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Introduction Readmission to the hospital following a hip fracture is common, often involves an adverse event, and strains an already overburdened health care system. Objectives To assess the rate of 30-day readmission to the hospital after discharge for care of hip fracture. A secondary objective was measurement of the 30-day mortality rate for those patients readmitted versus those patients not readmitted to the hospital after discharge. Materials and methods Study design was a retrospective review of registry data comparing readmitted patients to those not readmitted after hip fracture. Setting was a university affiliated level 3 trauma center. Participants: 1,081 patients aged 65 and older. Measurements: rate of readmission, rate of mortality, predictors of readmission. Results 129 patients (11.9 %) were readmitted to the hospital within 30 days of their initial discharge date. The primary causes of readmission were surgical in nature for 24/129 (18.6 %) patients and 105/129 (81.4 %) were readmitted for medical or other reasons. Twenty-four (18.6 %) patients who were readmitted died during readmission. The one-year mortality rate for patients readmitted within 30 days was 56.2 vs. a 21.8 % 1-year mortality rate for those patients not readmitted ( p  < 0.0001). Independent predictors of readmission were age >85 (OR = 1.52; p  = 0.03), time to surgery >24 h (OR = 1.50; p  = 0.05), Charlson score ≥4 (OR = 1.70; p  = 0.04), delirium (OR = 1.65; p  = 0.01), dementia (OR = 1.61; p  = 0.01), history of arrhythmia with pacemaker placement (OR = 1.75; p  = 0.02), and presence of a pre-op arrhythmia (OR = 1.62; p  = 0.02). Conclusion Readmission after hip fracture is harmful and undesirable—18.6 % of readmitted patients died during their readmission and the average length of stay was 8.7 days. Approximately one of every six readmissions was identified as potentially preventable with interventions.

Chronic disease places an enormous economic burden on both individuals and the healthcare system, and existing fee-for-service models of healthcare prioritize symptom management, medications, and procedures over treating the root causes of disease through changing health behaviors. Value-based care is gaining traction, and there is a need for value-based care models that achieve the quadruple aim of (1) improved population health, (2) enhanced patient experience, (3) reduced healthcare costs, and (4) improved work life and decreased burnout of healthcare providers. Lifestyle medicine (LM) has the potential to achieve these four aims, including promoting health and wellness and reducing healthcare costs; however, the economic outcomes of LM approaches need to be better quantified in research. This paper demonstrates proof of concept by detailing four cases that utilized an intensive, therapeutic lifestyle intervention change (ITLC) to dramatically reverse disease and reduce healthcare costs. In addition, priorities for lifestyle medicine economic research related to the components of quadruple aim are proposed, including conducting rigorously designed research studies to adequately measure the effects of ITLC interventions, modeling the potential economic cost savings enabled by health improvements following lifestyle interventions as compared to usual disease progression and management, and examining the effects of lifestyle medicine implementation upon different payment models.

Lifestyle medicine (LM) is a rapidly emerging clinical discipline that focuses on intensive therapeutic lifestyle changes to treat chronic disease, often producing dramatic health benefits. In spite of these well-documented benefits of LM approaches to provide evidence-based care that follows current clinical guidelines, LM practitioners have found reimbursement challenging. The objectives of this paper are to present the results of a cross-sectional survey of LM practitioners regarding lifestyle medicine reimbursement and to propose policy priorities related to the ability of practitioners to implement and achieve reimbursement for these necessary services. Results from a closed, online survey in 2019 were analyzed, with a total of n = 857 included in this analysis. Results were descriptively analyzed. This manuscript articulates policy proposals informed by the survey results. The study sample was 58% female, with median age of 51. A minority of the sample (17%) reported that all their practice was LM, while 56% reported that some of their practice was LM. A total of 55% of practitioners reported not being able to receive reimbursement for LM practice. Of those survey respondents who provided an answer to the question of what would make the practice of LM easier (n = 471), the following suggestions were offered: reimbursement overall (18%), reimbursement for more time spent with patients (17%), more support from leadership (16%), policy measures to incentivize health (13%), education in LM for practitioners (11%), LM-specific billing codes and billing knowledge along with better electronic medical record (EMR) capabilities and streamlined reporting/paperwork (11%), and reimbursement for the extended care team (10%). Proposed policy changes focus on three areas of focus: (1) support for the care process using a LM approach, (2) reimbursement emphasizing outcomes of health, patient experience, and delivering person-centered care, and (3) incentivizing treatment that produces disease remission/reversal. Rectifying reimbursement barriers to lifestyle medicine practice will require a sustained effort from health systems and policy makers. The urgency of this transition towards lifestyle medicine interventions to effectively address the epidemic of chronic diseases in a way that can significantly improve outcomes is being hindered by current reimbursement policies and models.

ObjectiveTo find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes.DesignAn international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers).SettingWestern Europe and the USA.ParticipantsThirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate).MeasuresParticipants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method.ResultsIn the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications.ConclusionThe indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Background/Objectives: Whole-food plant-based diets (WFPBDs) are beneficial in managing hypertension in the general population but have not been well studied in chronic kidney disease (CKD), potentially due to concerns about hyperkalemia. We hypothesized that individuals with CKD 3 or 4 attending a 15-day WFPBD education program would achieve lower blood pressure compared to those who did not, without an increased risk of hyperkalemia. Methods: This was a pilot trial of 40 subjects with mild-to-moderate CKD and hypertension but without diabetes or proteinuria from a single academic center. The subjects were randomized to the 15-day education program or the control group. The changes in blood pressure, serum potassium, and other anthropometric and biochemical values were assessed. Results: Systolic blood pressure decreased from the baseline to day 15 in the intervention group by 8 mm Hg and increased in the control group by 2.7 mm Hg, although the difference in the blood pressure change did not reach statistical significance (p = 0.12). Diastolic blood pressure was not different between the two groups. Potassium changed by 0.01 mEq/L in the intervention group and −0.07 mEq/L in the control group (p = 0.52). The intervention subjects had significant decreases in body mass (−3.0 vs. −0.12 kg, p < 0.0001), total cholesterol (−39.4 vs. −5.0 mg/dL, p < 0.0001), low-density lipoprotein (−28.4 vs. −0.6 mg/dL, p < 0.0001), and high-density lipoprotein (−8.6 vs. −0.4 mg/dL, p = 0.006) compared to the controls. The changes in albumin and phosphorus were not different between the two groups. Conclusions: The subjects with mild-to-moderate CKD attending a 15-day WFPBD education program had a non-statistically significant reduction in systolic blood pressure without an increased risk of hyperkalemia compared to those who did not attend. The intervention subjects achieved significantly greater reductions in body mass and cholesterol without adverse effects on albumin or phosphorus. Larger and longer-duration trials using this approach in a diverse group of CKD patients are warranted.

Since the recent shootings in Tucson, Arizona; Aurora, Colorado; and Newtown, Connecticut, there has been an ever-increasing state and national debate regarding gun control. All 3 shootings involved an alleged shooter who attended college, and in hindsight, evidence of a mental illness was potentially present in these individuals while in school. What appears to be different about the current round of debate is that both pro–gun control and anti–gun control advocates are focusing on mentally ill individuals, early detection of mental illness during school years, and the interactions of such individuals with physicians and the mental health system as a way to solve gun violence. This raises multiple questions for our profession about the apparent increase in these types of events, dangerousness in mentally ill individuals, when to intervene (voluntary vs involuntary), and what role physicians should play in the debate and ongoing prevention. As is evident from the historic Tarasoff court case, physicians and mental health professionals often have new regulations/duties, changes in the physician-patient relationship, and increased liability resulting from high-profile events such as these. Given that in many ways the prediction of who will actually commit a violent act is difficult to determine with accuracy, physicians need to be cautious with how the current gun debate evolves not only for ourselves (eg, increased liability, becoming de facto agents of the state) but for our patients as well (eg, increased stigma, erosion of civil liberties, and changes in the physician-patient relationship). We provide examples of potential troublesome legislation and suggestions on what can be done to improve safety for our patients and for the public.

The treating psychiatrist's goal is to relieve symptoms in patients by using pharmacotherapy and psychotherapy. \"Forensic evaluators\" or \"expert witnesses\" do not have a therapeutic relationship with the persons they interview, who indeed are not their patients but are \"examinees\" or \"evaluees.\" Often, courts or attorneys hire expert witnesses with the goal of producing an objective report based on information gained through interviews and collateral sources.

Neurosarcoidosis is a rare disorder in which psychosis and dementia may occur. They usually appear subsequently to the diagnosis of pulmonary sarcoidosis. We report on a 39-year-old patient who presented with long-term decline and acute onset of psychosis and delirium, and who was found to have neurosarcoidosis.

Most patients who are admitted to the hospital with hip fractures are elderly, with a mean age of 85, and, as such, many also have multiple comorbid diseases that need to be managed perioperatively,(1) to optimize patient outcomes.

Maternal filicide may occur in the context of maternal suicide. Five percent of mothers who kill themselves take at least 1 of their children with them into death.9 Sixteen percent to 29% of mothers commit suicide subsequent to filicide, and many mothers make nonfatal suicide attempts.10 Just as some of our medical colleagues feel discomfort inquiring about suicidal thoughts, some psychiatrists are uncomfortable asking patients about thoughts of harming their children.