That patient, anonymized as “Michelle” in a new perspective article published in the Journal of General Internal Medicine, became a test case for a bold institutional experiment. A team led by hospitalist physicians at the University of California, San Francisco, launched a program embedding a community health worker, a trained health professional drawn from the community she serves, directly into the medicine wards. The worker, anonymized as “Alicia,” was a Black community health worker with experience in health care navigation, hired specifically to help Black patients navigate their hospitalizations, self-advocate, and communicate with clinicians. Over a single year, from November 2022 to October 2023, she supported 162 Black patients on the medicine wards, with the goal of improving patient experience, communication, and quality of care.

The rationale for the program rests on a substantial body of evidence documenting how anti-Black racism operates at both interpersonal and structural levels within US health care. Interpersonal racism, discriminatory interactions between individuals based on race-related assumptions, damages trust and impedes communication. Studies have shown that physicians engage in less patient-centered communication and display more negative affect with Black patients than with others. Two particularly well-documented manifestations involve pain: false beliefs that Black patients have higher pain tolerance and are more likely to be opioid-seeking. The consequences are measurable. Black patients are less likely to receive primary care pain screenings or opioid analgesics in emergency departments, even when presenting with the same conditions as non-Black patients. They are also less likely to receive physical therapy or surgery for pain management.

Structural racism extends far beyond individual encounters. Black people in the United States are systematically disadvantaged by inequities in health care, housing, education, and the criminal justice system, rooted in historic injustices that persist today. Even Black patients with high socioeconomic status and education face persistent barriers to care and health disparities. These structural forces produce earlier multimorbidity and mortality and a greater chronic disease burden. The authors note that Michelle’s difficulty refilling her pain medications reflects wider trends: Black patients on opioid analgesics are more likely to face restricted early refills, urine testing requirements, and lowered dosages, despite pain medication misuse being least common among Black patients.

These structural harms produce predictable downstream effects on trust and communication. Patients who have previously experienced racism in health care settings remain on higher alert for future racist encounters and may reasonably ascribe new challenges to racism regardless of their immediate cause. Michelle’s history of mistreatment, including wrongful diagnoses and an overdose from overprescribed medication, led her to view health care institutions as untrustworthy, which in turn complicated every interaction with her care team. The authors argue that while clinician compassion matters, the positive intentions of individuals are insufficient to overcome structural injustices. Institutions need interventions that operate at the level of the system itself.

For Michelle, the Health Advocate’s role was concrete and practical. Alicia attended care team meetings, listened, took notes, asked questions, and added context about Michelle’s preferences and goals. She validated Michelle’s frustrations, helped synthesize complex medical information, and brainstormed questions to ask physicians. She also helped manage expectations, reminding Michelle that surgery might not be possible and counseling her to stay focused on her core goals of increased mobility and pain control. Crucially, Alicia met with Michelle’s physicians separately, helping them understand Michelle’s perspective and relaying her concern about being perceived as non-compliant if she declined a proposed analgesic regimen she feared she could not refill. Michelle found the support so valuable that she requested no physician speak to her without Alicia present.

The program’s design drew on established models of cultural mediation and community-based advocacy, which have succeeded in reducing barriers to quality care for minoritized ethnic populations. Physician leadership recruited a Community Advisory Board of Black community members with patient or caregiving experience, which met monthly with Alicia and program leadership to advise on patient needs. The program used a patient-centered, participatory approach in which community members were active collaborators co-creating goals and outcomes, and early cases were discussed with leadership through a preceptorship model. Demand quickly exceeded capacity: patients expressed widespread appreciation, readmitted patients sought Alicia out immediately, and clinicians requested her support for additional patients, forcing her to prioritize the most urgent cases.

The evidence base for community health workers more broadly is encouraging. Because they share identities with the populations they serve, they are uniquely positioned to advocate for patients historically marginalized in health care. Randomized trials have shown that community health worker support improves patient-reported quality of care, satisfaction, and mental health, while benefiting health systems through reduced hospitalizations and shorter lengths of stay. By increasing trust, strengthening communication, promoting care access, and improving outcomes, the authors argue, these workers can address the downstream effects of structural racism that no individual clinician can dismantle alone.

Yet the program’s challenges were as instructive as its successes. There were no clear guidelines for integrating the role into the hospital, and although the Centers for Medicare and Medicaid Services and California’s CalAIM initiative have since published guidance, discrepancies remain and uncertainty persists about how best to incorporate community health workers. The team faced coordination difficulties with care teams, concerns that the role was redundant, and the absence of a clear department to house it. Sustainable financing proved equally difficult: a year-long internal grant protected faculty time and the health system funded the salary, but securing longer-term support was hard, even though the services were billable under Medicare, Medi-Cal, and commercial insurance.

The deepest challenges reflect the complexity of racism itself. The authors observed that attempts to minimize structural racism can inadvertently worsen interpersonal racism, for example if clinicians wrongly infer that community health workers are needed because Black patients are difficult to communicate with, or redirect racist comments toward the workers themselves. Community health workers, who share marginalized identities with their patients, are vulnerable to the same harms, along with moral distress and burnout. The team protected Alicia by rapidly involving leadership in difficult cases and escalating as needed, and they recommend hiring cohorts of workers within their own departments to build peer support, alongside clinician education and anti-racism training. They also flag a final concern: patients could become dependent on workers to speak for them, which the program countered by focusing on self-efficacy and empowering patients to advocate for themselves. If fully embraced and supported, the authors conclude, community health workers can help health systems deliver high-quality, anti-racist care to patients like Michelle, who have for too long been harmed by the very institutions meant to heal them.

Subject of Research: Community health worker integration to address structural racism and care inequities among hospitalized Black patients

Article Title: The Promise of Community Health Workers for Addressing Structural Drivers of Inequities Among Hospitalized Patients

Article References: Axelrod, J. K., Weiss Goitiandia, S., Brooks-Smith-Lowe, S., Sankaran, S., Shahram, Y., Oreper, S., Arrington, R., Burt, H., Garrison, X., Jr., Jones-Taplin, J., Loggins-Miller, I., John, M., & Dzeng, E. (2026). The Promise of Community Health Workers for Addressing Structural Drivers of Inequities Among Hospitalized Patients. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10872-y

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10872-y

Keywords: community health workers, structural racism, health disparities, hospital medicine, patient advocacy, health communication, pain management, health equity, patient trust, hospitalization, anti-racism, health care financing

The research, published in the Journal of Eating Disorders, was led by Quang Le and Majd Al-Ahmad of the University of Missouri together with colleagues at several other United States medical centers. The team performed what epidemiologists call a serial cross-sectional analysis, drawing on the National Inpatient Sample for the years 2016 through 2022. That database, maintained as part of the Healthcare Cost and Utilization Project, is the largest publicly available all-payer inpatient database in the United States, capturing a representative sample of hospital discharges that can be statistically weighted to estimate national totals. Because it records every diagnosis coded during each hospital stay, it allows researchers to ask which co-occurring conditions travel with fatal outcomes.

To build their cohort, the investigators identified every adult admission carrying an any-listed diagnosis of anorexia nervosa, using the ICD-10-CM code family F50.0x. Any-listed means the diagnosis appears anywhere in the record, not just as the reason for admission, which matters because many of these patients enter the hospital for medical crises rather than eating-disorder treatment. After survey weighting, the sample represented roughly 61,000 hospital admissions nationwide over the seven-year window. Within that population, 148 patients died before discharge, an in-hospital mortality rate of 1.21 percent. That figure may sound modest, but it is striking for a psychiatric diagnosis in a general hospital population, and it represents only deaths during the indexed admission, not the longer-term mortality that makes anorexia nervosa so feared.

The analytical engine of the study was survey-weighted logistic regression, a technique that accounts for the complex sampling design of the National Inpatient Sample while estimating how strongly each complication is associated with death. The models adjusted for age, sex, and the Charlson comorbidity index, a validated score that summarizes a patient’s burden of chronic illness. Because the researchers were testing many potential risk factors simultaneously, they applied Holm correction, a sequential method that tightens the threshold for statistical significance and guards against false positives when multiple comparisons are made. This detail matters: several associations that looked compelling in a primary model faded once every complication was modeled together, a pattern that honest analysis must surface rather than hide.

The results upend conventional assumptions. Severe malnutrition carried an adjusted odds ratio of 3.32, meaning patients with that diagnosis had more than three times the odds of dying compared with similar patients without it. Hypoglycemia was even more potent, with an adjusted odds ratio of 3.65. Heart failure showed an association in the primary model, with an odds ratio of 2.09, but this attenuated to 2.01 when all complications were modeled together, and the Holm-adjusted p-value of 0.07 fell just short of conventional significance. In other words, the heart’s pumping failure may matter, but the signal is far weaker than the metabolic collapse of starvation itself.

Most provocative of all, the rhythm abnormalities that dominate bedside vigilance showed no association with death at all. Bradyarrhythmia, the pathologically slow heart rate that clinicians watch so closely, had an adjusted odds ratio of 0.82, with a confidence interval spanning well below and above unity. Tachycardia fared no better, at 0.62. Coronary artery disease, another plausible cardiac culprit, was likewise unassociated, at 1.14. The authors are careful about what this does and does not mean. A slow heart rate may look harmless in administrative data precisely because it triggers closer monitoring and intervention, a form of detection bias that observational datasets cannot fully untangle. The finding is not an argument for reducing cardiac monitoring, but it is a strong argument that heart rate alone is a poor proxy for who will die.

One of the starkest findings concerned sex. Women make up the overwhelming majority of anorexia nervosa cases, yet men in the cohort died at roughly twice the rate. After adjustment, female sex carried an odds ratio of 0.42, meaning men had about two and a half times the odds of in-hospital death. The authors note that men did not appear more medically unwell on admission, which makes the disparity harder to explain. Possible contributors include delayed recognition of eating disorders in men, longer time to treatment, and differences in body composition that allow less physiological reserve before starvation becomes lethal. Whatever the mechanism, the signal suggests that clinicians should resist the stereotype that anorexia nervosa is a disease of young women whose presentation is always recognized early.

When the researchers examined what actually killed these patients, the picture sharpened further. Cause of death was approximated by the principal diagnosis and its Major Diagnostic Category, a coarse but informative classification. Among fatal admissions, infection and sepsis led the list, accounting for 27.0 percent of deaths. Most people who died had been admitted for a serious acute medical illness rather than for treatment of the eating disorder itself. This reframes the clinical problem: the hospitalized anorexia nervosa patient in danger is often not the one with a dramatic cardiac rhythm on the monitor, but the one whose starved immune system is quietly losing a battle with pneumonia, a urinary infection, or an occult source of sepsis. Malnutrition impairs cell-mediated immunity, gut barrier integrity, and the febrile response, all of which can mask infection until it is advanced.

The study took care to address a potential confounder of the era: COVID-19. Because the study window overlapped the pandemic, the investigators repeated their analysis after excluding admissions coded for COVID-19, which made up only 1.1 percent of the cohort. The estimates were essentially unchanged, indicating that pandemic-era coding did not distort the central findings. The authors also disclosed that generative artificial intelligence tools were used for language editing and to cross-check diagnosis codes, with the authors verifying all content, and the study was exempt from institutional review board review because it analyzed de-identified, publicly available administrative records.

The practical message for hospital teams is a reordering of priorities. Inpatient vigilance, the authors conclude, should center on the severity of malnutrition, glycemic control, and infectious risk, with comorbidity weighted heavily, rather than on heart rate in either direction. That does not diminish the importance of cardiac monitoring, which remains standard for severely malnourished patients at risk of prolongation of the QT interval and sudden arrhythmic death, outcomes that administrative data may simply fail to capture. But it does suggest that the most actionable warnings of impending death in these patients are metabolic and infectious, not electrical. For a disorder whose mortality has stubbornly resisted decades of clinical attention, a finding this counterintuitive, drawn from tens of thousands of real hospitalizations, deserves to change what clinicians watch first when a starving patient arrives on the ward.

Subject of Research: Acute cardiac and metabolic complications associated with in-hospital mortality in adults hospitalized with anorexia nervosa in the United States

Article Title: Acute cardiac complications and in-hospital mortality in adults hospitalized with anorexia nervosa: a national analysis, 2016–2022

Article References: Le, Q., Al-Ahmad, M., Dangol, G., Maharjan, S., Ahmad, Z., & Bhandari, A. (2026). Acute cardiac complications and in-hospital mortality in adults hospitalized with anorexia nervosa: a national analysis, 2016–2022. Journal of Eating Disorders. https://doi.org/10.1186/s40337-026-01766-9

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01766-9

Keywords: anorexia nervosa, in-hospital mortality, cardiac complications, malnutrition, hypoglycemia, sepsis, bradyarrhythmia, National Inpatient Sample, eating disorders, heart failure, sex differences, hospital medicine

The scale of the question is enormous. Between 50 and 72 percent of hospitalized patients carry a hypertension diagnosis, and roughly three-quarters experience at least one elevated blood pressure reading during their stay. Acute, symptomatic spikes that cause end-organ damage, known as hypertensive emergencies, demand rapid, high-intensity treatment. But for readings that fall well short of emergency territory and produce no symptoms, the evidence for intervening is remarkably thin, and what observational data exist point in a troubling direction: intensifying antihypertensive medications in the hospital may actually harm patients.

Those signals of harm are not subtle. In a propensity-matched cohort study, hospitalized patients who received antihypertensive medication on an as-needed basis had 24 percent higher odds of acute kidney injury, more than eight times the odds of ischemic stroke, and more than triple the odds of inpatient mortality. Intravenous antihypertensives, in particular, have been linked to prolonged hospital stays, while even oral intensification has been associated with kidney and myocardial injury. Worse, treating elevated blood pressure in the hospital does not appear to improve long-term blood pressure control and may raise the risk of adverse outcomes in the 30 days after discharge.

Recognizing this uncertainty, the American Heart Association issued a Scientific Statement in May 2024 concluding that the risk-benefit ratio of prescribing antihypertensives for asymptomatic elevated inpatient readings is unclear. Blood pressure can rise transiently because of pain, nausea, temperature, or stress, and in those cases the underlying cause, not the number on the monitor, is the appropriate target. But at some threshold, presumably, treatment becomes worthwhile. Where that threshold lies has never been established, which is precisely why a team led by Elizabeth R. Pfoh of the Cleveland Clinic set out to map what physicians actually think.

Between February and October 2024, the researchers emailed anonymous surveys to hospitalists at five academic medical centers: the Cleveland Clinic, Johns Hopkins School of Medicine, the University of Utah School of Medicine, the University of Nebraska Medical Center, and the University of Wisconsin-Madison. They defined elevated blood pressure as readings between 140/90 and 210/120 mmHg without symptoms of hypertensive emergency, deliberately excluding crises from the picture. Of 397 potential respondents, 166 physicians replied, an overall response rate of 42 percent that ranged from 24 to 64 percent across sites. Because the survey straddled the release of the AHA statement, the team also ran a sensitivity analysis comparing sites surveyed before and after May 2024.

The headline finding was a near-even split of professional opinion. When asked whether it is important to treat patients with an elevated blood pressure, 27 percent of hospitalists agreed while 47 percent disagreed, and the remaining quarter were neutral. On average, respondents leaned neutral overall, with a mean score of 3.3 on a five-point scale, but that average concealed a polarized profession: 8 percent strongly agreed treatment was warranted, 19 percent agreed, 30 percent disagreed, and 17 percent strongly disagreed. These attitudes were remarkably consistent across all five institutions, suggesting the divide is not a local quirk but a national pattern.

When it came to numbers, physicians converged loosely around a threshold but disagreed on the details. The median systolic trigger for intensifying medication was 170 to 179 mmHg, yet 38 percent of physicians said they would intensify below 169 mmHg, while 24 percent would hold off until readings reached at least 180 to 189 mmHg. Patience, however, was nearly universal: 79 percent of physicians would wait at least 12 hours before acting on an elevated reading. Patient characteristics mattered even more than the raw numbers. Physicians reported being more likely to treat patients with a history of heart failure (73 percent), stroke (73 percent), myocardial infarction (64 percent), or coronary disease (57 percent), and markedly less likely to treat patients whose elevated readings plausibly stemmed from withdrawal symptoms (81 percent less likely), pain (79 percent), fall risk (77 percent), substance use (61 percent), or nausea (53 percent).

Perhaps the most provocative finding concerned who, in practice, drives treatment. Sixty percent of physicians agreed that treatment is driven by nurses calling physicians, and an overwhelming 89 percent agreed they would prefer not to be contacted by a nurse about an asymptomatic systolic reading below 170 mmHg. Physicians who were least inclined to treat agreed most strongly that nursing calls were pushing them to prescribe, and they expressed the strongest preference for silence below both 170 and even 200 mmHg. The free-text responses laid bare the mechanism: repeated nursing calls create pressure to do something, and for many physicians, the perceived risk of prescribing feels smaller than the discomfort of ignoring an alarm. The AHA’s own framework, which urges hospitals to modify the culture of unnecessary treatment cascades, including default nurse-notification orders, appears aimed squarely at this dynamic.

Qualitative analysis of 133 open-ended responses revealed three broad rationales. Some physicians rejected routine treatment outright, with comments such as increasing medications without symptoms or clear indications puts the patient at higher risk for damage than benefit. Others would treat only when readings remained persistently elevated, for example beyond 24 hours, without another explanation. A third group would act only at very high values, though what counted as very high ranged from above 170 to over 200 mmHg. Underlying it all were two cross-cutting concerns: patient-specific conditions such as heart failure, and process worries such as poor outpatient follow-up after discharge. Meanwhile, only about a quarter of physicians felt there was clear guidance on when to prescribe, and 79 percent strongly disagreed that intravenous medication should ever be used for asymptomatic elevations, a view that hardened further among sites surveyed after the AHA statement.

The survey’s limitations are worth noting. It captured only academic medical centers in five states, response rates were moderate, and anonymity precluded comparisons between responders and non-responders, raising the possibility that physicians with strong opinions were more likely to reply. It is also possible that respondents imagined intensification as a permanent regimen change rather than a single dose, which could have shaped their answers. Still, the picture that emerges is of a profession practicing without a map. A 2024 systematic review found no guidelines at all for asymptomatic elevated inpatient blood pressure, only ten for hypertensive urgencies and eleven for emergencies. Compared with a 2010 survey in which 80 percent of residents called inpatient blood pressure control a high priority, the finding that just 27 percent of today’s hospitalists agree treatment is important suggests opinion has shifted as evidence of harm has accumulated. The authors conclude that randomized trial evidence is urgently needed to inform evidence-based guidelines, which in turn could reduce the wide practice variation that currently governs one of the most common decisions in hospital medicine. Until then, the most defensible approach, the researchers suggest, is the one the evidence already supports: treat the pain, the nausea, the stress, and the underlying illness, and let a truly asymptomatic number wait.

Subject of Research: Hospitalist attitudes toward treating asymptomatic elevated blood pressure readings in hospitalized patients

Article Title: Physicians’ Beliefs About Treating Asymptomatic Elevated Blood Pressure Readings Among Hospitalized Patients

Article References: Pfoh, E. R., Harris, C. M., Singh, M., Pappas, M. A., Ellenbogen, M. I., Shiffermiller, J., Kaiksow, F. A. A., Vaughn, V. M., & Rothberg, M. B. (2026). Physicians’ Beliefs About Treating Asymptomatic Elevated Blood Pressure Readings Among Hospitalized Patients. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10708-9

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10708-9

Keywords: hypertension, hospitalized patients, hospital medicine, antihypertensive medication, blood pressure, American Heart Association, inpatient care, physician survey, overtreatment, clinical guidelines, nursing calls, patient safety