Alvin H. Novack

Comparison of Length of Stay for Asthma by Hospital Type

Objective. To determine whether length of stay (LOS) for asthma admissions at a local university-affiliated childrens hospital (UACH) is similar to that of community hospitals within the same county. Methods. A retrospective analysis was performed using computerized hospital abstract records from 1989 through 1994. The study population was children 1 to 18 years old whose first or only hospitalization for a primary diagnosis of asthma occurred during the study period at either the UACH or one of the 17 community hospitals in King County, WA, that admit pediatric patients (n = 2491). Transfers and patients with chronic obstructive asthma or secondary diagnoses such as cystic fibrosis were not included in the study. Asthma patients were compared by sociodemographic and health risk characteristics such as age, sex, insurance status, and a comorbidity severity score. Differences between the two hospital populations were tested by χ2 and t tests. The effect of hospitalization at the UACH or the community hospitals on LOS was determined using analysis of covariance after adjusting for the sociodemographic and health risk covariates. Results. Sixty-two percent (62%) of the asthma patients in the study population were discharged from the UACH. Compared with patients discharged from the community hospitals, the UACH patients were significantly younger, more often male, used public insurance, and resided in areas with lower median household incomes. The severity of comorbidities was not different between the two hospital groups. Overall, adjusted mean LOS was not significantly longer at the UACH (2.1 days) than at the community hospitals (2.0 days); however, adjusted mean LOS for specific subgroups, most notably poor children and those with public insurance, was significantly longer at the UACH. Conclusion. LOS for first or only asthma hospitalizations during 1989 through 1994 at the UACH was similar to local community hospitals within the same county. Specific subgroups of children were hospitalized for a longer period at the UACH, but children with private insurance and from areas with higher median household incomes had similar LOS, and presumably costs, at the UACH and the community hospitals.

Training generalist physicians - Structural elements of the curriculum

To train more generalist physicians, structural changes must be made along the continuum of medical education. Future generalists require in-depth exposure to primary care practice, with substantive experience in the longitudinal management of patient panels and the opportunity to work with successful generalist role models. Clinical training and course work must incorporate a wide range of skills and disciplines, including areas now under-emphasized, such as epidemiology, health services, and psychosocial medicine. Recommendations for structural changes to increase the generalist focus of medical education include: 1) the development within institutions of central authorities, involving departments of internal medicine, family medicine, and pediatrics, in joint efforts to foster all aspects of generalist training, including recruitment, curriculum development, community linkages, innovative approaches to training, and recognition and support for successful generalist teachers; 2) commitment of a minimum of 50% of clinical training to ambulatory care settings at both medical school and residency levels; 3) required longitudinal care experiences for all medical students and a 20% or greater time commitment to longitudinal care for internal medicine, pediatrics, and family medicine residents; and 4) increased numbers of generalist faculty and enhanced teaching skills among faculty in the outpatient environment, to guarantee increased exposure of medical students and residents to generalist role models.