Sylvia C. McKean

U.S. physician satisfaction: A systematic review

INTRODUCTION There is concern in the US about the burden and potential ramifications of dissatisfaction among physicians. The purpose of this article is to systematically review the literature on US physician satisfaction. METHODS A MEDLINE search with the medical subject headings (MeSH) phrases: (physicians OR physicians role OR physicians women) AND (job satisfaction OR career satisfaction OR burnout), limited to humans and abstracts, with 1157 abstracts reviewed. After exclusions by 2 independent reviewers, 97 articles were included. Physician type sampled, sample size/response rate, satisfaction type, and satisfaction results were extracted for each study. Satisfaction trends were extracted from those studies with longitudinal or repeated cross sectional design. Variables associated with satisfaction were extracted from those studies that included multivariate analyses. RESULTS Physician satisfaction was relatively stable, with small decreases primarily among primary care physicians (PCPs). The major pertinent mediating factors of satisfaction for hospitalists include both physician factors (age and specialty), and job factors (job demands, job control, collegial support, income, and incentives). CONCLUSIONS The majority of factors associated with satisfaction are modifiable. Tangible recommendations for measuring and diminishing dissatisfaction are given.

Implementation of a physician assistant/hospitalist service in an academic medical center: Impact on efficiency and patient outcomes

BACKGROUND Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions have led to the widespread implementation of non-house staff services in academic medical centers, yet little is known about the quality and efficiency of patient care on such services. OBJECTIVE To evaluate the quality and efficiency of patient care on a physician assistant/hospitalist service compared with that of traditional house staff services. DESIGN Retrospective cohort study. SETTING Inpatient general medicine service of a 747-bed academic medical center. PATIENTS A total of 5194 consecutive patients admitted to the general medical service from July 2005 to June 2006, including 992 patients on the physician assistant/hospitalist service and 4202 patients on a traditional house staff service. INTERVENTION A geographically localized service staffed with physician assistants and supervised by hospitalists. MEASUREMENTS Length of stay (LOS), cost of care, inpatient mortality, intensive care unit (ICU) transfers, readmissions, and patient satisfaction. RESULTS Patients admitted to the study service were younger, had lower comorbidity scores, and were more likely to be admitted at night. After adjustment for these and other factors, and for clustering by attending physician, total cost of care was marginally lower on the study service (adjusted costs 3.9% lower; 95% confidence interval [CI] -7.5% to -0.3%), but LOS was not significantly different (adjusted LOS 5.0% higher; 95% CI, -0.4% to +10%) as compared with house staff services. No difference was seen in inpatient mortality, ICU transfers, readmissions, or patient satisfaction. CONCLUSIONS For general medicine inpatients admitted to an academic medical center, a service staffed by hospitalists and physician assistants can provide a safe alternative to house staff services, with comparable efficiency.

Core competencies in hospital medicine: Development and methodology

BACKGROUND The hospitalist model of inpatient care has been rapidly expanding over the last decade, with significant growth related to the quality and efficiency of care provision. This growth and development have stimulated a need to better define and characterize the field of hospital medicine. Training and developing curricula specific to hospital medicine are the next step in the evolution of the field. METHODS The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, introduces the expectations of hospitalists and provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians-in-training, and practicing hospitalists. This article outlines the process that was undertaken to develop the Core Competencies, which included formation of a task force and editorial board, development of a topic list, the solicitation for and writing of chapters, and the execution of multiple reviews by the editorial board and both internal and external reviewers. RESULTS This process culminated in the Core Competencies document, which is divided into three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in each section delineate the core knowledge, skills, and attitudes necessary for effective inpatient practice while also incorporating a systems organization and improvement approach to care coordination and optimization. CONCLUSIONS These competencies should be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve inpatient training practices.

Extended enoxaparin monotherapy for acute symptomatic pulmonary embolism

We investigated the efficacy and safety of extended enoxaparin monotherapy in symptomatic patients with acute pulmonary embolism (PE). We randomized 40 patients in a 1:1 allocation to enoxaparin monotherapy (1 mg/kg twice daily for 10-18 days, and then 1.5 mg/kg once daily until day 90) (n = 20) or to enoxaparin 1.0 mg/kg twice daily as a bridge to warfarin with a target international normalized ratio of 2.0-3.0 for 90 days (at least 10 doses of enoxaparin overlapping with warfarin for at least 4 days) (n = 20). All patients underwent echocardiography, cardiac troponin I (TnI), and brain natriuretic peptide testing to identify patients with an increased likelihood of adverse clinical outcomes. The end-points were newly diagnosed deep venous thrombosis (DVT) or PE and bleeding events through day 90. In 15 patients on extended enoxaparin therapy, we used repeated measure analysis of variance (ANOVA) to investigate differences in anti-Xa levels obtained at 2, 4, 8 and 12 weeks. The patients’ mean age was 52 ± 17 years; the most common comorbidities were obesity (58%), hypertension (30%), concomitant DVT (30%) and cancer (15%). Twelve (30%) patients had elevated cardiac TnI >0.1 mg/l and 11 (28%) had moderate or severe right ventricular dysfunction on echocardiography. Ten (25%) patients received thrombolysis with a continuous infusion of 100 mg alteplase prior to randomization. During a 90-day follow-up, one patient from the enoxaparin monotherapy group suffered symptomatic distal DVT; one from the warfarin group had recurrent symptomatic PE (p= 1.0). None of the study patients had major hemorrhage; two warfarin group patients had minor bleeding compared with none in the enoxaparin monotherapy group (p= 0.49). Repeated measure ANOVA did not reveal significant differences in anti-Xa levels over time (p= 0.217). In patients with acute symptomatic PE, extended enoxaparin monotherapy is feasible and warrants further investigation in a large clinical trial.

Transfusion-associated circulatory overload (TACO) and potential risk factors among the inpatient US elderly as recorded in Medicare administrative databases during 2011

Transfusion‐associated circulatory overload (TACO) is a serious transfusion complication resulting in respiratory distress. The studys objective was to assess TACO occurrence and potential risk factors among elderly Medicare beneficiaries (ages 65 and older) in the inpatient setting during 2011.

Hospitalists and the Quality of Care in Hospitals

BACKGROUND Little is known about the link between hospitalists and performance on hospital-level quality indicators. METHODS From October 1, 2005, through September 31, 2006, we linked the Hospital Quality Alliance (HQA) data to the American Hospital Association data on the presence of hospitalists. Main outcome measures included composite measurements of hospital-level quality of care for 3 conditions (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) and 2 dimensions of care (treatment and diagnosis, as well as counseling and prevention). We fitted a series of logistic regression models to examine the relationship between hospitalists and overall quality of care for each condition, controlling for all other hospital characteristics. RESULTS Of 3619 hospitals reporting HQA data, 1461 (40.4%) had hospitalists. Hospitals with hospitalists tended to be large, private, not-for-profit, teaching institutions located in the southern United States. The mean unadjusted composite scores were higher for hospitals with hospitalists vs those with no hospitalists for all 3 conditions (93% vs 86% for AMI, 82% vs 72% for CHF, and 75% vs 71% for pneumonia) and both dimensions of care (87% vs 77% for treatment and diagnosis and 75% vs 66% for counseling and prevention) (P < .001 for all comparisons). After multivariable adjustment, hospitals with hospitalists continued to perform significantly better than those without hospitalists across all composite scores except for CHF. CONCLUSION Hospitals with hospitalists were associated with better performance on HQA indicators for AMI, pneumonia, and the domains of overall disease treatment and diagnosis, as well as counseling and prevention.

How to use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development

BACKGROUND The seminal article that coined the term hospitalist, published in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital. Since that time the role of the hospitalist has evolved, and hospitalists are being called upon to demonstrate that they actually improve quality of care and the education of the next generation of physicians. A companion article in this issue describes in detail the rationale for the development of the Core Competencies document and the methods by which it was created. METHODS Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development. The cases illustrate 1) a specific problem and the need for improvement; 2) a needs assessment of the targeted learners (hospitalists and clinicians in training); 3) goals and specific measurable objectives; 4) educational strategies using the competencies to provide structure and guidance; 5) implementation (applying competencies to a variety of training opportunities and curricula); 6) evaluation and feedback; and 7) remaining questions and the need for additional research. RESULTS This article illustrates how to utilize The Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients. CONCLUSIONS Medical educators should compare their learning objectives to the Core Competencies to ensure that their trainees have achieved competency to practice hospital medicine and improve the hospital setting.

Febrile non-haemolytic transfusion reaction occurrence and potential risk factors among the U.S. elderly transfused in the inpatient setting, as recorded in Medicare databases during 2011–2012

Febrile non‐haemolytic transfusion reaction (FNHTR) is an acute transfusion complication resulting in fever, chills and/or rigours. Studys objective was to assess FNHTR occurrence and potential risk factors among inpatient U.S. elderly Medicare beneficiaries, ages 65 and older, during 2011–2012.

Assessing the risk of venous thromboembolism and identifying barriers to thromboprophylaxis in the hospitalized patient

Sylvia C. McKean, MD Steven B. Deitelzweig, MD, FACP Arthur Sasahara, MD Franklin Michota, MD, FACP Anne Jacobson, MPH 1 Academic Hospitalist Service, Brigham & Women’s Hospital, Boston, Massachusetts. 2 Department of Hospital Medicine, Ochsner Health System, New Orleans, Louisiana. 3 Cardiovascular Division, Brigham & Women’s Hospital, Boston, Massachusetts. 4 Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio. 5 Independent Medical Writer, Sanford, Florida.

Once daily enoxaparin for outpatient treatment of acute venous thromboembolism: a case-control study.

We studied the efficacy and safety of an investigational enoxaparin regimen, 1.5 mg/kg once daily, as a bridge to warfarin for the outpatient treatment of acute venous thromboembolism. We undertook a case-control design. We enrolled 40 acute venous thromboembolism cases prospectively and matched them by age, gender, and location of venous thromboembolism to 80 previously treated controls. All controls had received enoxaparin 1 mg/kg twice daily. The primary end point was recurrent venous thromboembolism. We followed the cases for 30 days. We discontinued enoxaparin after we achieved the target international normalized ratio between 2.0 and 3.0. One case (2.9%) and three controls (3.8%) had recurrent venous thromboembolic events (P = 1.00). There were no major bleeding complications in the case group, compared to 3 (3.8%) in the control group (P = .55). Once daily enoxaparin, 1.5 mg/kg, as a bridge to warfarin was as effective with a similar safety profile as twice daily enoxaparin, 1mg/kg, for initial treatment of acute venous thromboembolism in the outpatient setting. This case-control study provides the rationale for undertaking a randomized controlled trial comparing enoxaparin 1.5 mg/kg once daily versus enoxaparin 1.0 mg/kg twice daily as a bridge to warfarin in outpatients with acute venous thromboembolism.