Wound cultures from patients with the rare disease epidermolysis bullosa (EB) were most frequently positive for Staphylococcus aureus (SA), Pseudomonas aeruginosa (PA), and Streptococcus pyogenes (GAS) – and antibiotic resistance was common – in a retrospective analysis of over 700 wound cultures from 158 patients across the United States and Canada.

The findings from the EB Clinical Characterization and Outcomes Database speak to the value of surveillance cultures with routine testing for microbial resistance – including mupirocin resistance – and to the importance of antibiotic stewardship not only for oral antibiotics but for topicals as well, according to Laura E. Levin, MD, and Kimberly D. Morel, MD, of the departments of dermatology and pediatrics, Columbia University Irving Medical Center, New York, the lead and senior authors, respectively, of the paper recently published in Pediatric Dermatology.

Almost all of the 158 patients with at least one wound culture recorded in the database from the period of 2001-2018 had one or more positive culture results. Of 152 patients with positive cultures, 131 (86%) were positive for SA and 56 (37%) and 34 (22%) were positive for PA and GAS, respectively. Other bacteria isolated included Corynebacterium spp and Proteus spp. Nearly half (47%) of patients with SA-positive cultures had methicillin-resistant SA, and 68% had methicillin-susceptible SA. (Some patients grew both MSSA and MRSA at different points in time.)

Mupirocin-susceptibility testing was performed at only some of the 13 participating centers. Of 15 patients whose cultures had recorded SA mupirocin-susceptibility testing, 11 had cultures positive for mupirocin-susceptible SA and 6 (40%) had mupirocin-resistant SA isolates (2 patients grew both). Of these six patients, half had isolates that were also methicillin-resistant.

Mupirocin, a topical antibiotic, has been a cornerstone of decolonization regimens for MSSA and MRSA, but resistance has been demonstrated in other research as well and is not specific to EB, wrote Dr. Levin, Dr. Morel, and coauthors.

“Pediatric dermatologists often rely on topical antimicrobials in the treatment of patients’ open wounds to both prevent and treat infection, depending on the clinical scenario,” and surveillance cultures with routine testing for mupirocin resistance can help guide antibiotic choice and management strategies, Dr. Levin said in an interview.

More broadly, she added, “it’s helpful to know what bacteria are routinely colonizing wounds, not causing infection, versus those that are more likely to be associated with infection, chronic wounds, or the risk of developing skin cancer ... [to know] which wounds need to be treated more aggressively.”

A subset of patients with EB have been known to be at risk for squamous cell carcinoma, and research is implicating certain bacteria “as contributing to wound inflammation,” Dr. Morel said in an interview.

SCC was reported in 23 out of 717 patients in the database – but fewer than half of the patients with SCC had recorded wound cultures. The small numbers precluded the identification of microbes that may confer significant risk.

Correlating particular microbes with clinical features also will take more research. About half (57%) of the patients with recorded wound cultures had wounds with purulent exudate or other features of clinical infection. However, the presence or absence of clinical signs of infection was not temporally correlated with culture results in the database.

The 158 patients with recorded wound cultures had a mean age of 12.8 years and represented a range of EB subtypes.

PA was present in the wounds of patients as young as 1 month old, the authors noted. Investigators are “looking to further study PA and characterize clinical features ... to understand more about this microbe and its impact on patients with EB,” Dr. Morel said.

In the meantime, the analysis reaffirms the importance of antibiotic stewardship. Mupirocin is labeled to be used three times a day for a short period of time, but “tends to be prescribed and used less judiciously than intended,” Dr. Morel said. “It’s important [not to overuse it]. We have seen that patients’ culture results become sensitive to mupirocin again in the future when they avoid it for a period of time.”

The work was supported by the EB Research Partnership and EB Medical Research Foundation, as well as an NIH/NCATS grant. No investigator disclosures were listed.

SOURCE: Pediatr Dermatol. 2020 Nov 28. doi: 10.1111/pde.14444.

Wound cultures from patients with the rare disease epidermolysis bullosa (EB) were most frequently positive for Staphylococcus aureus (SA), Pseudomonas aeruginosa (PA), and Streptococcus pyogenes (GAS) – and antibiotic resistance was common – in a retrospective analysis of over 700 wound cultures from 158 patients across the United States and Canada.

The findings from the EB Clinical Characterization and Outcomes Database speak to the value of surveillance cultures with routine testing for microbial resistance – including mupirocin resistance – and to the importance of antibiotic stewardship not only for oral antibiotics but for topicals as well, according to Laura E. Levin, MD, and Kimberly D. Morel, MD, of the departments of dermatology and pediatrics, Columbia University Irving Medical Center, New York, the lead and senior authors, respectively, of the paper recently published in Pediatric Dermatology.

Almost all of the 158 patients with at least one wound culture recorded in the database from the period of 2001-2018 had one or more positive culture results. Of 152 patients with positive cultures, 131 (86%) were positive for SA and 56 (37%) and 34 (22%) were positive for PA and GAS, respectively. Other bacteria isolated included Corynebacterium spp and Proteus spp. Nearly half (47%) of patients with SA-positive cultures had methicillin-resistant SA, and 68% had methicillin-susceptible SA. (Some patients grew both MSSA and MRSA at different points in time.)

Mupirocin-susceptibility testing was performed at only some of the 13 participating centers. Of 15 patients whose cultures had recorded SA mupirocin-susceptibility testing, 11 had cultures positive for mupirocin-susceptible SA and 6 (40%) had mupirocin-resistant SA isolates (2 patients grew both). Of these six patients, half had isolates that were also methicillin-resistant.

Mupirocin, a topical antibiotic, has been a cornerstone of decolonization regimens for MSSA and MRSA, but resistance has been demonstrated in other research as well and is not specific to EB, wrote Dr. Levin, Dr. Morel, and coauthors.

“Pediatric dermatologists often rely on topical antimicrobials in the treatment of patients’ open wounds to both prevent and treat infection, depending on the clinical scenario,” and surveillance cultures with routine testing for mupirocin resistance can help guide antibiotic choice and management strategies, Dr. Levin said in an interview.

More broadly, she added, “it’s helpful to know what bacteria are routinely colonizing wounds, not causing infection, versus those that are more likely to be associated with infection, chronic wounds, or the risk of developing skin cancer ... [to know] which wounds need to be treated more aggressively.”

A subset of patients with EB have been known to be at risk for squamous cell carcinoma, and research is implicating certain bacteria “as contributing to wound inflammation,” Dr. Morel said in an interview.

SCC was reported in 23 out of 717 patients in the database – but fewer than half of the patients with SCC had recorded wound cultures. The small numbers precluded the identification of microbes that may confer significant risk.

Correlating particular microbes with clinical features also will take more research. About half (57%) of the patients with recorded wound cultures had wounds with purulent exudate or other features of clinical infection. However, the presence or absence of clinical signs of infection was not temporally correlated with culture results in the database.

The 158 patients with recorded wound cultures had a mean age of 12.8 years and represented a range of EB subtypes.

PA was present in the wounds of patients as young as 1 month old, the authors noted. Investigators are “looking to further study PA and characterize clinical features ... to understand more about this microbe and its impact on patients with EB,” Dr. Morel said.

In the meantime, the analysis reaffirms the importance of antibiotic stewardship. Mupirocin is labeled to be used three times a day for a short period of time, but “tends to be prescribed and used less judiciously than intended,” Dr. Morel said. “It’s important [not to overuse it]. We have seen that patients’ culture results become sensitive to mupirocin again in the future when they avoid it for a period of time.”

The work was supported by the EB Research Partnership and EB Medical Research Foundation, as well as an NIH/NCATS grant. No investigator disclosures were listed.

SOURCE: Pediatr Dermatol. 2020 Nov 28. doi: 10.1111/pde.14444.

Wound cultures from patients with the rare disease epidermolysis bullosa (EB) were most frequently positive for Staphylococcus aureus (SA), Pseudomonas aeruginosa (PA), and Streptococcus pyogenes (GAS) – and antibiotic resistance was common – in a retrospective analysis of over 700 wound cultures from 158 patients across the United States and Canada.

The findings from the EB Clinical Characterization and Outcomes Database speak to the value of surveillance cultures with routine testing for microbial resistance – including mupirocin resistance – and to the importance of antibiotic stewardship not only for oral antibiotics but for topicals as well, according to Laura E. Levin, MD, and Kimberly D. Morel, MD, of the departments of dermatology and pediatrics, Columbia University Irving Medical Center, New York, the lead and senior authors, respectively, of the paper recently published in Pediatric Dermatology.

Almost all of the 158 patients with at least one wound culture recorded in the database from the period of 2001-2018 had one or more positive culture results. Of 152 patients with positive cultures, 131 (86%) were positive for SA and 56 (37%) and 34 (22%) were positive for PA and GAS, respectively. Other bacteria isolated included Corynebacterium spp and Proteus spp. Nearly half (47%) of patients with SA-positive cultures had methicillin-resistant SA, and 68% had methicillin-susceptible SA. (Some patients grew both MSSA and MRSA at different points in time.)

Mupirocin-susceptibility testing was performed at only some of the 13 participating centers. Of 15 patients whose cultures had recorded SA mupirocin-susceptibility testing, 11 had cultures positive for mupirocin-susceptible SA and 6 (40%) had mupirocin-resistant SA isolates (2 patients grew both). Of these six patients, half had isolates that were also methicillin-resistant.

Mupirocin, a topical antibiotic, has been a cornerstone of decolonization regimens for MSSA and MRSA, but resistance has been demonstrated in other research as well and is not specific to EB, wrote Dr. Levin, Dr. Morel, and coauthors.

“Pediatric dermatologists often rely on topical antimicrobials in the treatment of patients’ open wounds to both prevent and treat infection, depending on the clinical scenario,” and surveillance cultures with routine testing for mupirocin resistance can help guide antibiotic choice and management strategies, Dr. Levin said in an interview.

More broadly, she added, “it’s helpful to know what bacteria are routinely colonizing wounds, not causing infection, versus those that are more likely to be associated with infection, chronic wounds, or the risk of developing skin cancer ... [to know] which wounds need to be treated more aggressively.”

A subset of patients with EB have been known to be at risk for squamous cell carcinoma, and research is implicating certain bacteria “as contributing to wound inflammation,” Dr. Morel said in an interview.

SCC was reported in 23 out of 717 patients in the database – but fewer than half of the patients with SCC had recorded wound cultures. The small numbers precluded the identification of microbes that may confer significant risk.

Correlating particular microbes with clinical features also will take more research. About half (57%) of the patients with recorded wound cultures had wounds with purulent exudate or other features of clinical infection. However, the presence or absence of clinical signs of infection was not temporally correlated with culture results in the database.

The 158 patients with recorded wound cultures had a mean age of 12.8 years and represented a range of EB subtypes.

PA was present in the wounds of patients as young as 1 month old, the authors noted. Investigators are “looking to further study PA and characterize clinical features ... to understand more about this microbe and its impact on patients with EB,” Dr. Morel said.

In the meantime, the analysis reaffirms the importance of antibiotic stewardship. Mupirocin is labeled to be used three times a day for a short period of time, but “tends to be prescribed and used less judiciously than intended,” Dr. Morel said. “It’s important [not to overuse it]. We have seen that patients’ culture results become sensitive to mupirocin again in the future when they avoid it for a period of time.”

The work was supported by the EB Research Partnership and EB Medical Research Foundation, as well as an NIH/NCATS grant. No investigator disclosures were listed.

SOURCE: Pediatr Dermatol. 2020 Nov 28. doi: 10.1111/pde.14444.

Black and Latinx children are more likely to be evaluated for child abuse and referred to child protective services than their White peers, according to research discussed by Tiffani J. Johnson, MD, an assistant professor of emergency medicine at the University of California, Davis.

Darrin Klimek/Thinkstock

“These disparities in child abuse evaluation and reporting are bidirectional,” she said. “We also recognize that abuse is more likely to be unrecognized in White children.”

Dr. Johnson presented data on the health disparities in child abuse reporting in a session at the annual meeting of the American Academy of Pediatrics, held virtually this year. Health care disparities, as defined by the National Academy of Sciences, refers to differences in the quality of care between minority and nonminority populations that are not caused by clinical appropriateness, access, need, or patient preference, she explained. Instead, they result from discrimination, bias, stereotyping, and uncertainty.
 

Disparities lead to harm in all children

For example, a 2018 systematic review found that Black and other non-White children were significantly more likely than White children to be evaluated with a skeletal survey. In one of the studies included, at a large urban academic center, Black and Latinx children with accidental fractures were 8.75 times more likely to undergo a skeletal survey than White children and 4.3 times more likely to be reported to child protective services.

“And let me emphasize that these are children who were ultimately found to have accidental fractures,” Dr. Johnson said.

Meanwhile, in an analysis of known cases of head trauma, researchers found that abuse was missed in 37% of White children, compared with 19% of non-White children.

“These only represent the tip of the iceberg as a true number of cases of abuse may never really be detected because some cases are still unknown,” Dr. Johnson told attendees. And the harm of these disparities runs in both directions.

“Failing to diagnose abuse in White children clearly puts them at increased risk for return visits and return evaluations for repeated abuse by the perpetrators,” she said. But harm also can result from overreporting and investigation, including psychological trauma and a waste of limited resources. Overinvestigation also can erode family-physician relationships and perpetuate distrust of medical care in communities of color.

Yet at the same time, it’s clear that Black children, adolescents, and young adults are not protected from harm in society more generally, when at home, where they learn, or where they play, Dr. Johnson said, referencing the deaths of Breonna Taylor and Tamir Rice as examples.

KatarzynaBialasiewicz/Thinkstock

“And now we’re seeing increased evidence that children are not protected in the health care center when we think about the many disparities that have been identified in the care and outcomes of children, including the disproportionality in terms of child abuse evaluation and referrals,” Dr. Johnson said.

Racism is a root cause of that harm to Black children, she said, as the systemic structure of opportunities unfairly disadvantages some individuals and communities while unfairly advantaging others, thereby “sapping the strength of the whole society through the waste of human resources.”

Tonya Chaffee, MD, MPH, a clinical professor of health sciences at the University of California, San Francisco, who attended the session, said she particularly appreciated “seeing data on which racial/ethnic populations have child abuse reports made and the disparities that exist that are similar to what we are noticing in our own institution.”
 

Role of individual-level implicit bias and racism

While institutional and structural racism play a substantial role in health care disparities, Dr. Johnson focused primarily on the impact of personal racism when it comes to child abuse evaluations, through overt discrimination, explicit bias, implicit bias, and stigmatization. The most challenging of these to identify and acknowledge is often implicit bias, a tendency to believe, even unconsciously, that some people or ideas are better than others, which results in unfair treatment.

For example, a 2016 study found that half of medical students and residents held at least one biological belief about differences between Black and White individuals that was actually false, such as Black people having more pain tolerance or stronger bones than White people, which then affected treatment recommendations.

“Implicit bias refers to our attitudes that lie below the surface, but they can still influence our behaviors,” Dr. Johnson explained. She encouraged providers to take the implicit bias test online to learn about their own unrecognized implicit biases. These biases have a hand in influencing decisions particularly in fast-paced environments where cognitive load is high – such as EDs, where many child abuse evaluations occur.

For example, in one study Dr. Johnson led, the researchers measured implicit bias in participants before and after an ED shift to assess how cognitive load affected bias. They found that participants who care for more than 10 patients, the average score for implicit bias increased.

Similarly, “when the ED was more overcrowded, there was also increased bias at the end of the shift, compared to the beginning of the shift,” Dr. Johnson said. She asked clinicians to take into consideration that at the start of the shift, they may feel well rested and freshly caffeinated, able to suppress or overcome the biases that they know they have.

“But our biases [are] more likely to come into play with every subsequent decision that we make throughout the day when we’re engaged in clinical encounters,” such as who does and does not receive a skeletal survey or get referred to child protective services, she said.

In another study where she hypothesized that resident physicians would have less bias on the child race implicit bias test than on the adult race one, Dr. Johnson reported that 85% of 91 residents working in an ED had an implicit pro-White/anti-Black bias in the test on adult race, but an even higher bias score – 91% – with child race.

Research has found that even children’s names can conjure implicit bias when it comes to stereotypically “White-sounding” names versus stereotypically “Black-sounding names.”

The implicit bias among clinicians extends beyond care of different children. Research has also identified association between higher implicit bias scores and less interpersonal treatment, less supportive communication, less patient-centered communication, poorer patient ratings of satisfaction, and greater patient-reported difficulty with following recommendations, Dr. Johnson said.

“I want you to think about that because I know that when we’re engaging with parents and making decisions about whether or not we’re going to do a skeletal survey or report someone for it, there is a lot of subjectivity that comes into play with how you’re interacting with families,” Dr. Johnson said. Those verbal and nonverbal cues may be triggering to parents, which then affects your interaction with them. Further, research shows that these biases may impact treatment decisions as well.

Personal-mediated racism also shows up in the use of stigmatizing language, Dr. Johnson said.

“When providers read stigmatizing language in the patient’s medical records, it was associated with them having more negative attitudes about that patient,” which then influenced their clinical decision-making, she said. “So when providers got primed with stigmatizing language, they subsequently had less aggressive pain management for those patients.”
 

Clinical implications for patient care

Dr. Johnson encouraged attendees to be careful about the language and tone they use in communicating with other health care providers and during documentation in medical records. Disparities in child abuse evaluation and reporting tend to be greater in EDs with more subjective conditions, whereas disparities are lower in departments with more established protocols.

She recommended several changes to practice that can reduce the impact of implicit bias. Universal screening for child abuse can increase how many injuries are found, but usually at the cost of increased resources and radiation. Another option is use of validated clinical decision support rules to identify who is at high or low risk for maltreatment, something Dr. Johnson is working on in her research.

But it’s also important for individual providers to confront their personal biases. Evidence-based strategies for reducing bias include perspective taking, focusing on common identities with patients, using counter-stereotypical imaging, seeking increased opportunity for cross-cultural contact, and mindfulness meditation.

“When you interact with people of different backgrounds, it helps to reduce the impact of stereotypes in society about those individuals,” Dr. Johnson told attendees. It’s also important to recognize how diversity in your clinical team can reduce bias.

“We need to work with our institutions to confront racial biases in child abuse reporting and develop quality improvement projects to ensure reporting is done objectively,” Dr. Chaffee said in an interview after attending the session. “This will require training and likely policy changes, including how reports are made to child welfare and/or the police moving forward.”

Black and Latinx children are more likely to be evaluated for child abuse and referred to child protective services than their White peers, according to research discussed by Tiffani J. Johnson, MD, an assistant professor of emergency medicine at the University of California, Davis.

Darrin Klimek/Thinkstock

“These disparities in child abuse evaluation and reporting are bidirectional,” she said. “We also recognize that abuse is more likely to be unrecognized in White children.”

Dr. Johnson presented data on the health disparities in child abuse reporting in a session at the annual meeting of the American Academy of Pediatrics, held virtually this year. Health care disparities, as defined by the National Academy of Sciences, refers to differences in the quality of care between minority and nonminority populations that are not caused by clinical appropriateness, access, need, or patient preference, she explained. Instead, they result from discrimination, bias, stereotyping, and uncertainty.
 

Disparities lead to harm in all children

For example, a 2018 systematic review found that Black and other non-White children were significantly more likely than White children to be evaluated with a skeletal survey. In one of the studies included, at a large urban academic center, Black and Latinx children with accidental fractures were 8.75 times more likely to undergo a skeletal survey than White children and 4.3 times more likely to be reported to child protective services.

“And let me emphasize that these are children who were ultimately found to have accidental fractures,” Dr. Johnson said.

Meanwhile, in an analysis of known cases of head trauma, researchers found that abuse was missed in 37% of White children, compared with 19% of non-White children.

“These only represent the tip of the iceberg as a true number of cases of abuse may never really be detected because some cases are still unknown,” Dr. Johnson told attendees. And the harm of these disparities runs in both directions.

“Failing to diagnose abuse in White children clearly puts them at increased risk for return visits and return evaluations for repeated abuse by the perpetrators,” she said. But harm also can result from overreporting and investigation, including psychological trauma and a waste of limited resources. Overinvestigation also can erode family-physician relationships and perpetuate distrust of medical care in communities of color.

Yet at the same time, it’s clear that Black children, adolescents, and young adults are not protected from harm in society more generally, when at home, where they learn, or where they play, Dr. Johnson said, referencing the deaths of Breonna Taylor and Tamir Rice as examples.

KatarzynaBialasiewicz/Thinkstock

“And now we’re seeing increased evidence that children are not protected in the health care center when we think about the many disparities that have been identified in the care and outcomes of children, including the disproportionality in terms of child abuse evaluation and referrals,” Dr. Johnson said.

Racism is a root cause of that harm to Black children, she said, as the systemic structure of opportunities unfairly disadvantages some individuals and communities while unfairly advantaging others, thereby “sapping the strength of the whole society through the waste of human resources.”

Tonya Chaffee, MD, MPH, a clinical professor of health sciences at the University of California, San Francisco, who attended the session, said she particularly appreciated “seeing data on which racial/ethnic populations have child abuse reports made and the disparities that exist that are similar to what we are noticing in our own institution.”
 

Role of individual-level implicit bias and racism

While institutional and structural racism play a substantial role in health care disparities, Dr. Johnson focused primarily on the impact of personal racism when it comes to child abuse evaluations, through overt discrimination, explicit bias, implicit bias, and stigmatization. The most challenging of these to identify and acknowledge is often implicit bias, a tendency to believe, even unconsciously, that some people or ideas are better than others, which results in unfair treatment.

For example, a 2016 study found that half of medical students and residents held at least one biological belief about differences between Black and White individuals that was actually false, such as Black people having more pain tolerance or stronger bones than White people, which then affected treatment recommendations.

“Implicit bias refers to our attitudes that lie below the surface, but they can still influence our behaviors,” Dr. Johnson explained. She encouraged providers to take the implicit bias test online to learn about their own unrecognized implicit biases. These biases have a hand in influencing decisions particularly in fast-paced environments where cognitive load is high – such as EDs, where many child abuse evaluations occur.

For example, in one study Dr. Johnson led, the researchers measured implicit bias in participants before and after an ED shift to assess how cognitive load affected bias. They found that participants who care for more than 10 patients, the average score for implicit bias increased.

Similarly, “when the ED was more overcrowded, there was also increased bias at the end of the shift, compared to the beginning of the shift,” Dr. Johnson said. She asked clinicians to take into consideration that at the start of the shift, they may feel well rested and freshly caffeinated, able to suppress or overcome the biases that they know they have.

“But our biases [are] more likely to come into play with every subsequent decision that we make throughout the day when we’re engaged in clinical encounters,” such as who does and does not receive a skeletal survey or get referred to child protective services, she said.

In another study where she hypothesized that resident physicians would have less bias on the child race implicit bias test than on the adult race one, Dr. Johnson reported that 85% of 91 residents working in an ED had an implicit pro-White/anti-Black bias in the test on adult race, but an even higher bias score – 91% – with child race.

Research has found that even children’s names can conjure implicit bias when it comes to stereotypically “White-sounding” names versus stereotypically “Black-sounding names.”

The implicit bias among clinicians extends beyond care of different children. Research has also identified association between higher implicit bias scores and less interpersonal treatment, less supportive communication, less patient-centered communication, poorer patient ratings of satisfaction, and greater patient-reported difficulty with following recommendations, Dr. Johnson said.

“I want you to think about that because I know that when we’re engaging with parents and making decisions about whether or not we’re going to do a skeletal survey or report someone for it, there is a lot of subjectivity that comes into play with how you’re interacting with families,” Dr. Johnson said. Those verbal and nonverbal cues may be triggering to parents, which then affects your interaction with them. Further, research shows that these biases may impact treatment decisions as well.

Personal-mediated racism also shows up in the use of stigmatizing language, Dr. Johnson said.

“When providers read stigmatizing language in the patient’s medical records, it was associated with them having more negative attitudes about that patient,” which then influenced their clinical decision-making, she said. “So when providers got primed with stigmatizing language, they subsequently had less aggressive pain management for those patients.”
 

Clinical implications for patient care

Dr. Johnson encouraged attendees to be careful about the language and tone they use in communicating with other health care providers and during documentation in medical records. Disparities in child abuse evaluation and reporting tend to be greater in EDs with more subjective conditions, whereas disparities are lower in departments with more established protocols.

She recommended several changes to practice that can reduce the impact of implicit bias. Universal screening for child abuse can increase how many injuries are found, but usually at the cost of increased resources and radiation. Another option is use of validated clinical decision support rules to identify who is at high or low risk for maltreatment, something Dr. Johnson is working on in her research.

But it’s also important for individual providers to confront their personal biases. Evidence-based strategies for reducing bias include perspective taking, focusing on common identities with patients, using counter-stereotypical imaging, seeking increased opportunity for cross-cultural contact, and mindfulness meditation.

“When you interact with people of different backgrounds, it helps to reduce the impact of stereotypes in society about those individuals,” Dr. Johnson told attendees. It’s also important to recognize how diversity in your clinical team can reduce bias.

“We need to work with our institutions to confront racial biases in child abuse reporting and develop quality improvement projects to ensure reporting is done objectively,” Dr. Chaffee said in an interview after attending the session. “This will require training and likely policy changes, including how reports are made to child welfare and/or the police moving forward.”

Black and Latinx children are more likely to be evaluated for child abuse and referred to child protective services than their White peers, according to research discussed by Tiffani J. Johnson, MD, an assistant professor of emergency medicine at the University of California, Davis.

Darrin Klimek/Thinkstock

“These disparities in child abuse evaluation and reporting are bidirectional,” she said. “We also recognize that abuse is more likely to be unrecognized in White children.”

Dr. Johnson presented data on the health disparities in child abuse reporting in a session at the annual meeting of the American Academy of Pediatrics, held virtually this year. Health care disparities, as defined by the National Academy of Sciences, refers to differences in the quality of care between minority and nonminority populations that are not caused by clinical appropriateness, access, need, or patient preference, she explained. Instead, they result from discrimination, bias, stereotyping, and uncertainty.
 

Disparities lead to harm in all children

For example, a 2018 systematic review found that Black and other non-White children were significantly more likely than White children to be evaluated with a skeletal survey. In one of the studies included, at a large urban academic center, Black and Latinx children with accidental fractures were 8.75 times more likely to undergo a skeletal survey than White children and 4.3 times more likely to be reported to child protective services.

“And let me emphasize that these are children who were ultimately found to have accidental fractures,” Dr. Johnson said.

Meanwhile, in an analysis of known cases of head trauma, researchers found that abuse was missed in 37% of White children, compared with 19% of non-White children.

“These only represent the tip of the iceberg as a true number of cases of abuse may never really be detected because some cases are still unknown,” Dr. Johnson told attendees. And the harm of these disparities runs in both directions.

“Failing to diagnose abuse in White children clearly puts them at increased risk for return visits and return evaluations for repeated abuse by the perpetrators,” she said. But harm also can result from overreporting and investigation, including psychological trauma and a waste of limited resources. Overinvestigation also can erode family-physician relationships and perpetuate distrust of medical care in communities of color.

Yet at the same time, it’s clear that Black children, adolescents, and young adults are not protected from harm in society more generally, when at home, where they learn, or where they play, Dr. Johnson said, referencing the deaths of Breonna Taylor and Tamir Rice as examples.

KatarzynaBialasiewicz/Thinkstock

“And now we’re seeing increased evidence that children are not protected in the health care center when we think about the many disparities that have been identified in the care and outcomes of children, including the disproportionality in terms of child abuse evaluation and referrals,” Dr. Johnson said.

Racism is a root cause of that harm to Black children, she said, as the systemic structure of opportunities unfairly disadvantages some individuals and communities while unfairly advantaging others, thereby “sapping the strength of the whole society through the waste of human resources.”

Tonya Chaffee, MD, MPH, a clinical professor of health sciences at the University of California, San Francisco, who attended the session, said she particularly appreciated “seeing data on which racial/ethnic populations have child abuse reports made and the disparities that exist that are similar to what we are noticing in our own institution.”
 

Role of individual-level implicit bias and racism

While institutional and structural racism play a substantial role in health care disparities, Dr. Johnson focused primarily on the impact of personal racism when it comes to child abuse evaluations, through overt discrimination, explicit bias, implicit bias, and stigmatization. The most challenging of these to identify and acknowledge is often implicit bias, a tendency to believe, even unconsciously, that some people or ideas are better than others, which results in unfair treatment.

For example, a 2016 study found that half of medical students and residents held at least one biological belief about differences between Black and White individuals that was actually false, such as Black people having more pain tolerance or stronger bones than White people, which then affected treatment recommendations.

“Implicit bias refers to our attitudes that lie below the surface, but they can still influence our behaviors,” Dr. Johnson explained. She encouraged providers to take the implicit bias test online to learn about their own unrecognized implicit biases. These biases have a hand in influencing decisions particularly in fast-paced environments where cognitive load is high – such as EDs, where many child abuse evaluations occur.

For example, in one study Dr. Johnson led, the researchers measured implicit bias in participants before and after an ED shift to assess how cognitive load affected bias. They found that participants who care for more than 10 patients, the average score for implicit bias increased.

Similarly, “when the ED was more overcrowded, there was also increased bias at the end of the shift, compared to the beginning of the shift,” Dr. Johnson said. She asked clinicians to take into consideration that at the start of the shift, they may feel well rested and freshly caffeinated, able to suppress or overcome the biases that they know they have.

“But our biases [are] more likely to come into play with every subsequent decision that we make throughout the day when we’re engaged in clinical encounters,” such as who does and does not receive a skeletal survey or get referred to child protective services, she said.

In another study where she hypothesized that resident physicians would have less bias on the child race implicit bias test than on the adult race one, Dr. Johnson reported that 85% of 91 residents working in an ED had an implicit pro-White/anti-Black bias in the test on adult race, but an even higher bias score – 91% – with child race.

Research has found that even children’s names can conjure implicit bias when it comes to stereotypically “White-sounding” names versus stereotypically “Black-sounding names.”

The implicit bias among clinicians extends beyond care of different children. Research has also identified association between higher implicit bias scores and less interpersonal treatment, less supportive communication, less patient-centered communication, poorer patient ratings of satisfaction, and greater patient-reported difficulty with following recommendations, Dr. Johnson said.

“I want you to think about that because I know that when we’re engaging with parents and making decisions about whether or not we’re going to do a skeletal survey or report someone for it, there is a lot of subjectivity that comes into play with how you’re interacting with families,” Dr. Johnson said. Those verbal and nonverbal cues may be triggering to parents, which then affects your interaction with them. Further, research shows that these biases may impact treatment decisions as well.

Personal-mediated racism also shows up in the use of stigmatizing language, Dr. Johnson said.

“When providers read stigmatizing language in the patient’s medical records, it was associated with them having more negative attitudes about that patient,” which then influenced their clinical decision-making, she said. “So when providers got primed with stigmatizing language, they subsequently had less aggressive pain management for those patients.”
 

Clinical implications for patient care

Dr. Johnson encouraged attendees to be careful about the language and tone they use in communicating with other health care providers and during documentation in medical records. Disparities in child abuse evaluation and reporting tend to be greater in EDs with more subjective conditions, whereas disparities are lower in departments with more established protocols.

She recommended several changes to practice that can reduce the impact of implicit bias. Universal screening for child abuse can increase how many injuries are found, but usually at the cost of increased resources and radiation. Another option is use of validated clinical decision support rules to identify who is at high or low risk for maltreatment, something Dr. Johnson is working on in her research.

But it’s also important for individual providers to confront their personal biases. Evidence-based strategies for reducing bias include perspective taking, focusing on common identities with patients, using counter-stereotypical imaging, seeking increased opportunity for cross-cultural contact, and mindfulness meditation.

“When you interact with people of different backgrounds, it helps to reduce the impact of stereotypes in society about those individuals,” Dr. Johnson told attendees. It’s also important to recognize how diversity in your clinical team can reduce bias.

“We need to work with our institutions to confront racial biases in child abuse reporting and develop quality improvement projects to ensure reporting is done objectively,” Dr. Chaffee said in an interview after attending the session. “This will require training and likely policy changes, including how reports are made to child welfare and/or the police moving forward.”

Pediatric Hospital Medicine (PHM) only recently became a recognized pediatric subspecialty with the first certification exam taking place in 2019. As a new field composed largely of women, it has a unique opportunity to set the example of how to operationalize gender equity in leadership by tracking metrics, creating intentional processes for hiring and promotion, and implementing policies in a transparent way.

In this issue of the Journal of Hospital Medicine, Allan et al¹ report that women, who comprise 70% of the field, appear proportionally represented in associate/assistant but not senior leadership roles when compared to the PHM field at large. Eighty-one percent of associate division directors but only 55% of division directors were women, and 82% of assistant fellowship directors but only 66% of fellowship directors were women. These downward trends in the proportion of women in leadership roles as the roles become more senior is not an unfamiliar pattern. This echoes academic pediatric positions more broadly: women’s representation slides from 63% of active physicians to approximately 57% active faculty and then to 26% as department chairs.² The same story holds true for deans’ offices in US medical schools, where 34% of associate deans are women and yet only 18% of deans are women. The number of women deans has only increased by about one each year, on average, since 2009.³ C-suite leadership roles in healthcare mimic this same downward trajectory.⁴ Burden et al found that while there was equal gender representation of hospitalists and general internists who worked in university hospitals, women led only a minority of (adult) hospital medicine (16%) or general internal medicine (35%) sections or divisions at university hospitals.⁵ Women with intersectionality, such as Black women and other women of color, are even more grossly underrepresented in leadership roles.

How can we change this pattern to ensure that leadership in PHM, and in medicine in general, represents diverse voices and reflects the community it serves? Allan et al have established an important baseline for tracking gender equity in PHM. Institutions, organizations, and societies must now prioritize, value and promote a culture of diversity, inclusivity, sponsorship, and allyship. For example, institutions can create and enforce policies in which compensation and promotion are tied to a leader’s achievement of transparent gender equity and diversity targets to ensure accountability. Institutions should commit dedicated and substantive funding to diversity, equity, and inclusion efforts and provide a regular diversity report that tracks gender distribution, hiring and attrition, and representation in leadership. Institutions should implement “best search practices” for all leadership positions. Additionally, all faculty should receive regular and ongoing professional development planning to enhance academic productivity and professional satisfaction and improve retention.

Women in medicine disproportionately experience many issues, including harassment, bias, and childcare and household responsibilities, that adversely affect their career trajectory. PHM is in a unique position to trailblaze a new framework for ensuring gender equity in its field. Let’s not lose this opportunity to set a new course that other specialties can follow.

Pediatric Hospital Medicine (PHM) only recently became a recognized pediatric subspecialty with the first certification exam taking place in 2019. As a new field composed largely of women, it has a unique opportunity to set the example of how to operationalize gender equity in leadership by tracking metrics, creating intentional processes for hiring and promotion, and implementing policies in a transparent way.

In this issue of the Journal of Hospital Medicine, Allan et al¹ report that women, who comprise 70% of the field, appear proportionally represented in associate/assistant but not senior leadership roles when compared to the PHM field at large. Eighty-one percent of associate division directors but only 55% of division directors were women, and 82% of assistant fellowship directors but only 66% of fellowship directors were women. These downward trends in the proportion of women in leadership roles as the roles become more senior is not an unfamiliar pattern. This echoes academic pediatric positions more broadly: women’s representation slides from 63% of active physicians to approximately 57% active faculty and then to 26% as department chairs.² The same story holds true for deans’ offices in US medical schools, where 34% of associate deans are women and yet only 18% of deans are women. The number of women deans has only increased by about one each year, on average, since 2009.³ C-suite leadership roles in healthcare mimic this same downward trajectory.⁴ Burden et al found that while there was equal gender representation of hospitalists and general internists who worked in university hospitals, women led only a minority of (adult) hospital medicine (16%) or general internal medicine (35%) sections or divisions at university hospitals.⁵ Women with intersectionality, such as Black women and other women of color, are even more grossly underrepresented in leadership roles.

How can we change this pattern to ensure that leadership in PHM, and in medicine in general, represents diverse voices and reflects the community it serves? Allan et al have established an important baseline for tracking gender equity in PHM. Institutions, organizations, and societies must now prioritize, value and promote a culture of diversity, inclusivity, sponsorship, and allyship. For example, institutions can create and enforce policies in which compensation and promotion are tied to a leader’s achievement of transparent gender equity and diversity targets to ensure accountability. Institutions should commit dedicated and substantive funding to diversity, equity, and inclusion efforts and provide a regular diversity report that tracks gender distribution, hiring and attrition, and representation in leadership. Institutions should implement “best search practices” for all leadership positions. Additionally, all faculty should receive regular and ongoing professional development planning to enhance academic productivity and professional satisfaction and improve retention.

Women in medicine disproportionately experience many issues, including harassment, bias, and childcare and household responsibilities, that adversely affect their career trajectory. PHM is in a unique position to trailblaze a new framework for ensuring gender equity in its field. Let’s not lose this opportunity to set a new course that other specialties can follow.

Pediatric Hospital Medicine (PHM) only recently became a recognized pediatric subspecialty with the first certification exam taking place in 2019. As a new field composed largely of women, it has a unique opportunity to set the example of how to operationalize gender equity in leadership by tracking metrics, creating intentional processes for hiring and promotion, and implementing policies in a transparent way.

In this issue of the Journal of Hospital Medicine, Allan et al¹ report that women, who comprise 70% of the field, appear proportionally represented in associate/assistant but not senior leadership roles when compared to the PHM field at large. Eighty-one percent of associate division directors but only 55% of division directors were women, and 82% of assistant fellowship directors but only 66% of fellowship directors were women. These downward trends in the proportion of women in leadership roles as the roles become more senior is not an unfamiliar pattern. This echoes academic pediatric positions more broadly: women’s representation slides from 63% of active physicians to approximately 57% active faculty and then to 26% as department chairs.² The same story holds true for deans’ offices in US medical schools, where 34% of associate deans are women and yet only 18% of deans are women. The number of women deans has only increased by about one each year, on average, since 2009.³ C-suite leadership roles in healthcare mimic this same downward trajectory.⁴ Burden et al found that while there was equal gender representation of hospitalists and general internists who worked in university hospitals, women led only a minority of (adult) hospital medicine (16%) or general internal medicine (35%) sections or divisions at university hospitals.⁵ Women with intersectionality, such as Black women and other women of color, are even more grossly underrepresented in leadership roles.

How can we change this pattern to ensure that leadership in PHM, and in medicine in general, represents diverse voices and reflects the community it serves? Allan et al have established an important baseline for tracking gender equity in PHM. Institutions, organizations, and societies must now prioritize, value and promote a culture of diversity, inclusivity, sponsorship, and allyship. For example, institutions can create and enforce policies in which compensation and promotion are tied to a leader’s achievement of transparent gender equity and diversity targets to ensure accountability. Institutions should commit dedicated and substantive funding to diversity, equity, and inclusion efforts and provide a regular diversity report that tracks gender distribution, hiring and attrition, and representation in leadership. Institutions should implement “best search practices” for all leadership positions. Additionally, all faculty should receive regular and ongoing professional development planning to enhance academic productivity and professional satisfaction and improve retention.

Women in medicine disproportionately experience many issues, including harassment, bias, and childcare and household responsibilities, that adversely affect their career trajectory. PHM is in a unique position to trailblaze a new framework for ensuring gender equity in its field. Let’s not lose this opportunity to set a new course that other specialties can follow.

Nearly 30% of healthcare spending may relate to overuse of unnecessary medical interventions.¹ Deimplementation of such practices can reduce negative outcomes and unnecessary costs.² Nonetheless, changing practice is difficult. Why is it so hard to stop doing things that don’t work? A variety of factors influences deimplementation, and research aiming to identify and understand these factors can promote the delivery of more appropriate care.²

In this issue, Wolk et al describe barriers and facilitators in deimplementing non-guideline adherent use of continuous pulse oximetry (CPO) in pediatric patients with bronchiolitis not requiring supplemental oxygen.³ Unnecessary CPO use for these patients is associated with increased hospitalization rates, length of stay, alarm fatigue, and costs, without evidence of improved clinical outcomes. Despite these data, many hospitals participating in the multicenter Eliminating Monitor Overuse study struggled to decrease CPO usage. The authors conducted semistructured interviews with a broad range of stakeholders from 12 hospitals, representing a variety of institutions with low and high CPO utilization rates.

Specific barriers to deimplementation included institutional factors, eg, unclear or missing guidelines, a culture of high utilization, and challenges educating medical staff. Perceived parental discomfort with stopping CPO was also observed. Four key facilitators were noted: strong institutional leadership, evidence-based guidelines, electronic health record order sets or reminders, and clear institutional policy. These results are similar to other deimplementation studies.

A commonality to deimplementation studies is the difficulty of changing practice. Much like implementation, deimplementation requires multipronged approaches that are sensitive to contextual factors. Interventions must account for local conditions, such as resource availability, practice norms, current workflows and processes of care, relationships among clinicians, and leadership, to create feasible and sustainable change.

Deimplementation may be even more challenging than implementation of new practices, however, because of loss aversion—the tendency to prefer avoiding losses to acquiring equivalent gains. “Taking away” something that clinicians are used to, even when proven to not be helpful, can feel uncomfortable, hindering adoption. Rather than simply discontinuing a practice, replacing it with a better option may help to overcome behavioral inertia and motivate change.

Underscoring the importance of local influences, clinicians often respond more to their close colleagues’ practices than to knowledge of national guidelines. Leveraging existing peer networks can facilitate collaboration, learning, and behavior change.⁴ Nudge strategies, in which local contexts are primed to promote desired behaviors, are also increasingly used.⁴ Priming has been effective in deimplementation efforts in medication prescribing and diagnostic testing.⁴

Including patients’ and families’ perspectives in deimplementation research is critical to practice change. Because diagnostic and treatment plans occur in the context of collaborative decision-making with patients, caregivers, and families, these groups are critical to engage in deimplementation efforts.

Hospitalists’ efforts at the front line of improvement require us to become more proficient in not only adopting evidence-based practices, but also in discontinuing ineffective ones. Identifying what we should stop doing is only the first step. Deimplementation is critical to this effort. Wolk et al provide insights into factors that influence deimplementation success. However, more work is needed, particularly regarding adapting approaches to local contexts, minimizing perceived loss, leveraging local conditions to shape behavior, and partnering with patients and families to achieve higher-value care.

Nearly 30% of healthcare spending may relate to overuse of unnecessary medical interventions.¹ Deimplementation of such practices can reduce negative outcomes and unnecessary costs.² Nonetheless, changing practice is difficult. Why is it so hard to stop doing things that don’t work? A variety of factors influences deimplementation, and research aiming to identify and understand these factors can promote the delivery of more appropriate care.²

In this issue, Wolk et al describe barriers and facilitators in deimplementing non-guideline adherent use of continuous pulse oximetry (CPO) in pediatric patients with bronchiolitis not requiring supplemental oxygen.³ Unnecessary CPO use for these patients is associated with increased hospitalization rates, length of stay, alarm fatigue, and costs, without evidence of improved clinical outcomes. Despite these data, many hospitals participating in the multicenter Eliminating Monitor Overuse study struggled to decrease CPO usage. The authors conducted semistructured interviews with a broad range of stakeholders from 12 hospitals, representing a variety of institutions with low and high CPO utilization rates.

Specific barriers to deimplementation included institutional factors, eg, unclear or missing guidelines, a culture of high utilization, and challenges educating medical staff. Perceived parental discomfort with stopping CPO was also observed. Four key facilitators were noted: strong institutional leadership, evidence-based guidelines, electronic health record order sets or reminders, and clear institutional policy. These results are similar to other deimplementation studies.

A commonality to deimplementation studies is the difficulty of changing practice. Much like implementation, deimplementation requires multipronged approaches that are sensitive to contextual factors. Interventions must account for local conditions, such as resource availability, practice norms, current workflows and processes of care, relationships among clinicians, and leadership, to create feasible and sustainable change.

Deimplementation may be even more challenging than implementation of new practices, however, because of loss aversion—the tendency to prefer avoiding losses to acquiring equivalent gains. “Taking away” something that clinicians are used to, even when proven to not be helpful, can feel uncomfortable, hindering adoption. Rather than simply discontinuing a practice, replacing it with a better option may help to overcome behavioral inertia and motivate change.

Underscoring the importance of local influences, clinicians often respond more to their close colleagues’ practices than to knowledge of national guidelines. Leveraging existing peer networks can facilitate collaboration, learning, and behavior change.⁴ Nudge strategies, in which local contexts are primed to promote desired behaviors, are also increasingly used.⁴ Priming has been effective in deimplementation efforts in medication prescribing and diagnostic testing.⁴

Including patients’ and families’ perspectives in deimplementation research is critical to practice change. Because diagnostic and treatment plans occur in the context of collaborative decision-making with patients, caregivers, and families, these groups are critical to engage in deimplementation efforts.

Hospitalists’ efforts at the front line of improvement require us to become more proficient in not only adopting evidence-based practices, but also in discontinuing ineffective ones. Identifying what we should stop doing is only the first step. Deimplementation is critical to this effort. Wolk et al provide insights into factors that influence deimplementation success. However, more work is needed, particularly regarding adapting approaches to local contexts, minimizing perceived loss, leveraging local conditions to shape behavior, and partnering with patients and families to achieve higher-value care.

Nearly 30% of healthcare spending may relate to overuse of unnecessary medical interventions.¹ Deimplementation of such practices can reduce negative outcomes and unnecessary costs.² Nonetheless, changing practice is difficult. Why is it so hard to stop doing things that don’t work? A variety of factors influences deimplementation, and research aiming to identify and understand these factors can promote the delivery of more appropriate care.²

In this issue, Wolk et al describe barriers and facilitators in deimplementing non-guideline adherent use of continuous pulse oximetry (CPO) in pediatric patients with bronchiolitis not requiring supplemental oxygen.³ Unnecessary CPO use for these patients is associated with increased hospitalization rates, length of stay, alarm fatigue, and costs, without evidence of improved clinical outcomes. Despite these data, many hospitals participating in the multicenter Eliminating Monitor Overuse study struggled to decrease CPO usage. The authors conducted semistructured interviews with a broad range of stakeholders from 12 hospitals, representing a variety of institutions with low and high CPO utilization rates.

Specific barriers to deimplementation included institutional factors, eg, unclear or missing guidelines, a culture of high utilization, and challenges educating medical staff. Perceived parental discomfort with stopping CPO was also observed. Four key facilitators were noted: strong institutional leadership, evidence-based guidelines, electronic health record order sets or reminders, and clear institutional policy. These results are similar to other deimplementation studies.

A commonality to deimplementation studies is the difficulty of changing practice. Much like implementation, deimplementation requires multipronged approaches that are sensitive to contextual factors. Interventions must account for local conditions, such as resource availability, practice norms, current workflows and processes of care, relationships among clinicians, and leadership, to create feasible and sustainable change.

Deimplementation may be even more challenging than implementation of new practices, however, because of loss aversion—the tendency to prefer avoiding losses to acquiring equivalent gains. “Taking away” something that clinicians are used to, even when proven to not be helpful, can feel uncomfortable, hindering adoption. Rather than simply discontinuing a practice, replacing it with a better option may help to overcome behavioral inertia and motivate change.

Underscoring the importance of local influences, clinicians often respond more to their close colleagues’ practices than to knowledge of national guidelines. Leveraging existing peer networks can facilitate collaboration, learning, and behavior change.⁴ Nudge strategies, in which local contexts are primed to promote desired behaviors, are also increasingly used.⁴ Priming has been effective in deimplementation efforts in medication prescribing and diagnostic testing.⁴

Including patients’ and families’ perspectives in deimplementation research is critical to practice change. Because diagnostic and treatment plans occur in the context of collaborative decision-making with patients, caregivers, and families, these groups are critical to engage in deimplementation efforts.

Hospitalists’ efforts at the front line of improvement require us to become more proficient in not only adopting evidence-based practices, but also in discontinuing ineffective ones. Identifying what we should stop doing is only the first step. Deimplementation is critical to this effort. Wolk et al provide insights into factors that influence deimplementation success. However, more work is needed, particularly regarding adapting approaches to local contexts, minimizing perceived loss, leveraging local conditions to shape behavior, and partnering with patients and families to achieve higher-value care.

In recent years, there has been increased scrutiny of transitions of care in medicine, particularly at hospital discharge. Much focus has been on preventing readmissions, motivated at least in part by the Affordable Care Act’s Hospital Readmissions Reduction Program, which financially penalizes hospitals for higher-than-expected readmission rates.¹ However, the problem of transition from hospital to home is not just a readmissions issue—it is a quality and patient safety issue.² Therefore, measuring readmissions alone is inadequate. More effective systems for transition from hospital to home are needed in order to deliver high-quality care that actually restores patient well-being after hospitalization.

In this month’s issue of Journal of Hospital Medicine, Schnipper and Samal, et al report the results of a stepped-wedge randomized trial examining the effect of a multifaceted intervention on postdischarge patient-centered outcomes when compared with usual care.³ At 30 days after discharge, adverse events were reduced from 23 per 100 patients in the usual care group to 18 per 100 patients in the intervention group, with an incidence rate ratio of 0.55 (95% CI, 0.35-0.84) after adjustment for study month and baseline characteristics. Interestingly, there was no statistically significant difference in nonelective readmissions, and penetrance was notably poor: The majority of components of the intervention were received by fewer than half of intended patients, and 13% failed to receive any component at all.

With such incomplete implementation, what explains the reduction in adverse events? To best answer this, it is helpful to recognize the transition from hospital to home as a complex problem rather than a complicated one.⁴ The difference is key. Complicated problems follow a predictable set of rules that can be thought of and planned for, and when the plan is methodically followed, complicated problems can be solved. Complex problems, on the other hand, have a more unpredictable interplay between multiple nonindependent and sometimes unknown factors. Complex problems cannot be solved by merely following a well-designed plan; rather, they require tremendous preparation, adaptability, and active management as the problem plays itself out.

Fortunately, Schnipper and Samal, et al properly identified the problem of transition from hospital to home as complex and approached it from a complexity mindset. In their design of a multifaceted intervention, they aimed high and cast a wide net. Understanding that different practices have different cultures and resources, they standardized the function of the intervention components rather than the exact form. As the trial progressed, they allowed for modification of the intervention, incorporating input from multiple stakeholders and feedback from early failures. Thus, by recognizing and embracing the complexity of the problem, the authors set themselves and their patients up for success. The most likely explanation for the observed effect of the intervention on this complex problem is therefore quite simple: The study design allowed for the components most likely to work to be most readily implemented on a patient-by-patient and practice-by-practice basis.

While the trial aims to imitate the “real world,” it does not leave clear-cut answers for real healthcare professionals. Without knowing if any individual component of the intervention was effective on its own, it may be difficult for institutions to justify the cost of implementation. And while there should be adequate incentive to action for any intervention that improves how patients function or feel, without a reduction in readmissions, the financial downside may in some instances be prohibitive.

Despite these limitations, the path forward is clear. Institutions looking to implement a similar program now should approach the problem with a complexity mindset, even if their downstream interventions may differ. Researchers looking to design similar trials should focus on narrowing the scope of the intervention while maintaining a complexity mindset, which might help lead to more widespread implementation of evidence-based interventions in the future. In teaching us more about the approach to finding a solution than the solution itself, the present study marks an important next step in hospital to home transitions of care and transitions-of-care research.

In recent years, there has been increased scrutiny of transitions of care in medicine, particularly at hospital discharge. Much focus has been on preventing readmissions, motivated at least in part by the Affordable Care Act’s Hospital Readmissions Reduction Program, which financially penalizes hospitals for higher-than-expected readmission rates.¹ However, the problem of transition from hospital to home is not just a readmissions issue—it is a quality and patient safety issue.² Therefore, measuring readmissions alone is inadequate. More effective systems for transition from hospital to home are needed in order to deliver high-quality care that actually restores patient well-being after hospitalization.

In this month’s issue of Journal of Hospital Medicine, Schnipper and Samal, et al report the results of a stepped-wedge randomized trial examining the effect of a multifaceted intervention on postdischarge patient-centered outcomes when compared with usual care.³ At 30 days after discharge, adverse events were reduced from 23 per 100 patients in the usual care group to 18 per 100 patients in the intervention group, with an incidence rate ratio of 0.55 (95% CI, 0.35-0.84) after adjustment for study month and baseline characteristics. Interestingly, there was no statistically significant difference in nonelective readmissions, and penetrance was notably poor: The majority of components of the intervention were received by fewer than half of intended patients, and 13% failed to receive any component at all.

With such incomplete implementation, what explains the reduction in adverse events? To best answer this, it is helpful to recognize the transition from hospital to home as a complex problem rather than a complicated one.⁴ The difference is key. Complicated problems follow a predictable set of rules that can be thought of and planned for, and when the plan is methodically followed, complicated problems can be solved. Complex problems, on the other hand, have a more unpredictable interplay between multiple nonindependent and sometimes unknown factors. Complex problems cannot be solved by merely following a well-designed plan; rather, they require tremendous preparation, adaptability, and active management as the problem plays itself out.

Fortunately, Schnipper and Samal, et al properly identified the problem of transition from hospital to home as complex and approached it from a complexity mindset. In their design of a multifaceted intervention, they aimed high and cast a wide net. Understanding that different practices have different cultures and resources, they standardized the function of the intervention components rather than the exact form. As the trial progressed, they allowed for modification of the intervention, incorporating input from multiple stakeholders and feedback from early failures. Thus, by recognizing and embracing the complexity of the problem, the authors set themselves and their patients up for success. The most likely explanation for the observed effect of the intervention on this complex problem is therefore quite simple: The study design allowed for the components most likely to work to be most readily implemented on a patient-by-patient and practice-by-practice basis.

While the trial aims to imitate the “real world,” it does not leave clear-cut answers for real healthcare professionals. Without knowing if any individual component of the intervention was effective on its own, it may be difficult for institutions to justify the cost of implementation. And while there should be adequate incentive to action for any intervention that improves how patients function or feel, without a reduction in readmissions, the financial downside may in some instances be prohibitive.

Despite these limitations, the path forward is clear. Institutions looking to implement a similar program now should approach the problem with a complexity mindset, even if their downstream interventions may differ. Researchers looking to design similar trials should focus on narrowing the scope of the intervention while maintaining a complexity mindset, which might help lead to more widespread implementation of evidence-based interventions in the future. In teaching us more about the approach to finding a solution than the solution itself, the present study marks an important next step in hospital to home transitions of care and transitions-of-care research.

In recent years, there has been increased scrutiny of transitions of care in medicine, particularly at hospital discharge. Much focus has been on preventing readmissions, motivated at least in part by the Affordable Care Act’s Hospital Readmissions Reduction Program, which financially penalizes hospitals for higher-than-expected readmission rates.¹ However, the problem of transition from hospital to home is not just a readmissions issue—it is a quality and patient safety issue.² Therefore, measuring readmissions alone is inadequate. More effective systems for transition from hospital to home are needed in order to deliver high-quality care that actually restores patient well-being after hospitalization.

In this month’s issue of Journal of Hospital Medicine, Schnipper and Samal, et al report the results of a stepped-wedge randomized trial examining the effect of a multifaceted intervention on postdischarge patient-centered outcomes when compared with usual care.³ At 30 days after discharge, adverse events were reduced from 23 per 100 patients in the usual care group to 18 per 100 patients in the intervention group, with an incidence rate ratio of 0.55 (95% CI, 0.35-0.84) after adjustment for study month and baseline characteristics. Interestingly, there was no statistically significant difference in nonelective readmissions, and penetrance was notably poor: The majority of components of the intervention were received by fewer than half of intended patients, and 13% failed to receive any component at all.

With such incomplete implementation, what explains the reduction in adverse events? To best answer this, it is helpful to recognize the transition from hospital to home as a complex problem rather than a complicated one.⁴ The difference is key. Complicated problems follow a predictable set of rules that can be thought of and planned for, and when the plan is methodically followed, complicated problems can be solved. Complex problems, on the other hand, have a more unpredictable interplay between multiple nonindependent and sometimes unknown factors. Complex problems cannot be solved by merely following a well-designed plan; rather, they require tremendous preparation, adaptability, and active management as the problem plays itself out.

Fortunately, Schnipper and Samal, et al properly identified the problem of transition from hospital to home as complex and approached it from a complexity mindset. In their design of a multifaceted intervention, they aimed high and cast a wide net. Understanding that different practices have different cultures and resources, they standardized the function of the intervention components rather than the exact form. As the trial progressed, they allowed for modification of the intervention, incorporating input from multiple stakeholders and feedback from early failures. Thus, by recognizing and embracing the complexity of the problem, the authors set themselves and their patients up for success. The most likely explanation for the observed effect of the intervention on this complex problem is therefore quite simple: The study design allowed for the components most likely to work to be most readily implemented on a patient-by-patient and practice-by-practice basis.

While the trial aims to imitate the “real world,” it does not leave clear-cut answers for real healthcare professionals. Without knowing if any individual component of the intervention was effective on its own, it may be difficult for institutions to justify the cost of implementation. And while there should be adequate incentive to action for any intervention that improves how patients function or feel, without a reduction in readmissions, the financial downside may in some instances be prohibitive.

Despite these limitations, the path forward is clear. Institutions looking to implement a similar program now should approach the problem with a complexity mindset, even if their downstream interventions may differ. Researchers looking to design similar trials should focus on narrowing the scope of the intervention while maintaining a complexity mindset, which might help lead to more widespread implementation of evidence-based interventions in the future. In teaching us more about the approach to finding a solution than the solution itself, the present study marks an important next step in hospital to home transitions of care and transitions-of-care research.

Optical treatments for acne are emerging as promising alternatives to conventional treatments, a development that inspires clinician researchers such as Fernanda H. Sakamoto, MD, PhD.

“I love treating acne, because it can have a huge impact on our patients’ lives,” Dr. Sakamoto, a dermatologist at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Acne is the most common disease in dermatology, affecting about 80% of our patients. Eleven percent of these patients have difficult-to-treat acne, and it is also the No. 1 cause of depression and suicide among teenagers and young adults. And, even though there’s no strong evidence that optical treatments work better than conventional acne treatments, people still spend a lot on those treatments: more than 220 million in 2019.”

Early results from a pilot study suggest that use of a novel laser system known as Accure in patients with mild to moderate acne resulted in an 80% reduction in acne lesions at 12 weeks. The laser prototype, which uses a 1,726 nm wavelength and is being developed by researchers at the Wellman Center for Photomedicine, features a built-in thermal camera in the handpiece that allows the user to monitor the skin’s temperature during treatment.

In initial pilot studies of the device, Dr. Sakamoto and colleagues observed consistent damage of the sebaceous glands, with no damage to the epidermis, surrounding dermis, or other follicular structures. “But because the contrast of absorption of lipids and water is not very high, we needed to create a laser with features that we have never seen before,” she said. “One of them is a robust cooling system. The second prototype features a built-in thermal camera within the handpiece that allows us to see the temperature while we’re treating the patient. It also has built-in software that would shut down the laser if the temperature is too high. “This is the first laser with some safety features that will give the user direct feedback while treating the patient,” she said, noting that its “unique cooling system and real-time monitoring ... makes it different from any of the lasers we see on the market right now.”

Dr. Sakamoto and colleagues (Emil Tanghetti, MD, in San Diego, Roy Geronemus, MD, in New York, and Joel L. Cohen, MD, in Colorado) are conducting a clinical trial of the device, to evaluate whether Accure can selectively target sebaceous glands. As of Oct. 23, 2020, the study enrolled more than 50 patients, who are followed at 4, 8, 12, and 24 weeks post treatment, she said.

To date, 16 patients have completed the study, and the researchers have observed an average lesion reduction of 80% at 12 weeks post treatment, after four treatment sessions. This amounted to more than 12,000 trigger pulls of the device, with no unexpected adverse events. Average visual analogue scale pain scores immediately after treatment have been 1.09 out of 10.

Histologic assessment of skin samples collected from the study participants have revealed selective damage of the sebaceous glands with a normal epidermis and surrounding dermis. “Because this laser is near infrared, it is not absorbed by melanin, making it possible for a safe treatment in darker skin tones,” Dr. Sakamoto said during the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine.

“We have shown that it is possible to create a selective laser for acne treatment at 1,726 nm. We have proven it mathematically as well as with histological samples,” she said. “Now we are moving on to a larger clinical trial for the FDA clearance.”

Another strategy being developed for acne treatment is to make nonselective lasers selective by adding gold microparticles into the hair follicle and sebaceous glands, to allow the lasers to be absorbed. In a study that used a free electron laser, Dr. Sakamoto and colleagues demonstrated that these microparticles can stay within the sebaceous glands for selective damage of the sebaceous glands. In a subsequent pilot clinical trial they showed that the addition of the gold microparticles followed by a diode laser treatment made it possible to reduce both inflammatory and noninflammatory lesions.

More recently, an open-label European study of acne treatment with light absorbing gold microparticles and optical pulses demonstrated that the treatment led to an 80%-90% reduction of inflammatory lesions at 12 weeks, with a reduction of Investigator’s Global Assessment scale from 2 to 4.

The Food and Drug Administration cleared the treatment, Sebacia Microparticles, for the treatment of mild to moderate acne in September of 2018, but according to Dr. Sakamoto, “the company has struggled, as they were only commercializing the device in California and Washington, DC.”

Photodynamic therapy (PDT) is also being studied as an acne treatment. “PDT uses a photosensitizer that needs to be activated by a light source,” she noted. “The combination of red light and aminolevulinic acid (ALA) or methyl ester ALA has been shown to damage the sebaceous glands”.

In a recent randomized controlled trial that compared PDT to adapalene gel plus oral doxycycline, PDT showed superiority. “Because PDT induces apoptosis of the sebaceous glands, it causes a lot of pain and side effects after treatment,” Dr. Sakamoto said. “However, it can clear 80%-90% of acne in 80%-90% of patients. But because of the side effects, PDT should be limited to those patients who cannot take conventional treatments.”

Dr. Sakamoto reported having received research funding and/or consulting fees from numerous device and pharmaceutical companies.

dbrunk@mdedge.com

Optical treatments for acne are emerging as promising alternatives to conventional treatments, a development that inspires clinician researchers such as Fernanda H. Sakamoto, MD, PhD.

“I love treating acne, because it can have a huge impact on our patients’ lives,” Dr. Sakamoto, a dermatologist at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Acne is the most common disease in dermatology, affecting about 80% of our patients. Eleven percent of these patients have difficult-to-treat acne, and it is also the No. 1 cause of depression and suicide among teenagers and young adults. And, even though there’s no strong evidence that optical treatments work better than conventional acne treatments, people still spend a lot on those treatments: more than 220 million in 2019.”

Early results from a pilot study suggest that use of a novel laser system known as Accure in patients with mild to moderate acne resulted in an 80% reduction in acne lesions at 12 weeks. The laser prototype, which uses a 1,726 nm wavelength and is being developed by researchers at the Wellman Center for Photomedicine, features a built-in thermal camera in the handpiece that allows the user to monitor the skin’s temperature during treatment.

In initial pilot studies of the device, Dr. Sakamoto and colleagues observed consistent damage of the sebaceous glands, with no damage to the epidermis, surrounding dermis, or other follicular structures. “But because the contrast of absorption of lipids and water is not very high, we needed to create a laser with features that we have never seen before,” she said. “One of them is a robust cooling system. The second prototype features a built-in thermal camera within the handpiece that allows us to see the temperature while we’re treating the patient. It also has built-in software that would shut down the laser if the temperature is too high. “This is the first laser with some safety features that will give the user direct feedback while treating the patient,” she said, noting that its “unique cooling system and real-time monitoring ... makes it different from any of the lasers we see on the market right now.”

Dr. Sakamoto and colleagues (Emil Tanghetti, MD, in San Diego, Roy Geronemus, MD, in New York, and Joel L. Cohen, MD, in Colorado) are conducting a clinical trial of the device, to evaluate whether Accure can selectively target sebaceous glands. As of Oct. 23, 2020, the study enrolled more than 50 patients, who are followed at 4, 8, 12, and 24 weeks post treatment, she said.

To date, 16 patients have completed the study, and the researchers have observed an average lesion reduction of 80% at 12 weeks post treatment, after four treatment sessions. This amounted to more than 12,000 trigger pulls of the device, with no unexpected adverse events. Average visual analogue scale pain scores immediately after treatment have been 1.09 out of 10.

Histologic assessment of skin samples collected from the study participants have revealed selective damage of the sebaceous glands with a normal epidermis and surrounding dermis. “Because this laser is near infrared, it is not absorbed by melanin, making it possible for a safe treatment in darker skin tones,” Dr. Sakamoto said during the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine.

“We have shown that it is possible to create a selective laser for acne treatment at 1,726 nm. We have proven it mathematically as well as with histological samples,” she said. “Now we are moving on to a larger clinical trial for the FDA clearance.”

Another strategy being developed for acne treatment is to make nonselective lasers selective by adding gold microparticles into the hair follicle and sebaceous glands, to allow the lasers to be absorbed. In a study that used a free electron laser, Dr. Sakamoto and colleagues demonstrated that these microparticles can stay within the sebaceous glands for selective damage of the sebaceous glands. In a subsequent pilot clinical trial they showed that the addition of the gold microparticles followed by a diode laser treatment made it possible to reduce both inflammatory and noninflammatory lesions.

More recently, an open-label European study of acne treatment with light absorbing gold microparticles and optical pulses demonstrated that the treatment led to an 80%-90% reduction of inflammatory lesions at 12 weeks, with a reduction of Investigator’s Global Assessment scale from 2 to 4.

The Food and Drug Administration cleared the treatment, Sebacia Microparticles, for the treatment of mild to moderate acne in September of 2018, but according to Dr. Sakamoto, “the company has struggled, as they were only commercializing the device in California and Washington, DC.”

Photodynamic therapy (PDT) is also being studied as an acne treatment. “PDT uses a photosensitizer that needs to be activated by a light source,” she noted. “The combination of red light and aminolevulinic acid (ALA) or methyl ester ALA has been shown to damage the sebaceous glands”.

In a recent randomized controlled trial that compared PDT to adapalene gel plus oral doxycycline, PDT showed superiority. “Because PDT induces apoptosis of the sebaceous glands, it causes a lot of pain and side effects after treatment,” Dr. Sakamoto said. “However, it can clear 80%-90% of acne in 80%-90% of patients. But because of the side effects, PDT should be limited to those patients who cannot take conventional treatments.”

Dr. Sakamoto reported having received research funding and/or consulting fees from numerous device and pharmaceutical companies.

dbrunk@mdedge.com

Optical treatments for acne are emerging as promising alternatives to conventional treatments, a development that inspires clinician researchers such as Fernanda H. Sakamoto, MD, PhD.

“I love treating acne, because it can have a huge impact on our patients’ lives,” Dr. Sakamoto, a dermatologist at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Acne is the most common disease in dermatology, affecting about 80% of our patients. Eleven percent of these patients have difficult-to-treat acne, and it is also the No. 1 cause of depression and suicide among teenagers and young adults. And, even though there’s no strong evidence that optical treatments work better than conventional acne treatments, people still spend a lot on those treatments: more than 220 million in 2019.”

Early results from a pilot study suggest that use of a novel laser system known as Accure in patients with mild to moderate acne resulted in an 80% reduction in acne lesions at 12 weeks. The laser prototype, which uses a 1,726 nm wavelength and is being developed by researchers at the Wellman Center for Photomedicine, features a built-in thermal camera in the handpiece that allows the user to monitor the skin’s temperature during treatment.

In initial pilot studies of the device, Dr. Sakamoto and colleagues observed consistent damage of the sebaceous glands, with no damage to the epidermis, surrounding dermis, or other follicular structures. “But because the contrast of absorption of lipids and water is not very high, we needed to create a laser with features that we have never seen before,” she said. “One of them is a robust cooling system. The second prototype features a built-in thermal camera within the handpiece that allows us to see the temperature while we’re treating the patient. It also has built-in software that would shut down the laser if the temperature is too high. “This is the first laser with some safety features that will give the user direct feedback while treating the patient,” she said, noting that its “unique cooling system and real-time monitoring ... makes it different from any of the lasers we see on the market right now.”

Dr. Sakamoto and colleagues (Emil Tanghetti, MD, in San Diego, Roy Geronemus, MD, in New York, and Joel L. Cohen, MD, in Colorado) are conducting a clinical trial of the device, to evaluate whether Accure can selectively target sebaceous glands. As of Oct. 23, 2020, the study enrolled more than 50 patients, who are followed at 4, 8, 12, and 24 weeks post treatment, she said.

To date, 16 patients have completed the study, and the researchers have observed an average lesion reduction of 80% at 12 weeks post treatment, after four treatment sessions. This amounted to more than 12,000 trigger pulls of the device, with no unexpected adverse events. Average visual analogue scale pain scores immediately after treatment have been 1.09 out of 10.

Histologic assessment of skin samples collected from the study participants have revealed selective damage of the sebaceous glands with a normal epidermis and surrounding dermis. “Because this laser is near infrared, it is not absorbed by melanin, making it possible for a safe treatment in darker skin tones,” Dr. Sakamoto said during the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine.

“We have shown that it is possible to create a selective laser for acne treatment at 1,726 nm. We have proven it mathematically as well as with histological samples,” she said. “Now we are moving on to a larger clinical trial for the FDA clearance.”

Another strategy being developed for acne treatment is to make nonselective lasers selective by adding gold microparticles into the hair follicle and sebaceous glands, to allow the lasers to be absorbed. In a study that used a free electron laser, Dr. Sakamoto and colleagues demonstrated that these microparticles can stay within the sebaceous glands for selective damage of the sebaceous glands. In a subsequent pilot clinical trial they showed that the addition of the gold microparticles followed by a diode laser treatment made it possible to reduce both inflammatory and noninflammatory lesions.

More recently, an open-label European study of acne treatment with light absorbing gold microparticles and optical pulses demonstrated that the treatment led to an 80%-90% reduction of inflammatory lesions at 12 weeks, with a reduction of Investigator’s Global Assessment scale from 2 to 4.

The Food and Drug Administration cleared the treatment, Sebacia Microparticles, for the treatment of mild to moderate acne in September of 2018, but according to Dr. Sakamoto, “the company has struggled, as they were only commercializing the device in California and Washington, DC.”

Photodynamic therapy (PDT) is also being studied as an acne treatment. “PDT uses a photosensitizer that needs to be activated by a light source,” she noted. “The combination of red light and aminolevulinic acid (ALA) or methyl ester ALA has been shown to damage the sebaceous glands”.

In a recent randomized controlled trial that compared PDT to adapalene gel plus oral doxycycline, PDT showed superiority. “Because PDT induces apoptosis of the sebaceous glands, it causes a lot of pain and side effects after treatment,” Dr. Sakamoto said. “However, it can clear 80%-90% of acne in 80%-90% of patients. But because of the side effects, PDT should be limited to those patients who cannot take conventional treatments.”

Dr. Sakamoto reported having received research funding and/or consulting fees from numerous device and pharmaceutical companies.

dbrunk@mdedge.com

The early days of the coronavirus disease 2019 (COVID-19) pandemic were fraught with uncertainty as hospitalists struggled to develop standards of care for noncritically ill patients. Although data were available from intensive care units (ICUs) in Asia and Europe, it was unclear whether these findings applied to the acute but noncritically ill patients who would ultimately make up most coronavirus admissions. Which therapeutics could benefit these patients? Who needs continuous cardiopulmonary monitoring? And perhaps most importantly, which patients are at risk for clinical deterioration?

In this issue, Nemer et al begin to answer these questions using a retrospective analysis of 350 noncritically ill COVID-19 patients admitted to non-ICU care at Cleveland Clinic hospitals in Ohio and Florida between March 13 and May 1, 2020.¹ The primary outcome was a composite of three endpoints: increased respiratory support (high-flow nasal cannula, noninvasive positive pressure ventilation, or intubation), ICU transfer, or death. The primary outcome occurred in 18% of all patients and the risk was greatest among patients with high admission levels of C-reactive protein (CRP). This analysis found that while clinically significant arrhythmias occurred in 14% of patients, 90% of those were in patients with either known cardiac disease or an elevated admission troponin T level and in only one case (<1%) necessitated transition to a higher level of care. Overall mortality for COVID-19 patients initially admitted to non-ICU settings was 3%.

While several tests have been proposed as clinically relevant to coronavirus disease, those recommendations are based on studies performed on critically ill patients outside of the US and have focused on survival, not clinical deterioration.^2,3 In their cohort of noncritically ill patients in the US, Nemer et al found that not only is CRP associated with clinical worsening, but that increasing levels of CRP are associated with increasing risk of deterioration. Perhaps even more interesting was the finding that no patient with a normal CRP suffered the composite outcome, including death. The authors did not report levels of other laboratory tests that have been associated with severe coronavirus disease, such as platelets, fibrin degradation products, or prolonged prothrombin time/activated partial thromboplastin time. As many clinicians will note, CRP’s lack of specificity may be its Achilles heel, potentially lowering its prognostic value. Still, given its wide availability, low cost, and rapid turnaround, CRP could serve as a screening tool to risk stratify admitted coronavirus patients, while also providing reassurance when it is normal.

The results of this study could also impact use of hospital resources. The findings regarding the low risk of arrhythmias provide support for limiting the use of continuous cardiac monitoring in noncritically ill patients without previous histories of cardiac disease or elevated admission troponin levels. Patients with normal admission CRP levels could potentially be monitored safely with intermittent pulse oximetry. Continuous pulse oximetry and cardiac monitoring are already overused in many hospitals, and in the case of coronavirus the implications are even more significant given the importance of minimizing unnecessary healthcare worker exposures.

The vast majority (79% to 90%) of patients hospitalized for coronavirus will be cared for in non–ICU settings,^4,5 yet most research has thus far focused on ICU patients. Nemer et al provide much-needed information on how to care for the noncritically ill coronavirus patients whom hospitalists are most likely to treat. As a resurgence of infections is expected this winter, this work has the potential to help physicians identify not only those who have the highest probability of deteriorating, but also those who may not. In a world of limited resources, knowing which patient is unlikely to deteriorate may be just as important as recognizing which one is.

The early days of the coronavirus disease 2019 (COVID-19) pandemic were fraught with uncertainty as hospitalists struggled to develop standards of care for noncritically ill patients. Although data were available from intensive care units (ICUs) in Asia and Europe, it was unclear whether these findings applied to the acute but noncritically ill patients who would ultimately make up most coronavirus admissions. Which therapeutics could benefit these patients? Who needs continuous cardiopulmonary monitoring? And perhaps most importantly, which patients are at risk for clinical deterioration?

In this issue, Nemer et al begin to answer these questions using a retrospective analysis of 350 noncritically ill COVID-19 patients admitted to non-ICU care at Cleveland Clinic hospitals in Ohio and Florida between March 13 and May 1, 2020.¹ The primary outcome was a composite of three endpoints: increased respiratory support (high-flow nasal cannula, noninvasive positive pressure ventilation, or intubation), ICU transfer, or death. The primary outcome occurred in 18% of all patients and the risk was greatest among patients with high admission levels of C-reactive protein (CRP). This analysis found that while clinically significant arrhythmias occurred in 14% of patients, 90% of those were in patients with either known cardiac disease or an elevated admission troponin T level and in only one case (<1%) necessitated transition to a higher level of care. Overall mortality for COVID-19 patients initially admitted to non-ICU settings was 3%.

While several tests have been proposed as clinically relevant to coronavirus disease, those recommendations are based on studies performed on critically ill patients outside of the US and have focused on survival, not clinical deterioration.^2,3 In their cohort of noncritically ill patients in the US, Nemer et al found that not only is CRP associated with clinical worsening, but that increasing levels of CRP are associated with increasing risk of deterioration. Perhaps even more interesting was the finding that no patient with a normal CRP suffered the composite outcome, including death. The authors did not report levels of other laboratory tests that have been associated with severe coronavirus disease, such as platelets, fibrin degradation products, or prolonged prothrombin time/activated partial thromboplastin time. As many clinicians will note, CRP’s lack of specificity may be its Achilles heel, potentially lowering its prognostic value. Still, given its wide availability, low cost, and rapid turnaround, CRP could serve as a screening tool to risk stratify admitted coronavirus patients, while also providing reassurance when it is normal.

The results of this study could also impact use of hospital resources. The findings regarding the low risk of arrhythmias provide support for limiting the use of continuous cardiac monitoring in noncritically ill patients without previous histories of cardiac disease or elevated admission troponin levels. Patients with normal admission CRP levels could potentially be monitored safely with intermittent pulse oximetry. Continuous pulse oximetry and cardiac monitoring are already overused in many hospitals, and in the case of coronavirus the implications are even more significant given the importance of minimizing unnecessary healthcare worker exposures.

The vast majority (79% to 90%) of patients hospitalized for coronavirus will be cared for in non–ICU settings,^4,5 yet most research has thus far focused on ICU patients. Nemer et al provide much-needed information on how to care for the noncritically ill coronavirus patients whom hospitalists are most likely to treat. As a resurgence of infections is expected this winter, this work has the potential to help physicians identify not only those who have the highest probability of deteriorating, but also those who may not. In a world of limited resources, knowing which patient is unlikely to deteriorate may be just as important as recognizing which one is.

The early days of the coronavirus disease 2019 (COVID-19) pandemic were fraught with uncertainty as hospitalists struggled to develop standards of care for noncritically ill patients. Although data were available from intensive care units (ICUs) in Asia and Europe, it was unclear whether these findings applied to the acute but noncritically ill patients who would ultimately make up most coronavirus admissions. Which therapeutics could benefit these patients? Who needs continuous cardiopulmonary monitoring? And perhaps most importantly, which patients are at risk for clinical deterioration?

In this issue, Nemer et al begin to answer these questions using a retrospective analysis of 350 noncritically ill COVID-19 patients admitted to non-ICU care at Cleveland Clinic hospitals in Ohio and Florida between March 13 and May 1, 2020.¹ The primary outcome was a composite of three endpoints: increased respiratory support (high-flow nasal cannula, noninvasive positive pressure ventilation, or intubation), ICU transfer, or death. The primary outcome occurred in 18% of all patients and the risk was greatest among patients with high admission levels of C-reactive protein (CRP). This analysis found that while clinically significant arrhythmias occurred in 14% of patients, 90% of those were in patients with either known cardiac disease or an elevated admission troponin T level and in only one case (<1%) necessitated transition to a higher level of care. Overall mortality for COVID-19 patients initially admitted to non-ICU settings was 3%.

While several tests have been proposed as clinically relevant to coronavirus disease, those recommendations are based on studies performed on critically ill patients outside of the US and have focused on survival, not clinical deterioration.^2,3 In their cohort of noncritically ill patients in the US, Nemer et al found that not only is CRP associated with clinical worsening, but that increasing levels of CRP are associated with increasing risk of deterioration. Perhaps even more interesting was the finding that no patient with a normal CRP suffered the composite outcome, including death. The authors did not report levels of other laboratory tests that have been associated with severe coronavirus disease, such as platelets, fibrin degradation products, or prolonged prothrombin time/activated partial thromboplastin time. As many clinicians will note, CRP’s lack of specificity may be its Achilles heel, potentially lowering its prognostic value. Still, given its wide availability, low cost, and rapid turnaround, CRP could serve as a screening tool to risk stratify admitted coronavirus patients, while also providing reassurance when it is normal.

The results of this study could also impact use of hospital resources. The findings regarding the low risk of arrhythmias provide support for limiting the use of continuous cardiac monitoring in noncritically ill patients without previous histories of cardiac disease or elevated admission troponin levels. Patients with normal admission CRP levels could potentially be monitored safely with intermittent pulse oximetry. Continuous pulse oximetry and cardiac monitoring are already overused in many hospitals, and in the case of coronavirus the implications are even more significant given the importance of minimizing unnecessary healthcare worker exposures.

The vast majority (79% to 90%) of patients hospitalized for coronavirus will be cared for in non–ICU settings,^4,5 yet most research has thus far focused on ICU patients. Nemer et al provide much-needed information on how to care for the noncritically ill coronavirus patients whom hospitalists are most likely to treat. As a resurgence of infections is expected this winter, this work has the potential to help physicians identify not only those who have the highest probability of deteriorating, but also those who may not. In a world of limited resources, knowing which patient is unlikely to deteriorate may be just as important as recognizing which one is.

“Our goals can only be reached through the vehicle of a plan. There is no other route to success.”

—Pablo Picasso

Whether it be a research manuscript, quality improvement (QI) initiative, or educational curriculum, busy clinicians often struggle getting projects past the idea stage. Barriers to completion, such as a busy clinical schedule or lack of experience and mentorship, are well known. Importantly, these projects serve as “academic currency” used for promotion and advancement and also create generalizable knowledge, which can help others improve clinical practice or operational processes. Those who are successful in completing their academic project frequently follow a well-structured path. Consider the following principles to get your idea across the finish line:

Find a blueprint. Among most academic projects, whether a research paper, QI project or new curriculum, an underlying formula is commonly applied. Before starting, do your background research. Is there a paper or method that resembles your desired approach? Is there a question or concept that caught your eye? Using a blueprint from existing evidence allows you to identify important structures, phrases, and terms to inform your manuscript. Once you have identified the blueprint, define your project and approach.

Find a mentor. While career mentorship is important for professional growth, you first need a project mentor. Being a project mentor is a smaller ask for a more senior colleague than being a career mentor, and it’s a great way to test-drive a potential long-term working relationship. Moreover, the successful completion of one project can potentially lead to further opportunities, and perhaps even a long-term career mentor.

Take initiative. In business, there is a common adage: “Never bring a problem to your boss without a proposed solution in hand.”¹ In academics, consider: “Never show up with an idea without bringing a proposal.” By bringing a defined proposal to the conversation, your inquiry is more likely to get a response because (a) it is not a blind-ask and (b) it creates a foundation to build on. This is analogous to an early learner presenting their assessment and plan in the clinical setting; you don’t stop at the diagnosis (your idea) without having a plan for how you want to manage it.

Get an accountability partner. Publicly committing to a goal increases the probability of accomplishing your task by 65%, while having an accountability partner increases that by 95%.² An accountability partner serves as a coach to help you accomplish a task. This individual can be a colleague, spouse, or friend and is typically not a part of the project. By leveraging peer pressure, you increase the odds of successfully completing your project.

Carve out dedicated time. The entrepreneur and author Jim Rohn once said, “Discipline is the bridge between goals and accomplishments.”³ To complete a project, you have to make the time to do the work. While many believe that successful writers sit and write for hours on end, many famous writers only wrote for a few hours at a time—but they did so consistently.⁴ Create your routine by setting aside consistent, defined time to work on your project. To extract the most value, select a time of the day in which you work best (eg, early morning). Then, set a timer for 30 minutes and write—or work.

Because you are a busy clinician with constant demands on your time, having the skillset to reliably turn an idea into “academic currency” is a necessity. Having a plan and following these principles will help you earn that academic coin.

“Our goals can only be reached through the vehicle of a plan. There is no other route to success.”

—Pablo Picasso

Whether it be a research manuscript, quality improvement (QI) initiative, or educational curriculum, busy clinicians often struggle getting projects past the idea stage. Barriers to completion, such as a busy clinical schedule or lack of experience and mentorship, are well known. Importantly, these projects serve as “academic currency” used for promotion and advancement and also create generalizable knowledge, which can help others improve clinical practice or operational processes. Those who are successful in completing their academic project frequently follow a well-structured path. Consider the following principles to get your idea across the finish line:

Find a blueprint. Among most academic projects, whether a research paper, QI project or new curriculum, an underlying formula is commonly applied. Before starting, do your background research. Is there a paper or method that resembles your desired approach? Is there a question or concept that caught your eye? Using a blueprint from existing evidence allows you to identify important structures, phrases, and terms to inform your manuscript. Once you have identified the blueprint, define your project and approach.

Find a mentor. While career mentorship is important for professional growth, you first need a project mentor. Being a project mentor is a smaller ask for a more senior colleague than being a career mentor, and it’s a great way to test-drive a potential long-term working relationship. Moreover, the successful completion of one project can potentially lead to further opportunities, and perhaps even a long-term career mentor.

Take initiative. In business, there is a common adage: “Never bring a problem to your boss without a proposed solution in hand.”¹ In academics, consider: “Never show up with an idea without bringing a proposal.” By bringing a defined proposal to the conversation, your inquiry is more likely to get a response because (a) it is not a blind-ask and (b) it creates a foundation to build on. This is analogous to an early learner presenting their assessment and plan in the clinical setting; you don’t stop at the diagnosis (your idea) without having a plan for how you want to manage it.

Get an accountability partner. Publicly committing to a goal increases the probability of accomplishing your task by 65%, while having an accountability partner increases that by 95%.² An accountability partner serves as a coach to help you accomplish a task. This individual can be a colleague, spouse, or friend and is typically not a part of the project. By leveraging peer pressure, you increase the odds of successfully completing your project.

Carve out dedicated time. The entrepreneur and author Jim Rohn once said, “Discipline is the bridge between goals and accomplishments.”³ To complete a project, you have to make the time to do the work. While many believe that successful writers sit and write for hours on end, many famous writers only wrote for a few hours at a time—but they did so consistently.⁴ Create your routine by setting aside consistent, defined time to work on your project. To extract the most value, select a time of the day in which you work best (eg, early morning). Then, set a timer for 30 minutes and write—or work.

Because you are a busy clinician with constant demands on your time, having the skillset to reliably turn an idea into “academic currency” is a necessity. Having a plan and following these principles will help you earn that academic coin.

“Our goals can only be reached through the vehicle of a plan. There is no other route to success.”

—Pablo Picasso

Whether it be a research manuscript, quality improvement (QI) initiative, or educational curriculum, busy clinicians often struggle getting projects past the idea stage. Barriers to completion, such as a busy clinical schedule or lack of experience and mentorship, are well known. Importantly, these projects serve as “academic currency” used for promotion and advancement and also create generalizable knowledge, which can help others improve clinical practice or operational processes. Those who are successful in completing their academic project frequently follow a well-structured path. Consider the following principles to get your idea across the finish line:

Find a blueprint. Among most academic projects, whether a research paper, QI project or new curriculum, an underlying formula is commonly applied. Before starting, do your background research. Is there a paper or method that resembles your desired approach? Is there a question or concept that caught your eye? Using a blueprint from existing evidence allows you to identify important structures, phrases, and terms to inform your manuscript. Once you have identified the blueprint, define your project and approach.

Find a mentor. While career mentorship is important for professional growth, you first need a project mentor. Being a project mentor is a smaller ask for a more senior colleague than being a career mentor, and it’s a great way to test-drive a potential long-term working relationship. Moreover, the successful completion of one project can potentially lead to further opportunities, and perhaps even a long-term career mentor.

Take initiative. In business, there is a common adage: “Never bring a problem to your boss without a proposed solution in hand.”¹ In academics, consider: “Never show up with an idea without bringing a proposal.” By bringing a defined proposal to the conversation, your inquiry is more likely to get a response because (a) it is not a blind-ask and (b) it creates a foundation to build on. This is analogous to an early learner presenting their assessment and plan in the clinical setting; you don’t stop at the diagnosis (your idea) without having a plan for how you want to manage it.

Get an accountability partner. Publicly committing to a goal increases the probability of accomplishing your task by 65%, while having an accountability partner increases that by 95%.² An accountability partner serves as a coach to help you accomplish a task. This individual can be a colleague, spouse, or friend and is typically not a part of the project. By leveraging peer pressure, you increase the odds of successfully completing your project.

Carve out dedicated time. The entrepreneur and author Jim Rohn once said, “Discipline is the bridge between goals and accomplishments.”³ To complete a project, you have to make the time to do the work. While many believe that successful writers sit and write for hours on end, many famous writers only wrote for a few hours at a time—but they did so consistently.⁴ Create your routine by setting aside consistent, defined time to work on your project. To extract the most value, select a time of the day in which you work best (eg, early morning). Then, set a timer for 30 minutes and write—or work.

Because you are a busy clinician with constant demands on your time, having the skillset to reliably turn an idea into “academic currency” is a necessity. Having a plan and following these principles will help you earn that academic coin.

We enter the new year still in the midst of the coronavirus disease 2019 (COVID-19) pandemic and remain humbled by its impact. It is remarkable how much, and how little, has changed. Hospitalists in the early days of the COVID-19 pandemic were struggling. We were caring for patients who were suffering and dying from a new and mysterious disease. There weren’t enough tests (or, if there were tests, there weren’t swabs).¹ We were using protocols for managing respiratory failure that, we would learn later, may not have been the best for improving outcomes. Rumors of unproven therapies came from everywhere: our patients, our colleagues, and even the highest realms of the federal government. We also knew very little about how best to protect ourselves. In many cases, we did not have enough personal protective equipment (PPE). There were no face shields, or “zoom rounds,” or even awareness that we probably shouldn’t sit in the tiny conference room (maskless) discussing patients with the large team of doctors, nurses, respiratory therapists, and social workers.

Perhaps worst of all, we were haunted. We were alarmed by the large numbers of young patients who were ill, and our elderly patients, many of whom we knew and had cared for many times, had suddenly just stopped showing up.² In our free moments, we worried about them; maybe they were afraid to come to the hospital, maybe they were home sick with COVID-19, or maybe they had died alone. And children, initially thought to be spared the most serious consequences of COVID-19, started coming to the hospital with a rare but severe new COVID-19-associated complication, termed multisystem inflammatory syndrome in children (MIS-C). We had to learn to manage yet another manifestation of COVID-19, largely through trial and error.

And, of course, clinical care was only one of our many responsibilities. We were also busy hunting for ventilators, setting up makeshift medical wards and intensive care units, revamping medical education, and scouring the literature for any information to help guide patient care. We worried about getting sick ourselves and bringing the disease home to our families. Our impatience grew as day after day there was no (and still is no) coordinated federal response.

A glimmer of hope slowly emerged. Our colleagues designed and rapidly evaluated respiratory protocols and provided early evidence about the strategies (eg, proning) that were associated with improved outcomes.³ Researchers began to generate knowledge and move us beyond rumors regarding potential therapies. We cheered as our administrators concocted unusual strategies to remedy the PPE and testing shortages.⁴

At the Journal of Hospital Medicine, we were faced with another challenge: How would we describe the chaos and the challenges of being a physician during the COVID-19 era? How would we document the way our colleagues were rising to the challenge and identifying opportunities to rethink hospital care in the United States?

In April, we began to receive a deluge of personal essays from frontline physicians about their experiences with COVID-19. Generally, medical journals publish and disseminate original, high-impact research. Personal essays rarely fit this model. Given the unprecedented circumstances, however, we decided these essays could help chronicle an important moment in medical history. In our May 2020 issue, we published only these essays. We continue to publish them online almost daily.

Some of the essays described how the healthcare system—previously thought to be hyperspecialized, profit-driven, and resistant to change—pivoted within days, as hospitalist physicians trained other physicians to “unspecialize” and pediatricians began to care for adults in an otherwise overwhelmed hospital system.^5,6 Another essay focused on the need to trust that medical students who had graduated early would be able to function as physicians.⁷ And yet another essay expressed concern about the widespread use of unproven therapies in hospitalized patients. “Even in times of global pandemic, we need to consider potential harms and adverse consequences of novel treatments,’’ the physicians wrote. “Sometimes inaction is preferable to action.”⁸

Several essays reflected on the impact of the pandemic on healthcare disparities, suggesting that the pandemic had made (the well-known but often ignored) differences in health outcomes between White patients and racial minorities more obvious. Still another essay reflected on the intersection between structural racism, poor access to care, and interpersonal racism, describing the grief caused by losses of Black lives to both police violence and COVID-19.⁹

There also were personal stories of hardship and survival. One hospitalist physician with asthma described coughing as ``the new leprosy.”¹⁰ She wrote, “This is a particularly unpropitious time in history to be a Chinese-American doctor who can’t stop coughing.”

There were drawbacks to our decision to focus on personal essays. Although it was clear even before the pandemic, COVID-19 has highlighted that a path for quick dissemination of original peer-reviewed research is needed. If existing medical journals do not fill that role, websites that publish and disseminate non–peer-reviewed work (aka, “preprints”) will become the preferred method for distribution of high-impact, timely original research.¹¹ The journal’s pivot to reviewing and publishing personal essays may have kept us from improving our approach to rapid peer review and dissemination. In those early days, however, there was no peer-reviewed work to publish, but there was an intense desire (from our members and physicians generally) for information and stories from the front lines. In a way, the essays we published were early “case reports,” that hypothesized about how we might rethink healthcare delivery in pandemic conditions.

Furthermore, our decision to solicit and publish personal essays addressing shortcomings of the federal response and consequences of the pandemic meant that the Journal of Hospital Medicine became part of the pandemic’s political discourse. As editors, we have historically kept the journal away from political arguments or endorsements. In this case, however, we decided that even if some of the opinions were political, they were an appropriate response to the widespread anti-science rhetoric endorsed by the current administration. The resultant erosion of trust in public health has undoubtedly contributed to persistence of the pandemic.¹² A stance against masks, for example, rejects the recommendations of nearly all scientists in favor of (a selfish and problematic idea of) “self-determination.” Those who proclaim that such a mandate infringes on their personal freedom reject evidence-based recommendations of scientists and disregard public health strategies meant to protect everyone.

As we reflect on the past year, our most important lesson may be that our previous emphasis on publishing high-impact original research likely missed important personal and professional insights, insights that could have changed practice, improved patient experience, and reduced physician burnout. Anecdotes are not scientific evidence, but we have discovered their incredible power to help us learn, empathize, commiserate, and survive. Hospitals learned that they must adapt in the moment, a notion that runs counter to the notoriously slow pace of change in paradigms of healthcare. Hospitalists learned to “find their battle buddies” to ward off isolation and to cherish their teams in the face of overwhelming trauma, an approach requiring empathy, humility, and compassion.¹³ We won’t soon forget that, when things were most dire, it was stories—not data—that gave us hope. We look forward to 2021 with great optimism. New vaccines and new federal leaders who value and respect science give us hope that the end of the pandemic is in sight. We are indebted to all frontline workers who have transformed care delivery and remained courageous in the face of great personal risk. As a journal, we will continue, as one scientist noted, to use our “platform for advocacy, unabashedly.”¹⁴

We enter the new year still in the midst of the coronavirus disease 2019 (COVID-19) pandemic and remain humbled by its impact. It is remarkable how much, and how little, has changed. Hospitalists in the early days of the COVID-19 pandemic were struggling. We were caring for patients who were suffering and dying from a new and mysterious disease. There weren’t enough tests (or, if there were tests, there weren’t swabs).¹ We were using protocols for managing respiratory failure that, we would learn later, may not have been the best for improving outcomes. Rumors of unproven therapies came from everywhere: our patients, our colleagues, and even the highest realms of the federal government. We also knew very little about how best to protect ourselves. In many cases, we did not have enough personal protective equipment (PPE). There were no face shields, or “zoom rounds,” or even awareness that we probably shouldn’t sit in the tiny conference room (maskless) discussing patients with the large team of doctors, nurses, respiratory therapists, and social workers.

Perhaps worst of all, we were haunted. We were alarmed by the large numbers of young patients who were ill, and our elderly patients, many of whom we knew and had cared for many times, had suddenly just stopped showing up.² In our free moments, we worried about them; maybe they were afraid to come to the hospital, maybe they were home sick with COVID-19, or maybe they had died alone. And children, initially thought to be spared the most serious consequences of COVID-19, started coming to the hospital with a rare but severe new COVID-19-associated complication, termed multisystem inflammatory syndrome in children (MIS-C). We had to learn to manage yet another manifestation of COVID-19, largely through trial and error.

And, of course, clinical care was only one of our many responsibilities. We were also busy hunting for ventilators, setting up makeshift medical wards and intensive care units, revamping medical education, and scouring the literature for any information to help guide patient care. We worried about getting sick ourselves and bringing the disease home to our families. Our impatience grew as day after day there was no (and still is no) coordinated federal response.

A glimmer of hope slowly emerged. Our colleagues designed and rapidly evaluated respiratory protocols and provided early evidence about the strategies (eg, proning) that were associated with improved outcomes.³ Researchers began to generate knowledge and move us beyond rumors regarding potential therapies. We cheered as our administrators concocted unusual strategies to remedy the PPE and testing shortages.⁴

At the Journal of Hospital Medicine, we were faced with another challenge: How would we describe the chaos and the challenges of being a physician during the COVID-19 era? How would we document the way our colleagues were rising to the challenge and identifying opportunities to rethink hospital care in the United States?

In April, we began to receive a deluge of personal essays from frontline physicians about their experiences with COVID-19. Generally, medical journals publish and disseminate original, high-impact research. Personal essays rarely fit this model. Given the unprecedented circumstances, however, we decided these essays could help chronicle an important moment in medical history. In our May 2020 issue, we published only these essays. We continue to publish them online almost daily.

Some of the essays described how the healthcare system—previously thought to be hyperspecialized, profit-driven, and resistant to change—pivoted within days, as hospitalist physicians trained other physicians to “unspecialize” and pediatricians began to care for adults in an otherwise overwhelmed hospital system.^5,6 Another essay focused on the need to trust that medical students who had graduated early would be able to function as physicians.⁷ And yet another essay expressed concern about the widespread use of unproven therapies in hospitalized patients. “Even in times of global pandemic, we need to consider potential harms and adverse consequences of novel treatments,’’ the physicians wrote. “Sometimes inaction is preferable to action.”⁸

Several essays reflected on the impact of the pandemic on healthcare disparities, suggesting that the pandemic had made (the well-known but often ignored) differences in health outcomes between White patients and racial minorities more obvious. Still another essay reflected on the intersection between structural racism, poor access to care, and interpersonal racism, describing the grief caused by losses of Black lives to both police violence and COVID-19.⁹

There also were personal stories of hardship and survival. One hospitalist physician with asthma described coughing as ``the new leprosy.”¹⁰ She wrote, “This is a particularly unpropitious time in history to be a Chinese-American doctor who can’t stop coughing.”

There were drawbacks to our decision to focus on personal essays. Although it was clear even before the pandemic, COVID-19 has highlighted that a path for quick dissemination of original peer-reviewed research is needed. If existing medical journals do not fill that role, websites that publish and disseminate non–peer-reviewed work (aka, “preprints”) will become the preferred method for distribution of high-impact, timely original research.¹¹ The journal’s pivot to reviewing and publishing personal essays may have kept us from improving our approach to rapid peer review and dissemination. In those early days, however, there was no peer-reviewed work to publish, but there was an intense desire (from our members and physicians generally) for information and stories from the front lines. In a way, the essays we published were early “case reports,” that hypothesized about how we might rethink healthcare delivery in pandemic conditions.

Furthermore, our decision to solicit and publish personal essays addressing shortcomings of the federal response and consequences of the pandemic meant that the Journal of Hospital Medicine became part of the pandemic’s political discourse. As editors, we have historically kept the journal away from political arguments or endorsements. In this case, however, we decided that even if some of the opinions were political, they were an appropriate response to the widespread anti-science rhetoric endorsed by the current administration. The resultant erosion of trust in public health has undoubtedly contributed to persistence of the pandemic.¹² A stance against masks, for example, rejects the recommendations of nearly all scientists in favor of (a selfish and problematic idea of) “self-determination.” Those who proclaim that such a mandate infringes on their personal freedom reject evidence-based recommendations of scientists and disregard public health strategies meant to protect everyone.

As we reflect on the past year, our most important lesson may be that our previous emphasis on publishing high-impact original research likely missed important personal and professional insights, insights that could have changed practice, improved patient experience, and reduced physician burnout. Anecdotes are not scientific evidence, but we have discovered their incredible power to help us learn, empathize, commiserate, and survive. Hospitals learned that they must adapt in the moment, a notion that runs counter to the notoriously slow pace of change in paradigms of healthcare. Hospitalists learned to “find their battle buddies” to ward off isolation and to cherish their teams in the face of overwhelming trauma, an approach requiring empathy, humility, and compassion.¹³ We won’t soon forget that, when things were most dire, it was stories—not data—that gave us hope. We look forward to 2021 with great optimism. New vaccines and new federal leaders who value and respect science give us hope that the end of the pandemic is in sight. We are indebted to all frontline workers who have transformed care delivery and remained courageous in the face of great personal risk. As a journal, we will continue, as one scientist noted, to use our “platform for advocacy, unabashedly.”¹⁴

We enter the new year still in the midst of the coronavirus disease 2019 (COVID-19) pandemic and remain humbled by its impact. It is remarkable how much, and how little, has changed. Hospitalists in the early days of the COVID-19 pandemic were struggling. We were caring for patients who were suffering and dying from a new and mysterious disease. There weren’t enough tests (or, if there were tests, there weren’t swabs).¹ We were using protocols for managing respiratory failure that, we would learn later, may not have been the best for improving outcomes. Rumors of unproven therapies came from everywhere: our patients, our colleagues, and even the highest realms of the federal government. We also knew very little about how best to protect ourselves. In many cases, we did not have enough personal protective equipment (PPE). There were no face shields, or “zoom rounds,” or even awareness that we probably shouldn’t sit in the tiny conference room (maskless) discussing patients with the large team of doctors, nurses, respiratory therapists, and social workers.

Perhaps worst of all, we were haunted. We were alarmed by the large numbers of young patients who were ill, and our elderly patients, many of whom we knew and had cared for many times, had suddenly just stopped showing up.² In our free moments, we worried about them; maybe they were afraid to come to the hospital, maybe they were home sick with COVID-19, or maybe they had died alone. And children, initially thought to be spared the most serious consequences of COVID-19, started coming to the hospital with a rare but severe new COVID-19-associated complication, termed multisystem inflammatory syndrome in children (MIS-C). We had to learn to manage yet another manifestation of COVID-19, largely through trial and error.

And, of course, clinical care was only one of our many responsibilities. We were also busy hunting for ventilators, setting up makeshift medical wards and intensive care units, revamping medical education, and scouring the literature for any information to help guide patient care. We worried about getting sick ourselves and bringing the disease home to our families. Our impatience grew as day after day there was no (and still is no) coordinated federal response.

A glimmer of hope slowly emerged. Our colleagues designed and rapidly evaluated respiratory protocols and provided early evidence about the strategies (eg, proning) that were associated with improved outcomes.³ Researchers began to generate knowledge and move us beyond rumors regarding potential therapies. We cheered as our administrators concocted unusual strategies to remedy the PPE and testing shortages.⁴

At the Journal of Hospital Medicine, we were faced with another challenge: How would we describe the chaos and the challenges of being a physician during the COVID-19 era? How would we document the way our colleagues were rising to the challenge and identifying opportunities to rethink hospital care in the United States?

In April, we began to receive a deluge of personal essays from frontline physicians about their experiences with COVID-19. Generally, medical journals publish and disseminate original, high-impact research. Personal essays rarely fit this model. Given the unprecedented circumstances, however, we decided these essays could help chronicle an important moment in medical history. In our May 2020 issue, we published only these essays. We continue to publish them online almost daily.

Some of the essays described how the healthcare system—previously thought to be hyperspecialized, profit-driven, and resistant to change—pivoted within days, as hospitalist physicians trained other physicians to “unspecialize” and pediatricians began to care for adults in an otherwise overwhelmed hospital system.^5,6 Another essay focused on the need to trust that medical students who had graduated early would be able to function as physicians.⁷ And yet another essay expressed concern about the widespread use of unproven therapies in hospitalized patients. “Even in times of global pandemic, we need to consider potential harms and adverse consequences of novel treatments,’’ the physicians wrote. “Sometimes inaction is preferable to action.”⁸

Several essays reflected on the impact of the pandemic on healthcare disparities, suggesting that the pandemic had made (the well-known but often ignored) differences in health outcomes between White patients and racial minorities more obvious. Still another essay reflected on the intersection between structural racism, poor access to care, and interpersonal racism, describing the grief caused by losses of Black lives to both police violence and COVID-19.⁹

There also were personal stories of hardship and survival. One hospitalist physician with asthma described coughing as ``the new leprosy.”¹⁰ She wrote, “This is a particularly unpropitious time in history to be a Chinese-American doctor who can’t stop coughing.”

There were drawbacks to our decision to focus on personal essays. Although it was clear even before the pandemic, COVID-19 has highlighted that a path for quick dissemination of original peer-reviewed research is needed. If existing medical journals do not fill that role, websites that publish and disseminate non–peer-reviewed work (aka, “preprints”) will become the preferred method for distribution of high-impact, timely original research.¹¹ The journal’s pivot to reviewing and publishing personal essays may have kept us from improving our approach to rapid peer review and dissemination. In those early days, however, there was no peer-reviewed work to publish, but there was an intense desire (from our members and physicians generally) for information and stories from the front lines. In a way, the essays we published were early “case reports,” that hypothesized about how we might rethink healthcare delivery in pandemic conditions.

Furthermore, our decision to solicit and publish personal essays addressing shortcomings of the federal response and consequences of the pandemic meant that the Journal of Hospital Medicine became part of the pandemic’s political discourse. As editors, we have historically kept the journal away from political arguments or endorsements. In this case, however, we decided that even if some of the opinions were political, they were an appropriate response to the widespread anti-science rhetoric endorsed by the current administration. The resultant erosion of trust in public health has undoubtedly contributed to persistence of the pandemic.¹² A stance against masks, for example, rejects the recommendations of nearly all scientists in favor of (a selfish and problematic idea of) “self-determination.” Those who proclaim that such a mandate infringes on their personal freedom reject evidence-based recommendations of scientists and disregard public health strategies meant to protect everyone.

As we reflect on the past year, our most important lesson may be that our previous emphasis on publishing high-impact original research likely missed important personal and professional insights, insights that could have changed practice, improved patient experience, and reduced physician burnout. Anecdotes are not scientific evidence, but we have discovered their incredible power to help us learn, empathize, commiserate, and survive. Hospitals learned that they must adapt in the moment, a notion that runs counter to the notoriously slow pace of change in paradigms of healthcare. Hospitalists learned to “find their battle buddies” to ward off isolation and to cherish their teams in the face of overwhelming trauma, an approach requiring empathy, humility, and compassion.¹³ We won’t soon forget that, when things were most dire, it was stories—not data—that gave us hope. We look forward to 2021 with great optimism. New vaccines and new federal leaders who value and respect science give us hope that the end of the pandemic is in sight. We are indebted to all frontline workers who have transformed care delivery and remained courageous in the face of great personal risk. As a journal, we will continue, as one scientist noted, to use our “platform for advocacy, unabashedly.”¹⁴

Poor sleep health and attention regulation problems are common in young children with atopic dermatitis (AD), and the burden intensifies with worse severity, results from a national survey demonstrated.

“We think it’s important for dermatologists and pediatricians to be monitoring children with AD for sleep and attention dysregulation,” Nina Y. Zhou said during a late-breaking research session at the Revolutionizing Atopic Dermatitis virtual symposium. “It’s also important to highlight sleep hygiene habits to improve sleep health overall.”

In an effort to determine the impact of AD severity on these symptoms in young children with AD and characterize sleep health and attention regulation behaviors, Ms. Zhou, a medical student at Northwestern University, Chicago, and colleagues drew from a national survey distributed via panel company OP4G and the National Eczema Association that was conducted with parents of 60 children with AD aged 1-5 years. Questionnaires included the Patient Reported Outcomes Measurement Information System (PROMIS) Early Childhood Sleep Health Measures to assess sleep health, the Peak Pruritus NRS to measure itch severity, and the Multidimensional Assessment Profile of Attention Regulation (MAPS-AR) to measure attention dysregulation related to inattention and hyperactivity. The researchers performed linear regression to determine the predictors of sleep health and attention dysregulation.

The mean age of 60 children was 3 years, 55% were male, 32% were black, 42% had severe disease, 42% had moderate disease, and 16% had mild disease. Children with more extensive AD were significantly more likely to report worse sleep disturbance. The proportion of children who reported sleep disturbance on at least 5 nights per week was 67% among those with severe AD, 24% among those with moderate AD, and 0% among those with mild AD.

In addition, 72% of parents of children with severe AD reported trouble paying attention at least 3 times per week “no matter what was going on,” compared with 24% of those with moderate AD and none of those with mild AD.

Parents of children with more severe AD reported more itch-related burden and significantly decreased quality of life for their children. For example, 76% of parents with children who had severe AD reported “because of itch, their child was frustrated,” compared to 44% of those with moderate AD and 10% with mild AD.

In fully adjusted linear regression analysis, the strongest predictors of sleep disturbance were AD severity (unstandardized beta value = 0.79, P less than .01) and being Black (unstandardized beta value = 3.89, P = .03). AD severity (unstandardized beta value = 1.22, P less than .01) and being Black (unstandardized beta value = 7.79, P less than .01) also predicted more attention dysregulation.

Household income appeared to differ significantly based on AD severity groups. “If you have mild AD, you are more likely to come from a higher income household,” Ms. Zhou said.

She concluded her presentation by calling for future studies with larger samples sizes to establish causality and directional effects between AD severity, itch, sleep, race, and attention.

The study was funded by the Agency for Healthcare Research and Quality. Ms. Zhou reported having no financial disclosures.

dbrunk@mdedge.com

Poor sleep health and attention regulation problems are common in young children with atopic dermatitis (AD), and the burden intensifies with worse severity, results from a national survey demonstrated.

“We think it’s important for dermatologists and pediatricians to be monitoring children with AD for sleep and attention dysregulation,” Nina Y. Zhou said during a late-breaking research session at the Revolutionizing Atopic Dermatitis virtual symposium. “It’s also important to highlight sleep hygiene habits to improve sleep health overall.”

In an effort to determine the impact of AD severity on these symptoms in young children with AD and characterize sleep health and attention regulation behaviors, Ms. Zhou, a medical student at Northwestern University, Chicago, and colleagues drew from a national survey distributed via panel company OP4G and the National Eczema Association that was conducted with parents of 60 children with AD aged 1-5 years. Questionnaires included the Patient Reported Outcomes Measurement Information System (PROMIS) Early Childhood Sleep Health Measures to assess sleep health, the Peak Pruritus NRS to measure itch severity, and the Multidimensional Assessment Profile of Attention Regulation (MAPS-AR) to measure attention dysregulation related to inattention and hyperactivity. The researchers performed linear regression to determine the predictors of sleep health and attention dysregulation.

The mean age of 60 children was 3 years, 55% were male, 32% were black, 42% had severe disease, 42% had moderate disease, and 16% had mild disease. Children with more extensive AD were significantly more likely to report worse sleep disturbance. The proportion of children who reported sleep disturbance on at least 5 nights per week was 67% among those with severe AD, 24% among those with moderate AD, and 0% among those with mild AD.

In addition, 72% of parents of children with severe AD reported trouble paying attention at least 3 times per week “no matter what was going on,” compared with 24% of those with moderate AD and none of those with mild AD.

Parents of children with more severe AD reported more itch-related burden and significantly decreased quality of life for their children. For example, 76% of parents with children who had severe AD reported “because of itch, their child was frustrated,” compared to 44% of those with moderate AD and 10% with mild AD.

In fully adjusted linear regression analysis, the strongest predictors of sleep disturbance were AD severity (unstandardized beta value = 0.79, P less than .01) and being Black (unstandardized beta value = 3.89, P = .03). AD severity (unstandardized beta value = 1.22, P less than .01) and being Black (unstandardized beta value = 7.79, P less than .01) also predicted more attention dysregulation.

Household income appeared to differ significantly based on AD severity groups. “If you have mild AD, you are more likely to come from a higher income household,” Ms. Zhou said.

She concluded her presentation by calling for future studies with larger samples sizes to establish causality and directional effects between AD severity, itch, sleep, race, and attention.

The study was funded by the Agency for Healthcare Research and Quality. Ms. Zhou reported having no financial disclosures.

dbrunk@mdedge.com

Poor sleep health and attention regulation problems are common in young children with atopic dermatitis (AD), and the burden intensifies with worse severity, results from a national survey demonstrated.

“We think it’s important for dermatologists and pediatricians to be monitoring children with AD for sleep and attention dysregulation,” Nina Y. Zhou said during a late-breaking research session at the Revolutionizing Atopic Dermatitis virtual symposium. “It’s also important to highlight sleep hygiene habits to improve sleep health overall.”

In an effort to determine the impact of AD severity on these symptoms in young children with AD and characterize sleep health and attention regulation behaviors, Ms. Zhou, a medical student at Northwestern University, Chicago, and colleagues drew from a national survey distributed via panel company OP4G and the National Eczema Association that was conducted with parents of 60 children with AD aged 1-5 years. Questionnaires included the Patient Reported Outcomes Measurement Information System (PROMIS) Early Childhood Sleep Health Measures to assess sleep health, the Peak Pruritus NRS to measure itch severity, and the Multidimensional Assessment Profile of Attention Regulation (MAPS-AR) to measure attention dysregulation related to inattention and hyperactivity. The researchers performed linear regression to determine the predictors of sleep health and attention dysregulation.

The mean age of 60 children was 3 years, 55% were male, 32% were black, 42% had severe disease, 42% had moderate disease, and 16% had mild disease. Children with more extensive AD were significantly more likely to report worse sleep disturbance. The proportion of children who reported sleep disturbance on at least 5 nights per week was 67% among those with severe AD, 24% among those with moderate AD, and 0% among those with mild AD.

In addition, 72% of parents of children with severe AD reported trouble paying attention at least 3 times per week “no matter what was going on,” compared with 24% of those with moderate AD and none of those with mild AD.

Parents of children with more severe AD reported more itch-related burden and significantly decreased quality of life for their children. For example, 76% of parents with children who had severe AD reported “because of itch, their child was frustrated,” compared to 44% of those with moderate AD and 10% with mild AD.

In fully adjusted linear regression analysis, the strongest predictors of sleep disturbance were AD severity (unstandardized beta value = 0.79, P less than .01) and being Black (unstandardized beta value = 3.89, P = .03). AD severity (unstandardized beta value = 1.22, P less than .01) and being Black (unstandardized beta value = 7.79, P less than .01) also predicted more attention dysregulation.

Household income appeared to differ significantly based on AD severity groups. “If you have mild AD, you are more likely to come from a higher income household,” Ms. Zhou said.

She concluded her presentation by calling for future studies with larger samples sizes to establish causality and directional effects between AD severity, itch, sleep, race, and attention.

The study was funded by the Agency for Healthcare Research and Quality. Ms. Zhou reported having no financial disclosures.

dbrunk@mdedge.com