Resident Perspectives on Palliative Care at an Urban Teaching Hospital

Background There has been an increasing need to address end of life (EOL) care and palliative care in an era when measures to extend life for terminal illnesses are often initiated without consideration of quality of life. Addressing the barriers for resident physicians to initiate EOL conversations with patients is an important step towards eliminating the disconnect between patient wishes and provider goals. Purpose To assess resident physician perspectives on initiating palliative care conversations with terminally ill patients at an urban teaching hospital. Methods This paper solicited the experiences of pediatric, general surgery, and internal medicine residents through an anonymous survey to assess exposure to palliative care during training, comfort with providing palliative care, and barriers to implementing effective palliative care. Results 45% of residents reported exposure to palliative care prior to medical training. Ninety-three percent of these residents reported being formally introduced to palliative care during medical training through formal lecture, although the majority reported also being exposed through either small group discussions or informal teaching sessions. Time constraints and lack of knowledge on how to initiate and continue conversations surrounding EOL care were the greatest barriers to effectively caring for patients with terminal illnesses. Residents concurred that either attending physicians or hospital-designated palliative care providers should initiate palliative care discussions, with care managed by an interdisciplinary palliative care team; this consensus demonstrates a potential assumption that another provider will initiate EOL discussions. Conclusions This study evaluated the current state of physician training in EOL care and provided support for the use of experience-based training as an important adjunct to traditional didactic lectures in physician education.

Admission trends in pediatric isolated linear skull fracture across the United States

OBJECTIVE Pediatric isolated linear skull fractures commonly result from head trauma and rarely require surgery, yet patients are often admitted to the hospital—a costly care plan. In this study, the authors utilized a national database to investigate trends in admission for skull fractures across the United States. METHODS Children younger than 18 years with isolated linear skull fracture, according to ICD-9 diagnosis codes in the Kids’ Inpatient Database of the Healthcare and Utilization Project (HCUP), who presented between 2003 and 2016 were included. HCUP collected data in 2003, 2006, 2009, 2012, and 2016. Children with a depressed skull fracture, multiple traumatic injuries, and acute intracranial findings were excluded. Sample-level data were translated into population-level data by using an HCUP-specific discharge weight. RESULTS Overall, 11,355 patients (64% males) were admitted to 1605 hospitals. National admissions decreased from 3053 patients in 2003 to 1203 in 2016. The mean ± SD age at admission also decreased from 6.3 ± 5.9 years to 1.2 ± 3.0 years (p < 0.001). The proportion of patients in the lowest quartile of median household income increased by 9%, while that in the highest income quartile decreased by 7% (p < 0.001). Admission was generally more common in the summer months (June, July, and August) and on weekdays (68%). The mean ± SD hospital length of stay decreased from 2.0 ± 3.1 days to 1.4 ± 1.4 days between 2003 and 2012, and then increased to 2.1 ± 6.8 days in 2016 (p < 0.001). When adjusted for inflation, the mean total hospital charges increased from $13,099 to $21,204 (p < 0.001). The greatest proportion of admissions was in the South (35%), and the lowest was in the Northeast (17%). The proportion of patients admitted to large hospitals increased (59% to 72%, p < 0.001), which corresponded to a decrease in patients admitted to small hospitals (16% to 9%, p < 0.001). Overall, the total proportion of admissions to rural hospitals decreased by 6%, and that to urban teaching centers increased by 15% (p < 0.001). Since 2003, no child has undergone a neurosurgical procedure or died as an inpatient. CONCLUSIONS This study identified a general nationwide decrease in admissions for pediatric linear isolated skull fracture, but associated costs increased. Admissions became less common at smaller rural hospitals and more common at larger urban teaching hospitals. This patient population required no inpatient neurosurgical intervention after 2003.

A STUDY OF AWARENESS, ATTITUDE AND PRACTICES TOWARDS COVID-19 PANDEMIC IN THE TEACHING COMMUNITY OF HIGHER EDUCATION

BACKGROUND: COVID-19 has been declared a pandemic by the World Health Organization. The unprecedented global health crisis we are facing is affecting all parts of society and changing lives and livelihoods. International efforts have been applied to prevent the spread of the virus through personal hygiene, masks and social distancing as prevention measures. AIMS:To assess the Awareness, Attitude and Practices towards COVID-19 Pandemic in the Teaching Community. METHOD:An online survey consisting of self-rated questions related to Awareness, Attitude and Practices towards COVID-19 Pandemic in the Teaching Community was carried out between December 2020 and January 2021. The main outcome measures were awareness, attitude and practices towards COVID-19 Pandemic in the Teaching Community. RESULTS: 80 teaching community respondents participated in the survey. A signicant and positive correlation was seen between attitude and their practices (r=0.3110, p=0.0050). Asignicant differences were observed between age groups with mean attitude and practice scores (p<0.05) and urban teaching community have signicant and higher practice scores as compared to rural teaching community (p<0.05) CONCLUSION: Results indicate there is an average level of awareness, attitude and practice towards COVID-19 Pandemic in the Teaching Community. But urban teaching community have good attitude and practices towards the COVID-19. It is important to monitor and address the rural teaching community about the awareness, attitude and practices towards COVID-19 Pandemic after the lockdown.

Where Are They Now?

Available evidence suggests that inequities exist in the distribution of qualified teachers within high-poverty urban schools, and further, that such inequities adversely affect student achievement in these schools. This paper highlights the role of teacher education in addressing this challenge by describing the findings of a study of the graduates of University of Alabama at Birmingham’s Urban Teacher Enhancement Program. The career paths of program graduates who began teaching in urban schools were examined at the first-, fifth-, and tenth-year mark to investigate their longevity in urban schools, their perceptions of their greatest rewards and challenges, their perspectives regarding their reasons for entering and/or staying in urban teaching, and their thoughts about the role their teacher education program played in their career trajectory. Findings indicate that retention rates of study participants compare favorably with national averages, and that program participants felt that their teacher education program had a positive influence on their longevity in urban teaching.

Abstract P429: Hospital Level Diagnostic Disparities of Cerebral Amyloid Angiopathy in the United States Nationwide Hospitalizations

Background/Objective: There is limited knowledge of the nationwide prevalence of cerebral amyloid angiopathy (CAA) diagnosis and disparity amongst US hospitalization. The aim of this study is to assess the prevalence of CAA diagnosis and identify hospital-level disparity in the CAA diagnosis amongst US hospitalizations. Methods: A cross-sectional study was performed using the National Inpatient Sample [2016-2017] for adult hospitalizations. We extracted a cohort of patients with a diagnosis of CAA using ICD 10 code. Age was categorized as <50 years, 50-59, 60-69, 70-79, and ≥80 years. Weighted analysis using chi-square and multivariable survey logistic regression was performed to identify the prevalence of CAA and evaluate the diagnostic disparity of CAA amongst USA hospitalization. Results: Out of total 60,609,519 US hospitalizations, 16040 (0.027%) had a diagnosis of CAA. Patients with CAA were of higher age 71-80 years (39.9% vs 16.4%), ≥81 years (36.4% vs 14.9%), men (48.1% vs 42.1%), white (71.5% vs 67.5%), and more likely admitted to urban-teaching hospitals (83.9% vs 66.0%), Northeast region hospitals (26.5% vs 18.8%), and hospitals with large bed-size (65.7% vs 51.2%) compared to patients without CAA (p<0.0001). On regression analysis, urban non-teaching (aOR 2.1; 95%CI 1.6-2.9; ref=rural), urban-teaching hospitals [5.4 (4.1-7.2); ref=rural], median size hospital [1.3 (1.1-1.5); ref=small], and large bed size hospitals [2.3 (2-2.7); ref=small] had higher odds of diagnosis of CAA. Compared to the Northeast region, Midwest [0.8 (0.7-0.97)] and South [0.7 (0.6-0.8)] region hospitals had lower odds of a diagnosis of CAA. Conclusion: CAA was present in 0.03% of hospitalized patients in 2016-17. It was more commonly diagnosed in urban teaching, urban non-teaching, large and medium bed size hospitals compared to rural and small bed size hospitals. Lack of awareness of CAA diagnosis in rural and small hospitals could be a potential factor for these disparities.

The systemic inflammatory response and clinicopathological characteristics in patients admitted to hospital with COVID-19 infection: Comparison of 2 consecutive cohorts

BackgroundIn order to manage the COVID-19 systemic inflammatory response, it is important to identify clinicopathological characteristics across multiple cohorts.MethodsElectronic patient records for 2 consecutive cohorts of patients admitted to two urban teaching hospitals with COVID-19 during two 7-week periods of the COVID-19 pandemic in Glasgow, U.K. (cohort 1: 17th March 2020 – 1st May 2020) and (cohort 2: 18th May 2020 – 6th July 2020) were examined for routine clinical, laboratory and clinical outcome data.ResultsCompared with cohort 1, cohort 2 were older (p<0.001), more likely to be female (p<0.05) and have less independent living circumstances (p<0.001). More patients in cohort 2 were PCR positive, CXR negative (both p<0.001) and had low serum albumin concentrations (p<0.001). 30-day mortality was similar between both cohorts (23% and 22%). Over the 2 cohorts, age ≥70 (p<0.001), male gender (p<0.05), hypertension (p<0.01), heart failure (p<0.05), cognitive impairment (p<0.001), frailty (p<0.001), COPD (p<0.05), delirium (p<0.001), elevated perioperative Glasgow Prognostic Score (p≤0.001), elevated neutrophil-lymphocyte ratio (p<0.001), low haematocrit (p<0.01), elevated urea (p<0.001), creatinine (p<0.001), glucose (p<0.05) and lactate (p<0.01); and the 4C score were associated with 30-day mortality. When compared with the 4C score, greater frailty (OR 10.2, 95% C.I. 3.4 – 30.6, p<0.01) and low albumin (OR 5.6, 95% C.I. 2.0 – 15.6, p<0.01) were strongly independently associated with 30-day mortality.ConclusionIn addition to the 4C mortality score, frailty score and a low albumin were strongly independently associated with 30-day mortality in two consecutive cohorts of patients admitted to hospital with COVID-19.Article summaryIn two consecutive cohorts of patients with COVID-19 infection admitted to two urban teaching hospitals in Glasgow, UK, there were variations in a number of clinicopathological characteristics despite similar mortality (23 and 22%).In these two cohorts, in a multivariate analysis that included the 4C mortality score, clinical frailty score >3, low serum albumin concentration (<35 g/L), high neutrophil-lymphocyte ratio (≥5), and abnormal serum sodium concentration (<133/>145 mmol/L) remained independently associated with 30-day mortality.

The Impact of Payment Reform on Pediatric Craniofacial Fracture Care in Maryland

Study Design: Retrospective, quasi-experimental difference-in-differences investigation. Objective: Pediatric craniofacial fractures are often associated with substantial morbidity and consumption of healthcare resources. Maryland’s All Payer Model (APM) represents a unique case study of the health economics surrounding pediatric craniofacial fractures. The APM implemented global hospital budgets to disincentivize low-value care and encourage preventive, community-based efforts. The objective of this study was to investigate how this reform has impacted pediatric craniofacial fracture care in Maryland. Methods: Children (≤18 years) receiving inpatient craniofacial fracture-related care in Maryland between January, 2009 through December, 2016 were investigated. New Jersey was used for comparison. Data were abstracted from the Kid’s Inpatient Database (Healthcare Cost and Utilization Project). Results: Between 2009–2016, 3,655 pediatric patients received inpatient care for craniofacial fractures in Maryland and New Jersey. Prior to APM implementation, around 20% of Maryland patients received care outside of urban teaching hospitals. After APM implementation, less than 6% of patients received care outside of urban teaching hospitals ( p = 0.003). Implementation of the APM in Maryland also resulted in fewer pediatric craniofacial fracture admissions than New Jersey, though this only reached borderline significance (adjusted difference-in-differences estimate: −1.1 fewer admissions, 95% confidence interval: −2.1 to 0.0, p = 0.05). Inpatient costs for pediatric craniofacial care and mean did not change post-APM. Conclusions: Maryland’s APM consolidated pediatric craniofacial fracture inpatient care at urban, teaching hospitals. Inpatient costs and lengths of stay did not change after policy implementation, but overall admission rates decreased. Such considerations are important when considering national expansion of global hospital budgeting.