John R. Stephens

Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification

ABSTRACTBACKGROUNDClinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates.OBJECTIVESTo develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol’s implementation.DESIGNReview of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation.PARTICIPANTSPatients presenting for alcohol detoxification.INTERVENTIONDevelopment and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification.MAIN MEASURESNumber of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation.RESULTSWe identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p = 0.037). There was no difference in readmission rate or length of stay.CONCLUSIONSCreation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions.

Healthcare Utilization and Spending for Constipation in Children With Versus Without Complex Chronic Conditions.

Objectives: The aim of the study was to examine the prevalence of diagnosis and treatment for constipation among children receiving Medicaid and to compare healthcare utilization and spending for constipation among children based on number of complex chronic conditions (CCCs). Methods: Retrospective cohort study of 4.9 million children ages 1 to 17 years enrolled in Medicaid from 2009 to 2011 in 10 states in the Truven Marketscan Database. Constipation was identified using International Classification of Disease, 9th revision codes for constipation (564.0x), intestinal impaction (560.3x), or encopresis (307.7). Outpatient and inpatient utilization and spending for constipation were assessed. CCC status was identified using validated methodology. Results: A total of 267,188 children (5.4%) were diagnosed with constipation. Total constipation spending was

Getting hip to vitamin D: A hospitalist project for improving the assessment and treatment of vitamin D deficiency in elderly patients with hip fracture

79.5 million. Outpatient constipation spending was

Constipation-Related Health Care Utilization in Children Before and After Hospitalization for Constipation:

66.8 million (84.1%) during 406,814 visits, mean spending

Things we do for no reason: Echocardiogram in unselected patients with syncope

120/visit. Among children with constipation, 1363 (0.5%) received inpatient treatment, accounting for

Things we do for no reason: Hospitalization for the evaluation of patients with low-risk chest pain

12.2 million (15.4%) of constipation spending, mean spending

Things We Do For No Reason: Blood Cultures for Uncomplicated Skin and Soft Tissue Infections in Children

7815/hospitalization. Of children hospitalized for constipation, 552 (40.5%) did not have an outpatient visit for constipation before admission. Approximately 6.8% of children in the study had ≥1 CCC; these children accounted for 33.5% of total constipation spending, 70.3% of inpatient constipation spending, and 19.8% of emergency department constipation spending. Constipation prevalence was 11.0% for children with 1 CCC, 16.6% with 2 CCCs, and 27.1% with ≥3 CCCs. Conclusions: Although the majority of pediatric constipation treatment occurs in the outpatient setting, inpatient care accounts for a sizable percentage of spending. Children with CCCs have a higher prevalence of constipation and account for a disproportionate amount of constipation healthcare utilization and spending.

Implementation of a process for initiating naltrexone in patients hospitalized for alcohol detoxification or withdrawal

BACKGROUND Vitamin D deficiency is common in elderly patients with hip fracture, and clinical practice guidelines recommend screening this population. Our hospitalist group cares for all patients admitted with hip fracture, yet lacked a standardized approach to screening for and treating vitamin D deficiency in this population. OBJECTIVES To standardize and improve the assessment and treatment of vitamin D deficiency in elderly patients with hip fracture. DESIGN Quality improvement implementation. SETTING Tertiary academic hospital. PATIENTS Adults age >50 years with hip fracture. INTERVENTIONS We implemented a computerized hip fracture order set with preselected orders for 25-OH vitamin D level and initial supplementation with 1000 IU/day of vitamin D. We presented a review of the literature and performance data to our hospitalist group. MEASUREMENTS Percentage of patients with acute hip fracture screened for vitamin D deficiency and percentage of deficient or insufficient patients discharged on recommended dose of vitamin D (50,000 IU/wk if level <20 ng/mL). RESULTS The percentage of patients screened for vitamin D deficiency improved from 37.2% (n = 196) before implementation to 93.5% (n = 107) after (P < 0.001). The percentage of deficient or insufficient patients discharged on the recommended vitamin D dose improved from 40.9% to 68.0% (P = 0.008). The prevalence of vitamin D deficiency or insufficiency (25-OH vitamin D level <30 ng/mL) was 50.0%. CONCLUSIONS Simple interventions, consisting of a change in computerized order set and presentation of evidence and data from group practice, led to significant improvement in the assessment and treatment of vitamin D deficiency in elderly patients with hip fracture.

Issues Identified by Postdischarge Contact after Pediatric Hospitalization: A Multisite Study

We studied constipation-related health care among children before and after constipation admission. Index admissions for constipation in 2010-2011 were identified in the Truven Marketscan Database, which includes children receiving Medicaid in 10 states. We measured number of and spending for outpatient constipation visits 12 months before and after index hospitalizations. We also measured spending for constipation hospitalizations and rehospitalization rate. There were 780 index constipation admissions. The median number of outpatient constipation visits was 1 (interquartile range [IQR] = 0, 3) in the 12 months before and 2 (IQR [0, 4]) after admission (P = .001). Median outpatient spending for constipation was

Hemiconvulsion–Hemiplegia–Epilepsy Syndrome

110 (IQR [0, 429]) before and