A “leaky pipeline” exists in leadership for medicine in Switzerland, with majorities of women among resident or attending physicians, yet only 32

Importance Although the YEARS algorithm is a safe and efficient way to rule out acute pulmonary embolism (PE), robust evidence on its accuracy in patients with cancer is lacking, and current guidelines suggest proceeding directly to computed tomographic pulmonary angiography (CTPA). Objective To compare the safety and efficiency of the YEARS algorithm with CTPA only to rule out acute PE in patients with active cancer. Design, Setting, and Participants The Hydra study was an open-label, randomized, investigator-initiated, noninferiority trial with blinded central outcome adjudication conducted from August 22, 2019, to August 21, 2025, the date of final follow-up. Patients with active cancer and suspected acute PE were recruited from emergency departments or medical units in 21 hospitals in the Netherlands, Italy, Switzerland, Belgium, France, and Spain. Interventions Patients were randomly assigned in a 1:1 ratio to receive diagnostic management by the YEARS algorithm (n = 352)—consisting of assessing YEARS items, D-dimer levels, and performing risk-dependent CTPA—or by CTPA only (n = 346). Main Outcomes and Measures The primary outcome was centrally adjudicated symptomatic venous thromboembolism or (possible) PE-related death within 90 days after ruling out PE at baseline, assessed in a per-protocol noninferiority analysis with a 2.6% margin for the upper bound of a 1-sided 99.9% CI. The key secondary outcome was the proportion of negative CTPA results at baseline, assessed in a superiority analysis. Results A total of 698 patients were randomized (median age, 65 years [IQR, 56-72 years], 422 female [60%]), and 104 patients (15%) had PE diagnosed at baseline. One patient was lost to follow-up. Of those in whom PE was considered excluded, 5 of 282 patients (1.8%) in the per-protocol YEARS group vs 15 of 273 patients (5.5%) in the per-protocol CTPA-only group had a primary outcome (absolute risk difference, −3.7%; 99.9% CI, −8.8% to 1.4%; P = 3.4 × 10 −5 for noninferiority). In the intention-to-diagnosis analysis, the absolute risk difference between the YEARS algorithm and CTPA only was −2.6% (99.9% CI, −7.5% to 2.4%; P = 5.9 × 10 −4 for noninferiority). Diagnostic management of PE was carried out for 77 of 352 patients (22%) in the YEARS group without CTPA. No difference in the proportion of negative CTPA ( P = .93) was observed between the groups. Conclusions and Relevance In patients with cancer and suspected PE, a diagnostic strategy using the YEARS diagnostic algorithm was as safe as using CTPA only, thus, obviating the need to perform CTPA in 22% of patients. Trial Registration ccmo.nl Identifier: NL-OMON52383

BACKGROUND:Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in medical inpatients. The Cleveland Clinic Model (CCM), a novel risk assessment model (RAM) to guide thromboprophylaxis, has never been independently validated. OBJECTIVE:To validate and update the CCM, and compare its prognostic accuracy with the Padua Prediction Score (PPS) and the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) score. METHODS:We used data from a prospective cohort of medical inpatients admitted >24 h to general internal medicine wards at 3 Swiss university hospitals (06/2020-01/2022). The outcome was objectively confirmed symptomatic VTE within 90 days. Patients were stratified into higher and low VTE-risk groups by RAM. We compared test characteristics across 3 versions of the CCM (original CCM and 2 updated versions, 1 with a derived cut-off, and 1 modified derived cut-off version with 45-day follow-up and without missing variables), the PPS, and the IMPROVE score and drew calibration plots for the original and modified derived cut-off CCM. RESULTS:Of 1352 medical inpatients, 28 (2.1%) experienced VTE within 90 days. The 90-day VTE cumulative incidence was 2.48% in higher-risk vs. 1.91% in low-risk patients (P = 0.52) according to the original CCM. Discrimination was poor across all RAMs (areas under the receiver operating characteristics curve ≤60%). In calibration plots, the original and modified derived cut-off CCMs underestimated the VTE risk. CONCLUSION:In this non-U.S., non-ICU cohort, all RAMs showed comparable but limited accuracy for predicting VTE up to 90 days. Updating the original CCM did not improve predictive performance.

BACKGROUND:The effect of a shared decision-making approach on patients' code status decisions remains unknown. We compared an approach for shared decision-making with usual care to evaluate the effect on patients' code status preferences and quality of decision-making. METHODS:In a pragmatic cluster-randomized controlled trial conducted in six teaching hospitals in Switzerland, we randomly assigned residents to conduct code status discussions based on either an approach incorporating didactic teaching, observation, and feedback and a shared decision-making checklist with a decision aid, or usual care. The primary end point was patients choosing a do-not-resuscitate (DNR) code status in the event of a cardiac arrest. The key secondary end point was patients' decisional uncertainty, measured by the Decisional Conflict Scale (range 0 to 100, with lower scores indicating lower decisional uncertainty). RESULTS:A total of 206 residents caring for 2663 medical patients were included in the trial. Compared with patients in the usual care group, patients in the intervention group had a significantly higher frequency of choosing DNR as their code status (685/1370 (50.0%) vs. 481/1293 (37.2%); adjusted risk ratio, 1.37 (95% confidence interval, 1.25 to 1.50); P<0.001). The intervention was associated with lower decisional uncertainty (Decisional Conflict Scale score, 14.4±15.3 vs. 21.8±20.2 points; adjusted difference, -7.06 (95% confidence interval, -9.43 to -4.68). CONCLUSIONS:An approach for shared decision-making that included the discussion of expected outcomes had a significant influence on the code status of medical patients, with a higher preference for DNR code status, and was associated with less uncertainty around the decision. (Funded by the Swiss National Science Foundation and the Swiss Society of General Internal Medicine; ClinicalTrials.gov number, NCT03872154.).

BACKGROUND:High-dose long-term opioid treatment for chronic non-cancer pain (CNCP) has become an increasing burden in industrialised countries. Opioid tapering and withdrawal in patients with CNCP remain challenging. This study evaluated a two-phase inpatient opioid withdrawal (OW) programme aimed at safely discontinuing opioid use in CNCP patients. METHODS:This prospective observational study was conducted from 2018 to 2023 at a Swiss tertiary care centre, involving CNCP patients on long-term opioid therapy (≥ 6 months, ≥ 100 mg morphine equivalent daily dose) who had failed outpatient withdrawal attempts. The programme consisted of a withdrawal phase (Phase 1) followed by multimodal pain rehabilitation (Phase 2). Outcomes included the proportion of patients opioid-free after Phase 2 (primary) and at 3 months, pain intensity changes, and adverse events (secondary). RESULTS:Among the 38 enrolled patients (58% female, median age 54 years [IQR 49, 62]), 34 (89%) completed both phases, and 32 (84%) were opioid-free at the end of Phase 2. At 3 months, 23 patients (61%) remained opioid-free, while 4 (11%) resumed opioids, and 11 (29%) were lost to follow-up. Median pain intensity remained stable after discharge. One patient died by suicide 10 days post-withdrawal. CONCLUSIONS:This two-phase inpatient withdrawal and rehabilitation programme enabled most CNCP patients to discontinue opioids without increased pain intensity, with a majority remaining opioid-free at 3 months. These findings highlight the importance of ongoing psychological support and careful patient selection in OW management. SIGNIFICANCE STATEMENT:This study introduces a structured inpatient opioid withdrawal model tailored for chronic non-cancer pain patients on high-dose opioid therapy, demonstrating that high cessation rates can be achieved without worsening pain intensity. By addressing the gap in care for patients who fail outpatient tapering, this research provides clinical insights into optimising withdrawal protocols and highlights the need for targeted resource allocation for intensive, multidisciplinary pain management. These findings support evidence-based decision-making in designing more effective opioid tapering strategies.

Objective: To identify and quantify risk factors for in-hospital falls in medical patients. Data Sources: Six databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) were systematically screened until April 11, 2023, to identify relevant articles. Study Selection: All titles and abstracts of the retrieved articles were independently screened by 2 researchers who also read the full texts of the remaining articles. Quantitative studies that assessed risk factors for falls among adult patients acutely hospitalized were included in the review. Publications that did not capture internal medicine patients or focused on other specific populations were excluded. Data Extraction: Information on study characteristics and potential risk factors were systematically extracted. Risk of bias was assessed using the Quality in Prognosis Studies tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses of Observational Studies in Epidemiology guidelines were followed for reporting. Data Synthesis: The main outcome was any in-hospital falls. Using a random-effects meta-analysis model, association measures for each risk factor reported in 5 or more studies were pooled. Separate analyses according to effect measure and studies adjusted for sex and age at least were performed. Of 5067 records retrieved, 119 original publications from 25 countries were included. In conclusion, 23 potential risk factors were meta- analyzed. Strong evidence with large effect sizes was found for a history of falls (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.63-3.96; I2, 91%), antidepressants (pooled OR, 2.25; 95% CI, 1.92-2.65; I2, 0%), benzodiazepines (OR, 1.97; 95% CI, 1.68-2.31; I2, 0%), hypnotics-sedatives (OR, 1.90; 95% CI, 1.53-2.36; I2, 46%), and antipsychotics (OR, 1.61; 95% CI, 1.33-1.95; I2, 0%). Furthermore, evidence of associations with male sex (OR, 1.22, 95% CI, 0.99-1.50; I2, 65%) and age (OR, 1.17, 95% CI, 1.02-1.35; I2, 72%) were found, but effect sizes were small. Conclusions: The comprehensive list of risk factors, which specifies the strength of evidence and effect sizes, could assist in the prioritization of preventive measures and interventions. Archives of Physical Medicine and Rehabilitation 2025;106:292-9 (c) 2024 by the American Congress of Rehabilitation Medicine. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Background Physicians are increasingly interested in part-time employment. However, the impact of part-time work on efficiency and quality of care of inpatients is unknown.Objectives To investigate the association between part-time clinical work of hospitalists in General Internal Medicine (GIM) and resource utilisation and short-term patient outcomes.Design Retrospective study.Setting GIM wards of 3 Swiss teaching hospitals.Participants Each inpatient was categorised as having received care mainly (>50%) by part-time or full-time hospitalists. Part-time clinical work was defined as employment of <100% as a clinician. We included 3557 cases cared for mainly by part-time and 4973 by full-time physicians.Primary and secondary outcome measures Primary outcome was length of hospital stay, secondary outcomes included 30-day readmission, in-hospital mortality, hospitalisation cost and time to completion of the discharge letter. We assessed the association between both groups and outcomes using generalised estimating equations, clustering for individual patients and adjusting for patient and hospitalist characteristics.Results There was no statistically relevant difference in length of stay in cases cared for mainly by part-time (mean 7.3 days, 95% CI 7.1 to 7.6) compared with full-time hospitalists (mean 7.6 days, 95% CI 7.3 to 7.8; p=0.18). Time to completion of the discharge letter was longer in the part-time (mean 11.4 days, 95% CI 11.0 to 11.8) versus full-time group (mean 10.9 days, 95% CI 10.6 to 11.2, p=0.049). There was no statistically significant difference between groups for the other outcomes.Conclusion We found no evidence that part-time clinical work of hospitalists negatively affects resource utilisation and short-term patient outcomes compared with full-time work.

Knowledge of multiple medication use and medication adherence is important to assess treatment effectiveness and prevent worsening of disease, re-hospitalization, and increased healthcare costs. Limited data exist on individuals with hyperpolypharmacy (ten or more concurrent medications) and their adherence. The objective of the study was to identify potential factors associated with hyperpolypharmacy, and medication adherence in participants with hyperpolypharmacy, as well as explore the relationship between hyperpolypharmacy and medication adherence. This is a cross-sectional analysis of baseline data from OPERAM, a multicenter study across four large European hospitals. Adults aged ≥ 70 years with multimorbidity and polypharmacy (five or more regular medications) were included. Demographic, clinical, and healthcare utilization data were assessed. Outcomes were hyperpolypharmacy and low/medium medication adherence (i.e., a score < 8 out of a maximum of 8) based on the Morisky Medication Adherence Scale-8 (MMAS-8©). Multivariable logistic regression was used to identify factors associated with hyperpolypharmacy or low/medium adherence. Of 2005 patients with multimorbidity and polypharmacy, 1029 (51

Follow-up care in adult childhood cancer survivors (ACCS) aims to screen for, prevent, and treat potential late effects. The trajectory of ACCS’ health-related quality of life (HRQoL) attending follow-up care is unclear. We investigated changes in HRQoL of ACCS attending a follow-up care program. The primary outcome was the minimal clinically important decrease (MCID) in HRQoL of ≥ 5 points in the mental (MCS) and/or physical component score (PCS) of the 36-item Short Form (SF-36) between baseline and follow-up (3-months after the first visit). We compared baseline characteristics, psychological factors, satisfaction, and distress (measured using the Brief Symptom Inventory). In 47 ACCS (100%), no significant change in the overall median MCS and PCS was observed. In 14 ACCS (29.8%) a MCID in HRQoL was observed. Compared to ACCS without a MCID, they reported lower PCS (median 45.2 [31.7; 51.4] vs. 55.6 [46.1; 57.6], p = 0.007), a higher proportion of low physical health (PCS < 48; 71.4% vs. 27.3%, p = 0.009) and distress (50% vs. 18.8%, p = 0.030) at baseline. Satisfaction was high (94.9%). One in three ACCS experienced a clinically important decrease in HRQoL after follow-up care, with higher rates in those with lower physical health and higher psychological distress at baseline.

With the aim to optimize delirium management, an algorithm was introduced in general internal medicine wards of a Swiss University Hospital in 2018. We evaluated its impact on prevalence, therapeutic measures, and outcomes of delirium in a real-world setting. Retrospective before/after study of patients aged ≥ 65 years hospitalized in general internal medicine. During 2018, an interprofessional delirium algorithm was introduced. We compared the delirium prevalence and secondary outcomes including mortality, length of stay (LoS), discharge home, delirium duration, and use of pharmacological and non-pharmacological interventions between the pre-intervention (2017) and the post-intervention (2019) periods in unadjusted and adjusted analyses. Of 4855 cases (pre 2253/post 2602), the overall delirium prevalence was 10.3

ImportanceThromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking.ObjectivesTo prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs.Design, Setting, and ParticipantsThis prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included.ExposuresAt admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM.Main Outcomes and MeasuresSymptomatic VTE within 90 days.ResultsOf 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score.Conclusions and RelevanceThis head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

Objective To assess the effect of goal-directed mobilisation (GDM) on physical functioning in medical inpatients.Design Randomised, controlled, single-centre, parallel, superiority trial with a 3-month follow-up and blinded outcome assessment.Setting General internal medicine wards of a Swiss tertiary acute hospital, September 2021 to April 2023.Participants Adults with expected hospitalisation of ≥5 days, physiotherapy prescription and ability to follow study procedures.Intervention GDM during hospitalisation, which includes personal goal setting and a short session of patient education through a physiotherapist (experimental group), versus standard care (control group).Outcome measures The primary outcome was the change in physical activity between baseline and day 5 (De Morton Mobility Index (DEMMI)). Secondary outcomes included in-hospital accelerometer-measured mobilisation time; in-hospital falls; delirium; length of stay; change in independence in activities of daily living, concerns of falling and quality of life; falls, readmission and mortality within 3 months.Results The study was completed by 123 of 162 (76%) patients enrolled, with the primary outcome collected at day 5 in 126 (78%) participants. DEMMI Score improved by 8.2 (SD 15.1) points in the control group and 9.4 (SD 14.2) in the intervention group, with a mean difference of 0.3 (adjusted for the stratification factors age and initial DEMMI Score, 95% CI −4.1 to 4.8, p=0.88). We did not observe a statistically significant difference in effects of the interventions on any secondary outcome.Conclusions The patient’s physical functioning improved during hospitalisation, but the improvement was similar for GDM and standard of care. Improving physical activity during an acute medical hospitalisation remains challenging. Future interventions should target additional barriers that can be implemented without augmenting resources.Trial registration number NCT04760392.

ObjectivesSex differences occur in atrial fibrillation (AF), including age at first manifestation, pathophysiology, treatment allocation, complication rates and quality of life. However, optimal doses of cardiovascular pharmacotherapy used in women with AF with or without heart failure (HF) are unclear. We investigated sex-specific associations of beta-blocker and renin–angiotensin system (RAS) inhibitor doses with cardiovascular outcomes in patients with AF or AF with concomitant HF.MethodsWe used data from the prospective Basel Atrial Fibrillation and Swiss Atrial Fibrillation cohorts on patients with AF. The outcome was major adverse cardiovascular events (MACEs), including death, myocardial infarction, stroke, systemic embolisation and HF-related hospitalisation. Predictors of interest were spline (primary analysis) or quartiles (secondary analysis) of beta-blocker or RAS inhibitor dose in per cent of the maximum dose (reference), in interaction with sex. Cox models were adjusted for demographics, comorbidities and comedication.ResultsAmong 3961 patients (28% women), MACEs occurred in 1113 (28%) patients over a 5-year median follow-up. Distributions of RAS inhibitor and beta-blocker doses were similar in women and men. Cox models revealed no association between beta-blocker dose or RAS inhibitor dose and MACE. In a subgroup of patients with AF and HF, the lowest hazard of MACE was observed in women prescribed 100% of the RAS inhibitor dose. However, there was no association between RAS dose quartiles and MACE.ConclusionsIn this study of patients with AF, doses of beta-blockers and RAS inhibitors did not differ by sex and were not associated with MACE overall.

Objectives In our study, we aimed to characterise adult childhood cancer survivors (ACCS), assess their health issues, gauge health-related quality of life (HRQOL) and evaluate visit satisfaction.Design Prospective cohort study using data from clinical visits and questionnaires.Setting Interdisciplinary follow-up programme for ACCS based on the long-term follow-up (LTFU) guidelines of the Children’s Oncology Group and overseen by internists in two Swiss hospitals.Participants ACCS attending our LTFU clinics between April 2017 and January 2022 were eligible.Interventions We documented medical history, current health status and assessed HRQOL using Short Form-36 V.2, comparing it with Swiss general population (SGP) norms (T mean=50, SD=10; age stratified). 3 months post visit, a feedback questionnaire was distributed.Main results Among 102 ACCS (mean age: 32 years (range: 18–62 years), 68% women), 43 had no prior follow-up (36 ACCS>28 years, 7 ACCS≤28 years). A notable 94% had health issues, affecting an average of 6.1 (SD=3.3) organ systems. HRQOL was lower in ACCS>28 years than the SGP>28 years (physical: 44.8 (SD=11.65) vs 49.3 (SD=10.29), p=0.016; mental: 44.4 (SD=13.78) vs 50.53 (SD=9.92), p=0.004). Older ACCS (>28 years) reported inferior physical (44.8 vs 50.1 (SD=9.30), p=0.017) and mental HRQOL (44.4 vs 50.3 (SD=7.20), p=0.009) than younger ACCS. The majority of respondents reported high levels of satisfaction with the consultation, exceeding 90%.Conclusion ACCS attending LTFU clinics face diverse health issues impacting multiple organ systems and exhibit lower HRQOL compared with the SGP. Thus, internist-led LTFU clinics are crucial for optimising follow-up care.

Background: Health-related quality of life (QoL) impairment is common after pulmonary embolism (PE). Whether the severity of the initial PE has an impact on QoL is unknown. Objectives: To evaluate the association between severity of PE and QoL over time. Methods: We prospectively assessed PE-specific QoL using the Pulmonary Embolism Quality of Life (lower scores indicate better QoL) questionnaire and generic QoL using the Short Form 36 (higher scores indicate better QoL) questionnaire at baseline and 3 and 12 months in older patients with acute PE. We examined whether QoL differed by PE severity based on hemodynamic status, simplified Pulmonary Embolism Severity Index (sPESI), right ventricular function, and high-sensitivity troponin T in mixed-effects models, adjusting for known QoL predictors after PE. Results: Among 546 patients with PE (median age, 74 years), severe vs nonsevere PE based on the sPESI was associated with a worse PE-specific (adjusted mean Pulmonary Embolism Quality of Life score difference of 6.1 [95% CI, 2.4-9.8] at baseline, 7.6 [95% CI, 4.0-11.3] at 3 months, and 6.7 [95% CI, 2.9-10.4] at 12 months) and physical generic QoL (adjusted mean Short Form 36 Physical Component Summary score difference of -3.8 [95% CI, -5.5 to -2.1] at baseline, -4.8 [95% CI, -6.4 to -3.1] at 3 months, and -4.1 [95% CI, -5.8 to -2.3] at 12 months). Elevated troponin levels were also associated with lower PE-specific QoL at 3 months and lower physical generic QoL at 3 and 12 months. QoL did not differ by hemodynamic status or right ventricular function. Conclusion: Severe PE based on the sPESI was consistently associated with worse PEspecific and physical generic QoL over time as compared to nonsevere PE.

Background: To reduce adverse outcomes of low hospital mobility, we need interventions that are scalable in everyday practice. This study assessed the feasibility and acceptability of the INTOMOB multilevel intervention addressing barriers to hospital mobility without requiring unavailable resources. Methods: The INTOMOB intervention, targeting older patients, healthcare professionals (HCPs) and the hospital environment, was implemented on acute general internal medicine wards of three hospitals (12/2022-03/2023). Feasibility and acceptability of the intervention were assessed and two types of accelerometers compared in a mixed methods study (patient and HCP surveys and interviews). Quantitative data were analyzed descriptively and qualitative data using a deductive approach. Results were integrated through meta-inferences. Results: Of 20 patients (mean age 74.1 years), 90% found the intervention helpful and 82% said the environment intervention (posters) stimulated mobility. The majority of 44 HCPs described the intervention as clear and helpful. There was no major implementation or technical issue. About 60% of patients and HCPs preferred a wrist-worn over an ankle-worn accelerometer. Conclusions: The INTOMOB intervention is feasible and well accepted. Patients' and HCPs' feedback allowed to further improve the intervention that will be tested in a cluster randomized trial and provides useful information for future mobility-fostering interventions.

Introduction Burnout and low job satisfaction are increasing among the General Internal Medicine (GIM) workforce. Whether part-time compared to full-time clinical employment is associated with better wellbeing, job satisfaction and health among hospitalists remains unclear. Materials and methods We conducted an anonymized cross-sectional survey among board-certified general internists (i.e. hospitalists) from GIM departments in 14 Swiss hospitals. Part-time clinical work was defined as employment of <100% as a clinician. The primary outcome was well-being, as measured by the extended Physician Well-Being Index (ePWBI), an ePWBI ≥3 indicating poor wellbeing. Secondary outcomes included depressive symptoms, mental and physical health, and job satisfaction. We compared outcomes in part-time and full time workers using propensity score-adjusted multivariate regression models. Results Of 199 hospitalists invited, 137 (69%) responded to the survey, and 124 were eligible for analysis (57 full-time and 67 part-time clinicians). Full-time clinicians were more likely to have poor wellbeing compared to part-time clinicians (ePWBI ≥3 54% vs. 31%, p = 0.012). Part-time compared to full-time clinical work was associated with a lower risk of poor well-being in adjusted analyses (odds ratio 0.20, 95% confidence interval 0.07–0.59, p = 0.004). Compared to full-time clinicians, there were fewer depressive symptoms (3% vs. 18%, p = 0.006), and mental health was better (mean SF-8 Mental Component Summary score 47.2 vs. 43.2, p = 0.028) in part-time clinicians, without significant differences in physical health and job satisfaction. Conclusions Full-time clinical hospitalists in GIM have a high risk of poor well-being. Part-time compared to full-time clinical work is associated with better well-being and mental health, and fewer depressive symptoms.

Introduction: Pharmacological thromboprophylaxis slightly increases bleeding risk. The only risk assessment model to predict bleeding in medical inpatients, the IMPROVE bleeding risk score, has never been validated using prospectively collected outcome data.Methods: We validated the IMPROVE bleeding risk score in a prospective multicenter cohort of medical inpatients. Primary outcome was in-hospital clinically relevant bleeding (CRB) within 14 days of admission, a secondary outcome was major bleeding (MB). We classified patients according to the score in high or low bleeding risk. We assessed the score's predictive performance by calculating subhazard ratios (sHRs) adjusted for thromboprophylaxis use, positive and negative predictive values (PPV, NPV), and the area under the receiver operating characteristic curves (AUC).Results: Of 1155 patients, 8 % were classified as high bleeding risk. CRB and MB within 14 days occurred in 0.94 % and 0.47 % of low-risk and in 5.6 % and 3.4 % of high-risk patients, respectively. Adjusted for thromboprophylaxis, classification in the high-risk group was associated with an increased risk of 14-day CRB (sHR 4.7, 95 % confidence interval [CI] 1.5-14.5) and MB (sHR 4.9, 95%CI 1.0-23.4). PPV was 5.6 % and 3.4 %, while NPV was 99.1 % and 99.5 % for CRB and MB, respectively. The AUC was 0.68 (95%CI 0.66-0.71) for CRB and 0.73 (95%CI 0.71-0.76) for MB.Conclusion: The IMPROVE bleeding risk score showed moderate to good discriminatory power to predict bleeding in medical inpatients. The score may help identify patients at high risk of in-hospital bleeding, in whom careful assessment of the risk-benefit ratio of pharmacological thromboprophylaxis is warranted.

Background:Thromboprophylaxis (TPX) prescription is recommended in medical inpatients categorized as high risk of venous thromboembolism (VTE) by validated risk assessment models (RAMs), but how various RAMs differ in categorizing patients in risk groups, and whether the choice of RAM influences estimates of appropriate TPX use is unknown.Objectives:To determine the proportion of medical inpatients categorized as high or low risk according to validated RAMs, and to investigate the appropriateness of TPX prescription.Methods:This is a prospective cohort study of acutely ill medical inpatients from 3 Swiss university hospitals. Participants were categorized as high or low risk of VTE by validated RAMs (ie, the Padua, the International Medical Prevention Registry on Venous Thromboembolism, simplified, and original Geneva scores). We assessed prescription of any TPX at baseline. We considered TPX prescription in high-risk and no TPX prescription in low-risk patients as appropriate.Results:Among 1352 medical inpatients, the proportion categorized as high risk ranged from 29.8% with the International Medical Prevention Registry on Venous Thromboembolism score to 66.1% with the original Geneva score. Overall, 24.6% were consistently categorized as high risk, and 26.3% as low risk by all 4 RAMs. Depending on the RAM used, TPX prescription was appropriate in 58.7% to 63.3% of high-risk (ie, 36.7%-41.3% underuse) and 52.4% to 62.8% of low-risk patients (ie, 37.2%-47.6% overuse).Conclusion:The proportion of medical inpatients considered as high or low VTE risk varied widely according to different RAMs. Only half of patients were consistently categorized in the same risk group by all RAMs. While TPX remains underused in high-risk patients, overuse in low-risk patients is even more pronounced.