Robert B. Baron

Implementation of a Voluntary Hospitalist Service at a Community Teaching Hospital: Improved Clinical Efficiency and Patient Outcomes

Context Many studies suggest that hospitalists reduce average length of stay and costs but have little or no effect on patient survival. Contribution This 2-year cohort study from a community-based urban teaching hospital found that patients cared for by faculty hospitalists rather than community physicians had shorter lengths of stay, lower costs, and better in-hospital and 1- and 2-month survival rates. Implications Length of stay and cost benefits were apparent only in year 2 of the study, which suggests that experience is an important aspect of successful care by hospitalists. Cautions The study was retrospective, was done in a single site, and involved only five hospitalists. The Editors The organization of inpatient services has been transformed with the development of the hospitalist (1). Traditionally, primary care physicians have cared for their own inpatients. In the hospitalist model, a hospitalist becomes the patients attending physician during hospitalization and the outpatient physician resumes supervision of the patient after discharge (2). Several studies have demonstrated improved clinical efficiency in the hospitalist model, but these studies have focused largely on academic centers or health maintenance organizations, or have not used concurrent controls or reported longer periods of follow-up (3-7). One published study examining a hospitalist system at a community-based teaching hospital suggested improvement in clinical efficiency and a reduction in readmissions (8). However, analytic limitations open these findings to many interpretations. To examine the effects of implementation of a hospitalist service on resource utilization and patient outcomes over time, we studied 5308 consecutive patients admitted to an urban community teaching hospital in San Francisco, California. Methods Study Site Mount Zion Hospital (San Francisco, California) was a 280-bed community-based teaching hospital affiliated with University of California, San Francisco. Mount Zions inpatient facilities were closed in November 1999 because of financial pressures. During the year before closure, all physicians were aware of the hospitals financial difficulties, but no individual or group was made a focus of efforts to improve clinical efficiency. Discussions about possible closure began 1 month after this study ended, and the hospital closed 5 months later. Medical patients at Mount Zion Hospital were admitted to one of four medical teams composed of a resident, one to two interns, and zero to three medical students. Mount Zion medical teams cared for common inpatient diagnoses, as well as specialty-associated diagnoses such as cancer, acute myocardial infarction, and cerebrovascular accidents. Housestaff wrote all orders and provided 24-hour coverage to inpatients. Each team had a ward attending physician who before 1 July 1997 was a full-time faculty member serving in this role for 1 month each year. Community-based physicians remained the physician of record for most patients and worked with house officers in the care of their hospitalized patients. On 1 July 1997, Mount Zion implemented a voluntary hospitalist service. Hospitalists, who were University of California, San Francisco, faculty based at Mount Zion, served as ward attendings 6 to 8 months per year and spent their remaining time in ambulatory practice or teaching. Hospitalists cared for patients without primary physicians, patients with faculty or house officer primary care physicians, and patients whose community-based physician chose to use the hospitalist service. Rotating nonhospitalist faculty continued to provide some inpatient care after implementation of the hospitalist service. Patients were admitted to rotating faculty according to the same criteria used for hospitalist services. There were no differences in other inpatient care systems available to community, rotating, or hospitalist physicians (for example, level of housestaff coverage, computer systems, case managers, social workers, or nursing staff). Patients Between 1 July 1997 and 30 June 1999, 5907 patients 18 years of age or older were admitted to the medical service at Mount Zion Hospital. We excluded patients who were admitted for chemotherapy or as part of a research protocol (n = 167) and those for whom some data on primary diagnosis were missing (n = 30). The resulting cohort was composed of 5710 patients, of whom 3693 (65%) were cared for by community-based physicians, 1615 (28%) were cared for by hospitalists, and 402 (7%) were cared for by rotating faculty. Data Management At Mount Zion Hospital, data were drawn from TSI (Transition Systems, Inc., Boston, Massachusetts) administrative databases, a cost-accounting system that collects data abstracted from patient charts at discharge. These databases contain information on sociodemographic characteristics, principal diagnosis (in the form of International Classification of Diseases, 9th revision, codes), diagnosis-related group, length of stay, costs, number of consultations, and whether the patient was in an intensive care unit during hospitalization. Data were manually screened for validity of physician designation as hospitalist or community physician by using previously published definitions of hospitalist physician characteristics (1, 2). Discharge summaries of patients who died during hospitalization were examined to validate deaths. An additional 200 discharge summaries of randomly selected patients discharged alive were also reviewed, revealing no errors. Information regarding physician characteristics and board certification was obtained from hospital credentialing databases. Patient survival to points in time after hospitalization was determined by using data from the California State Death Index (for patients admitted before 1 January 1999) and Social Security death indexes (for patients admitted on or after 1 January 1999 and for those who did not reside in California). Statistical Analysis To satisfy normality requirements and stabilize variance of residuals, we explored two methods of transforming skewed data on cost and length of stay: logarithmic conversion and truncation at the mean + 3 SDs. Since both techniques yielded similar results, we chose to present results by using truncation, as has been done in previous studies of inpatient costs and utilization (4, 9-11). All costs were adjusted to 1999 U.S. dollars by using an annual inflation rate of 3% (4). Primary analyses compared 5308 patients cared for by community or hospital-based physicians; we excluded the few patients cared for by rotating physicians from core analyses. This method was chosen to maximize our ability to discern differences in rare outcomes (such as death or readmission), to determine trends in frequent outcomes (such as length of stay), and to maintain focus on our primary question: hospitalist-directed versus community physiciandirected inpatient care. For bivariable comparisons, we used the Fisher exact test or the Wilcoxon rank-sum test. Unadjusted survival rates were estimated by using KaplanMeier product-limit methods. We then used multivariable models to determine the independent effect of hospitalist care on patient outcomes. Using automated forward and stepwise selection techniques along with manually entered variables, we fit multivariable linear regression models to determine the independent association of hospitalist care with length of stay and costs. Items were selected on the basis of the statistical significance of their association with the outcome or on observed confounding with other independent variables, or to maintain face validity of the model. Similar methods were used in fitting logistic models of readmission; use of consultations; and Cox proportional-hazards models of survival to discharge, 30 days, and 60 days. All analyses were performed by using SAS software, version 8.0 for Windows (SAS Institute, Inc., Cary, North Carolina). Multivariable models contained adjustment for patient age, sex, ethnicity, insurance type, source of admission (for example, emergency department), site of discharge, whether a cardiovascular procedure was performed during hospitalization, whether the patient received care in an intensive care unit during hospitalization, and case-mix measures. For case-mix measures, specific diagnoses were defined by using International Classification of Diseases, 9th revision, codes for pneumonia, asthma, congestive heart failure, acute myocardial infarction, angina, unstable angina, chest pain, cancer, gastrointestinal hemorrhage, HIV infection, and cerebrovascular accident. Models also contained a variable indexed to admission date to adjust for secular trends. Trends in adjusted outcomes were tested by using variables dummy-coded to indicate service and year of admission. Because patients were not randomly assigned to hospitalists or community physicians, we performed secondary analyses using a propensity score (12, 13). In our analyses, the propensity score represents the likelihood that any given patient would be admitted to a hospitalist attending physician. The propensity score was calculated in a logistic regression model with attending designation [that is, hospitalist vs. community physician] as the dependent variable. The model contained all covariates in core models, as well as variables found to contribute to nonrandom allocation of patients to specialty care at a P value less than or equal to 0.20. The propensity score was then used in analyses of cost, length of stay, and mortality in two ways: 1) multivariable analyses stratified within tertiles of propensity score and 2) multivariable analyses using the score as a continuous adjustment variable. Results Physician Characteristics One hundred thirteen community physicians, 20 rotating physicians, and 5 hospitalist physicians admitted patients to Mount Zion Hospital during the 2 years of this study. The mean age was 34 years for hospital

The effects of propranolol on cognitive function and quality of life: a randomized trial among patients with diastolic hypertension ∗

PURPOSE We sought to determine whether propranolol has adverse effects on cognitive function, depressive symptoms, and sexual function in patients treated for diastolic hypertension. SUBJECTS AND METHODS We performed a placebo-controlled trial among 312 men and women, 22 to 59 years of age, who had untreated diastolic hypertension (90 to 104 mm Hg). Patients were randomly assigned to treatment with propranolol (80 to 400 mg/day) or matching placebo tablets. Thirteen tests of cognitive function were assessed at baseline, 3 months, and 12 months. Five tests measured reaction time to, or accuracy in, interpreting visual stimuli; one test measured the ability to acquire, reproduce, and change a set of arbitrary stimulus-response sets; and seven tests measured memory or learning verbal information. Depressive symptoms and sexual function were assessed by questionnaires at baseline and 12 months. RESULTS There were no significant differences by treatment assignment for 11 of the 13 tests of cognitive function at either 3 or 12 months of follow-up. Compared with placebo, participants treated with propranolol had slightly fewer correct responses at 3 months (33 +/- 3 [mean +/- SD] versus 34 +/- 2, P = 0.02) and slightly more errors of commission at 3 months (4 +/-5 versus 3 +/- 3, P = 0.04) and at 12 months (4 +/- 4 versus 3 +/- 3, P = 0.05). At 12 months, depressive symptoms and sexual function and desire did not differ by treatment assignment. CONCLUSIONS Treatment of hypertension with propranolol had limited adverse effects on tests of cognitive function that were of questionable clinical relevance, and there were no documented adverse effects on depressive symptoms or sexual function. Selection of beta-blockers for treatment of hypertension should be based on other factors.

Factors Associated with Intern Fatigue

ABSTRACTBACKGROUNDPrior data suggest that fatigue adversely affects patient safety and resident well-being. ACGME duty hour limitations were intended, in part, to reduce resident fatigue, but the factors that affect intern fatigue are unknown.OBJECTIVETo identify factors associated with intern fatigue following implementation of duty hour limitations.DESIGNCross-sectional confidential survey of validated questions related to fatigue, sleep, and stress, as well as author-developed teamwork questions.SUBJECTSInterns in cognitive specialties at the University of California, San Francisco.MEASUREMENTSUnivariate statistics characterized the distribution of responses. Pearson correlations elucidated bivariate relationships between fatigue and other variables. Multivariate linear regression models identified factors independently associated with fatigue, sleep, and stress.RESULTSOf 111 eligible interns, 66 responded (59%). In a regression analysis including gender, hours worked in the previous week, sleep quality, perceived stress, and teamwork, only poorer quality of sleep and greater perceived stress were significantly associated with fatigue (p < 0.001 and p = 0.02, respectively). To identify factors that may affect sleep, specifically duty hours and stress, a secondary model was constructed. Only greater perceived stress was significantly associated with diminished sleep quality (p = 0.04), and only poorer teamwork was significantly associated with perceived stress (p < 0.001). Working >80 h was not significantly associated with perceived stress, quality of sleep, or fatigue.CONCLUSIONSSimply decreasing the number of duty hours may be insufficient to reduce intern fatigue. Residency programs may need to incorporate programmatic changes to reduce stress, improve sleep quality, and foster teamwork in order to decrease intern fatigue and its deleterious consequences.

Improving Chronic Care of Type 2 Diabetes Using Teams of Interprofessional Learners

Purpose To improve the care and outcomes of adult patients with type 2 diabetes by teaching interprofessional teams of learners the principles and practices of the Improving Chronic Illness Care Model. Method The study population consisted of 384 adult patients with type 2 diabetes. The study design was a nonrandomized, parallel-group, clinical trial conducted during 18 months in the University of California, San Francisco internal medicine clinics. Interprofessional team care provided by primary care internal medicine residents, nurse practitioner students, and pharmacy students was compared with usual care by internal medicine residents only. Processes of care, clinical status, and health utilization were measured in both patient groups. Learner outcomes also were assessed and compared. Results At study completion, intervention patients more frequently received assessments of glycosolated hemoglobin (79% versus 67%; P = .01), LDL-C (69% versus 55%; P = .009), blood pressure (86% versus 79%; P = .08), microalbuminuria (40% versus 30%; P = .05), smoking status assessment (43% versus 31%; P = .02), and foot exams (38% versus 20%; P = .0005). Intervention patients had more planned general medicine visits (7.9 ± 6.2 versus 6.2 ± 5.7; P = .006) than did control patients. Interprofessional learners rated themselves significantly higher on measures of accomplishment, preparation, and success for chronic care than did the usual care learners. Conclusions Interprofessional team care by learners was effective in improving quality of care for adult patients with diabetes treated in general medicine clinics. The chronic illness framework resulted in more appropriate health care utilization.

Industry Support of CME — Are We at the Tipping Point?

U.S. medicine may have reached a tipping point in limiting industry involvement in continuing medical education. Progress appears to be accelerating, and further restrictions are likely to become more widespread, thanks to shifting norms in the culture of medicine.

Clinician Attitudes About Commercial Support of Continuing Medical Education: Results of a Detailed Survey

BACKGROUND Pharmaceutical and medical device company funding supports up to 60% of accredited continuing medical education (CME) costs in the United States. Some have proposed measures to limit the size, scope, and potential influence of commercial support for CME activities. We sought to determine whether participants at CME activities perceive that commercial support introduces bias, whether this is affected by the amount or type of support, and whether they would be willing to accept higher fees or fewer amenities to decrease the need for such funding. METHODS We delivered a structured questionnaire to 1347 participants at a series of 5 live CME activities about the impact of commercial support on bias and their willingness to pay additional amounts to eliminate the need for commercial support. RESULTS Of the 770 respondents (a 57% response rate), most (88%) believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias. Only 15%, however, supported elimination of commercial support from CME activities, and less than half (42%) were willing to pay increased registration fees to decrease or eliminate commercial support. Participants who perceived bias from commercial support more frequently agreed to increase registration fees to decrease such support (2- to 3-fold odds ratio). Participants greatly underestimated the costs of ancillary activities, such as food, as well as the degree of support actually provided by commercial funding. CONCLUSION Although the medical professionals responding to this survey were concerned about bias introduced from commercial funding of CME, many were not willing to pay higher fees to offset or eliminate such funding sources.

Comparison of a lifestyle modification program with propranolol use in the management of diastolic hypertension.

OBJECTIVE: To compare the management of mild diastolic hypertension (90 to 104 mm Hg) using a nonpharmacologic intervention with that using propranolol or placebo.DESIGN: Randomized, placebo-controlled trial with a 2×2 factorial design.SETTING: University-based ambulatory care center.PARTICIPANTS: Two hundred seven men and 105 women, 22 to 59 years of age, 73% white, who had mild diastolic hypertension untreated for at least eight weeks.INTERVENTIONS: 1) a multicomponent lifestyle modification intervention (lifestyle focus group, or LFG) administered in eight weekly meetings+placebo, 2) LFG+propranolol, 3) propranolol alone, and 4) placebo alone, followed for 12 months.MEASUREMENTS: Systolic blood pressure (SBP), diastolic blood pressure (DBP), and self-reported adverse effects at each of nine follow-up visits; fasting total cholesterol, triglycerides, and glucose at baseline and 12 months; 24-hour urine sodium (Na+) and potassium (K+), three-day food records and physical activity questionnaire at three and 12 months; and a quality of life questionnaire at 12 months.MAIN RESULTS: The mean decreases in DBP at 12 months were: 8.5 mm Hg in the LFG+propranolol group; 7.7 mm Hg in the propranolol-only group; 5.9 mm Hg in the placebo-only group; and 5.4 mm Hg in the LFG+placebo group. Repeated-measures analysis of covariance showed that level of baseline DBP (p<0.0001), time of follow-up (p<0.0001), and propranolol use (p<0.0001) were significantly associated with a decrease in DBP at 12 months. Despite reductions in urinary Na+ (−35 mEq; 95% CI=−50, −19), dietary Na+ (−521 mg; 95% CI=−710, −332), total calories ingested (−238; 95% CI=−335, −140), and weight (−1.4 lb; 95% CI=−3.7, +0.8), and significant increases in dietary K+ (+294 mg; 95% CI=+107, +480) and in mets-minutes of exercise (+43; 95% CI=+20, +67) at three months, assignment to the LFG intervention had no effect on DBP at three or 12 months. The subjects assigned to take propranolol more frequently reported fatigue during ordinary activities, sleep disturbance, decrease in sexual activity, and depressed feelings, when compared with the subjects taking placebo, but the numbers of study withdrawals did not differ by drug assignment. No significant difference in total cholesterol and glucose levels was observed by group assignment. Triglycerides increased significantly in the subjects assigned to propranolol (mean difference=+20 mg/dL; 95% CI of difference +1.5, +39). There was no difference in the responses to 21 quality of life items between the subjects assigned to propranolol and those assigned to placebo.CONCLUSIONS: This multicomponent lifestyle modification intervention was unable to promote persistent behavior changes and thus was inferior to propranolol therapy for the treatment for mild diastolic hypertension. Future research should focus on single modifiable factors to lower blood pressure.

Changing Resident Test Ordering Behavior A Multilevel Intervention to Decrease Laboratory Utilization at an Academic Medical Center

Hospital laboratory test volume is increasing, and overutilization contributes to errors and costs. Efforts to reduce laboratory utilization have targeted aspects of ordering behavior, but few have utilized a multilevel collaborative approach. The study team partnered with residents to reduce unnecessary laboratory tests and associated costs through multilevel interventions across the academic medical center. The study team selected laboratory tests for intervention based on cost, volume, and ordering frequency (complete blood count [CBC] and CBC with differential, common electrolytes, blood enzymes, and liver function tests). Interventions were designed collaboratively with residents and targeted components of ordering behavior, including system changes, teaching, social marketing, academic detailing, financial incentives, and audit/feedback. Laboratory ordering was reduced by 8% cumulatively over 3 years, saving

Training generalist physicians - Structural elements of the curriculum

2 019 000. By involving residents at every stage of the intervention and targeting multiple levels simultaneously, laboratory utilization was reduced and cost savings were sustained over 3 years.

Reviewing Residents' Competence : A Qualitative Study of the Role of Clinical Competency Committees in Performance Assessment

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.