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Background Recent guidelines include aspirin as an option to prevent venous thromboembolism (VTE) in selected patients undergoing hip or knee replacement surgery. However, the efficacy of aspirin after arthroplasty has not been well-defined, particularly in more contemporary patient populations. We compared rates of post-operative VTE between patients who received aspirin-only versus anticoagulants after hip or knee arthroplasty, using data from a large US-based administrative database. Materials and methods We conducted a retrospective cohort study of 231,780 adults who underwent total knee arthroplasty and 110,621 who underwent total hip arthroplasty in 2009–2012 and who received pharmacologic VTE prophylaxis (aspirin or anticoagulant) within the first 7 days after surgery. We compared the risk of post-operative VTE between patients receiving aspirin-only vs. anticoagulants, controlling for clinical and hospital characteristics using multivariable logistic regression with propensity score adjustment. Results Aspirin-only prophylaxis was administered to 7.5% of patients after knee arthroplasty and 8.0% after hip arthroplasty. Post-operative VTE was diagnosed in 2217 (0.96%) patients after knee arthroplasty and 454 (0.41%) after hip arthroplasty. Compared to anticoagulants, aspirin was not associated with a higher risk for post-operative VTE either after knee arthroplasty (adjusted odds ratio and 95% confidence interval [OR] 0.34 [0.24–0.48]) or hip arthroplasty (OR 0.82 [0.45–1.51]). Conclusions Aspirin was uncommonly administered as the sole prophylactic agent after hip or knee arthroplasty in this study. However, patients who received aspirin-only had similar rates of post-operative VTE compared to patients who received anticoagulants. Further research should focus on distinguishing which patients benefit more from anticoagulants versus aspirin after arthroplasty.

Our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide and to examine regional differences and factors associated with the mode of transport to the emergency department (ED).Patients with a primary discharge diagnosis of stroke based on previously validated International Classification of Disease, 9th revision codes were abstracted from the National Hospital Ambulatory Medical Care Survey for the years 2007 to 2009. We excluded subjects18 years of age and those with missing data. Using logistic regression, we identified independent predictors of arrival by ambulance to the ED.Overall, 566 patients met the entry criteria, representing 2,153,234 patient records nationally, based on 2010 US census data. Of these, 50.4% arrived by ambulance. After adjustment for potential confounders, age was associated with use of an ambulance. In addition, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (South: odds ratio [OR] 0.45 and 95% confidence interval [CI] 0.26-0.76; West: OR 0.45 and 95% CI 0.25-0.84; Midwest: OR 0.56 and 95% CI 0.31-1.01). Compared to the Medicare population, privately insured and self-insured patients had lower odds of arriving by ambulance (OR for private insurance 0.48 and 95% CI 0.28-0.84; OR for self-payers 0.36 and 95% CI 0.14-0.93). Gender, race, urban or rural location of ED, and safety net status was not independently associated with ambulance use.Patients with stroke arrive by ambulance more frequently in the Northeast than in other regions of the United States. Identifying reasons for this difference may be useful in improving stroke care.

Background Improving communication between caregivers is an important approach to improving safety. Objective To implement teamwork and communication interventions and evaluate their impact on patient outcomes. Design A prospective, interrupted time series of a three-phase intervention: a run-in period (phase 1), during which a training programme was given to providers and staff on each unit; phase 2, which focused on unit-based safety teams to identify and address care problems using skills from phase 1; and phase 3, which focused on engaging patients in communication efforts. Setting General medical inpatient units at three northern California hospitals. Patients Administrative data were collected from all adults admitted to the target units, and a convenience sample of patients interviewed during and after hospitalisation. Measurements Readmission, length of stay and patient reports of teamwork, problems with care, and overall satisfaction. Results 10 977 patients were admitted; 581 patients (5.3% of total sample) were interviewed in hospital, and 313 (2.9% overall, 53.8% of interviewed patients) completed 1-month surveys. No phase of the study was associated with adjusted differences in readmission or length of stay. The phase 2 intervention appeared to be associated with improvement in reports of whether physicians treated them with respect, whether nurses treated them with respect or understood their needs (p

Background: Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness. Objective: To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults. Methods: A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level. Results: There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29–45%] vs. 31% [95% CI 23–39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43–61%] vs. 48% [95% CI 39–57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7–33%] vs. 50% [95% CI 32–68%], respectively; p = 0.01). Conclusions: Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness.

Background: The relationship between surgeon and hospital procedure volumes and clinical outcomes in total joint arthroplasty has long fueled a debate over regionalization of care. At the same time, numerous policy initiatives are focusing on improving quality by incentivizing surgeons to adhere to evidence-based processes of care. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardization of care on short-term postoperative outcomes and resource utilization in lower-extremity total joint arthroplasty. Methods: An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta-blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first thirty days after discharge. Hierarchical models were used to estimate the effects of hospital and surgeon procedure volume and process standardization on individual and combined surgical outcomes and length of stay. Results: After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of hospital stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality, lower risk of readmission, and higher likelihood of being discharged home. The impact of process standardization was substantial; maximizing adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume. Conclusions: Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardization is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established; however, our findings suggest that process standardization could help providers optimize quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Provision of asthma education is associated with decreased hospitalizations and emergency department visits for patients with asthma. Our objective was to describe national trends in the provision of asthma education by primary care physicians in office settings.We used the National Ambulatory Medical Care Survey, a nationally representative dataset of patient visits to office-based physicians. We identified visits to primary care physicians for patients where asthma was a reason for the visit (asthma-related visits) or who had a diagnosis of asthma, but asthma was not a specific reason for the visit (asthma-unrelated visits) and estimated the percentage of visits where asthma education was provided. Data were available for asthma-related visits from 2001-2006 and from 2005-2006 only for asthma-unrelated visits. We examined time trends in asthma education and used multivariable logistic regression to identify independent patient and system-related factors that were predictors of asthma education.The percentage of asthma-related visits where asthma education was provided declined during the study period, from 50% in 2001-2002 to 38% in 2005-2006 (p = 0.03). Asthma education was provided less frequently during asthma-unrelated visits compared to asthma-related visits (12% vs. 38%, p0.0001). Independent predictors of providing asthma education included ageor = 18 years, receipt of a controller medication, incorporation of an allied health professional during the visit, longer visit duration and Northeast region.Asthma education is underused by primary care physicians and rates have declined from 2001-2006. Interventions designed to promote awareness and greater use of asthma education are needed.

Objectives: Health care providers cite patient satisfaction as a common reason for prescribing antibiotics for viral acute upper respiratory infections (URIs), even though quality performance measures emphasize nonantibiotic treatment for these conditions. In a secondary analysis of a cluster-randomized trial to test a combined patient and physician educational intervention to reduce antibiotic prescribing for URIs, the authors examined whether satisfaction is greater among patients diagnosed with URIs who are prescribed antibiotics in emergency department (ED) settings. Methods: This was a follow-up telephone survey of 959 patients who received care for acute respiratory infections at any of eight Veterans Administration (VA) hospital EDs or eight location-matched non-VA hospital EDs around the United States. Patients reported their satisfaction with the amount of time spent in the ED, the explanation of treatment, the provider treatment, and overall satisfaction on a five-point Likert scale. The primary measure of effect was the association between antibiotic prescription and visit satisfaction, adjusted for patient and visit characteristics. Results: Antibiotic treatment was significantly associated with increased overall visit satisfaction in non-VA EDs (adjusted odds ratio [OR] = 1.97, 95% confidence interval [CI] = 1.23 to 3.17), but not VA EDs (adjusted OR = 1.13, 95% CI = 0.81 to 1.58). Patients managed in non-VA EDs who received antibiotics were also significantly more likely to be satisfied with the explanation of treatment and the manner in which they were treated by the provider. Conclusions: Antibiotic prescriptions are associated with increased overall patient satisfaction in non-VA, but not VA, ED visits for URIs. Continued efforts to reduce unnecessary prescriptions in these settings must address ways to maintain patient satisfaction and still reduce antibiotic prescriptions.

Emergency departments (EDs) provide a disproportionate amount of care to disenfranchised and vulnerable populations. We examined social support levels among a diverse population of adults seeking ED care for acute respiratory tract infections. A convenience sample of adults seeking care in 1 of 15 US EDs was telephone interviewed 1 to 6 weeks postvisit. The Multidimensional Scale of Perceived Social Support (7-point Likert) assessed social support across 3 domains: friends, family, and significant others. Higher scores indicate higher support. Of 1104 subjects enrolled, 704 (64%) completed the follow-up interview. Factor analysis yielded 3 factors. Mean social support score was 5.54 (SD 1.04). Female sex, greater household income, and better health status were independently associated with higher levels of social support. Social support levels among adults seeking care in the ED for acute respiratory tract infections are similar to general population cohorts, suggesting that social support is not a strong determinant of health care seeking in EDs.

Study objective We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections. Methods Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics. Results The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval −3% to 5%) and at intervention sites decreased by 10% (95% confidence interval −18% to −2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction. Conclusion Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.

Background and aimsEmergency Departments (ED) can serve as a gateway to specialty care for patients with cirrhosis with limited care access. We described the rates and characteristics of patients with cirrhosis who access United States (US) EDs, and identified factors associated with subsequent hospitalization.MethodsUsing data from the National Hospital Ambulatory Medical Care Survey, cirrhosis-related ED from 2000 to 2009 were identified and compared to all other ED visits.ResultsFrom 2000 to 2009, there were an estimated 1,029,693 cirrhosis and 877 million non-cirrhosis visits. Compared to the general ED population, those with cirrhosis were more frequently male (58 vs. 44 %, p = 0.02), Hispanic (18.6 vs. 10.6 %, p < 0.05), seeking care in urban areas (91.6 vs. 73.4 %, p < 0.05) and had Medicaid/no insurance (43 vs. 35 %, p < 0.01). Patients with cirrhosis were more frequently triaged immediately or emergently (72.3 vs. 54.2 %, p < 0.01). The majority were admitted or transferred to another hospital (66.8 vs. 17.4 %, p < 0.01). Among patients with cirrhosis, patients with age ≥ 65 years were more likely to be admitted (adjusted OR 2.49, 95 % CI 1.08-5.73), and Medicaid/uninsured (adjusted OR 0.34; 95 % CI 0.17-0.67) were less likely to be admitted, after adjusting for patient demographics, hospital characteristics, and triage score.ConclusionsPatient with cirrhosis account for approximately 100,000 US ED visits annually. The higher admission rates among patients with cirrhosis indicate a high acuity of illness. Older age among those admitted may reflect poorer functional status. Finally, high visit but low admission rates among those with Medicaid/no insurance suggest a gap in specialty care.

Study objective The accurate diagnosis of influenza remains a diagnostic dilemma. We examine the performance of various strategies for diagnosing influenza infection in an unselected sample of adults during influenza season. Methods Consecutive adults presenting to a university emergency department or urgent care clinic between January and March 2002 with acute respiratory complaints were eligible for this prospective observational study. The performance of clinician judgment, a rapid influenza test, and a clinical prediction rule in predicting influenza infection was evaluated using referent standard of reverse transcriptase polymerase chain reaction. Statistical significance was assessed using McNemar's test of proportions. Results Fifty-three of 258 (21%) patients had a positive influenza reverse transcriptase polymerase chain reaction test. Overall, clinician judgment showed sensitivity of 29% (95% confidence interval [CI] 18% to 43%) and specificity of 92% (95% CI 87% to 95%). The rapid influenza test showed a sensitivity of 33% (95% CI 22% to 47%) and specificity of 98% (95% CI 96% to 99%). The clinical prediction rule showed a sensitivity of 40% (95% CI 27% to 54%) and specificity of 92% (95% CI 87% to 95%). Clinician judgment when patients presented within 48 hours showed a sensitivity of 67% (95% CI 39% to 86%) and specificity of 96% (95% CI 81% to 99%). Neither the rapid influenza test (P=.10) nor the clinical prediction rule (P=.42) was superior to clinician judgment alone in the diagnosis of influenza. Conclusion The suggestion that a clinical decision rule or a rapid influenza test is better than clinical judgment alone for the diagnosis of influenza in an unselected patient population is not supported by this study.

Background: Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed. Methods: We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure. Results: The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51). Conclusion: Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure. LEVEL OF EVIDENCE: Prognostic and epidemiologic, level III. © 2014 2014 Lippincott Williams & Wilkins.

Reducing hospital readmissions is a national healthcare priority. Little is known about how readmission rates vary across unique primary care practices.To calculate all-cause 30-day hospital readmission rates at the level of individual primary care practices and identify factors associated with variations in these rates.Retrospective analysisSeven primary care clinics affiliated with the University of California, San Francisco (UCSF).Adults ≥18 years old with a primary care provider (PCP) at UCSF MEASUREMENTS: All-cause 30-day readmission rates were calculated for primary care clinics for discharges between July 1, 2009 and June 30, 2012. We built a model to identify demographic, clinical, and hospital factors associated with variation in rates.There were 12,564 discharges for patients belonging to the 7 clinics, with 8685 index discharges and 1032 readmissions. Readmission rates varied across practices, from 14.9% in Human Immunodeficiency Virus primary care and 7.7% in women's health. In multivariable analyses, factors associated with variation in readmission rates included: male gender (odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.05-1.40), Medicare insurance (OR: 1.31, 95% CI: 1.05, 1.64; Ref = private), Medicare-Medicaid dual eligible (OR: 1.26, 95% CI: 1.01-1.56), multiple comorbidities, and admitting services. Patients with a departed PCP awaiting transfer assignment to a new PCP had an OR of 1.59 (95% CI: 1.16-2.17) compared with having a current faculty PCP.Primary care practices are important partners in improving care transitions and reducing hospital readmissions, and this study introduces a new way to view readmission rates. PCP turnover may be an important risk factor for hospital readmissions.

ImportanceSingle-site studies have described an association between use of selective serotonin reuptake inhibitors (SSRIs) and adverse outcomes of surgery. Multicenter studies including a broad range of surgical procedures that explore rare outcomes, such as bleeding and mortality, and that account for indications for administration of SSRIs are needed.ObjectiveTo determine whether perioperative use of SSRIs is associated with adverse outcomes of surgery in a national sample of patients.DesignRetrospective study of patients 18 years or older who underwent major surgery from January 1, 2006, through December 31, 2008, at 375 US hospitals. We used multivariable hierarchical models to estimate associations between SSRI use and our outcomes. Pharmacy data were used to determine whether a patient received an SSRI in the perioperative period.SettingThree hundred seventy-five US hospitals.ParticipantsFive hundred thirty thousand four hundred sixteen patients 18 years or older.ExposurePerioperative use of SSRIs.Main outcomes and measuresIn-hospital mortality, length of stay, readmission at 30 days, bleeding events, transfusions, and incidence of ventricular arrhythmias.ResultsPatients receiving SSRIs were more likely to have obesity, chronic pulmonary disease, or hypothyroidism (P < .001 for each) and more likely to have depression (41.0% vs 6.2%, P < .001). After adjustment, patients receiving SSRIs had higher odds of in-hospital mortality (adjusted odds ratio, 1.20 [95% CI, 1.07-1.36]), bleeding (1.09 [1.04-1.15]), and readmission at 30 days (1.22 [1.18-1.26]). Similar results were observed in propensity-matched analyses, although the risk of inpatient mortality was attenuated among patients with depression. Sensitivity analyses suggest that, to invalidate our results, an unmeasured covariate would have to have higher prevalence and be more strongly associated with mortality than any covariate included in our models.Conclusions and relevanceReceiving SSRIs in the perioperative period is associated with a higher risk for adverse events. Determining whether patient factors or SSRIs themselves are responsible for elevated risks requires prospective study.

The burden of caring for critically ill patients in the United States is massive, currently accounting for nearly 1% of the gross domestic product and affecting large sectors of the U.S. healthcare system including the emergency department (ED) (1–3). The majority of critical care in the United States are provided to patients over the age of 65, and this population is predicted to grow by 50% from 2000 to 2020 (4, 5). The rising demand for critical care in the face of already insufficient capacity has become an area of concern for clinicians, hospital administrators, and policymakers (6–9). In 2000, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine Committee on Manpower for Pulmonary and Critical Care Societies forecast large shortfalls in the critical care workforce. A 2006 Health Resources and Services Administration report to Congress not only confirmed the predicted shortages, but also projected worsening shortages into the future (4). There currently exist little data on how system-wide increases in the demand for critical care are affecting U.S. EDs. Most patients, critically ill patients in the United States are admitted from an ED (10). These patients typically require medically complex and resource intensive care often begins outside the ICU in the ED (2, 3, 10, 11). The provision of critical care in the ED is a potentially important factor in ED crowding. The Institute of Medicine report “Hospital-Based Emergency Care: At The Breaking Point” identified that the inability to promptly admit critically ill ED patients to inpatient beds can lead to boarding and contributes to ED crowding (12). Several studies suggest that the proportion of critically ill patients presenting to U.S. EDs is increasing (13–15). Additionally, other studies have questioned the ability of many EDs to provide optimal care for critically ill patients in crowded conditions and linked prolonged ED stays by critically ill patients with increased mortality (16–18). This study investigates changes in the total hours of ED care provided to patients ultimately admitted to an ICU from U.S. EDs between 2001 and 2009. To evaluate the hypothesis that EDs are providing an increasing amount of critical care, we examined both trends in ED visit ICU admissions and trends in the median ED length of stay (EDLOS) for these patients. Additionally, we analyzed trends in the national ED capacity to estimate changes in the average daily hours of care provided to patients admitted to an ICU at an average U.S. ED.

BACKGROUND: The impact of rapid response teams (RRT) on patient outcomes remains uncertain. OBJECTIVE: To examine the effect of proactive rounding by an RRT on outcomes of hospitalized adults discharged from intensive care. DESIGN: Retrospective, observational study. SETTING: Academic medical center. PATIENTS: All adult patients discharged alive from the intensive care unit (ICU) at the University of California San Francisco Medical Center between January 2006 and June 2009. INTERVENTION: Introduction of proactive rounding by an RRT. MEASUREMENTS: Outcomes included the ICU readmission rate, ICU average length of stay (LOS), and in-hospital mortality of patients discharged from the ICU. Data were obtained from administrative billing databases and analyzed using an interrupted time series (ITS) model. RESULTS: We analyzed 17 months of preintervention data and 25 months of postintervention data. Introduction of proactive rounding by the RRT did not change the ICU readmission rate (6.7% before vs 7.3% after; P = 0.24), the ICU LOS (5.1 days vs 4.9 days; P = 0.24), or the in-hospital mortality of patients discharged from the ICU (6.0% vs 5.5%; P = 0.24). ITS models testing the impact of proactive rounding on secular trends found no improvement in any of the 3 clinical outcomes relative to their preintervention trends. CONCLUSIONS: Proactive rounding by an RRT did not improve patient outcomes, raising further questions about RRT benefits. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine

Although major noncardiac surgery is common, few large-scale studies have examined the incidence and consequences of post-operative atrial fibrillation (POAF) in this population. We sought to define the incidence of POAF and its impact on outcomes after major noncardiac surgery.Using administrative data, we retrospectively reviewed the hospital course of adults who underwent major noncardiac surgery at 375 US hospitals over a 1-year period. Clinically significant POAF was defined as atrial fibrillation occurring during hospitalization that necessitated therapy.Of 370,447 patients, 10,957 (3.0%) developed clinically significant POAF while hospitalized. Of patients with POAF, 7,355 (67%) appeared to have pre-existing atrial fibrillation and 3,602 (33%) had newly diagnosed atrial fibrillation. Black patients had a lower risk of POAF (adjusted odds ratio, 0.53; 95% CI, 0.48-0.59; P.001). Patients with POAF had higher mortality (adjusted odds ratio, 1.72; 95% CI, 1.59-1.86; P.001), markedly longer length of stay (adjusted relative difference, +24.0%; 95% CI, +21.5% to +26.5%; P.001), and higher costs (adjusted difference, +$4,177; 95% CI, +$3,764 to +$4,590; P.001). These findings did not differ by whether POAF was a recurrence of pre-existing atrial fibrillation, or a new diagnosis.POAF following noncardiac surgery is not uncommon and is associated with increased mortality and cost. Our study identifies risk factors for POAF, which appear to include race. Strategies are needed to not only prevent new POAF, but also improve management of patients with pre-existing atrial fibrillation.

Context Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients. Objective To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status. Design, Setting, and Participants The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance. Main Outcome Measures Emergency Department length-of-stay measure compliance by disposition and safety-net status. Results Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non–safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non–safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]). Conclusion Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non–safety-net hospitals.

Although statin lipid-lowering medications likely reduce perioperative ischemic complications, few data exist to describe statins' effects on risk for and outcomes of atrial fibrillation following noncardiac surgery.To examine the association between treatment with statin medications and clinically significant postoperative atrial fibrillation (POAF) following major noncardiac surgery.A retrospective cohort study of patients aged 18 years or older who underwent major noncardiac surgery between January 1, 2008, and December 31, 2008. Cases of clinically significant POAF were selected by using a combination of International Classification of Diseases-9 codes and clinical variables. We defined statin users as those whose pharmacy data included a charge for a statin drug on the day of surgery, the day after surgery, or both.Of 370,447 patients, 10,957 (3.0%) developed clinically significant POAF; overall, 79,871 (21.6%) received a perioperative statin. Patients receiving statins were generally older (68.8 vs 61.1 years; P.001) and more likely to be receiving a beta-blocker (50.3% vs 21.6%; P.001). Statin use was associated with a lower unadjusted rate of POAF (2.6% vs 3.0%; P.001). After adjustment for patient risk factors and surgery type, odds for POAF remained significantly lower among statin-treated patients (adjusted odds ratio = 0.79; 95% confidence interval = 0.71-0.87; P.001). Statin use was not associated with differences in cost, length of stay, or mortality among patients who developed POAF.Treatment with statin agents appears to be associated with a lower risk for clinically significant POAF following major noncardiac surgery.

To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings.We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys.Secondary data analysis.An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]).Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.

Summary. Background: The number of spinal fusion operations in the USA is rapidly rising, but little is known about optimal venous thromboembolism prophylaxis after spinal surgery. Objectives: To examine the use of and outcomes associated with venous thromboembolism prophylaxis after spinal fusion surgery in a cohort of 244 US hospitals. Patients/Methods: We identified all patients with a principal procedure code for spinal fusion surgery in hospitals participating in the Premier Perspective database from 2003 to 2005, and searched for receipt of pharmacologic prophylaxis (subcutaneous unfractionated heparin, low molecular weight heparin, or fondaparinux) and/or mechanical prophylaxis (compression devices and elastic stockings) within the first 7 days after surgery. We also searched for discharge diagnosis codes for venous thromboembolism and postoperative hemorrhage during the index hospitalization and within 30 days after surgery. Results: Among 80 183 spinal fusions performed during the time period, cervical fusions were the most common (49.0%), followed by lumbar fusions (47.8%). Thromboembolism prophylaxis was administered to 60.6% of patients within the first week postoperatively, with the most frequent form being mechanical prophylaxis alone (47.6%). Of the 244 hospitals, 26.2% provided prophylaxis to ≥ 90% of their patients undergoing spinal fusion; however, 33.2% provided prophylaxis to fewer than 50% of their patients. The rate of diagnosed venous thromboembolism within 30 days after surgery was 0.45%, and the rate of postoperative hemorrhage was 1.1%. Conclusions: Substantial variation exists in the use of thromboembolism prophylaxis after spinal fusion surgery in the USA. Nevertheless, overall rates of diagnosed thromboembolism after spinal fusion appear to be low.

In recent years, hospital medicine programs have adopted "procedure teams" that supervise residents in performing invasive bedside procedures. The effect of procedure teams on patient satisfaction is unknown.We sought to measure patient satisfaction with procedures performed by a hospitalist-supervised, intern-based procedure service (HPS) with a focus on patient perception of bedside communication.This was a prospective survey.We surveyed all patients referred to the HPS for bedside thoracentesis, paracentesis, lumbar puncture, and arthrocentesis at a single academic medical center. Following each procedure, surveys were administered to English-speaking patients who could provide informed consent. Survey questions focused on patients' satisfaction with specific aspects of procedure performance as well as the quality and impact of communication with the patient and between members of the team.Of 95 eligible patients, 65 (68%) completed the survey. Nearly all patients were satisfied or very satisfied with the overall experience (100%), explanation of informed consent (98%), pain control (92%), and expertise (95%) of physicians. The majority of patients were satisfied with procedure duration (88%) and in those with therapeutic procedures most (89%) were satisfied with improvement in symptoms. Hearing physicians discuss the procedure at the bedside was reassuring to most patients (84%), who felt this to be a normal part of doing a procedure (94%).Patients are highly satisfied with procedure performance by supervised trainees, and many patients were reassured by physician communication during the procedure. These results suggest that patient experience and teaching can be preserved with a hospitalist-supervised procedure service.

Standard order sets often increase the use of desirable interventions for patients likely to benefit from them. Whether such order sets also increase misuse of these interventions in patients potentially harmed by them is unknown. We measured the association between a paper-based standard admission order set with a venous thromboembolism pharmacoprophylaxis (VTEP) module and use of VTEP for patients likely to benefit from it as well as patients with unclear benefit or potential harm from it.We conducted a retrospective cohort study using administrative and pharmacy charge data of patients admitted between 1 July 2005 and 31 December 2008 to two medical and three surgical services that implemented a standard admission order set in August 2006. The primary outcome was use of VTEP in patients with likely benefit, unclear benefit, and potential harm from VTEP prior to and following order set implementation.A total of 8,429 patients (32%) were admitted prior to and 17,635 (68%) following order set implementation. There was a small unadjusted rise in overall VTEP use after implementation (51% to 58%, p 0.001). In multivariable models with interrupted time series analysis, patients with potential harm from VTEP had the largest increase in VTEP use at the time of implementation [adjusted odds ratio = 1.58; 95% confidence interval (CI), 1.12-2.22]. The increased likelihood of receiving VTEP in this subgroup gradually returned to baseline (adjusted odds ratio per month = 0.98; 95% CI, 0.96-0.99).Implementation of a standard admission order set transiently increased VTEP in patients with potential harm from it. Order set and guideline success should be judged based on the degree to which they successfully target patients likely to benefit from the intervention without inadvertently targeting patients potentially harmed.

Context The potential effects of increasing numbers of uninsured and underinsured persons on US emergency departments (EDs) is a concern for the health care safety net. Objective To describe the changes in ED visits that occurred from 1997 through 2007 in the adult and pediatric US populations by sociodemographic group, designation of safety-net ED, and trends in ambulatory care–sensitive conditions. Design, Setting, and Participants Publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 through 2007 were stratified by age, sex, race, ethnicity, insurance status, safety-net hospital classification, triage category, and disposition. Codes from the International Classification of Diseases, Ninth Revision (ICD-9), were used to extract visits related to ambulatory care–sensitive conditions. Visit rates were calculated using annual US Census estimates. Main Outcome Measures Total annual visits to US EDs and ED visit rates for population subgroups. Results Between 1997 and 2007, ED visit rates increased from 352.8 to 390.5 per 1000 persons (rate difference, 37.7; 95% confidence interval [CI], −51.1 to 126.5; P = .001 for trend); the increase in total annual ED visits was almost double of what would be expected from population growth. Adults with Medicaid accounted for most of the increase in ED visits; the visit rate increased from 693.9 to 947.2 visits per 1000 enrollees between 1999 and 2007 (rate difference, 253.3; 95% CI, 41.1 to 465.5; P = .001 for trend). Although ED visit rates for adults with ambulatory care–sensitive conditions remained stable, ED visit rates among adults with Medicaid increased from 66.4 in 1999 to 83.9 in 2007 (rate difference, 17.5; 95% CI, −5.8 to 40.8; P = .007 for trend). The number of facilities qualifying as safety-net EDs increased from 1770 in 2000 to 2489 in 2007. Conclusion These findings indicate that ED visit rates have increased from 1997 to 2007 and that EDs are increasingly serving as the safety net for medically underserved patients, particularly adults with Medicaid.

Background Readmissions are costly both financially for our healthcare system and emotionally for our patients. Identifying factors that increase risk for readmissions may be helpful to focus resources to optimize the discharge process and reduce avoidable readmissions. Objective To identify factors associated with readmission within 30 days for general medicine patients. Methods We performed a retrospective observational study of an administrative database at an urban 550-bed tertiary care academic medical center. Cohort patients were discharged from the general medicine service over a 2-year period from June 1, 2006, to May 31, 2008. Clinical, operational, and sociodemographic factors were evaluated for association with readmission. Results Our cohort included 10,359 consecutive admissions (6805 patients) discharged from the general medicine service. The 30-day readmission rate was 17.0%. In multivariate analysis, factors associated with readmission included black race (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.24-1.65), inpatient use of narcotics (1.33; 1.16-1.53) and corticosteroids (1.24; 1.09-1.42), and the disease states of cancer (with metastasis 1.61; 1.33-1.95; without metastasis 1.95; 1.54-2.47), renal failure (1.19; 1.05-1.36), congestive heart failure (1.30; 1.09-1.56), and weight loss (1.26; 1.09-1.47). Medicaid payer status (1.15; 0.97-1.36) had a trend toward readmission. Conclusion Readmission of general medicine patients within 30 days is common and associated with several easily identifiable clinical and nonclinical factors. Identification of these risk factors can allow providers to target interventions to reduce potentially avoidable readmissions.

The objectives of this study were to compare the risk of venous thromboembolism (VTE), bleeding, surgical site infection, and mortality in patients receiving aspirin or guideline-approved VTE prophylactic therapies (warfarin, low-molecular-weight heparins, synthetic pentasaccharides) in total knee arthroplasty (TKA). We analyzed clinical and administrative data from 93,840 patients who underwent primary TKA at 307 US hospitals over a 24-month period. Fifty-one thousand nine hundred twenty-three (55%) patients received warfarin, 37,198 (40%) received injectable agents, and 4719 (5%) received aspirin. After adjustment for patient and hospital factors, patients who received aspirin VTE prophylaxis (VTEP) had lower odds for thromboembolism compared to warfarin patients but with similar odds compared with injectable VTEP; there were no differences in risk of bleeding, infection, or mortality after adjustment. Our results suggest that aspirin, when used in conjunction with other clinical care protocols, may be effective VTEP for certain TKA patients.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs) in the United States. It is unknown whether this development has affected the national rate of visits to primary care practices and emergency departments (EDs) and whether changes in antibiotic prescribing have occurred.We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing.Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P = .003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P.001 for trend). The largest relative increases occurred in EDs (especially in high safety-net-status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P.001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting.The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.

There is growing interest in collaborative management of surgical patients. However, few data describe how medical consultation influences quality of care or resource use. The objective of this study was to determine whether medical consultation improves care in surgical patients.Observational cohort of patients undergoing surgery between May 1, 2004, and May 31, 2006, at a university-based hospital. The outcomes included costs, hospital length of stay, use of preventive therapies (such as perioperative beta-blockers) and clinical outcomes.Of 1,282 patients, 117 (9.1%) underwent a perioperative medical consultation. Consulted patients were of a similar age, sex, and race, but more frequently had an American Society of Anesthesiologists score of 4 or higher (34.2% vs 13.0%; P.001), diabetes mellitus (29.1% vs 16.1%; P.001), vascular disease (35.0% vs 10.6%; P.01), or chronic renal failure (23.9% vs 5.6%; P.001). After adjusting for severity of illness and likelihood of receiving a consultation, patients were just as likely to have a serum glucose level of less than 200 mg/dL (11.1 mmol/L), receive perioperative beta-blockers, or receive venous thromboembolism prophylaxis. Consulted patients had a longer adjusted length of stay (12.98% longer; 95% confidence interval, 1.61%-25.61%) and higher adjusted costs (24.36% higher; 95% confidence interval, 13.54%-36.34%). Patients who had a consultation from a generalist did not receive different quality of care, but had costs and length of stay similar to nonconsulted patients. Our results may be influenced by unaccounted referral bias or severity of illness.Perioperative internal medicine consultation produces inconsistent effects on efficiency and quality of care in surgical patients. Modifying the consultative model may represent an opportunity to improve care.

We evaluated the acceptability and impact of an audiovisual, bilingual, interactive computer module relating to appropriate antibiotic use. In winter 2001, adults seeking urgent care for acute respiratory infections at an inner-city urgent care clinic were invited to complete the computer module and survey (N = 296). After responding to questions about their symptoms, patients were provided information about their illness and appropriate antibiotic use, and then asked several questions about the acceptability of the module. The main outcomes, reflecting qualities known to enhance diffusion of innovations, were "learning something new about colds and flu" and trusting the computer information. Spanish-language respondents (16%) were much less likely to report prior computer experience, more likely to need help, and strongly preferred answering to a person compared with English-language respondents. In multivariable analysis, Spanish-language respondents were more likely to report learning something new (OR = 5.0; 95% CI: 2.0, 12.4) and trusting the information (OR = 2.5; 95% CI: 1.0, 6.0). We conclude that an interactive computer module was well received among a medically underserved urgent care clinic population. Benefits appear greatest among populations having the least experience with this medium.

OBJECTIVE: To validate and implement a computer module for the management of uncomplicated urinary tract infections (UTI). PARTICIPANTS: Women age 18 to 64 years, with a previous UTI, voiding symptoms, and absence of complicating features (comorbidities, vaginal discharge, back pain, emesis, and fever/chills). MEASUREMENTS: The computer module was validated against clinician diagnosis and urine culture. Following validation, the module was implemented in the urgent care clinic as a management option for women with suspected UTI; computer-directed therapy (CDT)-eligible women received antibiotic treatment without a clinician examination. Patient satisfaction with the module and return visits for UTI-related complaints were assessed. RESULTS: In the validation study, 18 of 68 women (26%) were CDT-eligible. Clinicians diagnosed 17/18 CDT-eligible women with uncomplicated UTI. Sixty-seven percent of CDT-eligible women had a positive urine culture. Since implementation, 162 women have accessed the module, and 35% have received CDT. Ninety-eight percent (95% confidence interval: 95% to 100%) found the program easy to use and 95% (89% to 100%) would recommend it to friends/family. Two (4%) CDT-treated women had a return visit to our institution for a UTI-related illness within 2 weeks. CONCLUSIONS: A computer module accurately identifies women with culture-confirmed, uncomplicated UTIs. Patients are highly satisfied with the module.

Objective The aim of the study was to identify and quantify patient, physician, hospital, and system factors that are associated with a longer ED length of stay. Methods Data were from the 2001-2003 National Hospital Ambulatory Medical Care Survey. The primary outcome was length of stay in minutes. Predictor variables were patient level (eg, age, triage score), physician level (eg, level of training), and hospital/system level (eg, geographic location, ownership). Results Admitted patients' median length of stay was 255 minutes (interquartile range, 160-400); discharged patients stayed a median of 120 minutes (interquartile range, 70-199). Factors independently associated with longer ED stays for admitted patients were Hispanic ethnicity (+20 minutes), computed tomography scan or magnetic resonance imaging (+36 minutes), and hospital location in a metropolitan area (+32 minutes). Intensive care unit admissions had a shorter length of stay (−30 minutes). Conclusion Several factors are associated with significant increases in ED length of stay and may be important factors in strategies to reduce length of stay.

Multiple organizations have called for decreases in excess antibiotic use in ambulatory practice as an important component of strategies to combat antimicrobial resistance in the United States (Jernigan, Cetron, and Breiman 1996). This public health imperative is driven by two key observations from the past decade: (1) antibiotic resistance among community-acquired bacterial pathogens (e.g., Streptococcus pneumoniae, Staphylococcus aureus, and Escherichia coli) is rising rapidly (Herold et al. 1998; Chen et al.1999; Gupta, Scholes, and Stamm 1999; Whitney et al. 2000; Hyde et al. 2001); and (2) recent antibiotic use is one of the strongest risk factors for carriage or infection with resistant bacteria (Nava et al. 1994; Hofmann et al. 1995; Arnold et al. 1996; Nuorti et al. 1998). Strategies to reduce inappropriate prescribing of antibiotics in the ambulatory setting must focus on the management of acute respiratory tract infections (ARIs), which resulted in 76 million visits to office-based physician practices in the U.S. during 2000 (Source: National Ambulatory Medical Care Survey, public use datafiles). These infections account for the vast majority of ambulatory antibiotic prescriptions in the U.S. (McCaig and Hughes 1995). Yet, many of these prescriptions likely provided little clinical benefit since the overwhelming majority of ARIs have a viral etiology; particularly colds, unspecified upper respiratory tract infections, and acute bronchitis (Gonzales et al. 1997). It appears that physicians and the public are beginning to heed the call to limit the over-use of antibiotics for ARIs in U.S. office-based practices. Between 1990 and 2000, the proportion of children with ARIs treated with antibiotics decreased by 14 percent (McCaig, Besser, and Hughes 2002). While this secular trend is promising, greater reductions are needed, since it has been estimated that over 50 percent of antibiotic prescriptions for ARIs are not necessary (Gonzales et al. 2001b). A number of controlled studies in the U.S. have confirmed the benefit of combined patient and physician educational interventions in reducing antibiotic use for ARIs beyond that attributable to secular trends (Gonzales et al. 1999; Belongia et al. 2001; Finkelstein et al. 2001; Perz et al. 2002). To date, however, there have been no community-based intervention trials, aimed at reducing excess antibiotic use, that have targeted adults in traditional fee-for-service, private office practices. The present study was designed to assess the impact of adding patient education to an existing physician-centered intervention directed at reducing antibiotic prescribing for children with pharyngitis and adults with acute bronchitis. In the first phase of the Minimizing Antibiotic Resistance in Colorado Project, we designed and launched this trial of a household- and office-based patient education intervention, known as the “Be S.M.A.R.T. about Antibiotics” campaign (S.M.A.R.T.=Strategies for Minimizing Antibiotic Resistance Together) in November 2001. The major hypothesis was that a combined patient and physician intervention would be more effective than a physician-centered intervention alone in reducing excess antibiotic use in private office practices.

To evaluate the performance of a rapid, bedside whole blood C-reactive protein test as a diagnostic test for pneumonia in adults.We enrolled consecutive adults who presented with acute cough (durationor =3 weeks). A fingerstick blood specimen for C-reactive protein level was obtained. Patients also provided information about demographic characteristics and symptoms. Physical examination findings, diagnoses, and treatments were abstracted from the medical record; illness duration and subsequent office visits were determined with follow-up telephone calls. A clinical prediction rule for pneumonia was calculated for each patient and compared with C-reactive protein levels.Twenty (12%) of the 168 patients in the study had radiographic evidence of pneumonia. Median C-reactive protein levels were significantly higher for patients with pneumonia than in the remaining patients (60 mg/L vs. 9 mg/L, P0.0001). The area under the receiver operating characteristic (ROC) curve for C-reactive protein level as a predictor of pneumonia was 0.83. C-reactive protein level and the clinical prediction rule were independently associated with pneumonia, yielding a combined area under the ROC curve of 0.93. C-reactive protein level was not associated with hospitalization or resolution of symptoms.C-reactive protein levels could be a valuable addition to clinical prediction rules for pneumonia. A C-reactive protein levelor =100 mg/L might be a useful indication for chest radiography or empiric antibiotic therapy when the diagnosis of pneumonia is in doubt.

To examine the effect of Spanish interpretation method on satisfaction with care.Self-administered post-visit questionnaire.Urban, university-affiliated walk-in clinic.Adult, English- and Spanish-speaking patients presenting for acute care of non-emergent medical problems.Satisfaction with overall clinic visit and with 7 provider characteristics was evaluated by multiple logistic regression, controlling for age, gender, ethnicity, education, insurance status, having a routine source of medical care, and baseline health. "Language-concordant" patients, defined as Spanish-speaking patients seen by Spanish-speaking providers and English-speaking patients, and patients using ATT telephone interpreters reported identical overall visit satisfaction (77%; P = .57), while those using family or ad hoc interpreters were significantly less satisfied (54% and 49%; P.01 and P = .007, respectively). ATT interpreter use and language concordance also yielded similar satisfaction rates for provider characteristics (P.2 for all values). Compared to language-concordant patients, patients who had family members interpret were less satisfied with provider listening (62% vs 85%; P = .003), discussion of sensitive issues (60% vs 76%; P = .02), and manner (62% vs 89%; P = .005). Patients who used ad hoc interpreters were less satisfied with provider skills (60% vs 83%; P = .02), manner (71% vs 89%; P = .02), listening (54% vs 85%; P = .002), explanations (57% vs 84%; P = .02), answers (57% vs 84%; P = .05), and support (63% vs 84%; P = .02).Spanish-speaking patients using ATT telephone interpretation are as satisfied with care as those seeing language-concordant providers, while patients using family or ad hoc interpreters are less satisfied. Clinics serving a large population of Spanish-speaking patients can enhance patient satisfaction by avoiding the use of untrained interpreters, such as family or ad hoc interpreters.

Importance: Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a "nonemergency" condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care. Objective: To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use. Design, Setting, and Participants: The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all "primary care-treatable" visits. The 2009 NHAMCS data set contains 34 942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses. Main Outcomes and Measures: Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits. Results: Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room. Conclusions and Relevance: Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits. ©2013 American Medical Association. All rights reserved.

Background Shared management of surgical patients between surgeons and hospitalists (comanagement) is increasingly common, yet few studies have described its effects. Methods Retrospective, interrupted time-series analysis of data collected from adults admitted to a neurosurgery service at our university-based teaching hospital between June 1, 2005, and December 31, 2008. Data regarding length of stay, costs, inpatient mortality rate, and 30-day readmission rate were collected from administrative sources; patient and caregiver satisfaction was assessed through surveys. We used multivariable models to estimate the effect of comanagement on key outcomes after adjusting for secular trends and patient-specific risk factors. Results During the study period, 7596 patients were admitted to the neurosurgery service: 4203 (55.3%) before July 1, 2007, and 3393 (44.7%) after comanagement began. Of those admitted during the postimplementation period, 988 (29.1%) were comanaged. After implementation of comanagement, no differences were found in patient mortality rate, readmission, or length of stay. No consistent improvements were seen in patient satisfaction, but strong perceived improvements occurred in care quality reported by nurses and nonnurse health care professionals. In addition, we observed a reduction in hospital costs of $1439 per admission. Conclusions Implementation of a hospitalist comanagement service had little effect on patient outcomes or satisfaction but appeared to reduce hospital costs and improve health care professionals' perceptions of care quality. As comanagement models are adopted, more emphasis should be placed on developing systems that improve patient outcomes.

Care from high-volume centers or surgeons has been associated with lower mortality rates in coronary artery bypass surgery, but how volume and quality of care relate to each other is not well understood.To determine how volume and differences in quality of care influence outcomes after coronary artery bypass surgery.Observational cohort.164 hospitals in the United States.81,289 patients 18 years or older who had coronary artery bypass grafting from 1 October 2003 to 1 September 2005.Hospital and surgeon case volumes were estimated by using a data set. Quality measures were defined by whether patients received specific medications and by counting the number of measures missed. Hierarchical models were used to estimate effects of volume and quality on death and readmission up to 30 days.After adjustment for clinical factors, lowest surgeon volume and highest hospital volume were associated with higher mortality rates and lower readmission risk, respectively. Patients who did not receive aspirin (odds ratio, 1.89 [95% CI, 1.65 to 2.16) or beta-blockers (odds ratio, 1.29 [CI, 1.12 to 1.49]) had higher odds for death, after adjustment for clinical risk factors and case volume. Adjustment for individual quality measures did not alter associations between volume and readmission or death. However, if no quality measures were missed, mortality rates at the lowest-volume centers (adjusted mortality rate, 1.05% [CI, 0.81% to 1.29%]) and highest-volume centers (adjusted mortality rate, 0.98% [CI, 0.72% to 1.25%]) were similar.Because administrative data were used, the quality measures may not replicate measures collected through chart abstraction.Maximizing adherence to quality measures is associated with improved mortality rates, independent of hospital or surgeon volume.California HealthCare Foundation.

Poor and non-white patients are disproportionately infected with the hepatitis C virus (HCV). The objective of this research is to determine sociodemographic patterns of HCV-related ambulatory care visits over time. Data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey-Outpatient (NHAMCS-OPD) for the years 1997–2005 were analyzed in 3-year intervals. Demographic and other variables were compared for each period, and multivariable logistic regression was performed to examine whether the likelihood of a visit being HCV-related (versus non-HCV) was independently associated with (1) race and/or (2) Medicaid status over time. The total number of HCV-related ambulatory visits more than doubled from 3,583,585 during the years 1997–1999 to 8,027,166 during 2003–2005. During this time, the proportion of non-whites and Medicaid recipients presenting for HCV-related visits approximately doubled (non-whites: 16% vs. 33%, P = 0.04; Medicaid recipients: 10% vs. 25%, P = 0.07). In 2003–2005, HCV-related visits were more than twice as likely to occur among non-white patients vs. white patients (OR = 2.49; 95% CI: 1.60–3.86) and patients on Medicaid vs. non-Medicaid (3.49; 1.79–6.80). Our results show that HCV-associated ambulatory care visits are increasing, with a greater proportion of visits occurring among non-white patients and Medicaid recipients.