Robert L. Fogerty

Comprehensive quality of discharge summaries at an academic medical center

BACKGROUND Discharge summaries are essential for safe transitions from hospital to home. OBJECTIVE To conduct a comprehensive quality assessment of discharge summaries. DESIGN Prospective cohort study. SUBJECTS Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MEASURES Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC). RESULTS A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content. CONCLUSIONS Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission.

Novel Integration of Systems-Based Practice Into Internal Medicine Residency Programs: The Interactive Cost-Awareness Resident Exercise (I-CARE)

Background: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic. Description: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty. Evaluation: Anonymous, voluntary survey of all participants and comparison of expenditures by training level were used to assess this pilot program. The educational quality of the I-CARE was rated higher than the prior format of Morning Report by participants (10-point Likert scale; 8.57, 6.81 respectively; p < .001). Open-ended comments were overwhelmingly supportive from faculty and trainees. Cost was lower for attending physicians than for trainees (

Impact of laboratory cost display on resident attitudes and knowledge about costs

1,027.45 vs.

Sepsis as 2 problems: Identifying sepsis at admission and predicting onset in the hospital using an electronic medical record–based acuity score ☆ ☆☆

4,264.00, p = .02) and diagnostic accuracy was also highest for attending physicians. Conclusions: The I-CARE is easy and quick to implement, and the preliminary results show a popular cost-awareness educational experience for internal medicine trainees. Further study is needed to determine change in practice habits.

The Growth of Hospitalists and the Future of the Society of General Internal Medicine: Results from the 2014 Membership Survey

Aim Cost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have had mixed results. We sought to assess resident physician cost awareness following sustained visual display of costs into electronic health record (EHR) order entry screens. Study Design We completed a preintervention and postintervention web-based survey. Participants were physicians in internal medicine, paediatrics, combined medicine and paediatrics, obstetrics and gynaecology, emergency medicine, and orthopaedic surgery at one tertiary co are academic medical centre. Costs were displayed in the EHR for 1032 unique laboratory orders. We measured attitudes towards costs and estimates of Medicare reimbursement rates for 11 common laboratory and imaging tests. Results We received 209 survey responses during the preintervention period (response rate 71.1%) and 194 responses during the postintervention period (response rate 66.0%). The proportion of residents that agreed/strongly agreed that they knew the costs of tests they ordered increased after the cost display (8.6% vs 38.2%; p<0.001). Cost estimation accuracy among residents increased after the cost display from 24.0% to 52.4% for laboratory orders (p<0.001) and from 37.7% to 49.6% for imaging orders (p<0.001). Conclusions Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.

Predictors for patients understanding reason for hospitalization

Purpose: Early identification and treatment improve outcomes for patients with sepsis. Current screening tools are limited. We present a new approach, recognizing that sepsis patients comprise 2 distinct and unequal populations: patients with sepsis present on admission (85%) and patients who develop sepsis in the hospital (15%) with mortality rates of 12% and 35%, respectively. Methods: Models are developed and tested based on 258 836 adult inpatient records from 4 hospitals. A “present on admission” model identifies patients admitted to a hospital with sepsis, and a “not present on admission” model predicts postadmission onset. Inputs include common clinical measurements and the Rothman Index. Sepsis was determined using International Classification of Diseases, Ninth Revision, codes. Results: For sepsis present on admission, area under the curves ranged from 0.87 to 0.91. Operating points chosen to yield 75% and 50% sensitivity achieve positive predictive values of 17% to 25% and 29% to 40%, respectively. For sepsis not present on admission, at 65% sensitivity, positive predictive values ranged from 10% to 20% across hospitals. Conclusions: This approach yields good to excellent discriminatory performance among adult inpatients for predicting sepsis present on admission or developed within the hospital and may aid in the timely delivery of care. HighlightsThere are 2 unequal but distinct sepsis populations.Eighty‐five percent of sepsis patients arrive with sepsis; mortality: 12%.Fifteen percent of sepsis patients develop sepsis in the hospital; mortality: 35%.Two models built using the RI identify and predict onset.Models flag 65% to 75% of sepsis patients with reasonable PPVs.

Association of an Opioid Standard of Practice Intervention With Intravenous Opioid Exposure in Hospitalized Patients

According to the most recent annual membership surveys, hospitalists are a rapidly growing component of the Society of General Internal Medicine (SGIM). Should this trend continue, hospitalists could increase from 22% of SGIM membership in 2014 to nearly 33% by 2020. Only 34% of hospitalists who responded to the survey, however, consider SGIM their academic home, compared to 54% of non-hospitalist respondents. Based on these survey findings, it is clear that the landscape of general internal medicine is changing with the growth of hospitalists, and SGIM will need to strategize to keep these hospitalist members actively engaged in the organization.

Case 7-2017

Objective To examine predictors for understanding reason for hospitalization. Methods This was a retrospective analysis of a prospective, observational cohort study of patients 65 years or older admitted for acute coronary syndrome, heart failure, or pneumonia and discharged home. Primary outcome was complete understanding of diagnosis, based on post-discharge patient interview. Predictors assessed were the following: jargon on discharge instructions, type of medical team, whether outpatient provider knew if the patient was admitted, and whether the patient reported more than one day notice before discharge. Results Among 377 patients, 59.8% of patients completely understood their diagnosis. Bivariate analyses demonstrated that outpatient provider being aware of admission and having more than a day notice prior to discharge were not associated with patient understanding diagnosis. Presence of jargon was not associated with increased likelihood of understanding in a multivariable analysis. Patients on housestaff and cardiology teams were more likely to understand diagnosis compared to non-teaching teams (OR 2.45, 95% CI 1.30–4.61, p<0.01 and OR 3.83, 95% CI 1.92–7.63, p<0.01, respectively). Conclusions Non-teaching team patients were less likely to understand their diagnosis. Further investigation of how provider-patient interaction differs among teams may aid in development of tools to improve hospital to community transitions.

Effect of therapeutic interchange on medication reconciliation during hospitalization and upon discharge in a geriatric population

Importance Opioids are commonly used to treat pain in hospitalized patients; however, intravenous administration carries an increased risk of adverse effects compared with oral administration. The subcutaneous route is an effective method of opioid delivery with favorable pharmacokinetics. Objective To assess an intervention to reduce intravenous opioid use, total parenteral opioid exposure, and the rate of patients administered parenteral opioids. Design, Setting, and Participants A pilot study was conducted in an adult general medical unit in an urban academic medical center. Attending physicians, nurse practitioners, and physician assistants who prescribed drugs were the participants. Use of opioids was compared between a 6-month control period and 3 months following education for the prescribers on opioid routes of administration. Interventions Adoption of a local opioid standard of practice, preferring the oral and subcutaneous routes over intravenous administration, and education for prescribers and nursing staff on awareness of the subcutaneous route was implemented. Main Outcomes and Measures The primary outcome was a reduction in intravenous doses administered per patient-day. Secondary measures included total parenteral and overall opioid doses per patient-day, parenteral and overall opioid exposure per patient-day, and daily rate of patients receiving parenteral opioids. Pain scores were measured on a standard 0- to 10-point Likert scale over the first 5 days of hospitalization. Results The control period included 4500 patient-days, and the intervention period included 2459 patient-days. Of 127 patients in the intervention group, 59 (46.5%) were men; mean (SD) age was 57.6 (18.5) years. Intravenous opioid doses were reduced by 84% (0.06 vs 0.39 doses per patient-day, P < .001), and doses of all parenteral opioids were reduced by 55% (0.18 vs 0.39 doses per patient-day, P < .001). In addition, mean (SD) daily parenteral opioid exposure decreased by 49% (2.88 [0.72] vs 5.67 [1.14] morphine-milligram equivalents [MMEs] per patient-day). The daily rate of patients administered any parenteral opioid decreased by 57% (6% vs 14%; P < .001). Doses of opioids given by oral or parenteral route were reduced by 23% (0.73 vs 0.95 doses per patient-day, P = .02), and mean daily overall opioid exposure decreased by 31% (6.30 [4.12] vs 9.11 [7.34] MMEs per patient-day). For hospital days 1 through 3, there were no significant postintervention vs preintervention differences in mean reported pain score for patients receiving opioid therapy: day 1, –0.19 (95% CI, −0.94 to 0.56); day 2, −0.49 (95% CI, −1.01 to 0.03); and day 3, −0.54 (95% CI, −1.18 to 0.09). However, significant improvement was seen in the intervention group on days 4 (−1.07; 95% CI, −1.80 to −0.34) and 5 (−1.06; 95% CI, −1.84 to −0.27). Conclusions and Relevance An intervention targeting the use of intravenous opioids may be associated with reduced opioid exposure while providing effective pain control to hospitalized adults.

Promoting Cost Transparency to Reduce Financial Harm to Patients.

A 73-year-old man with a history of heart failure, pulmonary hypertension, and a hepatic venovenous malformation presented with confusion. CT of the abdomen revealed pneumatosis of the ascending colon to the level of the hepatic flexure. Diagnostic tests were performed.