:0.73, 95%CI:0.63,0.85; food:0.78, 95%CI:0.67,0.92; both:0.69, 95%CI:0.59,0.82), worse general health status (housing:-0.06 95%CI:-0.11,-0.01; food:-0.16, 95%CI:-0.21,-0.10; both:-0.14, 95%CI:-0.20,-0.09), and an increased number of poor mental health days (housing:1.73, 95%CI:0.83,2.63; food:2.08, 95%CI:1.16,3.00; both:1.97, 95%CI:1.05,2.90). Food insecurity was also associated with lower odds of receiving diabetes education (0.86, 95%CI:0.74,0.99) and an increased number of poor physical health days (0.95, 95%CI:0.14,1.76). CONCLUSION: Changes to our healthcare delivery system are critical to improving standards of care and quality of life in all populations and may require a shift towards consideration of overlapping social risk factors rather than the siloed approach currently used.

Utilization of a National Writing Challenge to Promote Scholarly Work: A Pilot Study.

Background Hospitalists value mentorship and scholarly work, yet often struggle to find time and mentors amid busy clinical workloads. Objective To help catalyze writing for hospitalists nationally, we created a Writing Challenge, where we asked hospitalists to commit to the goal of writing 400 words a day, four days a week, for four weeks. Methods Prospective, programmatic evaluation with daily logs followed by a survey at the completion of the project. The four-week Writing Challenge occurred between June 7 and July 5, 2021. Email invitations to participate in the challenge were disseminated to peer networks, and the challenge was promoted using social media. Participants agreed to attempt to write 400 words per day, four days per week, for four weeks. Results Seventy-four individuals from 28 institutions registered for the Writing Challenge, with 36 (49%) participating in the challenge by logging their writing. Participants wrote an average of 4,372 +/- 4,324 words during the challenge. Sixty-eight percent of the participants reported that their amount of writing increased during the challenge and 50% of the participants stated they planned to publish their work, though many participants (46%) reported struggling to write each day. Conclusions The Writing Challenge is one way to generate increased writing and may result in increased scholarly output for academic hospitalists.

Cyclic Vomiting Syndrome-Related Hospitalizations Trends, Comorbidities & Health Care Costs in Children: A Population Based Study.

AIM: To analyze the clinical characteristics, trends in hospitalization and health care resource utilization of pediatric patients with cyclical vomiting syndrome (CVS). METHODS: We analyzed the latest 5 Healthcare Cost and Utilization Project-Kids Inpatient Database (HCUP-KID) datasets including years 2003, 2006, 2009, 2012 and 2016 for patients aged 1-20 years with a primary diagnosis of CVS and were compared with Age/gender-matched controls for comorbidities, clinical outcomes, and healthcare resource utilization. RESULTS: A total of 12,396 CVS-related hospitalizations were analyzed. The mean age of CVS patients was 10.4 ± 6.7 years. CVS was associated with dysautonomia (OR: 12.1; CI: 7.0 to 20.8), dyspepsia (OR: 11.9; CI: 8.8 to 16.03), gastroesophageal reflux disease (OR: 6.9; Confidence Interval (CI): 6.4 to 7.5), migraine headaches (OR: 6.8; CI: 5.9 to 7.7) and irritable bowel syndrome (OR: 2.08; CI: 1.2 to 4.3) (all p < 0.001). CVS was also associated with increased cannabis use (OR: 5.26, 4.6 to 5.9; p < 0.001), anxiety disorder (OR: 3.9; CI: 3.5 to 4.4) and stress reaction (OR: 3.6; CI: 2.06 to 6.3), p < 0.001. Mean CVS-related hospitalization costs (inflation adjusted) more than doubled from $3199 in 2003 to $6721 in 2016, incurring $84 million/year in total costs. CONCLUSION: Hospitalized CVS patients have increased prevalence of DGBIs, dysautonomia, psychiatric conditions and cannabis use compared to non-CVS controls. CVS-related hospitalizations in U.S. is associated with increasing health care costs. Better management of CVS and comorbid conditions is warranted to reduce health care costs and improve outcomes.

Short-term impact of COVID-19 on quality of life, perceived stress, and serious psychological distress in an adult population in the midwest United States.

PURPOSE: This study aimed to investigate changes over time in quality of life, perceived stress, and serious psychological distress for individuals diagnosed with COVID-19 in an urban academic health system. METHODS: Phone-based surveys were completed with adult patients tested for COVID-19 during emergency department visits, hospitalizations, or outpatient visits at the Froedtert and Medical College of Wisconsin Health Network. Data were then matched to medical record data. Unadjusted and adjusted mixed effects linear models using random intercept were run for each outcome (physical health-related quality of life, mental health-related quality of life, perceived stress, and serious psychological distress) with time (baseline vs 3-month follow-up) as the primary independent variable. Individuals were treated as a random effect, with all covariates (age, sex, race/ethnicity, payor, comorbidity count, hospitalization, and intensive care unit (ICU) stay) treated as fixed effects. RESULTS: 264 adults tested positive for COVID-19 and completed baseline and 3-month follow-up assessments. Of that number, 31.8% were hospitalized due to COVID-19, and 10.2% were admitted for any reason to the ICU. After adjustment, patients reported higher physical health-related quality of life at 3 months compared to baseline (0.63, 95% CI 0.15, 1.11) and decreased stress at 3 months compared to baseline (- 0.85, 95% CI - 1.33, - 0.37). There were no associations between survey time and mental health-related quality of life or serious psychological distress. CONCLUSIONS: Results suggest the influence of COVID-19 on physical health-related quality of life and stress may resolve over time, however, the influence of mental health on daily activities, work, and social activities may not.

The impact of learning-curve-experience on transcatheter aortic valve replacement outcomes: Insights from the United Kingdom and Ireland all-comers second-generation ACURATE neo™ transcatheter aortic heart valve registry.

BACKGROUND: The ACURATE neo™ is a novel, second-generation self-expanding supra-annular transcatheter heart valve (THV). The objective of this multi-centre registry is to assess the safety, clinical utility, and impact of 'learning-curve-experience' (LCE) on transcatheter aortic valve replacement outcomes in the United Kingdom (UK) and Ireland. METHODS: We prospectively collected data from seven ACURATE neo™ THV implanting centres (n = 484) between February 2016 and November 2020. We compared mortality rates and outcomes in the LCE group (n = 120) compared to next successive 120 cases. RESULTS: The mean age of the cohort was 81.9(SD: 6.1) years and the majority were in the moderate risk category (EuroSCORE-II):3.3(SD: 3). The 97.5% of cases were performed under local anesthetic. The valve was successfully deployed in 98.8% of cases. The survival rate at 30 days was 97.9%. The incidence of stroke was 2.5%. Life threatening bleeding occurred in 0.6% of cases and vascular access complications occurred in 21 (4.3%) patients. Implantation-related conduction abnormalities occurred in 8.3% but only 5.6% required a PPM. The successful valve deployment occurred in 96% of the patients in the LCE group compared to 100% in the other group (p = 0.04; OR-2[CI 1.7-2.3]). The mortality rates at 30 days (1.7% vs. 1.7%) and 1 year (1.9% vs. 2.7%) were comparable between the two groups. CONCLUSIONS: This study represents the largest published UK and Ireland real-world experience of the ACURATE neo™ valve. The procedural success rates and safety outcomes were excellent and endorse its utility in clinical practice. The LCE appears to have an impact on the successful valve deployment but without translating into short-term or long-term outcomes.

Worse Outcomes Associated With Liver Transplants: An Increasing Trend.

Background and aim Since individuals in the early stages of liver cirrhosis are typically asymptomatic, the prevalence of liver cirrhosis may be underestimated. Liver cirrhosis has a significant morbidity and mortality rate, with 1.03 million deaths worldwide each year. For end-stage liver disease, liver transplantation is a potential therapeutic option. The goal of our research was to examine the current trend in liver transplants using data from a national database. Methods Using the International Classification of Diseases (ICD)-9 codes, we identified individuals who had a liver transplant during the index hospital admission in the Nationwide Inpatient Sample from 2007 to 2011. This national sample of patients is from the United States. We looked at the yearly trend in liver transplants and related outcomes, such as duration of hospitalization (DOH), hospital expenses, and mortality in the hospital. In order to find determinants of mortality, we used a multivariate analysis. Results There were 25,331 patients hospitalized (weighted for national estimate). Between 2007 and 2011, the number of transplants grew by 1.2%. The majority of transplant recipients were Caucasian (57%), with an average age of 54 years, had a private healthcare plan (53%), and had average earnings in the upper quartile by zip code (26%). Patients with a higher Charlson Comorbidity Index (79% had a score of four) were more likely to be admitted to a southern hospital (33%), an academic hospital (>99%), and a large capacity hospital (90%). Seventy percent of liver transplant recipients received cadaver donors. Hepatitis C was the most prevalent reason for transplant (30%), followed by hepatocellular carcinoma (HCC) (29%) and alcoholic liver disease (25%). In 2011, compared to 2007, there was an upward rise in fatality (from 3.8% to 5.1%), average hospital expenditures (from $335,504 to $498,369), and DOH (from 17.4 to 22.7 days). The cost of hospitalization was two billion dollars per year. The independent variables related to an increased mortality on multivariate analysis were African American race (OR: 2.0, 95%, CI: 1.2-3.2; p=0.005) and large capacity hospitals (OR: 2.5, 95% CI: 1.6-4.1; p=0.0002). Predictors linked to lower mortality included private healthcare coverage (vs. Medicare: OR: 0.7, 95%, CI: 0.51-0.97; p=0.03), academic hospital (OR: 0.6, 95% CI: 0.4-0.8; p=0.005), cadaver donor (OR: 0.6, 95% CI: 0.5-0.8; p=0.002), HCC (OR: 0.6, 95% CI: 0.4-0.9; p=0.01), and non-alcoholic steatohepatitis (NASH) cirrhosis (OR: 0.4, 95% CI: 0.2-0.9; p=0.02). Conclusion Our study found an increasing trend in worse outcomes (increased mortality, average hospital costs, and average DOH) after a liver transplant. Patients of the African American race and large capacity hospitals were associated with a higher risk of death, whereas private healthcare plans, academic hospitals, cadaver donors, HCC, and NASH cirrhosis were associated with a lower risk.

Varicella Zoster Meningitis in Immunocompetent Hosts: A Case Series and Review of the Literature.

Meningitis caused by varicella zoster virus (VZV) infection is uncommon in immunocompetent patients. We report 3 cases of VZV meningitis with rash in immunocompetent adults from a single academic institution over a 1-year period. The low prevalence of VZV meningitis in this population is attributed to lack of early recognition or underreporting. We highlight the importance of considering VZV as a possible cause of meningitis even in previously healthy young individuals.

Gender-Based Discrimination and Sexual Harassment Among Academic Internal Medicine Hospitalists.

BACKGROUND: Gender-based discrimination and sexual harassment, both implicit and overt, have been reported in academic medicine. This study examines experiences of academic hospitalists regarding gender-based discrimination and sexual harassment. METHODS: A survey was distributed to Internal Medicine hospitalists at university-based academic institutions in the United States. Questions assessed experiences regarding gender-based discrimination and sexual harassment in their interactions with patients, as well as with other healthcare providers (HCPs). RESULTS: Eighteen institutions participated in the survey, resulting in 336 individual responses. Female hospitalists more frequently reported inappropriate touch, sexual remarks, gestures, and suggestive looks by patients compared with male peers both over their careers (P < .001) and in the last 30 days (P < .001). Similarly, females more frequently reported being referred to with inappropriate terms of endearment (eg, "dear," "honey," "sweetheart") by patients both over their careers (P < .001) and in the last 30 days (P < .001). Almost 100% of females reported being mistaken by patients for nonphysician HCPs over their careers, compared with 29% of males (P < .001) (76% vs 10%, in the last 30 days; P < .001). Similarly, females more frequently reported sexual harassment over their careers (P < .05) and being mistaken for nonphysician HCPs by colleagues both over their careers (P < .001) and in the last 30 days (P < .001). Females rated their sense of respect both by patients (P < .001) and colleagues (P < .001) lower than males (P < .001). More females than males reported that gender negatively impacted their career opportunities (P < .001). CONCLUSION: This survey demonstrates that gender-based discrimination and sexual harassment are commonly encountered by academic hospitalists, with a significantly higher number of females reporting these experiences.

Perceptions of Burnout Among Academic Hospitalists.

INTRODUCTION: There is a paucity of data on burnout among academic hospitalists in Wisconsin. OBJECTIVE/METHODS: To evaluate perceptions on burnout among academic hospitalists at an academic center in Wisconsin, a survey was distributed to academic hospitalists at the Medical College of Wisconsin. Questions addressed job satisfaction, factors contributing to burnout and its consequences, and various preventive steps. A section was included for respondents to provide any additional comments. RESULTS: Out of 52 academic hospitalists surveyed, 43 (83%) responded. Sixty-two percent of participants reported feeling burnout. Burnout rates did not differ by gender (males vs females, 58% vs 73%, respectively; P = 0.65), career length as a hospitalist (P = 0.28), or satisfaction as a hospitalist (P = 0.11). High patient census (94%) and unrealistic workload (83%) were the most commonly cited factors for burnout. Possible consequences of burnout included lack of enthusiasm (95%) and mental exhaustion (93%). A majority of respondents (81%) indicated that high clinical demands interfered with their ability to teach medical students. Improving the structure of work (88%) and incorporating respect, care, and compassion as a group culture (88%) were the most common themes reported to prevent burnout. CONCLUSION: This study shows a high prevalence of burnout among academic hospitalists and highlights various opportunities to reduce burnout risk.