Jennifer Friderici

Outcomes of Patients Admitted for Observation of Chest Pain

BACKGROUND Low-risk chest pain is a common cause of hospital admission; however, to our knowledge, there are no guidelines regarding the appropriate use of stress testing in such cases. METHODS We performed a retrospective cohort study of patients 21 years and older who were admitted to our tertiary care center with chest pain in 2007 and 2008. Using electronic records and chart review, we sought (1) to identify differences in the use of stress testing based on patient demographics and comorbidities, pretest probability of coronary artery disease, and house staff coverage and (2) to describe the results of stress testing and patient outcomes, including revascularization procedures and 30-day readmissions for myocardial infarction. RESULTS Of 2107 patients, 1474 (69.9%) underwent stress tests, and the results were abnormal in 184 patients (12.5%). Within 30 days, 22 patients (11.6%) with abnormal test results underwent cardiac catheterization, 9 (4.7%) underwent revascularization, and 2 (1.1%) were readmitted for myocardial infarction. In a multivariable model, stress test ordering was positively associated with age younger than 70 years (RR [relative risk], 1.12; 95% CI, 1.02-1.23), private insurance (vs Medicare/Medicaid: RR, 1.19; 95% CI, 1.11-1.27), and no house staff coverage (RR, 1.39; 95% CI, 1.28-1.50). Of patients with low (<10%) pretest probability, 68.0% underwent stress testing, but only 4.5% of these had abnormal test results. CONCLUSIONS Most patients who are admitted with low-risk chest pain undergo stress testing, regardless of pretest probability, but abnormal test results are uncommon and rarely acted on. Ordering stress tests based on pretest probability could improve efficiency without endangering patients.

Implementing a resident research program to overcome barriers to resident research.

Internal medicine residents are required to participate in scholarly activity, but conducting original research during residency is challenging. Following a poor Match at Baystate Medical Center, the authors implemented a resident research program to overcome known barriers to resident research. The multifaceted program addressed the following barriers: lack of interest, lack of time, insufficient technical support, and paucity of mentors. The program consisted of evidence-based medicine training to stimulate residents’ interest in research and structural changes to support their conduct of research, including protected time for research during ambulatory blocks, a research assistant to help with tasks such as institutional review board applications and data entry, a research nurse to help with data collection, easily accessible biostatistical support, and a resident research director to provide mentorship. Following implementation in the fall of 2005, there was a steady rise in the number of resident presentations at national meetings, then in the number of resident publications. From 2001 to 2006, the department saw 3 resident publications. From 2006 to 2012, that number increased to 39 (P< .001). The department also saw more original research (29 publications) and resident first authors (12 publications) after program implementation. The percentage of residents accepted into fellowships rose from 33% before program implementation to 49% after (P = .04). This comprehensive resident research program, which focused on evidence-based medicine and was tailored to overcome specific barriers, led to a significant increase in the number of resident Medline publications and improved the reputation of the residency program.

The cost of defensive medicine on 3 hospital medicine services.

The overuse of tests and procedures due to fear of malpractice litigation, known as defensive medicine,1 is estimated to cost

Impact of Pharmacy Student and Resident-Led Discharge Counseling on Heart Failure Patients

46 billion annually in the US,2 but these costs have been measured only indirectly. We estimated the cost of defensive medicine on three hospital medicine services in a health system by having physicians assess the defensiveness of their own orders. We hypothesized that physicians who were concerned about being targeted by litigation would practice more defensively and have higher overall costs.

Four years' experience with a hospitalist‐led medical emergency team: An interrupted time series

Purpose: Many health systems have implemented interventions to reduce the rate of heart failure readmissions. Pharmacists have the training and expertise to provide effective medication-related education. However, few studies have examined the impact of discharge education provided by pharmacy students and residents on patients hospitalized with heart failure exacerbations. Methods: This was a nonrandomized intervention study evaluating the impact of a pharmacy student and resident-led discharge counseling program on heart failure readmissions. The primary end point was the 30-day heart failure readmission rate. Secondary end points included self-reported patient understanding of medications, number of medication errors documented, and estimated associated cost avoidance. Results: A total of 86 and 94 patients were enrolled into the intervention and control groups, respectively. No statistically significant difference in readmission rates was detected between the intervention and the control groups. Thirty-four medication errors and discrepancies were documented, or 1 for every 2.5 patients counseled, resulting in an estimated cost avoidance of

Measurement of the quality of care of patients admitted with decompensated cirrhosis

4241 for the institution. Eighty-nine percent of patients who received discharge counseling agreed they had a better understanding of their medications after speaking with a pharmacy resident or student. Conclusions: There was no statistically significant difference in readmission rates; however, several medication errors were prevented, and a large percentage of patients expressed an improved understanding of their medications.

Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis

BACKGROUND The effect of Medical Emergency Teams (METs) on cardiopulmonary arrests (codes) and fatal codes remains unclear and widely debated. OBJECTIVE To describe the implementation of a hospitalist-led MET and compare the number of code calls and code deaths before and after implementation. DESIGN Interrupted time series. SETTING Tertiary care academic medical center. PATIENTS All hospitalized patients. INTERVENTION Implementation of an MET, consisting of a critical care nurse, respiratory therapist, intravenous therapist, and the patients physician. MEASUREMENTS Number of MET calls, code calls, cardiac arrests and other medical crises, and code deaths per 1000 admissions, stratified by location (inside vs outside critical care). RESULTS From implementation in March 2006 through December 2009, the MET logged 2717 calls, most commonly for respiratory distress (33%), cardiovascular instability (25%), and neurological abnormality (20%). Overall code calls declined significantly between pre-implementation and post-implementation of the MET from 7.30 (95% confidence interval [CI] 5.81, 9.16) to 4.21 (95% CI 3.42, 5.18) code calls per 1000 admissions. Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards, primarily due to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards. Code calls within critical care also declined. The rate of fatal codes was not affected. CONCLUSIONS A hospitalist-led MET decreased code call rates but did not affect mortality rates.

Impact of the 2008 U.S. Preventative Services Task Force Recommendation on Frequency of Prostate-Specific Antigen Screening in Older Men

Process‐based quality measures are increasingly used to evaluate hospital performance. However, practices vary, and patients with cirrhosis are a challenge to manage, given their risks of mortality, morbidity, and resources utilization. In 2010, process‐based quality measures were developed to improve the care of these patients. We examined adherence with these quality measures for a cohort of patients admitted with decompensated cirrhosis in 2009.

Effectiveness of varenicline for smoking cessation at 2 urban academic health centers

BACKGROUND AND AIMS Patients with decompensated cirrhosis (DC) have significant morbidity and resource utilization. In a cohort of patients with DC undergoing usual care (UC) in 2009, we demonstrated that quality indicators (QI) were met <50% of the time. We established a gastroenterology mandatory consultation (MC) to improve the care of patients with DC. We sought to evaluate the impact of the MC intervention on adherence to QI, and compared outcomes to UC. METHODS This was a prospective cohort study with historic control examining all admissions in a year for DC at an academic medical center. All admissions were seen by a gastroenterologist encouraged to implement QIs (MC). Scores were calculated for each group per admission as the proportion of QIs met versus QIs for which the patient was eligible. QI scores were examined as a function of group assignment multivariable fractional logit regression. We evaluated the impact of the intervention on compliance with QIs, length of stay (LOS), 30-day readmission, and inpatient death. RESULTS Three hundred three patients were observed in 695 hospitalizations (149 patients in 379 admissions [UC]; 154 patients in 316 admissions [MC]). The QI score was significantly higher in the MC group than the UC group (77.0% vs 46.0%, P < 0.001), reflecting better management of ascites and documentation of transplant evaluation. The management of variceal bleeding improved also but did not reach statistical significance. CONCLUSION The MC intervention was associated with greater adherence to recommended care but was not powered to detect difference in LOS, readmission, or mortality rates.

Reappearance and treatment of penicillin-susceptible Staphylococcus aureus in a tertiary medical centre

To evaluate the effect of the 2008 U.S. Preventative Services Task Force recommendation against prostate‐specific antigen (PSA) screening in men aged 75 and older on frequency of PSA screening in elderly men.