Association of weekend continuity of care with hospital length of stay.

Objective: The purpose of this study was to evaluate the association of physician continuity of care with length of stay, likelihood of weekend discharge, in-hospital mortality and 30-day readmission.

Design: A cohort study of hospitalized medical patients. The primary exposure was the weekend usual provider continuity (UPC) over the initial weekend of care.

Monitoring the pulse of hospital activity: electronic health record utilization as a measure of care intensity.

Background: Hospital care on weekends has been associated with reduced quality and poor clinical outcomes, suggesting that decreases in overall intensity of care may have important clinical effects. We describe a new measure of hospital intensity of care based on utilization of the electronic health record (EHR).

Methods: We measured global intensity of care at our academic medical center by monitoring the use of the EHR in 2011.

Guided ordering: clinician interactions with complex order-sets.

Background: Electronic order-sets increasingly ask clinicians to answer questions or follow algorithms. Cooperation with such requests has not been studied.

Setting: Internal Medicine service of an academic medical center.

Risk-adjusted mortality: problems and possibilities.

The ratio of observed-to-expected deaths is considered a measure of hospital quality and for this reason will soon become a basis for payment. However, there are drivers of that metric more potent than quality: most important are medical documentation and patient acuity. If hositals underdocument and therefore do not capture the full "expected mortality" they may be tempted to lower their observed/expected ratio by reducing "observed mortality" through limiting access to the very ill.

How do internal medicine residency programs evaluate their resident float experiences?

Objectives: We surveyed the nation's internal medicine residency training program directors to determine the range and frequency of existing methods by which float experiences are evaluated.

Methods: We sent questionnaires to the program directors of all 396 internal medicine residency training program sites in the country. Information requested included program characteristics, months devoted to float experiences in each year of training, and the location and purpose of the rotation.

Effect of implementing pain management standards.

Background: Historical undertreatment of pain among inpatients has resulted in a national requirement for pain practice standards.

Objective: We hypothesized that adoption/promulgation of practice standards in January 2003 at 1 suburban teaching hospital progressively increased compliance with those standards and decreased pain.

Design: We retrospectively reviewed medical records each month during 2003, when pain standards were adopted with repeated, institution-wide, and nursing-unit-based interventions.

Pounds of cure: chart weight as a measure of service intensity.

Intensity of hospital services is often estimated by length of stay (LOS). Increasing demands for documentation in the medical record suggested to us an alternate method: weighing the chart. In a retrospective study, we compared LOS and chart weight as predictors of actual hospital costs at a community teaching hospital.

Assigning patients with heart failure to observation status: B-type natriuretic peptide, ejection fraction, or physician judgment.

It is of clinical and financial importance to identify those heart failure patients who are likely to improve rapidly. The authors evaluated, as predictors of short-term resolution, three clinical variables often used to predict long-term outcome. Consenting patients admitted to the emergency department with dyspnea were examined daily until resolution (symptom reversion to baseline absent worsening clinical signs or x-ray).

Assessing quality and efficiency of discharge summaries.

Discharge summaries are intended to transfer important clinical information from inpatient to outpatient settings and between hospital admissions. The authors created a point scale that rated summaries in 4 key areas and applied the scale at a community teaching hospital over 3 years. Charts of 150 patients were selected equally from those discharged early and late in the academic year.

Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.

Background: There is limited information concerning the risks for, and occurrence of, cardiovascular complications because of GI endoscopy. Published data are based on questionnaire surveys, which have a potential for bias. Moreover, available studies pertain exclusively to out-patients.

A randomized trial of initial warfarin dosing based on simple clinical criteria.

Warfarin induction is accomplished by titrating dosage to coagulation test results. Algorithms can guide this process but not identify the starting dose. We hypothesized that an initial warfarin dose approximating the maintenance value would safely enhance rapidity of induction.

Can computerized cost data substitute for chart review?

Identification of alternatives to manual chart review might improve efficiency in quality improvement work. This study at a large community teaching hospital in central New Jersey considered whether selected charges from a patient-level costs database could identify compliance with Sixth Scope of Work indicators in congestive heart failure (CHF). Charges resulting from specific tests, from test outcomes, and from prescribed treatments were identified from among 75 randomly chosen patients with CHF.

Actual and potential effects of medical resident coverage on reimbursement for inpatient visits by attending physicians.

Context: The impact of residents on hospital finance has been studied; there are no data describing the economic effect of residents on attending physicians.

Objective: In a community teaching hospital, we compared allowable inpatient visit codes and payments (based on documentation in the daily progress notes) between a general medicine teaching unit and nonteaching general medicine units.

Design: Retrospective chart review, matched cohort study.