Read Pierce

Leveraging a Redesigned Morbidity and Mortality Conference That Incorporates the Clinical and Educational Missions of Improving Quality and Patient Safety.

PROBLEM The morbidity and mortality (M&M) conference is a vital event that can affect medical education, quality improvement, and peer review in academic departments. Historically, M&M conferences have emphasized cases that highlight diagnostic uncertainty or complex management conundrums. In this report, the authors describe the development, pilot, and refinement of a systems-based M&M conference model that combines the educational and clinical missions of improving quality and patient safety in the University of Colorado Department of Medicine. APPROACH In 2011, a focused taskforce completed a literature review that informed the development of a framework for the redesigned systems-based M&M conference. The new model included a restructured monthly conference, longitudinal curriculum for residents, and formal channels for interaction with clinical effectiveness departments. Each conference features an in-depth discussion of an adverse event using specific quality improvement tools. Areas for improvement and suggested action items are identified during the conference and delegated to the relevant clinical departments. OUTCOMES The new process has enabled the review of 27 adverse events over two years. Sixty-three action items were identified, and 33 were pursued. An average of 50 to 60 individuals participate in each conference, including interprofessional and interdisciplinary colleagues. Resident and faculty feedback regarding the new format has been positive, and other departments are starting to adopt this model. NEXT STEPS A more robust process for identifying and selecting cases to discuss is needed, as is a stable, sufficient mechanism to manage the improvement initiatives that come out of each conference.

Understanding predictors of prolonged hospitalizations among general medicine patients: A guide and preliminary analysis

Targeting patients with prolonged hospitalizations may represent an effective strategy for reducing average hospital length of stay (LOS). We sought to characterize predictors of prolonged hospitalizations among general medicine patients to guide future improvement efforts. We conducted a retrospective cohort study using administrative data of general medicine patients discharged from inpatient status from our academic medical center between 2012 and 2014. Multivariable logistic regression was performed to assess the association between sociodemographic and clinical variables with prolonged LOS, defined as >21 days. Of 18,363 discharges, 416 (2.3%) demonstrated prolonged LOS. Prolonged hospitalizations accounted for 18.6% of total inpatient days and contributed 0.8 days to an average LOS of 4.8 days during the study period. Prolonged hospitalizations were associated with younger age (odds ratio [OR]: 0.80 per 10-year increase in age, 95% confidence interval [CI]: 0.73-0.87) and Medicaid insurance (OR: 1.99, 95% CI: 1.29-3.05, REF = Medicare). Compared to patients without prolonged LOS, prolonged LOS patients were more likely to have methicillin-resistant Staphylococcus aureus septicemia (OR: 8.83, 95% CI: 1.72-45.36); require a palliative care consult (OR: 4.63, 95% CI: 2.86-7.49), ICU stay (OR: 6.66, 95% CI: 5.22-8.50), or surgery (OR: 5.04, 95% CI: 3.90-6.52); and be discharged to a post-acute-care facility (OR: 10.37, 95% CI: 6.92-15.56). Prolonged hospitalizations in a small proportion of patients were an important contributor to overall LOS and particularly affected Medicaid enrollees with complex hospital stays who were not discharged home. Further studies are needed to determine the reasons for discharge delays in this population.

The new education frontier: clinical teaching at night.

Regulations that restrict resident work hours and call for increased resident supervision have increased attending physician presence in the hospital during the nighttime. The resulting increased interactions between attendings and trainees provide an important opportunity and obligation to enhance the quality of learning that takes place in the hospital between 6 PM and 8 AM. Nighttime education should be transformed in a way that maintains clinical productivity for both attending and resident physicians, integrates high-quality teaching and curricula, and achieves a balance between patient safety and resident autonomy. Direct observation of trainees, instruction in communication, and modeling of cost-efficient medical practice may be more feasible during the night than during daytime hours. To realize the potential of this educational opportunity, training programs should develop skilled nighttime educators and establish metrics to define success.

Keys to career success: resources and barriers identified by early career academic hospitalists

Prior research in the field of academic hospital medicine has described challenges to achieving promotion for academic hospitalists. 2 A consensus conference identified barriers for academic hospitalist success including alignment of hospitalists with clinical priorities that may not be recognized for academic advancement, inadequate infrastructure to promote success, and lack of national funding for research in general inpatient medicine. Research is needed to better understand perspectives of academic hospitalists regarding the pathway to career success. This qualitative study explores the barriers and facilitators of career success as perceived by early career academic hospitalists.

What Is Career Success for Academic Hospitalists? A Qualitative Analysis of Early-Career Faculty Perspectives

BACKGROUND Understanding the concept of career success is critical for hospital medicine groups seeking to create sustainably rewarding faculty positions. Conceptual models of career success describe both extrinsic (compensation and advancement) and intrinsic (career satisfaction and job satisfaction) domains. How hospitalists define career success for themselves is not well understood. In this study, we qualitatively explore perspectives on how early-career clinician-educators define career success. METHODS We developed a semistructured interview tool of open-ended questions validated by using cognitive interviewing. Transcribed interviews were conducted with 17 early-career academic hospitalists from 3 medical centers to thematic saturation. A mixed deductive-inductive, qualitative, analytic approach was used to code and map themes to the theoretical framework. RESULTS The single most dominant theme participants described was “excitement about daily work,” which mapped to the job satisfaction organizing theme. Participants frequently expressed the importance of “being respected and recognized” and “dissemination of work,” which were within the career satisfaction organizing theme. The extrinsic organizing themes of advancement and compensation were described as less important contributors to an individual’s sense of career success. Ambivalence toward the “academic value of clinical work,” “scholarship,” and especially “promotion” represented unexpected themes. CONCLUSIONS The future of academic hospital medicine is predicated upon faculty finding career success. Clinician-educator hospitalists view some traditional markers of career advancement as relevant to success. However, early-career faculty question the importance of some traditional external markers to their personal definitions of success. This work suggests that the self-concept of career success is complex and may not be captured by traditional academic metrics and milestones.

A Tincture of Time—Latent Crystal Formation and Clinical Decision-Making in Acute Gout: A Teachable Moment

Story From the Front Lines A 51-year-old man without a history of gout presented 4 days after abrupt onset of a painful right elbow without trauma. He had no fevers or constitutional symptoms. He was monogamous and denied drug use. On examination, the patient appeared uncomfortable and resisted right elbow movement. The joint was swollen, erythematous, warm, and tender. Other joints were unaffected. Findings from the rest of his examination were normal. His white blood cell (WBC) count was within reference range (4500-11 000/μL; to convert WBC to 109/L, multiply by 0.001), and his serum glucose level was 147 mg/dL (to convert glucose to millimoles per liter, multiply by 0.0555). His uric acid level was not checked. A radiograph of the elbow revealed an effusion without erosions. Arthrocentesis produced straw-colored synovial fluid containing a WBC count of 9696/μL (91% neutrophils), and a glucose level of 133 mg/dL. Initial polarized light microscopy showed no crystal formation; results from Gram stain and bacterial culture were negative. The patient was treated for suspected culturenegative septic arthritis, and, on hospital day 3, was discharged home with oral antibiotics. Four days later, the patient returned for follow-up. His primary care clinician noted that the final fluid analysis report in the electronic health record (EHR) identified copious monosodium urate crystals, confirming a diagnosis of gout.

When the Music Stops, Choose Your Options Wisely: A Teachable Moment

Story From the Front Lines A man in his 70s with hypertension and type 2 diabetes mellitus presented to the clinic complaining of 6 days of sudden-onset, right-sided hearing loss. He reported hearing a phone ring, holding the phone to his right ear, and being unable to appreciate any sound. His left-sided hearing was unaffected. He stated that he had not had any recent upper respiratory infection, trauma, headache, slurred speech, weakness, facial droop, otalgia, imbalance, or tinnitus. On examination he had normal blood pressure, clear external auditory canals, and normal tympanic membranes. Findings from the neurologic examination were normal except for pronounced right-sided hearing loss. The otolaryngology service was consulted, but they were unable to perform an immediate in-person evaluation in the clinic. Instead, they recommended an urgent, noncontrast computed tomographic (CT) scan of the head as well as an audiologic examination. The results of the CT scan were normal. Same-day pure-tone audiometry demonstrated normal hearing in the patient’s left ear, and findings were consistent with sensorineural hearing loss (SNHL) in the right ear. Following current treatment guidelines, he was prescribed prednisone, 60 mg daily for 7 days. Within 1 week, his right-sided hearing had returned almost to baseline, and repeated audiologic testing 2 weeks later showed complete resolution.

Leadership Observation and Feedback Tool: A Novel Instrument for Assessment of Clinical Leadership Skills

Background While leadership training is increasingly incorporated into residency education, existing assessment tools to provide feedback on leadership skills are only applicable in limited contexts. Objective We developed an instrument, the Leadership Observation and Feedback Tool (LOFT), for assessing clinical leadership. Methods We used an iterative process to develop the tool, beginning with adapting the Leadership Practices Inventory to create an open-ended survey for identification of clinical leadership behaviors. We presented these to leadership experts who defined essential behaviors through a modified Delphi approach. In May 2014 we tested the resulting 29-item tool among residents in the internal medicine and pediatrics departments at 2 academic medical centers. We analyzed instrument performance using Cronbachs alpha, interrater reliability using intraclass correlation coefficients (ICCs), and item performance using linear-by-linear test comparisons of responses by postgraduate year, site, and specialty. Results A total of 377 (of 526, 72%) team members completed the LOFT for 95 (of 519, 18%) residents. Overall ratings were high-only 14% scored at the novice level. Cronbachs alpha was 0.79, and the ICC ranged from 0.20 to 0.79. Linear-by-linear test comparisons revealed significant differences between postgraduate year groups for some items, but no significant differences by site or specialty. Acceptability and usefulness ratings by respondents were high. Conclusions Despite a rigorous approach to instrument design, we were unable to collect convincing validity evidence for our instrument. The tool may still have some usefulness for providing formative feedback to residents on their clinical leadership skills.

Impact of state medicaid expansion status on length of stay and in‐hospital mortality for general medicine patients at US academic medical centers

BACKGROUND Medicaid is often associated with longer hospitalizations and higher in-hospital mortality than other insurance types. OBJECTIVE To characterize the impact of state Medicaid expansion status under the Affordable Care Act (ACA) on payer mix, length of stay (LOS), and in-hospital mortality. DESIGN/SETTING/PATIENTS Retrospective cohort study of general medicine patients discharged from academic medical centers (AMCs) within the University HealthSystem Consortium from October 1, 2012 to September 30, 2015. INTERVENTION/MEASUREMENTS Hospitals were stratified according to state Medicaid expansion status. The proportion of discharges by primary payer, LOS index, and mortality index were compared between Medicaid-expansion and nonexpansion hospitals before and after ACA implementation. ACA implementation was defined as January 1, 2014, for all states except Michigan, New Hampshire, Pennsylvania, and Indiana, which had unique dates of Medicaid expansion. RESULTS We identified 3,144,488 discharges from 156 hospitals in 24 Medicaid-expansion states and Washington, DC, and 1,114,464 discharges from 55 hospitals in 14 nonexpansion states during the study period. Hospitals in Medicaid-expansion states experienced a significant 3.7% increase in Medicaid discharges (P = 0.013) and a 2.9% decrease in uninsured discharges (P < 0.001) after ACA implementation, whereas hospitals in nonexpansion states saw no significant change in payer mix. In a difference-in-differences analysis, the changes in LOS and mortality indices pre- to post-ACA implementation did not differ significantly between hospitals in Medicaid-expansion versus nonexpansion states. CONCLUSIONS The differential shift in payer mix between Medicaid-expansion and nonexpansion states under the ACA did not influence LOS or in-hospital mortality for general medicine patients at AMCs in the United States. Journal of Hospital Medicine 2015;11:847-852.

Changes in Payer Mix and Physician Reimbursement After the Affordable Care Act and Medicaid Expansion.

Although uncompensated care for hospital-based care has fallen dramatically since the implementation of the Affordable Care Act and Medicaid expansion, the changes in hospital physician reimbursement are not known. We evaluated if payer mix and physician reimbursement by encounter changed between 2013 and 2014 in an academic hospitalist practice in a Medicaid expansion state. This was a retrospective cohort study of all general medicine inpatient admissions to an academic hospitalist group in 2013 and 2014. The proportion of encounters by payer and reimbursement/inpatient encounter were compared in 2013 versus 2014. A sensitivity analysis determined the relative contribution of different factors to the change in reimbursement/encounter. Among 37 540 and 40 397 general medicine inpatient encounters in 2013 and 2014, respectively, Medicaid encounters increased (17.3% to 30.0%, P < .001), uninsured encounters decreased (18.4% to 6.3%, P < 0.001), and private payer encounters also decreased (14.1% to 13.3%, P = .001). The median reimbursement/encounter increased 4.2% from