Search

IMPORTANCE: Although intensive care unit (ICU) adaptations to the coronavirus disease of 2019 (COVID-19) pandemic have received substantial attention , most patients hospitalized with COVID-19 have been in general medical units. OBJECTIVE: To characterize inpatient adaptations to care for non-ICU COVID-19 patients. DESIGN: Cross-sectional survey. SETTING: A network of 72 hospital medicine groups at US academic centers. MAIN OUTCOME MEASURES: COVID-19 testing, approaches to personal protective equipment (PPE), and features of respiratory isolation units (RIUs). RESULTS: Fifty-one of 72 sites responded (71%) between April 3 and April 5, 2020. At the time of our survey, only 15 (30%) reported COVID-19 test results being available in less than 6 hours. Half of sites with PPE data available reported PPE stockpiles of 2 weeks or less. Nearly all sites (90%) reported implementation of RIUs. RIUs primarily utilized attending physicians, with few incorporating residents and none incorporating students. Isolation and room-entry policies focused on grouping care activities and utilizing technology (such as video visits) to communicate with and evaluate patients. The vast majority of sites reported decreases in frequency of in-room encounters across provider or team types. Forty-six percent of respondents reported initially unrecognized non–COVID-19 diagnoses in patients admitted for COVID-19 evaluation; a similar number reported delayed identification of COVID-19 in patients admitted for other reasons. CONCLUSION: The COVID-19 pandemic has required medical wards to rapidly adapt with expanding use of RIUs and use of technology emerging as critical approaches. Reports of unrecognized or delayed diagnoses highlight how such adaptations may produce potential adverse effects on care. Journal of Hospital Medicine 2020;15:XXXXXX. © 2020 Society of Hospital Medicine

Limited data exist describing how hospital discharge readiness checklists might be incorporated into care. To evaluate how assessing patient readiness for discharge effects discharge outcomes. We assessed hospitalized adults’ readiness for discharge daily using a checklist. In the first feedback period, readiness data were given to patients, compared to the second feedback period, where data were given to patients and physicians. In the first feedback period, 163 patients completed 296 checklists, and in the second feedback period, 179 patients completed 371 checklists. In the first feedback period, 889 discharge barriers were identified, and 1154 in the second feedback period ( P = .27). We found no association between the mean number of discharge barriers by hospital day and whether data were provided to physicians ( P = .39). Eighty-nine physicians completed our survey, with 76 (85%) recalling receiving checklist data. Twenty-three (30%) of these thought the data helpful, and 45 (59%) stated it “never” or “rarely” highlighted anything new. Patients continued to report discharge barriers even when physicians received patient-reported data about key discharge transition domains.

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.

BACKGROUND Although guidelines now allow the use of aspirin as an alternative to anticoagulants for venous thromboembolism prophylaxis after knee or hip arthroplasty, there is limited data on contemporary use and outcomes with aspirin. OBJECTIVE To describe the use of pharmacologic thromboprophylaxis and to assess venous thromboembolic risk with aspirin compared with anticoagulation after knee or hip arthroplasty. DESIGN Retrospective cohort study using data from the US MedAssets database. PATIENTS Adults with a principal discharge diagnosis of knee or hip arthroplasty between January 1, 2013, and December 31, 2014. MAIN MEASURES We identified charges for medications used for thromboprophylaxis within 7 days after the index surgery from billing records. The primary outcome was postoperative venous thromboembolism identified by International Classification of Diseases, 9th edition codes, from the index hospitalization, rehospitalization within 30 days, or during an outpatient visit within 90 days postoperatively. We compared postoperative thromboembolic risk in patients receiving aspirin-only and those receiving anticoagulants using propensity score-adjusted multivariable logistic regression models. KEY RESULTS We identified 74,234 patients with knee arthroplasty and 36,192 with hip arthroplasty who received pharmacologic thromboprophylaxis. Aspirin-only was used in 27.9% of all patients, while 24.2% and 24.1% received warfarin or enoxaparin as prophylactic monotherapy, respectively. Postoperative venous thromboembolism occurred in 495 (0.67%) patients undergoing knee arthroplasty and 145 (0.40%) undergoing hip arthroplasty. Aspirin-only was not related to increased odds of postoperative venous thromboembolism compared with anticoagulants in multivariable adjusted analyses (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.56-0.87, and OR 0.93; 95% CI, 0.62-1.38 for knee or hip arthroplasty, respectively). CONCLUSIONS More than a fourth of all patients received aspirin as the sole antithrombotic agent after knee or hip arthroplasty. Postoperative thromboprophylaxis with aspirin-only was not associated with a higher risk of postoperative venous thromboembolism compared with anticoagulants after hip or knee arthroplasty.

Introduction: Venous thromboembolism (VTE) is a known complication of major orthopedic surgery. Although guidelines now allow the use of aspirin as an alternative to anticoagulants as VTE prophylaxis after knee or hip arthroplasty, there is limited data on contemporary use and outcomes with aspirin. We conducted a retrospective cohort study to describe antithrombotic agents used after knee and hip arthroplasty and post-operative VTE outcomes. Hypothesis: We assessed the hypothesis that VTE prevention with aspirin was not related to an increased risk of postoperative VTE after knee or hip arthroplasty compared to anticoagulation. Methods: We used data from MedAssets, which is an administrative database containing billing details on the patient-level from about 400 hospitals in the U.S., and included all adults with a principal hospital discharge diagnosis of knee or hip arthroplasty based on International Classification of Diseases, 9 th edition (ICD-9) codes between January 1, 2013, and December 31, 2014. We identified charges for medications used for VTE prophylaxis within 7 days after the index surgery. The primary outcome was postoperative VTE, identified by searching for VTE-specific ICD-9 codes from the index hospitalization, rehospitalization within 30 days, or during an outpatient visit within 90 days. We compared postoperative VTE risk between patients receiving aspirin-only and those receiving anticoagulants using propensity score-adjusted multivariable logistic regression models adjusted for VTE risk factors, hospital characteristics and length of stay. Results: We identified 74,234 patients who underwent knee arthroplasty and 36,192 with hip arthroplasty who received pharmacologic VTE prophylaxis. The most common post-operative anticoagulant medications were warfarin (25.2%; 27,850 of 110,426) and enoxaparin (24.1%; 26,560 of 110,426). Aspirin was used as the sole agent in 27.0% (20,047 of 74,234) of knee and 29.8% (10,769 of 36,192) of hip arthroplasties. Patients receiving only aspirin were younger and had fewer comorbidities compared to those who received anticoagulants. Postoperative VTE events occurred in 495 of 74,234 (0.67%) patients undergoing knee arthroplasty and 145 of 36,192 (0.40%) undergoing hip arthroplasty. Patients who received only aspirin after surgery did not have a higher risk for postoperative VTE compared to patients who received anticoagulants: adjusted odds ratio 0.92; 95% CI, 0.61-1.39 for knee and adjusted odds ratio 0.73; 95% CI, 0.56-0.95 for hip arthroplasty. Conclusions: In conclusion, aspirin was the most frequently administered individual antithrombotic agent in a large contemporary sample of U.S. patients undergoing knee or hip arthroplasty. Postoperative VTE prophylaxis with aspirin-only may be a safe option in this population and was not associated with a higher risk of postoperative VTE compared to anticoagulants.

Duty-hour restrictions have forced changes in care models for inpatient services, including an increase in shift work. In this study we aimed to determine whether a shift model compliant with 2011 Accreditation Council for Graduate Medical Education duty-hour standards was associated with more active patient care management. Residents caring for pediatric patients changed from a schedule with extended duty shifts and cross-coverage to one based on day/night shifts, limiting interns to 16 consecutive duty hours. We conducted a retrospective review of orders written under each model. After the intervention, there was a significant increase in the mean number of orders written within the first 12 hours (pre: 0.58 orders vs post: 1.12, P = 0.009) and 24 hours (pre: 1.52 vs post: 2.38, P = 0.004) following admission (not including admission orders), but we did not detect a significantly higher percentage of orders written at night. This shift-based coverage system was associated with a greater number of orders written early in the hospitalization, indicating more active management of clinical problems.

BACKGROUND Reducing hospital readmissions is a national healthcare priority. Little is known about how readmission rates vary across unique primary care practices. OBJECTIVE 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. DESIGN Retrospective analysis SETTING Seven primary care clinics affiliated with the University of California, San Francisco (UCSF). PATIENTS 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. RESULTS 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. CONCLUSIONS 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. Journal of Hospital Medicine 2014;9:688–694. © 2014 Society of Hospital Medicine

ObjectivesThis study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race.MethodsThe National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals).ResultsThere was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004).ConclusionsIn this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.

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.

STUDY OBJECTIVE To determine whether adaptations to comply with Accreditation Council for Graduate Medical Education (ACGME) duty hour requirements are associated with changes in total cost and length of stay. DESIGN Retrospective, interrupted time-series cohort study using concurrent control patients. SETTING UCSF Benioff Children's Hospital, San Francisco, CA. PATIENTS Inpatients newborn to 18 y on the primary pediatrics medical-surgical unit. Medical patients were studied before and after an intervention, and surgical patients served as a concurrent control group. INTERVENTION Pediatrics trainees' work schedules were changed from those that relied on prolonged call shifts to those primarily based on shorter day shifts and night shifts. RESULTS We detected significant relative reductions in length of stay but not in total cost. When the analysis was limited to the subset of patients who did not receive intensive care unit care, length of stay decreased by 18% and total cost decreased by 10%. We did not detect similar changes in the control group. CONCLUSIONS A trainee staffing model that included shorter shifts as consistent with current ACGME duty hour requirements was associated with reduced length of stay and total costs for patients not in the intensive care unit.

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

OBJECTIVES: To determine the prevalence and factors associated with use of potentially inappropriate medications (PIMs) in older adults undergoing surgery. DESIGN: Retrospective cohort study. SETTING: Three hundred seventy-nine acute care hospitals participating in the nationally representative Perspective database (2006�2008). PARTICIPANTS: Individuals aged 65 and older undergoing major inpatient gastrointestinal, gynecological, urological, and orthopedic surgery (N=272,351). MEASUREMENTS: Medications were classified as PIMs using previously published criteria defining 33 medications deemed potentially inappropriate in people aged 65 and older. Information about participant and provider characteristics and administration of PIMs was obtained from hospital discharge file data. Logistic regression techniques were used to examine factors associated with use of PIMs in the perioperative period. RESULTS: One-quarter of participants received at least one PIM during their surgical admission. Meperidine was the most frequently prescribed PIM (37,855, 14% of participants). In adjusted analysis, PIM use was less likely as age advanced (adjusted odds ratio (AOR)=0.98 per year of age, 95% confidence interval (CI)=0.97�0.98) and in men (AOR=0.83, 95% CI=0.81�0.85). PIMs were more likely to be prescribed to participants cared for by orthopedic surgeons than for those cared for by general surgeons (AOR=1.22, 95% CI=1.08�1.40). Participants undergoing surgery in the West (AOR=1.79, 95% CI=1.02�3.16) and South (AOR=2.24, 95% CI=1.38�3.64) were more likely to receive a PIM than those in the Northeast. CONCLUSION: Receipt of PIMs in older adults undergoing surgery is common and varies widely between providers and geographic regions and according to participant characteristics. Interventions aimed at reducing the use of PIMs in the perioperative period should be considered in quality improvement efforts.

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.

ACADEMIC EMERGENCY MEDICINE 2011; 18:700–707 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Overutilization of computed tomography (CT) is a growing public health concern due to increasing health care costs and exposure to radiation; these must be weighed against the potential benefits of CT for improving diagnoses and treatment plans. The objective of this study was to determine the national trends of CT and ultrasound (US) utilization for assessment of suspected urolithiasis in emergency departments (EDs) and if these trends are accompanied by changes in diagnosis rates for urolithiasis or other significant disorders and hospitalization rates. Methods: This was a retrospective cross-sectional analysis of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1996 and 2007. The authors determined the proportion of patient visits for flank or kidney pain receiving CT or US testing and calculated the diagnosis and hospitalization rates for urolithiasis and other significant disorders. Patient-specific and hospital-level variables associated with the use of CT were examined. Results: Utilization of CT to assess patients with suspected urolithiasis increased from 4.0% to 42.5% over the study period (p 0.05), and admitted to the hospital (approximately 11%, p = 0.49) did not change significantly. The following characteristics were associated with a higher likelihood of receiving a CT scan: male sex (odd ratio [OR] = 1.83, 95% confidence interval [CI] = 1.22 to 2.77), patients presenting with severe pain (OR = 2.96, 95% CI = 1.14 to 7.65), and those triaged in 15 minutes or less (OR = 2.41, 95% CI = 1.08 to 5.37). CT utilization was lower for patients presenting to rural hospitals (vs. urban areas; OR = 0.34, 95% CI = 0.19 to 0.61) and those managed by a nonphysician health care provider (OR = 0.19, 95% CI = 0.07 to 0.53). Conclusions: From 1996 to 2007, there was a 10-fold increase in the utilization of CT scan for patients with suspected kidney stone without an associated change in the proportion of diagnosis of kidney stone, diagnosis of significant alternate diagnoses, or admission to the hospital.

Ensuring patient safety is a major public health challenge. According to the Institute of Medicine (IOM), in the United States, as many as 98,000 deaths per year are attributable to preventable adverse events that occur in the hospital setting, with annual costs (lost income, disability, and health care costs) of between U.S.$17 billion and U.S.$29 billion(IOM 2000). Because the patient safety movement originated in and has focused on acute care settings (IOM 2000), less is known about safety outside the hospital setting (Wachter 2006; Sarkar et al. 2009). Adverse drug events (ADEs), defined as injuries resulting from a medication taken for medical intervention (Bates et al. 1995; Gurwitz et al. 2003; Bourgeois et al. 2009), constitute an important aspect of patient safety. Not all ADEs are preventable or can be considered medical errors; nevertheless, detection and prevention of ADEs is central to improving safety. Several studies have reported high rates of ADEs among specific populations, such as elderly patients (Gurwitz et al. 2003) and those with chronic diseases (Zhang et al. 2007), but important gaps in our current understanding of ambulatory ADEs remain. Apart from studies focused exclusively on emergency departments (EDs) (Budnitz et al. 2006, 2007), national population estimates for ADEs in the United States are lacking. Accordingly, we analyzed data from the National Center for Health Statistics (NCHS) to describe the frequency and distribution of ambulatory ADEs among U.S. adults, to estimate age-specific rates for ADE visits. In addition, we explored which medication classes are most commonly reported in ADE visits, and whether demographic and clinical characteristics were associated with ADE visits.

To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children.Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS.Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS.We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.

To determine whether systemic corticosteroids are under-prescribed (as measured by current NIH treatment guidelines) for children in the United States seen in the emergency department (ED) for acute asthma, and to identify factors associated with prescribing systemic corticosteroids.We used data from the 2001-2007 National Hospital Ambulatory Medical Care Survey. The study population was children ≤ 18 years old in the ED with a primary diagnosis of asthma (ICD-9-CM code 493.xx) who received bronchodilator(s). The primary outcome was receipt of a systemic corticosteroid in the ED. Independent variables included patient-level (e.g., demographics, insurance, fever, admission), physician-level (provider type, ancillary medications and tests ordered), and system-level factors (e.g., ED type, geographic location, time of day, season, year). We used multivariable logistic regression techniques to identify factors associated with systemic corticosteroid treatment.Systemic corticosteroids were prescribed at only 63% of pediatric acute asthma visits to EDs. Over the study period, there was a trend toward increasing systemic corticosteroid use (p for trend = .05). After adjusting for potential confounders, patients were more likely to receive systemic corticosteroids when treated in pediatric EDs than in general EDs (OR = 2.45; 95% CI: 1.26-4.77).Systemic corticosteroids are under-prescribed for children who present to EDs with acute asthma exacerbations. Pediatric EDs are more likely than general EDs to treat asthma exacerbations with systemic corticosteroids. Differences in the process of care in pediatric ED settings (compared to general EDs) may increase the likelihood of adherence to NIH treatment guidelines.

Background How case volume and quality of care relate to each other and to results of complex cancer surgery is not well-understood. Study Design Observational cohort of 14,170 patients 18 years or older who underwent pneumonectomy, esophagectomy, pancreatectomy, or pelvic surgery for cancer between October 1, 2003 and September 1, 2005 at a US hospital participating in a large benchmarking database. Case volumes were estimated within our dataset. Quality was measured by determining whether ideal patients did not receive appropriate perioperative medications (such as antibiotics to prevent surgical site infections), both as individual "missed"measures and as overall number missed. We used hierarchical models to estimate effects of volume and quality on 30-day readmission, in-hospital mortality, length of stay, and costs. Results After adjustment, we noted no consistent associations between higher hospital or surgeon volume and mortality, readmission, length of stay, or costs. Adherence to individual measures was not consistently associated with improvement in readmission, mortality, or other outcomes. For example, continuing antimicrobials past 24 hours was associated with longer length of stay (21.5% higher, 95% CI, 19.5–23.6%) and higher costs (17% higher, 95% CI, 16–19%). In contrast, overall adherence, although not associated with differences in mortality or readmission, was consistently associated with longer length of stay (7.4% longer with 1 missed measure and 16.4% longer with ≥2) and higher costs (5% higher with 1 missed measure, and 11% higher with ≥2). Conclusions Although hospital and surgeon volume were not associated with outcomes, lower overall adherence to quality measures is associated with higher costs, but not improved outcomes. This finding might provide a rationale for improving care systems by maximizing care consistency, even if outcomes are not affected.

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.

OBJECTIVES: Although osteoporosis treatment can dramatically reduce fracture risk, rates of treatment after hip fracture remain low. In-hospital initiation of recommended medications has improved outcomes in heart disease; hospitalization for hip fracture may represent a similar opportunity for improvement. The objective of this study was to examine rates of in-hospital treatment with a combination of calcium and vitamin D (Cal+D) and antiresorptive or bone-forming medications in patients hospitalized for hip fractures DESIGN: Observational cohort. SETTING: Three hundred eighteen hospitals in the United States. PARTICIPANTS: Fifty-one thousand three hundred forty-six patients aged 65 and older hospitalized for osteoporotic hip fracture. MEASUREMENTS: In-hospital administration of Cal+D and antiresorptive or bone-forming medications. RESULTS: Three thousand four hundred five patients (6.6%) received Cal+D anytime after a procedure to correct femoral fracture; 3,763 patients (7.3%) received antiresorptive or bone-forming medications. Only 1,023 patients (2.0%) were prescribed ideal therapy, receiving Cal+D and an antiresorptive or bone-forming medication. Treatment rates remained low across virtually all patient-, provider-, and hospital-level characteristics. The strongest predictor of treatment with Cal+D was the receipt of an antiresorptive or bone-forming medication (adjusted odds ratio=5.50, 95% confidence interval=4.84–6.25), but only 27.2% of patients who received these medications also received Cal+D. CONCLUSION: Rates of in-hospital initiation of osteoporosis treatment for patients with hip fracture are low and may represent an opportunity to improve care.

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.

OBJECTIVE: Delivery of critical care by intensivists has been recommended by several groups. Our objective was to understand the delivery of critical care physician services in Michigan and the role of intensivists and nonintensivist providers in providing care. DESIGN: Descriptive questionnaire. PARTICIPANTS AND SETTING: Intensive care unit (ICU) directors and nurse managers at 96 sites, representing 115 ICUs from 72 hospitals in Michigan. MEASUREMENTS AND RESULTS: The primary outcome measure was the percentage of sites utilizing a closed vs. an open model of ICU care. Secondary outcome measures included the percentage of ICUs utilizing a high-intensity service model, hospital size, ICU size, type of clinician providing care, and clinical activities performed. Twenty-four (25%) sites used a closed model of intensive care, while 72 (75%) had an open model of care. Hospitals with closed ICUs were larger and had larger ICUs than sites with open ICUs (P < 0.05). Hospitalists serving as attending physicians were strongly associated with an open ICU (odds ratio [OR] ¼ 12.2; 95% confidence interval [CI] ¼ 2.5-60.2), as was the absence of intensivists in the group (OR ¼ 12.2; 95%CI ¼ 1.4-105.8), while ICU and hospital size were not associated. At 18 sites (20%) all attendings were board certified in Critical Care. Sixty sites had less than 50% board-certified attending physicians. CONCLUSIONS: The closed intensivist-led model of intensive care delivery is not in widespread use in Michigan. In the absence of intensivists, alternate models of care, including the hospitalist model, are frequently used. Journal of Hospital Medicine 2010;5:4–9. V C 2010 Society of Hospital Medicine.

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.

Large-scale strategies are needed to reduce overuse of antibiotics in US communities.To evaluate the impact of a mass media campaign-"Get Smart Colorado"-on public exposure to campaign, antibiotic use, and office visit rates.Nonrandomized controlled trial.Two metropolitan communities in Colorado, United States.The general public, managed care enrollees, and physicians residing in the mass media (2.2 million persons) and comparison (0.53 million persons) communities.: The campaign consisting of paid outdoor advertising, earned media and physician advocacy ran between November 2002 and February 2003.Antibiotics dispensed per 1000 persons or managed care enrollees, and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign.After the mass media campaign, there was a 3.8% net decrease in retail pharmacy antibiotic dispenses per 1000 persons (P = 0.30) and an 8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members (P = 0.03) in the mass media community. Most of the decline occurred among pediatric members, and corresponded with a decline in pediatric office visit rates. There was no change in the office visit prescription rates among pediatric or adult managed care members, nor in visit rates for complications of acute respiratory tract infections.A low-cost mass media campaign was associated with a reduction in antibiotic use in the community, and seems to be mediated through decreases in office visits rates among children. The campaign seems to be cost-saving.

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.

Duty-hour restrictions have forced changes in care models for inpatient services, including an increase in shift work. In this study we aimed to determine whether a shift model compliant with 2011 Accreditation Council for Graduate Medical Education duty-hour standards was associated with more active patient care management. Residents caring for pediatric patients changed from a schedule with extended duty shifts and cross-coverage to one based on day/night shifts, limiting interns to 16 consecutive duty hours. We conducted a retrospective review of orders written under each model. After the intervention, there was a significant increase in the mean number of orders written within the first 12 hours (pre: 0.58 orders vs post: 1.12, P = 0.009) and 24 hours (pre: 1.52 vs post: 2.38, P = 0.004) following admission (not including admission orders), but we did not detect a significantly higher percentage of orders written at night. This shift-based coverage system was associated with a greater number of orders written early in the hospitalization, indicating more active management of clinical problems.

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.

Estimating the amount and cost of excess antibiotic use in ambulatory practice and identifying the conditions that account for most excess use are necessary to guide intervention and policy decisions. Data from the 1998 National Ambulatory Medical Care Survey, a sample survey of United States ambulatory physician practices, was used to estimate primary care office visits and antibiotic prescription rates for acute respiratory infections. Weight-averaged antibiotic costs were calculated with use of 1996 prescription marketing data and adjusted for inflation. In 1998, an estimated 76 million primary care office visits for acute respiratory infections resulted in 41 million antibiotic prescriptions. Antibiotic prescriptions in excess of the number expected to treat bacterial infections amounted to 55% (22.6 million) of all antibiotics prescribed for acute respiratory infections, at a cost of approximately $726 million. Upper respiratory tract infections (not otherwise specified), pharyngitis, and bronchitis were the conditions associated with the greatest amount of excess use. This study documents that the amount and cost of excessive antibiotic use for acute respiratory infections by primary care physicians are substantial and establishes potential target rates for antibiotic treatment of selected conditions.

To assess the accuracy of administrative claims data for measuring antibiotic prescribing behavior, we conducted a stratified randomized medical record review of office visits by children with pharyngitis, and adults with acute bronchitis, to primary care physicians in Colorado in 1998. The diagnoses of pharyngitis (n = 422) and acute bronchitis (n = 497) based on administrative data were verified in 83% and 79%, respectively, of medical records. The sensitivity, specificity, and positive predictive value of administrative data in identifying antibiotic treatment for pharyngitis was 68%, 91%, and 90%, respectively, and for bronchitis was 79%, 84% and 98%, respectively. The sensitivity, specificity, and negative predictive value of administrative data in identifying group A streptococcal test ordering for pharyngitis was 71%, 86%, and 30%, respectively. Absence of testing in administrative data (when present in the medical record) was more frequent among visits to physicians associated with a capitated health plan. We conclude that administrative claims data are accurate sources for measuring and profiling antibiotic prescribing practices in ambulatory practice, although they underestimate actual antibiotic treatment decisions by individual physicians. Measuring and profiling antibiotic prescribing behavior in relation to group A streptococcal test utilization may overestimate inappropriate antibiotic treatment by physicians enrolled in capitated contracts.

Study Objective: Antibiotics are often used to treat viral upper respiratory tract infections, even though they are usually ineffective. However, frequent inappropriate antibiotic use contributes to the emergence of drug-resistant bacterial pathogens. This study used a national database to evaluate antibiotic use in treating upper respiratory tract infections in emergency departments. Methods: Data were obtained from the 1996 National Hospital Ambulatory Medical Care Survey. Antibiotic prescribing rates were examined for colds, upper respiratory tract infections, and acute bronchitis. Patients with comorbid conditions or secondary diagnoses, such as chronic obstructive pulmonary disease, pneumonia, sinusitis, and HIV, were excluded. Bivariate and multivariate analyses were used to assess predictors of antibiotic use. Results: Overall, there were an estimated 2.7 million ED visits for colds, upper respiratory tract infections, and bronchitis by children and adults in 1996. Antibiotics were prescribed for 24.2% (95% CI 18.9, 29.5) of patients with common colds and upper respiratory tract infections and for 42.2% (95% CI 35.2, 49.2) of patients with bronchitis. There were no significant associations between antibiotic use and patient race, sex, Hispanic ethnicity, geographic location, or source of payment. Antibiotics were prescribed less often by interns or residents than by staff or other physicians (odds ratio 0.43; 95% CI 0.19, 0.98), and patients younger than 18 years were less likely to receive antibiotics than adults (odds ratio 0.32; 95% CI 0.20, 0.52). Smokers were 4.3 (95% CI 2.2, 8.3) times more likely to receive antibiotics than nonsmokers. Conclusion: Antibiotics are commonly prescribed for ED patients with upper respiratory tract infections even though they are usually ineffective in otherwise healthy adults. Efforts should be made to reduce inappropriate antibiotic use for the sake of containing costs, preventing side effects, and limiting the spread of antibiotic resistance. [Stone S, Gonzales R, Maselli J, Lowenstein SR. Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: a national study of hospital-based emergency departments. Ann Emerg Med. October 2000;36:320-327.]

In 2006, the Centers for Disease Control and Prevention recommended discontinuing the use of adamantanes (amantadine and rimantadine) to treat influenza because of high levels of resistance to this class of antivirals. We examined changes in prescribing practices resulting from this recommendation and found that prescribing of adamantanes declined nationwide, with these drugs accounting for approximately 40% of the antivirals prescribed for influenza from 2000 to 2005 and only 2% in 2006. This finding provides evidence of a rapid change in clinical practice associated with the dissemination of treatment guidelines. Evaluating the effectiveness with which public health recommendations are translated into practice is important given the ongoing emergence of resistance to antiviral drugs and a novel H1N1 influenza virus.

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.

ObjectiveThis study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation.MethodsThis was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids.ResultsOf 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19-4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10-3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33-5.83), or tachypneic (OR, 1.52; 95% CI, 1.05-2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65-164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11-3.27) or tachypnea (OR, 1.82; 95% CI, 1.17-2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07-0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67-0.94) were less likely to receive timely steroids.ConclusionsIn this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.

AIMS: To describe the inpatient health service use and insurance types for hospitalized children with spina bifida compared to children generally and to evaluate hospital discharge and insurance type trends over a 10-year study period. METHODS: The cross-sectional secondary data analyses were conducted using the 2000, 2003, 2006 and 2009 Kid’s Inpatient Databases. Diagnoses were identified by ICD-9 codes and hospital type was categorized based on the National Association of Children’s Hospitals and Related Institutions designations. Chi-squared tests and the Wald test of trend were used for the statistical analyses. RESULTS: Children with spina bifida are more likely to receive their inpatient care in children’s hospitals or pediatric units compared to all children. Children with spina bifida were most commonly admitted for shunt malfunction and repair. The percentage of children covered by Medicaid rose during the study period for both children with spina bifida and children generally. CONCLUSIONS: This study is the first of its kind to document longitudinal trends in inpatient utilization, insurance type, and reason for admission for children with spina bifida. The changing trends in insurance coverage should be closely monitored because insurance is closely linked to health care access, which is linked to health outcomes.

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.

Despite the importance of measuring weight and height at well-child visits, there are limited data on frequency of anthropometric documentation. The authors aimed to identify characteristics associated with missing weight and height documentation at preventive visits for children. Among preventive visits for children from birth to 18 years old, recorded in the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys for 2005-2009, the authors found that 20.8% had missing weight and/or height (n = 19 033) documentation. Compared with infants younger than 2 years, school-age children (odds ratio [OR] = 1.30; 95% confidence interval [CI] = 1.03-1.64), and adolescents (OR = 1.61; 95% CI = 1.26-2.04) were more likely to lack documentation. Missing documentation was also more likely for visits with nonphysicians (OR = 4.53; 95% CI = 3.17-6.48) and nonpediatricians (OR = 2.63; 95% CI = 2.02-3.41) compared with pediatricians. Efforts to improve weight and height surveillance should be directed to clinics in which midlevel providers and nonpediatric physicians are caring for school-age children and adolescents. © 2012 The Author(s).

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.

Overutilization of computed tomography (CT) is a growing public health concern due to increasing health care costs and exposure to radiation; these must be weighed against the potential benefits of CT for improving diagnoses and treatment plans. The objective of this study was to determine the national trends of CT and ultrasound (US) utilization for assessment of suspected urolithiasis in emergency departments (EDs) and if these trends are accompanied by changes in diagnosis rates for urolithiasis or other significant disorders and hospitalization rates.This was a retrospective cross-sectional analysis of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1996 and 2007. The authors determined the proportion of patient visits for flank or kidney pain receiving CT or US testing and calculated the diagnosis and hospitalization rates for urolithiasis and other significant disorders. Patient-specific and hospital-level variables associated with the use of CT were examined.Utilization of CT to assess patients with suspected urolithiasis increased from 4.0% to 42.5% over the study period (p0.001). In contrast, the use of US remained low, at about 5%, until it decreased beginning in 2005 to 2007 to 2.4% (p = 0.01). The proportion of patients diagnosed with urolithiasis (approximately 18%, p = 0.55), with other significant diagnoses (p0.05), and admitted to the hospital (approximately 11%, p = 0.49) did not change significantly. The following characteristics were associated with a higher likelihood of receiving a CT scan: male sex (odd ratio [OR] = 1.83, 95% confidence interval [CI] = 1.22 to 2.77), patients presenting with severe pain (OR = 2.96, 95% CI = 1.14 to 7.65), and those triaged in 15 minutes or less (OR = 2.41, 95% CI = 1.08 to 5.37). CT utilization was lower for patients presenting to rural hospitals (vs. urban areas; OR = 0.34, 95% CI = 0.19 to 0.61) and those managed by a nonphysician health care provider (OR = 0.19, 95% CI = 0.07 to 0.53).From 1996 to 2007, there was a 10-fold increase in the utilization of CT scan for patients with suspected kidney stone without an associated change in the proportion of diagnosis of kidney stone, diagnosis of significant alternate diagnoses, or admission to the hospital.

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.

OBJECTIVE: National guidelines do not recommend antibiotics as an asthma therapy. We sought to examine the frequency of inappropriate antibiotic prescribing during US ambulatory care pediatric asthma visits as well as the patient, provider, and systemic variables associated with such practice. PATIENTS AND METHODS: Data from the National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Survey were examined to assess office and emergency-department asthma visits made by children (aged RESULTS: From 1998 to 2007, an estimated 60.4 million visits occurred for asthma without another ICD-9 code justifying antibiotic prescription. Antibiotics were prescribed during 16% of these visits, most commonly macrolides (48.8%). In multivariate analysis, controlling for patient age, gender, race, insurance type, region, and controller medication use, systemic corticosteroid prescription (odds ratio [OR]: 2.69 [95% confidence interval (CI): 1.68–4.30]) and treatment during the winter (OR: 1.92 [95% CI: 1.05–3.52]) were associated with an increased likelihood of antibiotic prescription, whereas treatment in an emergency department was associated with decreased likelihood (OR: 0.48 [95% CI: 0.26–0.89]). A second multivariate analysis of only office-based visits demonstrated that asthma education during the visits was associated with reduced antibiotic prescriptions (OR: 0.46 [95% CI: 0.24–0.86]). CONCLUSIONS: Antibiotics are prescribed during nearly 1 in 6 US pediatric ambulatory care visits for asthma, ∼1 million prescriptions annually, when antibiotic need is undocumented. Additional education and interventions are needed to prevent unnecessary antibiotic prescribing for asthma.

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.