Hospital economics of the hospitalist.

Objective: To determine the economic impact on the hospital of a hospitalist program and to develop insights into the relative economic importance of variables such as reductions in mean length of stay and cost, improvements in throughput (patients discharged per unit time), payer methods of reimbursement, and the cost of the hospitalist program.

Data Sources: The primary data source was Tufts-New England Medical Center in Boston. Patient demographics, utilization, cost, and revenue data were obtained from the hospital's cost accounting system and medical records.

Utilization of pulmonary function tests by primary care internists in a community hospital.

Objective: A quality assurance effort to evaluate the use of pulmonary function tests by primary care physicians. Specifically, to examine the patient's understanding of the test, the types of tests physicians order, and the appropriateness of the ordered tests for answering questions posed by physicians.

Design: Concurrent chart review, clinical interviews, and patient interviews.

Relationship between practice characteristics of primary care internists and unnecessary hospital days.

Background: Inpatient utilization review remains a useful approach for hospitals to achieve cost savings, however utilization review efforts need to become more focused and sophisticated.

Methods: In order to identify physicians with a higher percentage of unnecessary hospital days, and to analyze how their practice characteristics distinguished them from their colleagues, 364 consecutive admissions of 57 primary care internists were reviewed concurrently, on a daily basis. Days without acute hospital level of care that occurred while patients were awaiting placement in a rehabilitation or in a chronic care facility were adjusted out of the calculation.

The UR hot line: purpose and process.

Institutions embarking on utilization endeavors require mechanisms to identify and quantitate institution-specific problems. This article describes, with examples, the application of a utilization hot line as a cost-effective tool to focus efforts and solve immediate problems.

Sputum eosinophilia negates need to perform sputum Gram's stain.

A total of 1878 sputum specimens were evaluated to assess the potential of encountering a sputum Gram's stain with clinically useful positive data in the presence of sputum eosinophilia. Wet preparations were used to assess the adequacy of the specimen and to quantitate eosinophils. Quantitative sputum Gram's stains were performed.

Identifying physicians and patterns generating unnecessary in-hospital days. An exploratory stage of developing an institution-specific physician-focused utilization effort.

A focused, concurrent utilization review effort identified the existence of a large number of unnecessary hospital days remaining even after a highly successful utilization review effort. Within a group of physicians identified as having the highest acuteness adjusted average lengths of stay, 38.3% of their patient's hospital days were unnecessary, with 83% of those days being within physician control.

This OWL (outpatient work-up liaison) would not fly. Environmental factors foil attempt to shift unnecessary inpatient days to the outpatient setting.

The last days of many appropriate hospital admissions have been identified as unnecessary when utilized for providing diagnostic or therapeutic modalities that could be provided in an outpatient setting. An outpatient work-up liaison team (OWL) was established to facilitate the completion of evaluations or therapy in the community. In spite of the commitment of experienced personnel and the cooperation of the staff physicians and hospital departments, the effort was unsuccessful.

Comparison of efficiency of cardiologists and internists in managing patients with suspected myocardial chest pain.

The charts of 56 patients with chest pain who were admitted to the critical care units to rule out myocardial infarction were evaluated concurrently and retrospectively to compare the efficiency of cardiologists and internists. The number of unnecessary days used to rule out myocardial infarction, the number of unnecessary inhospital days used after ruling out myocardial infarction, the length of cardiac work-up, and the length of hospital stay were determined for 23 patients of cardiologists and 33 patients of internists. The cardiologists' patients had fewer unnecessary days after ruling out myocardial infarction (2.

Congenital bronchial atresia. A report of 4 cases and a review of the literature.

The clinical, radiographic, and pathologic findings in 82 patients with congenital bronchial atresia (CBA) have been reviewed, and we have discussed 4 additional cases. Most patients are asymptomatic and come to attention because of abnormal radiographic findings of a round or lobulated perihilar, solid, or cystic mass--the mucoid impaction sign. Typically, the region distal to the mass is hyperinflated.

Bacteriologic assessment of the lower respiratory tract in intubated patients.

Twelve patients with an endotracheal tube and a new infiltrate were assessed for differences in the bacteriologic information that could be obtained by routine tracheal suctioning (RTS), a double-lumen protected-sheath brush passed through a flexible fiberoptic bronchoscope (B-FFB), and suctioning through a flexible fiberoptic bronchoscope (S-FEB). Gram stains and cultures were performed on all specimens. There was 100% agreement for the culture results obtained by RTS and S-FEB.

Overutilization of serum electrolyte determinations in critical care units. Savings may be more apparent than real but what is real is of increasing importance.

Electrolyte (E) utilization by medical and surgical house staff in the critical care units of a community teaching hospital was audited over a two-month period. One hundred forty-five patients involved in 708 patient days had 924 sets of electrolytes (SE). Of the 581 SE that were ordered as an additional set within 24 h, 10% were considered unnecessary and 65% could have had a single E substituted for the complete set.

Relation of inspired oxygen fraction to hypoxemia in mechanically ventilated adults.

To evaluate the recommendation that all adult patients started on mechanical ventilation (MV) should have an initial fraction of inspired oxygen (FIO2) of 1.0, 207 consecutive adult patients started on MV in the critical care units were studied. The initial FIO2, the resultant PaO2, and the level of training of the physician ordering the initial ventilator settings were recorded for each patient.

Sputum and blood eosinophils during corticosteroid treatment of acute exacerbations of asthma.

Eleven patients with chronic bronchial asthma were studied during a noninfectious exacerbation. Each patient received 80 mg of prednisone daily for three days. Spirometric values, total blood eosinophil counts, and 24-hour quantitation of sputum eosinophils were studied.

Patient readmission to critical care units during the same hospitalization at a community teaching hospital.

The incidence and cause of patient readmission, during the same hospitalization, to a critical care unit was studied in an urban community teaching hospital. During a 12-month period, there were 1069 admissions to the critical care units with 640 patients being at risk for readmission. The readmission rate was 11.

Pulmonary effects of head trauma.

Knowledge of the interrelation of the central nervous system-respiratory axis is crucial to the management of patients with head injuries with or without concomitant pulmonary-thoracic problems. Damage to the central nervous system (CNS) can result in unexplained hypoxemia, noncardiac pulmonary edema, altered patterns of respiration, and an increased risk of aspiration. The damaged thorax and lung can contribute to brain ischemia and rises in intracranial pressure.

Pleural effusion in systemic lupus erythematosus.

Three cases of systemic lupus erythematosus (SLE) with pleural effusion are reviewed. The characteristics of the effusions are presented, and the literature pertaining to lupus-related effusions is reviewed. There is great heterogeneity in lupus pleural effusions.

Computer interpretation of pulmonary function tests.

A computer program for interpretation of pulmonary function tests, including flow-volume loops, lung volumes, and diffusing capacity, is described. Comparisons of data obtained before and after administration of bronchodilators and comparison with previous tests are also available as part of the program. Computer interpretation of pulmonary function testing accelerates the reporting of test data and may have a role in education in the discipline of respiratory medicine and related fields.