Publications by authors named "Janice L Kwan"
Patients with rare conditions often experience substantial delays between presentation and diagnosis, and some remain undiagnosed. In this Perspective, we outline the many challenges in diagnosing rare conditions in the modern clinical context. We review relevant concepts of diagnostic reasoning as they relate to rare conditions.
View Article and Find Full Text PDFBackground: Diagnostic errors lead to patient harm; however, most research has been conducted in nonsurgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm.
Methods: We performed a retrospective analysis of closed medico-legal cases and complaints using a database representing more than 95% of all Canadian physicians.
BACKGROUND: Osmotic demyelination syndrome (ODS) is a rare but potentially devastating neurologic complication of hyponatremia. The primary objective of this study was to identify the proportion of patients who developed ODS in a large, contemporary, multicenter cohort of patients admitted to the hospital with hyponatremia. METHODS: We conducted a multicenter cohort study of patients admitted with hyponatremia at five academic hospitals in Toronto, Ontario, Canada, between April 1, 2010, and December 31, 2020.
View Article and Find Full Text PDFBackground: Little is known about patterns of coexisting conditions and their influence on clinical care or outcomes in adults admitted to hospital for community-acquired pneumonia (CAP). We sought to evaluate how coexisting conditions cluster in this population to advance understanding of how multimorbidity affects CAP.
Methods: We studied 11 085 adults admitted to hospital with CAP at 7 hospitals in Ontario, Canada.
Background: Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge.
Objective: To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests.
Importance: Recognizing and preventing patient deterioration is important for hospital safety.
Objective: To investigate whether critical illness events (in-hospital death or intensive care unit [ICU] transfer) are associated with greater risk of subsequent critical illness events for other patients on the same medical ward.
Design, Setting, And Participants: Retrospective cohort study in 5 hospitals in Toronto, Canada, including 118 529 hospitalizations.
Background: Prognostic information at the time of hospital discharge can help guide goals-of-care discussions for future care. We sought to assess the association between the Hospital Frailty Risk Score (HFRS), which may highlight patients' risk of adverse outcomes at the time of hospital discharge, and in-hospital death among patients admitted to the intensive care unit (ICU) within 12 months of a previous hospital discharge.
Methods: We conducted a multicentre retrospective cohort study that included patients aged 75 years or older admitted at least twice over a 12-month period to the general medicine service at 7 academic centres and large community-based teaching hospitals in Toronto and Mississauga, Ontario, Canada, from Apr.
Importance: End-of-rotation resident physician changeover is a key part of postgraduate training but could lead to discontinuity in patient care.
Objective: To test whether patients exposed to end-of-rotation resident changeover have longer hospital stays and whether this association is mitigated by separating resident and attending changeover days.
Design, Setting, And Participants: This retrospective cohort analysis included adult patients admitted to general internal medicine.
Background: Imaging procedures are commonly performed on hospitalized patients and waiting for these could increase length-of-stay. The study objective was to quantify delays for imaging procedures in General Internal Medicine and identify contributing patient, physician, and system factors.
Methods: This was a retrospective cohort study of medical inpatients admitted to 5 hospitals in Toronto, Ontario (2010-2019), with at least one imaging procedure (CT, MRI, ultrasound, or peripherally-inserted central catheter [PICC] insertion).
Importance: Hospitalized medical patients cared for by female physicians may have decreased mortality rates compared with patients of male physicians. However, this association has yet to be assessed outside of the US, and little is known about factors that may explain this difference.
Objective: To determine whether mortality, other hospital outcomes, and processes of care differed between the patients cared for by female and male physicians.
Background: Acute inpatient hospital admissions account for more than half of all health care costs related to diabetes. We sought to identify the most common and costly conditions leading to hospital admission among patients with diabetes compared with patients without diabetes.
Methods: We used data from the General Internal Medicine Inpatient Initiative (GEMINI) study, a retrospective cohort study, of all patients admitted to a general internal medicine service at 7 Toronto hospitals between 2010 and 2015.
Background: Patient characteristics, clinical care, resource use and outcomes associated with admission to hospital for coronavirus disease 2019 (COVID-19) in Canada are not well described.
Methods: We described all adults with COVID-19 or influenza discharged from inpatient medical services and medical-surgical intensive care units (ICUs) between Nov. 1, 2019, and June 30, 2020, at 7 hospitals in Toronto and Mississauga, Ontario.
Objective: Large clinical databases are increasingly used for research and quality improvement. We describe an approach to data quality assessment from the General Medicine Inpatient Initiative (GEMINI), which collects and standardizes administrative and clinical data from hospitals.
Methods: The GEMINI database contained 245 559 patient admissions at 7 hospitals in Ontario, Canada from 2010 to 2017.
Objective: To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets.
Design: Systematic review and meta-analysis.
Data Sources: Medline up to August 2019.
Background: The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities.
Methods: We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.
Background: Variations in inpatient medical care are typically attributed to system, hospital or patient factors. Little is known about variations at the physician level within hospitals. We described the physician-level variation in clinical outcomes and resource use in general internal medicine (GIM).
View Article and Find Full Text PDFBackground: Peripherally inserted central catheters (PICC) are among the most commonly used medical devices in hospital. This study sought to determine the appropriateness of inpatient PICC use in general medicine at five academic hospitals in Toronto, Ontario, Canada, based on the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).
Methods: This was a retrospective, cross-sectional study of general internal medicine patients discharged between 1 April 2010 and 31 March 2015 who received a PICC during hospitalisation.
Background: Over-testing is a recognized problem, but clinicians usually lack information about their personal test ordering volumes. In the absence of data, clinicians rely on self-perception to inform their test ordering practices. In this study we explore clinician self-perception of diagnostic test ordering intensity.
View Article and Find Full Text PDFBackground: Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention.
Methods: We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada.
Background: Computed tomography pulmonary angiography (CTPA) detects incidental findings that require follow-up. In just over 50% of cases, those incidental findings are pulmonary nodules. Fleischner guidelines recommend that patients with nodules that have a high risk of malignancy should undergo CT follow-up within 3-12 months.
View Article and Find Full Text PDFBackground: Short hospital stays may represent opportunities to avert unnecessary admissions or expedite inpatient care. To inform the design of interventions that target patients with potentially avoidable hospital admissions or brief stays, we examined the patient, physician and situational characteristics associated with short stays among patients admitted to general internal medicine wards and describe the use of hospital resources by these patients.
Methods: This was a multicentre cross-sectional study conducted between Apr.
Importance: Trauma of hospitalization refers to the depersonalizing and stressful experience of a hospital admission and is hypothesized to increase the risk of readmission after discharge.
Objectives: To characterize the trauma of hospitalization by measuring patient-reported disturbances in sleep, mobility, nutrition, and mood among medical inpatients, and to examine the association between these disturbances and the risk of unplanned return to hospital after discharge.
Design, Setting, And Participants: This prospective cohort study enrolled participants between September 1, 2016, and September 1, 2017, at 2 academic hospitals in Toronto, Canada.
Background: Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting.
Objective: To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up.