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1.  Evaluating the Brief Health Literacy Screen 
doi:10.1007/s11606-013-2655-2
PMCID: PMC3889980  PMID: 24129860
2.  Building continuity in handovers with shorter residency duty hours 
BMC Medical Education  2014;14(Suppl 1):S16.
As junior doctors work shorter hours in light of concerns about the harmful effects of fatigue on physician performance and health, it is imperative to consider how to ensure that patient safety is not compromised by breaks in the continuity of care. By reconceptualizing handover as a necessary bridge to continuity, and hence to safer patient care, the model of continuity-enhanced handovers has the potential to allay fears and improve patient care in an era of increasing fragmentation. “Continuity-enhanced handovers” differ from traditional handovers in several key aspects, including quality of information transferred, greater professional responsibility of senders and receivers, and a different philosophy of “coverage.” Continuity during handovers is often achieved through scheduling and staffing to maximize the provision of care by members of the primary team who have first-hand knowledge of patients. In this way, senders and receivers often engage in intra-team handovers, which can result in the accumulation of greater common ground or shared understanding of the patients they collectively care for through a series of repeated interactions. However, because maximizing team continuity is not always possible, other strategies such as cultivating high-performance teams, making handovers active learning opportunities, and monitoring performance during handovers are also important. Medical educators and clinicians should work toward adopting and testing principles of continuity-enhanced handovers in their local practices and share successes so that innovation and learning may spread easily among institutions and practices.
doi:10.1186/1472-6920-14-S1-S16
PMCID: PMC4304275  PMID: 25560954
3.  Sleep-disordered breathing and postoperative outcomes after bariatric surgery: Analysis of the Nationwide Inpatient Sample 
Obesity surgery  2013;23(11):1842-1851.
Background
Sleep-disordered breathing (SDB) has been increasingly recognized as a possible risk factor for adverse perioperative outcomes in non-bariatric surgeries. However, the impact of SDB on postoperative outcomes in patients undergoing bariatric surgery remains less clearly defined. We hypothesized that SDB would be independently associated with worse postoperative outcomes.
Methods
Data were obtained from the Nationwide Inpatient Sample database, and included a total of 91,028 adult patients undergoing bariatric surgeries from 2004 to 2008. The primary outcomes were in-hospital death, total charges and length of stay. There were two secondary outcomes of interest: respiratory and cardiac complications. Regression models were fitted to assess the independent association between SDB and the outcomes of interest.
Results
SDB was independently associated with decreased mortality (OR 0.34, 95% CI 0.23-0.50, p<0.001), total charges (-$869, p<0.001), and length of stay (-0.25 days, p<0.001). SDB was independently associated with significantly increased odds ratio of emergent endotracheal intubation (OR 4.35, 95% CI 3.97-4.77, p<0.001), noninvasive ventilation (OR 14.12, 95% CI 12.09-16.51, p<0.001), and atrial fibrillation (OR 1.25, 95% CI 1.11-1.41, p<0.001). Emergent intubation occurred significantly earlier in the postoperative course in patients with SDB. Although non-SDB patients had an overall lower risk of emergent intubation compared to SDB patients, their outcomes were significantly worse when they did get emergently intubated.
Conclusions
In this large nationally representative sample, despite the increased association of SDB with postoperative cardiopulmonary complications, the diagnosis of SDB was negatively, rather than positively, associated with in-hospital mortality and resource use.
doi:10.1007/s11695-013-0991-2
PMCID: PMC3791320  PMID: 23690272
Sleep-disordered breathing; bariatric surgery; obstructive sleep apnea; postoperative complications; intubation; respiratory failure; death; length of stay; cost
5.  What Do Patients Think About Year-End Resident Continuity Clinic Handoffs?: A Qualitative Study 
ABSTRACT
BACKGROUND
Although Internal Medicine year-end resident clinic handoffs affect numerous patients, little research has described patients’ perspectives of the experience.
OBJECTIVE
To describe patients’ perceptions of positive and negative experiences pertaining to the year-end clinic handoff; to rate patient satisfaction with aspects of the clinic handoff and identify whether or not patients could name their new physicians.
DESIGN
Qualitative study design using semi-structured interviews.
PARTICIPANTS
High-risk patients who underwent a year-end clinic handoff in July 2011.
MEASUREMENTS
Three months post-handoff, telephone interviews were conducted with patients to elicit their perceptions of positive and negative experiences. An initial coding classification was developed and applied to transcripts. Patients were also asked to name their primary care physician (PCP) and rate their satisfaction with the handoff.
RESULTS
In all, 103 telephone interviews were completed. Patient experiences regarding clinic handoffs were categorized into four themes: (1) doctor-patient relationships (i.e. difficulty building rapport); (2) clinic logistics (i.e. difficulty rescheduling appointments); (3) process of the care transition (i.e. patient unaware transition occurred); and (4) patient safety-related issues (i.e. missed tests). Only 59 % of patients could correctly name their new PCP. Patients who reported that they were informed of the clinic transition by letter or by telephone call from their new PCP were more likely to correctly name them (65 % vs. 32 % p = 0.007), report that their new doctor assumed care for them immediately (81 % [68/84] vs. 53 % [10/19], p = 0.009) and report satisfaction with communication between their old and new doctors (80 % [67/84] vs. 58 % [11/19], p = 0.04). Patients reported positive experiences such as learning more about their new physician through personal sharing, which helped them build rapport. Patients who reported being aware of the medical education mission of the clinic tended to be more understanding of the handoff process.
CONCLUSIONS
Patients face unique challenges during year-end clinic handoffs and provide insights into areas of improvement for a patient-centered handoff.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2395-3) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-013-2395-3
PMCID: PMC3710383  PMID: 23595932
outpatient handoffs; sign-out; resident continuity clinic; year-end transfer; transitions of care; patient-centered care; patient safety
6.  Participation and Experience of Third-Year Medical Students in Handoffs: Time to Sign Out? 
ABSTRACT
BACKGROUND
Although interns are expected to be competent in handoff communication, it is currently unclear what level of exposure, participation, and comfort medical students have with handoffs prior to graduation.
OBJECTIVE
The aim of this study is to characterize passive and active involvement of third-year medical students in the major components of the handoff process.
DESIGN
An anonymous voluntary retrospective cross-sectional survey administered in 2010.
PARTICIPANTS
Rising fourth-year students at two large urban private medical schools.
MAIN MEASURES
Participation and confidence in active and passive behaviors related to written signout and verbal handoffs during participants’ third-year clerkships.
KEY RESULTS
Seventy percent of students (n = 204) responded. As third-year medical students, they reported frequent participation in handoffs, such as updating a written signout for a previously admitted patient (58 %). Students who reported frequent participation (at least weekly) in handoff tasks were more likely to report being confident in that task (e.g., giving verbal handoff 62 % vs. 19 %, p < 0.001). Students at one site that did not have a handoff policy for medical students reported greater participation, more confidence, and less desire for training. Nearly all students believed they had witnessed an error in written signout (98 %) and almost two-thirds witnessed an error due to verbal handoffs (64 %).
CONCLUSIONS
During their third year, many medical students are participating in handoffs, although reported rates differ across training environments. Medical schools should consider the appropriate level of competence for medical student participation in handoffs, and implement corresponding curricula and assessment tools to ensure that medical students are able to effectively conduct handoffs.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2297-9) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2297-9
PMCID: PMC3710385  PMID: 23595921
signout; handoff; communication; medical student
7.  A novel mutation in LRSAM1 causes axonal Charcot-Marie-Tooth disease with dominant inheritance 
BMC Neurology  2014;14:118.
Background
Charcot-Marie-Tooth disease (CMT) refers to a heterogeneous group of genetic motor and sensory neuropathies. According to the primary site of damage, a distinction is made between demyelinating and axonal forms (CMT1 and 2, respectively, when inherited as an autosomal dominant trait). Leucine-rich repeat and sterile alpha motif-containing protein 1 (LRSAM1) is a ubiquitin-protein ligase with a role in sorting internalised cell-surface receptor proteins. So far, mutations in the LRSAM1 gene have been shown to cause axonal CMT in three different families and can confer either dominant or recessive transmission of the disease.
Case presentation
We have identified a novel mutation in LRSAM1 in a small family with dominant axonal CMT. Electrophysiological studies show evidence of a sensory axonal neuropathy and are interesting in so far as giant motor unit action potentials (MUAPs) are present on needle electromyography (EMG), while motor nerve conduction studies including compound motor action potential (CMAP) amplitudes are completely normal. The underlying mutation c.2046+1G >T results in the loss of a splice donor site and the inclusion of 63 additional base pairs of intronic DNA into the aberrantly spliced transcript. This disrupts the catalytically active RING (Really Interesting New Gene) domain of LRSAM1.
Conclusions
Our findings suggest that, beyond the typical length-dependent degeneration of motor axons, damage of cell bodies in the anterior horn might play a role in LRSAM1-associated neuropathies. Moreover, in conjunction with other data in the literature, our results support a model, by which disruption of the C-terminal RING domain confers dominant negative properties to LRSAM1.
doi:10.1186/1471-2377-14-118
PMCID: PMC4060843  PMID: 24894446
Axonal CMT; LRSAM1; Anterior horn cell disease; Splice site mutation; RING domain; Exome sequencing
8.  Sustainability and Effectiveness of a Quality Improvement Project to Improve Handoffs to Night Float Residents in an Internal Medicine Residency Program 
Background
Handoff is the process in which patient care is transitioned from one provider to another. In teaching hospitals, handoffs are frequent, and resident duty hour restrictions have increased the use of night float staff. To date, few studies have focused on long-term sustainability and effectiveness of a handoff quality improvement project.
Objective
The objective of our resident-driven quality improvement project was to evaluate the effectiveness and sustainability of a standardized template for handoff quality in a community hospital internal medicine program.
Methods
We used a multistep continuous quality improvement approach. Problems in the handoff process were identified through process mapping and anonymous needs assessment of the residents. A group of residents and faculty identified problems during biweekly discussions, created a standardized template, and adopted a new handoff process. We audited handoffs and surveyed residents at 3 and 9 months after implementation to assess effectiveness and sustainability.
Results
Before the intervention, only 40% of residents reported regular morning handoff. Using the standardized template, statistically significant, sustained improvements were seen in morning handoff frequency (59% preintervention, 90% at 3 months, 89% at 9 months), along with decreases in unreported overnight events (84% preintervention, 58% at 3 months, 50% at 9 months) and uncertainty about decisions because of poor handoffs (72% preintervention, 49% at 3 months, 37% at 9 months). Statistically significant decreases in missed content (69%–46%) and copy-and-paste behavior (78%–38%) at 3 months were not sustained.
Conclusions
We demonstrated sustained improvements in unreported events and uncertainty caused by poor handoffs. Initial improvements in missed content and copy-and-paste behavior that were not sustained suggest a need for ongoing reinforcement and monitoring of handoff quality.
doi:10.4300/JGME-D-12-00175.1
PMCID: PMC3693699  PMID: 24404278
9.  Resident Education in Free Clinics: An Internal Medicine Continuity Clinic Experience 
Background
Most internal medicine (IM) residency programs provide ambulatory training in academic medical centers. Community-based ambulatory training has been suggested to improve ambulatory and primary care education. Free clinics offer another potential training setting, but there have been few reports about the experience of IM residents in free clinics.
Objective
We assessed the feasibility and acceptability of inclusion of an ambulatory rotation in a free clinic and IM residency curriculum and the advantages of the free clinic setting over the traditional ambulatory clinic model.
Methods
In 2010, the University of Chicago Internal Medicine Residency Program partnered with a free clinic in order to establish a community-based continuity clinic experience. To assess the feasibility of this innovation, 16 residents were surveyed 9 months after implementation of the clinic to determine satisfaction, perceived preparation to address common medical conditions, and attitudes toward the underserved care population. A subset of these responses was compared to responses from residents in the traditional clinic model.
Results
Residents in the free clinic rotation were more satisfied and perceived they were more prepared to work in low-resource settings and reported similar levels of preparation regarding common outpatient conditions than residents in a traditional continuity clinic format. They reported increased future likelihood of working in an underserved clinic.
Conclusions
Our exploratory study suggests free clinics may be an effective platform for community-based continuity clinic training.
doi:10.4300/JGME-D-12-00127.1
PMCID: PMC3693704  PMID: 24404283
11.  Validation of a handoff assessment tool: the Handoff CEX 
Journal of clinical nursing  2012;22(0):1477-1486.
Aims and objectives
Test the feasibility and validity of a handoff evaluation tool for nurses.
Background
No validated tools exist to assess the quality of handoff communication during change of shift.
Design
Prospective cohort study.
Methods
A standardised tool, the Handoff CEX, was developed based on the mini-CEX. The tool consisted of seven domains scored on a 1–9 scale. Nurse educators observed shift-to-shift handoff reports among nurses and evaluated both the provider and recipient of the report. Nurses participating in the report simultaneously evaluated each other as part of their handoff.
Results
Ninety-eight evaluations were obtained from 25 reports. Scores ranged from 3–9 in all domains except communication and setting (4–9). Experienced (>five years) nurses received significantly higher mean scores than inexperienced (≤five years) nurses in all domains except setting and professionalism. Mean overall score for experienced nurses was 7·9 vs 6·9 for inexperienced nurses. External observers gave significantly lower scores than peer evaluators in all domains except setting. Mean overall score by external observers was 7·1 vs. 8·1 by peer evaluators. Participants were very satisfied with the evaluation (mean score 8·1).
Conclusions
A brief, structured handoff evaluation tool was designed that was well-received by participants, was felt to be easy to use without training, provided data about a wide range of communication competencies and discriminated well between experienced and inexperienced clinicians.
Relevance to clinical practice
This tool may be useful for educators, supervisors and practicing nurses to provide training, ongoing assessment and feedback to improve the quality of handoff.
doi:10.1111/j.1365-2702.2012.04131.x
PMCID: PMC3504166  PMID: 22671983
communication; evaluation; handover; nurses; nursing; nursing education; transfer of care
12.  IBCD: Development and Testing of a Checklist to Improve Quality of Care for Hospitalized General Medical Patients 
Background
Several studies have demonstrated the usefulness of medical checklists to improve quality of care in surgery and the ICU. The feasibility, effectiveness, and sustainability of a checklist was explored.
Methods
Literature on checklists and adherence to quality indicators in general medicine was reviewed to develop evidence-based measures for the IBCD checklist: (I) pneumococcal immunization (I), (B) pressure ulcers (bedsores), (C) catheter-associated urinary tract infections (CAUTIs), and (D) deep venous thrombosis (DVT) were considered conditions highly relevant to the quality of care in general medicine inpatients. The checklist was used by attending physicians during rounds to remind residents to perform four actions related to these measures. Charts were audited to document actions prompted by the checklist.
Results
The IBCD checklist was associated with significantly increased documentation of and adherence to care processes associated with these four quality indicators. Seventy percent (46/66) of general medicine teams during the intervention period of July 2010–March 2011 voluntarily used the IBCD checklist, for 1,168 (54%) of 2,161 patients. During the intervention period, average adherence for all four checklist items increased from 68% on admission to 82% after checklist use (p < .001). Average adherence after checklist use was also higher when compared to a historical control group from one year before implementation (82% versus 50%, p < .0001). In the six weeks after the checklist was transitioned to the electronic medical record (EMR), IBCD was noted in documentation of 133 (59%) of 226 patients admitted to general medicine.
Conclusion
A checklist is a useful and sustainable tool to improve adherence to, and documentation of, care processes specific to quality indicators in general medicine.
PMCID: PMC4005500  PMID: 23641534
13.  Development of a handoff evaluation tool for shift-to-shift physician handoffs: The handoff CEX 
Background
Increasing frequency of shift-to-shift handoffs coupled with regulatory requirements to evaluate handoff quality make a handoff evaluation tool necessary.
Objective
To develop a handoff evaluation tool
Design
Tool development
Setting
Two academic medical centers
Subjects
Nurse practitioners, medicine house staff and hospitalist attendings
Intervention
Concurrent peer and external evaluations of shift-to-shift handoffs.
Measurements
The Handoff CEX consists of 6 subdomains and one overall assessment, each scored from 1–9, where 1–3 is unsatisfactory and 7–9 is superior. We assessed range of scores, performance among subgroups, internal consistency, and agreement among types of raters.
Results
We conducted 675 evaluations of 97 unique individuals during 149 handoff sessions. Scores ranged from unsatisfactory to superior in each domain. The highest rated domain for handoff providers was professionalism (median 8, interquartile range [IQR] 7–9); the lowest was content (median 7, IQR 6–8). Scores at the two institutions were similar, and scores did not differ significantly by training level. Spearman correlation coefficients among the CEX sub-domains for provider scores ranged from 0.71–0.86, except for setting (0.39–0.40). Third-party external evaluators consistently gave lower marks for the same handoff than peer evaluators did. Weighted kappa scores for provider evaluations comparing external evaluators to peers ranged from 0.28 (95% CI, 0.01–0.56) for setting to 0.59 (0.38–0.80) for organization.
Conclusions
This handoff evaluation tool was easily used by trainees and attendings, had high internal consistency and performed similarly across institutions. Because peers consistently provided higher scores than external evaluators, this tool may be most appropriate for external evaluation.
doi:10.1002/jhm.2023
PMCID: PMC3621018  PMID: 23559502
handoff; evaluation; house staff; hospitalist; transfer of care
14.  Perceived Control and Sleep in Hospitalized Older Adults: A Sound Hypothesis? 
Background/Objectives
To examine the associations between perceived control over sleep, noise levels, sleep duration and noise complaints in a cohort of hospitalized adults.
Design
Prospective cohort study.
Setting
General medicine ward in an academic medical center.
Participants
118 hospitalized patients age 50 years and over (mean age 65 years, 57% female, 67% African American).
Measurements
Sleep duration was measured via wrist actigraphy and noise levels in patient rooms were measured via sound monitors. Validated questionnaires used to assess sleep characteristics at baseline and sleep quality for each night. Perceived control over sleep was measured at baseline using the Sleep Self-Efficacy (SSE) scale (range 9–45).
Results
Mean SSE score was 32.1 (SD = 9.4) and median score was 34 (IQR = 24–41). Average sleep duration for patients in the hospital was 333 minutes (5.5 hours). Forty-two percent of patients complained of noise disrupting their sleep. Linear regression clustered by subject showed that above median SSE was associated with longer sleep duration (+55 minutes 95%CI[14, 97], p=0.010). This association remained significant after controlling for objective noise levels and patient demographics (+50 minutes 95%CI [11, 90], p=0.014). In logistic regression controlling for noise level and patient demographics, those patients with high SSE were 51% less likely to complain of noise disruptions (OR=0.49 95%CI[0.25, 0.96], p=0.039).
Conclusion
Higher perceived control over sleep is associated with longer sleep duration, better sleep quality, and fewer reports of noise disruptions. In addition to noise control, interventions to boost perceived control may improve in-hospital sleep.
doi:10.1002/jhm.2027
PMCID: PMC3764606  PMID: 23504939
Hospitalized Patients; Sleep Quality; Perceived Control
15.  Supplementing Cross-Cover Communication with the Patient Acuity Rating 
ABSTRACT
BACKGROUND
Patient hand-offs at physician shift changes have limited ability to convey the primary team’s longitudinal insight. The Patient Acuity Rating (PAR) is a previously validated, 7-point scale that quantifies physician judgment of patient stability, where a higher score indicates a greater risk of clinical deterioration. Its impact on cross-covering physician understanding of patients is not known.
OBJECTIVE
To determine PAR contribution to sign-outs.
DESIGN
Cross-sectional survey.
SUBJECTS
Intern physicians at a university teaching hospital.
INTERVENTIONS
Subjects were surveyed using randomly chosen, de-identified patient sign-outs, previously assigned PAR scores by their primary teams. For each sign-out, subjects assigned a PAR score, then responded to hypothetical cross-cover scenarios before and after being informed of the primary team’s PAR.
MAIN MEASURE
Changes in intern assessment of the scenario before and after being informed of the primary team’s PAR were measured. In addition, responses between novice and experienced interns were compared.
KEY RESULTS
Between May and July 2008, 23 of 39 (59 %) experienced interns and 25 of 42 (60 %) novice interns responded to 480 patient scenarios from ten distinct sign-outs. The mean PAR score assigned by subjects was 4.2 ± 1.6 vs. 3.8 ± 1.8 by the primary teams (p < 0.001). After viewing the primary team’s PAR score, interns changed their level of concern in 47.9 % of cases, their assessment of the importance of immediate bedside evaluation in 48.7 % of cases, and confidence in their assessment in 43.2 % of cases. For all three assessments, novice interns changed their responses more frequently than experienced interns (p = 0.03, 0.009, and <0.001, respectively). Overall interns reported the PAR score to be theoretically helpful in 70.8 % of the cases, but this was more pronounced in novice interns (81.2 % vs 59.6 %, p < 0.001).
CONCLUSIONS
The PAR adds valuable information to sign-outs that could impact cross-cover decision-making and potentially benefit patients. However, correct training in its use may be required to avoid unintended consequences.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2257-4) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2257-4
PMCID: PMC3579954  PMID: 23129163
hospital medicine; medical education assessment methods; communication
16.  More Than Meets the Eye: Relationship Between Low Health Literacy and Poor Vision in Hospitalized Patients 
Journal of health communication  2013;18(0 1):197-204.
Patient-centered care includes involving patients and their families in self-management of chronic diseases. Identifying and addressing barriers to self-management, including those related to health literacy and vision limitations, may enhance one’s ability to self-manage. A set of brief verbal screening questions (BVSQ) that does not rely on sufficient vision to assess health literacy was developed by Chew and colleagues in the outpatient setting. We sought to evaluate the utility of this tool for hospitalized patients and to determine the prevalence of poor vision among inpatients. In a prospective study, the BVSQ and the Rapid Estimate of Adult Learning in Medicine–Revised (REALM-R; among participants with sufficient vision, ≥20/50 Snellen) were administered to general medicine inpatients. Of 893 participants, 79% were African-American, and 57% were female; the mean age was 53 years. Among 668 participants who completed both tools, the proportion with low health literacy was 38% with the BVSQ versus 47% with the REALM-R (p = .0001). Almost one fourth of participants had insufficient vision; participants with insufficient vision were more likely to be identified as having low health literacy by the BVSQ, compared to those with sufficient vision (59% vs. 38%, p < .001).
doi:10.1080/10810730.2013.830346
PMCID: PMC3807095  PMID: 24093356
17.  Religiosity, Spirituality, and End-of-Life Planning: A Single-Site Survey of Medical Inpatients 
Context
Prior studies suggest that terminally ill patients who use religious coping are less likely to have advance directives and more likely to opt for heroic end-of-life measures. Yet, no study to date has examined whether end-of-life practices are associated with measures of religiosity and spirituality.
Objectives
To assess the relationship between general measures of patient religiosity and spirituality and patients’ preferences for care at the end of life.
Methods
We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center. Primary outcomes were whether the patient had an advance directive, a do-not-resuscitate (DNR) order, a durable power of attorney for health care, and an informally designated decision maker. Primary predictors were religious attendance, intrinsic religiosity, and self-rated spirituality.
Results
The sample population (n=8,308) was predominantly African American (73%) and female (60%). In this population, 1.5% had advance directives and 10.4% had DNR orders. Half (51%) of patients had specified a decision maker. White patients were more likely than African-American patients to have an advance directive (adjusted odds ratio [OR] 2.1; 95% confidence interval [CI] 1.1, 4.0) and a DNR order (OR 1.7; 95% CI 1.0, 2.9). Patients reporting high intrinsic religiosity were more likely to have specified a decision maker than those with low intrinsic religiosity (OR 1.3; CI 1.1, 1.6). The same was true for those with high compared to low spirituality (OR 1.3; CI 1.1, 1.5). Religious characteristics were not significantly associated with having an advance directive or DNR order.
Conclusion
Among general medicine inpatients at an urban academic medical center, those who were highly religious and/or spiritual were more likely to have a designated decision-maker to help with end-of-life decisions, but did not differ from other patients in their likelihood of having an advance directive or DNR order.
doi:10.1016/j.jpainsymman.2011.12.277
PMCID: PMC3459155  PMID: 22727947
Advance directive; DNR order; religiosity; spirituality; end-of-life care; medical inpatient
18.  Outcomes for Resident-Identified High-Risk Patients and Resident Perspectives of Year-End Continuity Clinic Handoffs 
Journal of General Internal Medicine  2012;27(11):1438-1444.
BACKGROUND
Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.
OBJECTIVE
To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff
DESIGN
Retrospective cohort
PARTICIPANTS
Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009–2011. PGY2 IM residents surveyed from 2010–2011.
MEASUREMENTS
Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.
RESULTS
Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P < 0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p < 0.001) and those lost to follow-up (21 % vs. 17 % NSR, p = 0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as “theirs” until they are seen by them in clinic.
CONCLUSIONS
While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2100-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2100-y
PMCID: PMC3475812  PMID: 22644462
outpatient handoffs; signout; resident continuity clinic; year-end transfer; transitions of care
19.  Teaching the Use of Respiratory Inhalers to Hospitalized Patients with Asthma or COPD: a Randomized Trial 
Journal of General Internal Medicine  2012;27(10):1317-1325.
ABSTRACT
BACKGROUND
Hospitalized patients frequently misuse their respiratory inhalers, yet it is unclear what the most effective hospital-based educational intervention is for this population.
OBJECTIVE
To compare two strategies for teaching inhaler use to hospitalized patients with asthma or chronic obstructive pulmonary disease (COPD).
DESIGN
A Phase-II randomized controlled clinical trial enrolled hospitalized adults with physician diagnosed asthma or COPD.
PARTICIPANTS
Hospitalized adults (age 18 years or older) with asthma or COPD.
INTERVENTIONS
Participants were randomized to brief intervention [BI]: single-set of verbal and written step-by-step instructions, or, teach-to-goal [TTG]: BI plus repeated demonstrations of inhaler use and participant comprehension assessments (teach-back).
MAIN MEASURES
The primary outcome was metered-dose inhaler (MDI) misuse post-intervention (<75% steps correct). Secondary outcomes included Diskus® misuse, self-reported inhaler technique confidence and prevalence of 30-day health-related events.
KEY RESULTS
Of 80 eligible participants, fifty (63%) were enrolled (BI n = 26, TTG n = 24). While the majority of participants reported being confident with their inhaler technique (MDI 70%, Diskus® 94%), most misused their inhalers pre-intervention (MDI 62%, Diskus® 78%). Post-intervention MDI misuse was significantly lower after TTG vs. BI (12.5 vs. 46%, p = 0.01). The results for Diskus® were similar and approached significance (25 vs. 80%, p = 0.05). Participants with 30-day acute health-related events were less common in the group receiving TTG vs. BI (1 vs. 8, p = 0.02).
CONCLUSIONS
TTG appears to be more effective compared with BI. Patients over-estimate their inhaler technique, emphasizing the need for hospital-based interventions to correct inhaler misuse. Although TTG was associated with fewer post-hospitalization health-related events, larger, multi-centered studies are needed to evaluate the durability and clinical outcomes associated with this hospital-based education.
doi:10.1007/s11606-012-2090-9
PMCID: PMC3445679  PMID: 22592354
respiratory inhalers; teach-to-goal; hospitalized patients; health literacy; asthma; COPD
20.  Literacy-sensitive Intervention for COPD Patients 
doi:10.1007/s11606-012-2085-6
PMCID: PMC3514990  PMID: 22592352
21.  Interventions to Improve Outcomes for Minority Adults with Asthma: A Systematic Review 
Journal of General Internal Medicine  2012;27(8):1001-1015.
OBJECTIVES
To systematically review the literature to characterize interventions with potential to improve outcomes for minority patients with asthma.
DATA SOURCES
Medline, PsycINFO, CINAHL, Cochrane Trial Databases, expert review, reference review, meeting abstracts.
STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTEVENTIONS
Medical Subject Heading (MeSH) terms related to asthma were combined with terms to identify intervention studies focused on minority populations. Inclusion criteria: adult population; intervention studies with majority of non-White participants.
STUDY APPRAISAL AND SYNTHESIS OF METHODS
Study quality was assessed using Downs and Black (DB) checklists. We examined heterogeneity of studies through comparing study population, study design, intervention characteristics, and outcomes.
RESULTS
Twenty-four articles met inclusion criteria. Mean quality score was 21.0. Study populations targeted primarily African American (n = 14), followed by Latino/a (n = 4), Asian Americans (n = 1), or a combination of the above (n = 5). The most commonly reported post-intervention outcome was use of health care resources, followed by symptom control and self-management skills. The most common intervention-type studied was patient education. Although less-than half were culturally tailored, language-appropriate education appeared particularly successful. Several system–level interventions focused on specialty clinics with promising findings, although health disparities collaboratives did not have similarly promising results.
LIMITATIONS
Publication bias may limit our findings; we were unable to perform a meta-analysis limiting the review’s quantitative evaluation.
CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS
Overall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. Few were culturally tailored and one included a comparison group, limiting the conclusions that can be drawn from cultural tailoring. System-redesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Future research should evaluate the role of tailoring educational strategies, focus on patient-centered education, and incorporate outpatient follow-up and/or a team-based approach.
doi:10.1007/s11606-012-2058-9
PMCID: PMC3403146  PMID: 22798212
asthma; disparities; interventions; culturally tailored
22.  Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend? 
BACKGROUND
Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.
OBJECTIVE
To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.
DESIGN
Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.
PARTICIPANTS
Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.
MAIN MEASURES
Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.
KEY RESULTS
Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1–5 scale, in which 5 is “always” inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was “so they will reconsider staying in the hospital” (84.8% residents, 66.7% attendings, p = 0.008)
CONCLUSIONS
Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-1984-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-1984-x
PMCID: PMC3378751  PMID: 22331399
patient discharge; financial responsibility; hospital reimbursement
23.  Anticipated Consequences of the 2011 Duty Hours Standards: Views of Internal Medicine and Surgery Program Directors 
Academic Medicine  2012;87(7):895-903.
Purpose
To assess internal medicine (IM) and surgery program directors’ views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations.
Method
In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes.
Results
Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents’ relationships (P < 0.001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease.
Conclusions
IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.
doi:10.1097/ACM.0b013e3182584118
PMCID: PMC3386358  PMID: 22622221
24.  Expectations of iPad Use in an Internal Medicine Residency Program: Is It Worth the “Hype”? 
Background
While early reports highlight the benefits of tablet computing in hospitals, introducing any new technology can result in inflated expectations.
Objective
The aim of the study is to compare anticipated expectations of Apple iPad use and perceptions after deployment among residents.
Methods
115 internal medicine residents received Apple iPads in October 2010. Residents completed matched surveys on anticipated usage and perceptions after distribution 1 month prior and 4 months after deployment.
Results
In total, 99% (114/115) of residents responded. Prior to deployment, most residents believed that the iPad would improve patient care and efficiency on the wards; however, fewer residents “strongly agreed” after deployment (34% vs 15% for patient care, P<.001; 41% vs 24% for efficiency, P=.005). Residents with higher expectations were more likely to report using the iPad for placing orders post call and during admission (71% vs 44% post call, P=.01, and 16% vs 0% admission, P=.04). Previous Apple iOS product owners were also more likely to use the iPad in key areas. Overall, 84% of residents thought the iPad was a good investment for the residency program, and over half of residents (58%) reported that patients commented on the iPad in a positive way.
Conclusions
While the use of tablets such as the iPad by residents is generally well received, high initial expectations highlight the danger of implementing new technologies. Education on the realistic expectations of iPad benefits may be warranted.
doi:10.2196/jmir.2524
PMCID: PMC3650925  PMID: 23656727
iPad; mobile tablet computing; technology; expectation dynamics; hype
25.  The Patient Handoff: A Comprehensive Curricular Blueprint for Resident Education to Improve Continuity of Care 
In 2010, the Accreditation Council for Graduate Medical Education released its resident duty hours restrictions, requiring that faculty monitor their residents’ patient handoffs to ensure that residents are competent in handoff communications. Although studies have reported the need to improve the effectiveness of the handoff and a variety of curricula have been suggested and implemented, a common method for teaching and evaluating handoff skills has not been developed. Also in 2010, engineers, informaticians, and physicians interested in patient handoffs attended a symposium in Savannah, Georgia, hosted by the Association for Computing Machinery, entitled Handovers and Handoffs: Collaborating in Turns. As a result of this symposium, a workgroup formed to develop practical and readily implementable educational materials for medical educators involved in teaching patient handoffs to residents. In this article, the result of that yearlong collaboration, the authors aim to provide clarity on the definition of the patient handoff, to review the barriers to performing effective handoffs in academic health centers, to identify available solutions to improve handoffs, and to provide a structured approach to educating residents on handoffs via a curricular blueprint. The authors’ blueprint was developed to guide educators in customizing handoff education programs to fit their specific, local needs. Hopefully, it also will provide a starting point for future research into improving the patient handoff. Increasingly complex patient care environments require both innovations in handoff education and improvements in patient care systems to improve continuity of care.
doi:10.1097/ACM.0b013e318248e766
PMCID: PMC3409830  PMID: 22361791

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