Ken Kolodner

A Quality Improvement Intervention to Facilitate the Transition of Older Adults from Three Hospitals Back to Their Homes

OBJECTIVES: To study the feasibility and effectiveness of a discharge planning intervention.

Attributes of Excellent Attending-Physician Role Models

Background Although effective role models are important in medical education, little is known about the characteristics of physicians who serve as excellent clinical role models. We therefore conducted a case–control study to identify attributes that distinguish such physicians from their colleagues. Methods We asked members of the internal-medicine house staff at four teaching hospitals to name physicians whom they considered to be excellent role models. A total of 165 physicians named by one or more house-staff members were classified as excellent role models (these served as the case physicians in our study). A questionnaire was sent to them as well as to 246 physicians who had residency-level teaching responsibilities but who were not named (controls). Of these 411 physicians, 341 (83 percent) completed questionnaires while unaware of their case–control status. Results Of the 341 attending physicians who responded, 144 (42 percent) had been identified as excellent role models. Having greater assigned ...

Teaching the Teachers: National Survey of Faculty Development in Departments of Medicine of U.S. Teaching Hospitals

OBJECTIVE: To determine the prevalence, topics, methods, and intensity of ongoing faculty development (FD) in teaching skills.DESIGN: Mailed survey.PARTICIPANTS: Two hundred and seventy-seven of the 386 (72%) U.S. teaching hospitals with internal medicine residency programs.MEASUREMENTS: Prevalence and characteristics of ongoing FD.RESULTS: One hundred and eight teaching hospitals (39%) reported ongoing FD. Hospitals with a primary medical school affiliation (university hospitals) were more likely to have ongoing FD than nonuniversity hospitals. For nonuniversity hospitals, funding from the Health Resources Services Administration and >50 house staff were associated with ongoing FD. For university hospitals, >100 department of medicine faculty was associated. Ongoing programs included a mean of 10.4 topics (standard deviation, 5.4). Most offered half-day workshops (80%), but 22% offered ≥1-month programs. Evaluations were predominantly limited to postcourse evaluations forms. Only 14% of the hospitals with ongoing FD (5% of all hospitals) had “advanced” programs, defined as offering ≥10 topics, lasting >2 days, and using ≥3 experiential teaching methods. These were significantly more likely to be university hospitals and to offer salary support and/or protected time to their FD instructors. Generalists and hospital-based faculty were more likely to receive training than subspecialist and community-based faulty. Factors facilitating participation in FD activities were supervisor attitudes, FD expertise, and institutional culture.CONCLUSIONS: A minority of U.S. teaching hospitals offer ongoing faculty development in teaching skills. Continued progress will likely require increased institutional commitment, improved evaluations, and adequate resources, particularly FD instructors and funding.

Medications Used by Children With Asthma Living in the Inner City

Objective. The purpose of the study was to examine medication use reported by families participating in an urban school-based community intervention program and to relate this use to other social and medical variables. Design. The design of the study was a cross-sectional questionnaire survey. Setting. Patients and their families recruited from elementary schools in a community setting were interviewed between December 1991 and January 1992. Participants. A total of 508 children with asthma were identified by school health records and teacher surveys. Their families confirmed the diagnosis and agreed to enter the study. Questionnaires were completed by 392 families. Intervention. The 392 families participated in a controlled trial of asthma education after providing the data that are the basis of this report. Results. More than half of the children took two or more medications for asthma. Thirty-one percent took theophylline alone or in combination with an adrenergic agent; 11% took some form of daily antiinflammatory medication, either cromolyn (8%) or inhaled steroids (3%). The pattern of medication use related to measures of severity and to regular visits to physicians or nurses. In general, however, children were undermedicated. A total of 78 children (20%) reported no medication or over-the-counter medication use, although 37% reported asthma severe enough to be associated with ≥20 days of school missed per month, and 37% had had an emergency room visit for asthma in the past 6 months. More than half of children ≥9 years old supervised their own medication. Conclusions. We concluded that undermedication is common in poor children with asthma living in urban areas. Antiinflammatory medications are used less commonly than in the general population, and theophylline is used more often. School children may be likely to supervise their own medication.

Emergency department visits by urban African American children with asthma

BACKGROUND Asthma morbidity among African American children has been identified as a significant national health concern. High emergency department use is one index of this morbidity and may reflect disease severity, disease management, and social factors. OBJECTIVE This study examined the prevalence and correlates of emergency department use and other indices of asthma morbidity among a sample of urban, low-income, African American children. METHODS Parents of 392 elementary school children with asthma who had consented to participate in an asthma education program were interviewed by phone according to a standardized protocol. RESULTS Children had a mean of 6.2 days of restricted activity (SD 8.1) and 7.9 symptomatic nights (SD 8.1). The mean number of school days missed because of asthma was 9.7 (SD 13.5). Among children with asthma symptoms in the past 12 months, 73.2% could identify a specific physician or nurse who provided asthma care. For those families without an identified asthma primary care provider, 39.3% received their usual asthma care from the emergency department. A total of 43.6% of the children had been to the emergency department for asthma care without hospitalization in the previous 6 months. Close to 80% of children reported using one or more prescribed asthma medication, and of these only 12% reported using inhaled anti-inflammatory medications. Families of children who had used the emergency department in the prior 6 months reported more asthma symptoms, lower social support, problems paying for health care, and the absence of a hypoallergenic mattress cover and that they had seen a physician for regular asthma care in the past 6 months. CONCLUSIONS We conclude that asthma management for children in the inner city relies on episodic care and emergency care, that asthma medication management does not conform to current guidelines, and that asthma symptoms resulting in school absences and workdays lost are prevalent.

Relation of low-severity violence to women’s health

AbstractOBJECTIVE: To determine if women who experience low-severity violence differ in numbers of physical symptoms, psychological distress, or substance abuse from women who have never been abused and from women who experience high-severity violence. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Four community-based, primary care, internal medicine practices. PATIENTS: Survey respondents were 1,931 women aged 18 years or older. SURVEY DESIGN: Survey included questions on violence; a checklist of 22 physical symptoms; the Symptom Checklist-22 (SCL-22) to measure depression, anxiety, somatization, and self-esteem; CAGE questions for alcohol use; and questions about past medical history. Low-severity violence patients had been “pushed or grabbed” or had someone “threaten to hurt them or someone they love” in the year prior to presentation. High-severity violence patients had been hit, slapped, kicked, burned, choked, or threatened or hurt with a weapon. MAIN RESULTS: Of the 1,931 women, 47 met criteria for current low-severity violence without prior abuse, and 79 met criteria for current high-severity violence without prior abuse, and 1,257 had never experienced violence. The remaining patients reported either childhood violence or past adult abuse. When adjusted for socioeconomic characteristics, the number of physical symptoms increased with increasing severity of violence (4.3 for no violence, 5.3 for low-severity violence, 6.4 for high-severity violence, p<.0001). Psychological distress also increased with increasing severity of violence (mean total SCL-22 scores 32.6 for no violence, 35.7 for low-severity violence, 39.5 for high-severity violence, p<.0001). Women with any current violence were more likely to have a history of substance abuse (prevalence ratio [PR] 1.8 for low-severity, 1.9 for high-severity violence) and to have a substance-abusing partner (PR 2.4 for both violence groups). CONCLUSIONS: In this study, even low-severity violence was associated with physical and psychological health problems in women. The data suggest a dose-response relation between the severity of violence and the degree of physical and psychological distress.

Faculty Development in Teaching Skills: An Intensive Longitudinal Model

Although reflection contributes to the personal growth of clinician–educators and is important for effective teaching, few teaching skills programs report its use. The Johns Hopkins Faculty Development Program in Teaching Skills, first implemented in 1987 as a theoretically grounded, longitudinal model for faculty development of clinician–educators, comprises a set of conditions intended to promote reflective learning. This paper describes the program and reports evaluation results for 98 participants and a comparison group of 112 nonparticipants between 1988 and 1996. Participants met with facilitators weekly for nine months for 3.5 hours, in stable groups of four to six individuals. Educational methods used across seven content areas emphasized relationships and collaboration, and included information provision, experiential learning with reflection, and personal awareness sessions. A pre–post evaluation design with comparison group measured changes in self-assessed teaching and professional skills, teaching enjoyment, and learning effectiveness. A post-only evaluation design appraised overall program quality, educational methods, facilitation, learning environment, and perceived impact of participation. Program participants had significantly greater pre–post-change scores than nonparticipants for all 14 outcomes (p < .05). Multiple regression modeling indicated that program participation was associated with pre–post improvement in all outcomes except administration skills, controlling for all participant and nonparticipant baseline characteristics (p < .05). All measured programmatic characteristics were highly rated by participants. Experiential methods with reflection were rated significantly higher than information-provision and personal awareness sessions (p < .001). Evaluation results demonstrate a positive impact of this alternative approach to faculty development on clinician–educator perceptions of their attitudes and behaviors towards learners and colleagues.

Active bed management by hospitalists and emergency department throughput.

Context Can hospitalists help decrease crowding in emergency departments? Contribution This prepost case study describes a quality-improvement partnership between hospitalists and a university-affiliated emergency department. A hospitalist regularly visited the emergency department, assessed inpatient bed availability, and helped triage admitted patients to particular units. After implementing the program, the average time that admitted patients spent in the emergency department decreased from 458 to 360 minutes. The percentage of hours that the emergency department had to divert ambulances because of crowding and lack of intensive care unit beds decreased by 6% and 27%, respectively. Implication A hospitalist-led bed management program improved emergency department throughput and ambulance-diversion status. The Editors The Institute of Medicines 2006 report, Hospital-Based Emergency Care: At the Breaking Point, is explicitthere is a crisis in U.S. emergency departments (1). Ninety-one percent of emergency departments are crowded beyond capacity (1). Emergency department crowding often results in ambulance diversion: the practice of redirecting ambulances destined for a crowded emergency department to another facility. Diverting ambulances prolongs the lead time until therapy can be initiated and has been associated with increased mortality rates (2). In 2003, ambulance diversion occurred nationwide at the rate of 1 ambulance every minute (3). The primary cause of emergency department crowding is inpatient boarding, that is, holding admitted patients until a hospital bed becomes available. This procedure not only reduces patient satisfaction but also may negatively affect patient outcomes and quality measures (48). Most of the 12 recommendations in the Institute of Medicines report concentrated on factors within emergency departments and ways in which emergency departments interface with the larger health care system. However, 1 strategy focused on hospital processes and efficiency as a way to ameliorate crowding (1). Hospitalist physician groups, internists specializing in the care of hospitalized patients, are now ubiquitous (9). By the nature of their work in coordinating patient care from admission through discharge, hospitalists are uniquely positioned to effectuate efficiency. Our group of hospitalists partnered with the emergency department to address the problem of crowding in our emergency department. We describe the effect of our hospitalist-run service called active bed management. The primary objective of this service was to facilitate the safe transfer of patients from the emergency department to the appropriate inpatient clinical setting. Methods Setting and Design This study took place at Johns Hopkins Bayview Medical Center, a 335-bed university-affiliated medical center in Baltimore, Maryland. The emergency department is a designated level-II center for adult trauma, adult burn, and primary stroke. With capacity for 30 primary treatment rooms, the emergency department registered 54607 visits in the fiscal year ending June 2007. Historically, approximately 25% of the patients registered in the emergency department are admitted, which forms 61% of the hospitals total admissions. Roughly 75% of department of medicine admissions come from the emergency department, totaling approximately 9700 patients annually. The hospitalist division had 14.7 full-timeequivalent physician faculty, 3.0 nurse practitioners, and 4.6 physician assistants at the time of the study. In Maryland, the controlling authority for emergency medical services is the Maryland Institute for Emergency Medical Services Systems. It has defined 2 levels of ambulance diversion. First, an emergency department is put on yellow alert when experiencing a temporary overwhelming overload such that priority II or III patients may not be managed safely. During this period, the Emergency Department requests that absolutely no priority II or priority III patients be transported to their facility. Second, red alert is the designation used when a hospital does not have any electrocardiography-monitored or critical care beds available. During red alert, patients who are likely to require this type of care are not to be transported to the emergency department; instead they are taken to the next closest appropriate hospital (10). These distinct alerts can be invoked separately in coordination with Maryland Institute for Emergency Medical Services Systems, which keeps a record of all alerts for all institutions in Maryland. Using a prepost design, we compared the relevant institution-level clinical data from the intervention period (November 2006 to February 2007) with data from the control period (November 2005 to February 2006) (Figure 1). This study was exempt by the institutional review board. Figure 1. Study flow diagram. JHBMC = Johns Hopkins Bayview Medical Center. Active Bed Management Intervention Before active bed management, the emergency department assigned patients who were admitted to 1 of 5 department of medicine admission services (cardiac intensive care unit [ICU]; medical ICU; and cardiology, pulmonary, and general medicine units). For all units except the general medicine unit, once the department of medicine house officer or a physician assistant was informed of the proposed admission by emergency department personnel, they were expected to evaluate the patient in the emergency department and initiate the transfer to the assigned hospital unit. For the general medicine unit, patient assignments were communicated from the emergency department through a page to a triage physician (hospitalists from 8 a.m. to 8 p.m. and house officers overnight), and once accepted, transfers from the emergency department to the medical floor occurred without in-person evaluation by the department of medicine. Active bed management, done in 12-hour shifts, is coordinated and staffed solely by the hospitalist service 24 hours a day, 7 days a week. All hospitalists in the division rotate through the active bed management role, and the active bed management physician is freed from all other clinical care duties so that his or her only clinical responsibility is facilitation of the active bed management processes. Active bed management was strategically designed around 3 fundamental elements: proactive management of department of medicine resources, evaluation and assignment of all departmental admissions, and mobilization of additional resources by the bed director. Proactive Management of Department of Medicine Resources The active bed management hospitalist assesses bed availability in real time for 2 ICUs (12 beds each), the intermediate care unit (3 beds), 2 subspecialty units (cardiac and pulmonary), and the 4 large general medicine units. These continuous assessments are designed to identify potential resource shortages, such as limited ICU beds, before they occur. Assessments are done through collaboration with unit-specific attending physicians, nursing supervisors, and charge nurses in real time, as well as through twice-daily prediversion rounds in the ICUs. Prediversion rounds provide the ICU teams with information on hospital bed status and identify patients who can be downgraded from critical care status and transferred to nonintensive care settings. Prediversion rounds also serve to collect accurate bed information to allow collaboration between the active bed management hospitalist and emergency department physician on patient flow. Evaluation and Assignment of New Admissions to Department of Medicine Inpatient Clinical Settings The active bed management hospitalist makes collaborative triage decisions about the optimal clinical setting for each patient who requires admission through consultation with all admitting physicians (predominantly emergency department physicians) initially by telephone. Pertinent clinical data are documented on a triage template, and the hospitalist then decides about the need to evaluate selected emergency department patients directly. Authority to make determinations on the assignment of patients to beds in the various services in the department of medicine has been granted to the active bed management hospitalist by the department chairman. Once the hospitalist accepts the admission, the emergency department attending writes brief admitting orders from preexisting order sets. Non-ICU admissions are transferred to the inpatient floor as soon as a bed is available. The receiving medical teams are notified about patients on initial triage and on their arrival to the inpatient unit. Intensive care unit admissions are transferred to the unit no longer than 90 minutes after the disposition decision has been made. This brief period allows ICU teams time to ready themselves and stabilize other patients (if necessary) while facilitating the timely transfer of critically ill patients out of the emergency department. Role of the Bed Director The bed director position was created as part of this intervention to support the active bed management hospitalists. The bed director is the hospitalist leader on call (either division chief or associate division chief). The active bed management hospitalist notifies the bed director if the hospital is put on red or yellow alert, if an alert seems to be looming, or if emergency department throughput for admitted patients is long and resultant crowding is occurring. The bed director has the authority to activate additional resources, both internal and external, to the department of medicine to address such issues in real time. Some resources available to the bed director to shorten delays in throughput and prevent ambulance diversion include calling in additional hospitalists, redirecting admissions to departments outside of medicine, and assigning medical admissions to nondepartment of medicine inpatient beds (where they will be cared for by the hospitalists). The Johns Hopkins

Health Care Utilization and the Proportion of Primary Care Physicians

BACKGROUND The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus. METHODS Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas. RESULTS The average proportion of primary care physicians in each metropolitan statistical area was 0.34 (SD 0.46, range 0.20-0.54). Higher proportions of primary care physicians were associated with significantly decreased utilization, with each 1% increase in proportion of primary care physicians associated with decreased yearly utilization for an average-sized metropolitan statistical area of 503 admissions, 2968 emergency department visits, and 512 surgeries (all P <.03). These relationships were consistent each year studied. CONCLUSIONS Increased proportions of primary care physicians appear to be associated with significant decreases in measures of health care utilization across the 1990s. National efforts aimed at limiting health care utilization may benefit from focusing on the proportion of primary care physicians relative to specialists in this country.

Effectiveness of abstinence-based incentives: interaction with intake stimulant test results.

Intake urinalysis test result (drug positive vs. negative) has been previously identified as a strong predictor of drug abuse treatment outcome, but there is little information about how this prognostic factor may interact with the type of treatment delivered. The authors used data from a multisite study of abstinence incentives for stimulant abusers enrolled in outpatient counseling treatment (N. M. Petry, J. M. Peirce, et al., 2005) to examine this question. The first study urine was used to stratify participants into stimulant negative (n = 306) versus positive (n = 108) subgroups. Abstinence incentives significantly improved retention in those testing negative but not in those testing positive. Findings suggest that stimulant abusers presenting to treatment with a stimulant-negative urine benefit from abstinence incentives, but alternative treatment approaches are needed for those who test stimulant positive at intake.