A Program to Support Scholarship During Internal Medicine Residency Training: Impact on Academic Productivity and Resident Experiences

Problem: Although scholarship during residency training is an important requirement from the Accreditation Council for Graduate Medical Education, efforts to support resident scholarship have demonstrated inconsistent effects and have not comprehensively evaluated resident experiences. Intervention: We developed the Leadership and Discovery Program (LEAD) to facilitate scholarship among all non-research-track categorical internal medicine (IM) residents. This multifaceted program set expectations for all residents to participate in a scholarly project, supported faculty to manage the program, facilitated access to faculty mentors, established a local resident research day to highlight scholarship, and developed a didactic lecture series. Context: We implemented LEAD at a large university training program. We assessed resident scholarship before and after LEAD implementation using objective metrics of academic productivity (i.e., scientific presentations, peer-reviewed publications, and both presentations and publications). We compared these metrics in LEAD participants and a similar historical group of pre-LEAD controls. We also assessed these outcomes over the same two periods in research track residents who participated in research training independent from and predating LEAD (research track controls and pre-LEAD research track controls). We conducted focus groups to qualitatively assess resident experiences with LEAD. Outcome: Compared to 63 pre-LEAD controls, greater proportions of 52 LEAD participants completed scientific presentations (48.1% vs. 28.6%, p = .03) and scientific presentations and peer-reviewed publications (23.1% vs. 9.5%, p = .05). No significant differences existed for any academic productivity metrics among research track controls and pre-LEAD research track controls (p > .23, all comparisons). Perceived facilitators of participation in LEAD included residents' desire for research experiences and opportunities to publish prior to fellowship training; the main barrier to participation was feeling overwhelmed due to the time constraints imposed by clinical training. Suggestions for improvement included establishing clearer programmatic expectations and providing lists of potential mentors and projects. Lessons Learned: Implementation of a multifaceted program to support scholarship during residency was associated with significant increases in academic productivity among IM residents. Residents perceived that programs to support scholarship during residency training should outline clear expectations and identify available mentors and projects for residents who are challenged by the time constraints of clinical training.

Developing a team science workshop for early-career investigators

INTRODUCTION

High impact biomedical research is increasingly conducted by large, transdisciplinary, multisite teams in an increasingly collaborative environment. Thriving in this environment requires robust teamwork skills, which are not acquired automatically in the course of traditional scientific education. Team science skills training does exist, but most is directed at clinical care teams, not research teams, and little is focused on the specific training needs of early-career investigators, whose early team leadership experiences may shape their career trajectories positively or negatively. Our research indicated a need for team science training designed specifically for early-career investigators.

METHODS

To address this need, we designed and delivered a 2-day workshop focused on teaching team science skills to early-career investigators. We operationalized team science competencies, sought the advice of team science experts, and performed a needs assessment composed of a survey and a qualitative study. Through these multiple approaches, we identified and grouped training priorities into three broad training areas and developed four robust, hands-on workshop sessions.

RESULTS

Attendees comprised 30 pre- and post-doc fellows (TL1) and early-career faculty (KL2 and K12). We assessed impact with a pre- and post-workshop survey adapted from the Team Skills Scale. Results from the pre- and post-test Wilcoxon signed-rank analysis (n = 25) showed statistically significant improvement in team science skills and confidence. Open-ended responses indicated that the workshop focus was appropriate and well targeted to the trainees' needs.

CONCLUSIONS

Although team science education is still very much in its infancy, these results suggest that training targeted to early-career investigators improves team skills and may foster improved collaboration.

Assessing Competencies in a Master of Science in Clinical Research Program: The Comprehensive Competency Review

Competencies in Master of Science Clinical Research programs are becoming increasingly common. However, students and programs can only benefit fully from competency-based education if students' competence is formally assessed. Prior to a summative assessment, students must have at least one formative, formal assessment to be sure they are developing competence appropriate for their stage of training. This paper describes the comprehensive competency review (CCR), a milestone for MS students in Clinical Research at the University of Pittsburgh's Institute for Clinical Research Education. The CCR involves metacognitive reflection of the student's learning as a whole, written evidence of each competency, a narrative explaining the choice of evidence for demonstrating competencies, and a meeting in which two faculty members review the evidence and solicit further oral evidence of competence. CCRs allow for individualized feedback at the midpoint in degree programs, providing students with confidence that they will have the means and strategies to develop competence in all areas by the summative assessment of competence at their thesis defense. CCRs have also provided programmatic insight on the need for curricular revisions and additions. These benefits outweigh the time cost on the part of students and faculty in the CCR process.

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients.

Effectiveness of a physical activity and weight loss intervention for middle-aged women: healthy bodies, healthy hearts randomized trial

BACKGROUND

Physical inactivity is a significant risk factor for cardiovascular disease and remains highly prevalent in middle-aged women.

OBJECTIVE

We hypothesized that an interventionist-led (IL), primary-care-based physical activity (PA) and weight loss intervention would increase PA levels and decrease weight to a greater degree than a self-guided (SG) program.

DESIGN

We conducted a randomized trial.

PARTICIPANTS

Ninety-nine inactive women aged 45-65 years and with BMI ≥ 25 kg/m(2) were recruited from three primary care clinics.

INTERVENTIONS

The interventionist-led (IL) group (n = 49) had 12 weekly sessions of 30 min discussions with 30 min of moderate-intensity PA. The self-guided (SG) group (n = 50) received a manual for independent use.

MAIN MEASURES

Assessments were conducted at 0, 3, and 12 months; PA and weight were primary outcomes. Weight was measured with a standardized protocol. Leisure PA levels were assessed using the Modifiable Activity Questionnaire. Differences in changes by group were analyzed with a t-test or Wilcoxon rank-sum test. Mixed models were used to analyze differences in changes of outcomes by group, using an intention-to-treat principle.

KEY RESULTS

Data from 98 women were available for analysis. At baseline, mean (SD) age was 53.9 (5.4) years and 37 % were black. Mean weight was 92.3 (17.7) kg and mean BMI was 34.7 (5.9) kg/m(2). Median PA level was 2.8 metabolic equivalent hours per week (MET-hour/week) (IQR 0.0, 12.0). At 3 months, IL women had a significantly greater increase in PA levels (7.5 vs. 1.9 MET-hour/week; p = 0.02) than SG women; there was no significant difference in weight change. At 12 months, the difference between groups was no longer significant (4.7 vs. 0.7 MET-hour/week; p = 0.38). Mixed model analysis showed a significant (p = 0.048) difference in PA change between groups at 3 months only.

CONCLUSIONS

The IL intervention was successful in increasing the physical activity levels of obese, inactive middle-aged women in the short-term. No significant changes in weight were observed.

Characterization of investigators' approach to translational research: a qualitative study

BACKGROUND

Little is known about how investigators approach their research programs along the translational research continuum. Many consider the translational continuum to be linear, with research beginning at the bench and concluding with research at the bedside or in the community. We aimed to understand if translational investigators approach and view their research in this fashion.

METHODS

We conducted semistructured individual interviews with 16 graduates of the University of Pittsburgh's Multidisciplinary Clinical Research Scholars Program (KL2) in 2012.

RESULTS

Our research revealed three characteristic models. The first model we called "linear" and represented the traditional approach. The second we called "holistic"; these investigators began with central research questions and sought to explore them in every direction of translation, not necessarily taking linear steps. The third model we called "technical"; in this model, investigators focused on a unique technology or methodology and applied it across multiple research contexts.

CONCLUSION

This study found that there are multiple ways that translational investigators approach their research program. Better understanding of these models can help educators and mentors guide investigators so that they can be more productive in their clinical or translational research career.

Shortening the Work Preference Inventory for use with physician scientists: WPI-10

The Work Preference Inventory (WPI) is a four-factor, 30-item measure that assesses work motivation. Used to help individuals choose appropriate career paths, its length contributes to response burden, especially when combined with other measures. We aimed to develop a shortened, valid, and reliable version of the WPI. Trainees at the University of Pittsburgh's Institute for Clinical Research Education completed the 30-item WPI between 2007 and 2012. We conducted exploratory and confirmatory factor analyses to reduce the number of items. Of the 402 eligible trainees, 371 (92%) provided data for the exploratory factor analysis (EFA), and 134 of the eligible 144 trainees (93%) provided data for the confirmatory factor analysis (CFA). EFA revealed four factors that were roughly equivalent to those of the original. CFA used the three items with the highest loadings on each factor, with two items removed due to low loadings and R-squareds, resulting in a 10-item scale. Cronbach's alpha for each of the four factors ranged from 0.68 to 0.76. Factors in the WPI-10 were strongly and significantly associated with factors in the original WPI, indicating strong validity of the shortened measure. The WPI-10 shows evidence for similar validity and reliability to the original instrument while reducing respondent burden.

Measurement of social capital among clinical research trainees

While physical and human capital are established as important predictors of success among early-career clinical investigators, less is known about the role of social capital. The authors aimed to develop a brief scale to assess social capital in this population and test its reliability and validity. A three-item assessment was developed based on a conceptual framework and measures of social capital from other fields and was administered to 414 clinical research trainees at the University of Pittsburgh in 2007-2012. The measure exhibited good internal consistency reliability (α = 0.71) and a normal distribution. On a 10-point scale, mean social capital was 6.4 (SD = 1.7). Social capital was significantly associated with 7 of the 9 expected constructs: sex, age, confidence in research skills, work-related motivation, burnout, and social support. Exploratory multivariable regression analysis demonstrated that social capital was most strongly associated with higher research confidence (β = 0.35, p < 0.001), higher extrinsic motivation (β = 0.50, p = 0.003), and lower burnout (ptrend = 0.02). This three-item scale measures social capital in this population with adequate internal consistency reliability, face validity, and construct validity. This brief assessment provides a tool that may be valuable to benchmark social capital of clinical research trainees and to better contextualize programmatic and trainee outcomes.

A shortened version of the Clinical Research Appraisal Inventory: CRAI-12

PURPOSE

The original Clinical Research Appraisal Inventory (CRAI), which assesses the self-confidence of trainees in performing different aspects of clinical research, comprises 92 items. Completing the lengthy CRAI is time-consuming and represents a considerable burden to respondents, yet the CRAI provides useful data for evaluating research training programs. The purpose of this study is to develop a shortened version of the CRAI and to test its validity and reliability.

METHOD

Trainees in clinical research degree and career development programs at the University of Pittsburgh's Institute for Clinical Research Education completed the 92-item CRAI between 2007 and 2012, inclusive. The authors conducted, first, exploratory factor analysis on a training dataset (2007-2010) to reduce the number of items and, then, confirmatory factor analyses on a testing dataset (2011-2012) to test the psychometric properties of the shortened version.

RESULTS

Of 546 trainees, 394 (72%) provided study data. Exploratory factor analysis revealed six distinct factors, and confirmatory factor analysis identified the two items with the highest loadings per factor, for a total of 12 items. Cronbach alpha for the six new factors ranged from 0.80 to 0.94. Factors in the 12-item CRAI were strongly and significantly associated with factors in the 92-item CRAI; correlations ranged from 0.82 to 0.96 (P < .001 for each).

CONCLUSIONS

The 12-item CRAI is faster and less burdensome to complete but retains the strong psychometric properties of the original CRAI.

Doctoral programs to train future leaders in clinical and translational science

PURPOSE

Although the National Institutes of Health (NIH) has made extensive investments in educational programs related to clinical and translational science (CTS), there has been no systematic investigation of the number and characteristics of PhD programs providing training to future leaders in CTS. The authors undertook to determine the number of institutions that, having had received NIH-funded Clinical and Translational Science Awards (CTSAs), currently had or were developing PhD programs in CTS; to examine differences between programs developed before and after CTSA funding; and to provide detailed characteristics of new programs.

METHOD

In 2012, CTS program leaders at the 60 CTSA-funded institutions completed a cross-sectional survey focusing on four key domains related to PhD programs in CTS: program development and oversight; students; curriculum and research; and milestones.

RESULTS

Twenty-two institutions had fully developed PhD programs in CTS, and 268 students were earning PhDs in this new field; 13 institutions were planning PhD programs. New programs were more likely to have fully developed PhD competencies and more likely to include students in medical school, students working only on their PhD, students working on a first doctoral degree, and students working in T1 translational research. They were less likely to include physicians and students working in clinical or T2 research.

CONCLUSIONS

Although CTS PhD programs have similarities, they also vary in their characteristics and management of students. This may be due to diversity in translational science itself or to the relative infancy of CTS as a discipline.

Development, implementation, and evaluation of an interprofessional course in translational research

The advancement of research from basic science discovery to clinical application requires the extensive collaboration of individuals from multiple disciplines, therefore the ability to work as an effective interprofessional team is essential for researchers in clinical and translational science (CTS). Courses that build interprofessional skills are a key component in CTS education, but the development of these courses poses numerous administrative and educational challenges. This paper describes the processes of designing, implementing, and evaluating an innovative graduate-level course that combines online lectures and in-class facilitated group discussions to promote interprofessional interactions. The course offers students the opportunity to interact with and learn from individuals in a variety of disciplines, and it requires students to engage in interprofessional group work to meet the course objectives. During the past 4 years, 96 students from the schools of medicine, pharmacy, nursing, public health, and health and rehabilitation sciences at a large urban university have completed the course. The course has been well-received, with 87% of students rating its overall quality as excellent, good, or satisfactory. The course offers educators a model to teach graduate students the skills that are essential for becoming effective CTS researchers.

Information primary care physicians want to receive about their hospitalized patients

BACKGROUND AND OBJECTIVES

Communication between physicians caring for hospitalized patients and those patients' primary care providers (PCPs) is often suboptimal, which can lead to diminished health care quality and safety. It is unclear what hospital information PCPs would find most valuable in their patients' continuing care, as is how and when they would prefer to receive such information.

METHODS

Using the modified Delphi survey methodology, we developed a consensus list of information items PCPs want to receive about their hospitalized patients, using general internists and family physicians considered experts in primary care. Panelists rated items on a 5-point Likert scale signifying their level of agreement with the information's importance and with the information communication mode. Consensus agreement or disagreement was determined using 95% confidence intervals.

RESULTS

Twelve physicians (five family physicians, seven general internists), averaging 19.6 years of primary care experience, participated in Delphi round 1; 41.6% (37 of 89) of the items were accepted by consensus, one item was rejected (receiving daily progress notes), and the remaining 51 items were equivocal. In round 2, nine physician panelists participated (four family physicians, five general internists), and six additional items were accepted. They generally preferred notification at the patient's first hospital interaction and at discharge. No consensus was found regarding communication mode; e-mail was most favored.

CONCLUSIONS

We found broad areas of consensus regarding information PCPs wish to receive about their hospitalized patients that are generally consistent with previous surveys. Our findings also suggest that physicians are becoming more comfortable with patient-related electronic communications.

A comprehensive career-success model for physician-scientists

With today's focus on the translation of basic science discoveries into clinical practice, the demand for physician-scientists is growing. Yet, physicians have always found it challenging to juggle the demands of clinical care with the time required to perform research. The Research on Careers Workgroup of the Institute for Clinical Research Education at the University of Pittsburgh developed a comprehensive model for career success that would address, and allow for the evaluation of, the personal factors, organizational factors, and their interplay that contribute to career success. With this model, leaders of training programs could identify early opportunities for intervening with potential physician-scientists to ensure career success. Through an iterative process described in this article, the authors identified and examined potential models for career success from the literature, added other elements determined to be significant, and developed a comprehensive model to assess factors associated with career success for physician-scientists. The authors also present examples of ways in which this model can be adapted and applied to specific situations to assess the effects of different factors on career success.

Are hot flashes associated with sleep disturbance during midlife? Results from the STRIDE cohort study

OBJECTIVE

Sleep disturbance and hot flashes are common during menopause, but their association is not well understood. We sought to understand the associations among sleep disturbance and the frequency, bothersomeness, and interference of hot flashes in mid-life women.

STUDY DESIGN

STRIDE is a study of women ages 40-65 years at varied menopausal stages. We examined the cross-sectional associations of sleep disturbance with the frequency and bothersomeness of hot flashes, and interference of hot flashes with work, social, and leisure activities during the 2nd year of STRIDE.

MAIN OUTCOME MEASURE

Self-reported sleep disturbance.

RESULTS

Of the 623 women with complete data, 370 (59%) reported having hot flashes. Bivariate analyses showed that reporting hot flashes with bother, but not hot flashes alone, was associated with sleep disturbance (odds ratio [OR] [95% confidence interval (CI)]: 2.8 [2.0-4.0] and 1.3 [0.7-2.5], respectively). In multivariable models, women reporting bothersome hot flashes were more likely to report sleep disturbance (OR [95% CI]: 2.1 [1.4-3.2]) compared to women who reported no hot flashes. When the perceived interference of hot flashes with work, social activities, and leisure activities were included in the model, the relationships between bothersome hot flashes and sleep disturbance disappeared.

CONCLUSIONS

Hot flashes are not associated with sleep disturbance, unless they are bothersome. Mid-life patients should routinely be queried about the bothersomeness of their hot flashes.

The impact of menopause on health-related quality of life: results from the STRIDE longitudinal study

PURPOSE

We examine the impact of menopausal status, beyond menopausal symptoms, on health-related quality of life (HRQoL).

METHODS

Seven hundred thirty-two women aged 40-65, regardless of health condition or menopausal status, were enrolled from single general internal medicine practice. Women completed annual questionnaires including HRQoL, and menopausal status and symptoms.

RESULTS

The physical health composite of the RAND-36 is lower in late peri (45.6, P < .05), early post (45.4, P < .05), and late postmenopausal women (44.6, P < .01), and those who report a hysterectomy (44.2, P < .01) compared to premenopausal women (47.1), with effect sizes of Cohen's d = .12-.23. The mental health composite of the RAND-36 is lower in late peri (44.7, P < .01), early post (44.9, P < .01), and late postmenopausal women (45.0, P < .05) and those who report a hysterectomy (44.2, P < .01) compared to premenopausal women (46.8), with effect sizes of Cohen's d = .15-.20. Findings are comparable adjusted for menopausal symptom frequency and bother.

CONCLUSIONS

Over a 5-year follow-up period, we found a negative impact of menopause on some domains of HRQoL, regardless of menopausal symptoms. Clinicians should be aware of this relationship and work to improve HRQoL, rather than expect it to improve spontaneously when menopausal symptoms resolve.

Burnout among early career clinical investigators

Burnout is a pervasive problem among clinicians. However, little is known about burnout among early career clinical investigators, who must balance clinical responsibilities with challenges related to research. We aimed to determine the prevalence of and demographic associations with burnout in a cohort of early career clinical investigators. A cross-sectional questionnaire was administered to 179 trainees at the University of Pittsburgh Institute for Clinical Research Education in 2007-2008. We used chi-square analyses and Fisher's exact test to determine whether associations between demographic characteristics and burnout were significant. Of the participants, 29 (16%) reported feeling burned out. Burnout was more prevalent among those over 35 years of age relative to their younger counterparts (29% vs. 13%, p= 0.01) and among females relative to males (22% vs. 10%, p= 0.03). With regard to race and ethnicity, burnout was most common among underrepresented minorities (30%) followed by Caucasians (18%) and Asians (3%); these differences were significant (p= 0.02). Considering the early career status of these research trainees, rates of burnout were concerning. Certain demographic subgroups-including older trainees, females, and underrepresented minorities-had particularly high rates of burnout and may benefit from interventions that provide them with skills needed to sustain successful clinical research careers. Clin Trans Sci 2010; Volume 3: 186-188.

Psychometric properties of the mentor role instrument when used in an academic medicine setting

The Ragins and McFarlin Mentor Role Instrument (RMMRI) was originally developed to measure perceptions of mentoring relationships in research and development organizations. The current study was designed to evaluate the RMMRI's reliability and validity when the instrument was administered to clinical and translational science trainees at an academic medical center. The 33-item RMMRI was administered prospectively to a cohort of 141 trainees at the University of Pittsburgh in 2007-2008. Likert-scale items focused on perceptions of five mentoring roles in the career dimension (sponsor, coach, protector, challenger, and promoter) and six mentoring roles in the psychosocial dimension (friend, social associate, parent, role model, counselor, and acceptor). Outcome items included overall perceptions of mentoring satisfaction and effectiveness. Of 141 trainees, 53% were male, 66% were white, 22% were Asian, and 59% were medical doctors. Mean age was 32 years. Analyses showed strong within-factor inter-item correlations (Pearson Coefficients of 0.57-0.93); strong internal consistency (Cronbach alphas of 0.82-0.97); confirmatory factorial validity, as demonstrated by confirmatory factor analysis of the two mentoring dimensions, 11 mentoring roles, and 33 RMMRI items; and concurrent validity, as demonstrated by strong correlations (Pearson Coefficients of 0.56-0.71) between mentoring dimensions, satisfaction, and effectiveness. This article concludes that the RMMRI shows reliability and validity in capturing the multidimensional nature of mentoring when administered to clinical and translational science trainees in the academic setting.

Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial

CONTEXT

Depressive symptoms commonly follow coronary artery bypass graft (CABG) surgery and are associated with less positive clinical outcomes.

OBJECTIVE

To test the effectiveness of telephone-delivered collaborative care for post-CABG depression vs usual physician care.

DESIGN, SETTING, AND PARTICIPANTS

Single-blind effectiveness trial at 7 university-based and community hospitals in or near Pittsburgh, Pennsylvania. Participants were 302 post-CABG patients with depression (150, intervention; 152, usual care) and a comparison group of 151 randomly sampled post-CABG patients without depression recruited between March 2004 and September 2007 and observed as outpatients until June 2008.

INTERVENTION

Eight months of telephone-delivered collaborative care provided by nurses working with patients' primary care physicians and supervised by a psychiatrist and primary care physician from this study.

MAIN OUTCOME MEASURES

Mental health-related quality of life (HRQL) measured by the Short Form-36 Mental Component Summary (SF-36 MCS) at 8-month follow-up; secondary outcome measures included assessment of mood symptoms (Hamilton Rating Scale for Depression [HRS-D]), physical HRQL (SF-36 PCS), and functional status (Duke Activity Status Index [DASI]); and hospital readmissions.

RESULTS

The intervention patients reported greater improvements in mental HRQL (all P < or = .02) (SF-36 MCS: Delta, 3.2 points; 95% confidence interval [CI], 0.5-6.0), physical functioning (DASI: Delta, 4.6 points; 95% CI, 1.9-7.3), and mood symptoms (HRS-D: Delta, 3.1 points; 95% CI, 1.3-4.9); and were more likely to report a 50% or greater decline in HRS-D score from baseline (50.0% vs 29.6%; number needed to treat, 4.9 [95% CI, 3.2-10.4]) than usual care patients (P < .001). Men with depression were particularly likely to benefit from the intervention (SF-36 MCS: Delta, 5.7 points; 95% CI, 2.2-9.2; P = .001). However, the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group.

CONCLUSION

Compared with usual care, telephone-delivered collaborative care for treatment of post-CABG depression resulted in improved HRQL, physical functioning, and mood symptoms at 8-month follow-up.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00091962.

Pulmonary embolism incidence is increasing with use of spiral computed tomography

BACKGROUND

Pulmonary embolism causes significant morbidity in hospitalized patients, yet few studies have explored the impact of spiral computed tomography (CT) scanning on diagnosis and clinical outcome.

METHODS

Incidence rates of pulmonary embolism, chest and spiral CT rates, D-dimer assay, anticoagulation, and in-hospital mortality were assessed on statewide pulmonary embolism discharge data (1997-2001) from the Pennsylvania Health Care Cost Containment Council.

RESULTS

The incidence of pulmonary embolism increased from 47 to 63 per 100,000 patients from 1997 to 2001 (mean of 0.004% per year, P < .001). Mean pulmonary embolism incidence rates were higher for African American patients (0.031% per year higher than for white patients), patients aged 70 years or more (0.007% higher than for patients aged<70 years), and female patients (0.013% higher than for male patients) (all P < .001). Concomitantly, the proportion undergoing CT (including spiral) scans increased from 23.23% to 45.18% (odds ratio=1.30; P<.001), controlling for age, gender, race, and cancer, whereas rates for other procedures remained unchanged. By comparing 1999 and before with 2000 and after, there was a significant decrease in the 2 highest Atlas Severity of Illness categories (49.4%-37.7%) and a significant increase in the 3 lowest categories (50.6%-62.3%; P < .001). The risk of in-hospital deaths among patients with pulmonary embolism decreased in this period from 12.8% to 11.1% (P < .001).

CONCLUSION

The incidence of pulmonary embolism is increasing with the increasing use of spiral CT scans, with a lower severity of illness and lower mortality, suggesting the increase is due to earlier diagnosis.

A risk score to predict arrhythmias in patients with unexplained syncope

OBJECTIVES

To develop and validate a risk score predicting arrhythmias for patients with syncope remaining unexplained after emergency department (ED) noninvasive evaluation.

METHODS

One cohort of 175 patients with unexplained syncope (Geneva, Switzerland) was used to develop and cross-validate the risk score; a second cohort of 269 similar patients (Pittsburgh, PA) was used to validate the system. Arrhythmias as a cause of syncope were diagnosed by cardiac monitoring or electrophysiologic testing. Data from the patient's history and 12-lead emergency electrocardiography (ECG) were used to identify predictors of arrhythmias. Logistic regression was used to identify predictors for the risk-score system. Risk-score performance was measured by comparing the proportions of patients with arrhythmias at various levels of the score and receiver operating characteristic (ROC) curves.

RESULTS

The prevalence of arrhythmic syncope was 17% in the derivation cohort and 18% in the validation cohort. Predictors of arrhythmias were abnormal ECG (odds ratio [OR]: 8.1, 95% confidence interval [CI]=3.0 to 22.7), a history of congestive heart failure (OR: 5.3, 95% CI=1.9 to 15.0), and age older than 65 (OR: 5.4, 95% CI=1.1 to 26.0). In the derivation cohort, the risk of arrhythmias ranged from 0% (95% CI=0 to 6) in patients with no risk factors to 6% (95% CI=1 to 15) for patients with one risk factor, 41% (95% CI=26 to 57) for patients with two risk factors, and 60% (95% CI = 32 to 84) for those with three risk factors. In the validation cohort, these proportions varied from 2% (95% CI=0 to 7) with no risk factors to 17% (95% CI=10 to 27) with one risk factor, 35% (95% CI=24 to 46) with two risk factors, and 27% (95% CI=6 to 61) with three risk factors. Areas under the ROC curves ranged from 0.88 (95% CI=0.84 to 0.91) for the derivation cohort to 0.84 (95% CI=0.77 to 0.91) after cross-validation within the same cohort and 0.75 (95% CI=0.68 to 0.81) for the external validation cohort.

CONCLUSIONS

In patients with unexplained syncope, a risk score based on clinical and ECG factors available in the ED identifies patients at risk for arrhythmias.

Assessment of mortality after long-term follow-up of patients with community-acquired pneumonia

Although studies have assessed short-term mortality among patients with community-acquired pneumonia, there is limited data on prognosis and risk factors that affect long-term mortality. The mortality among patients enrolled at 4 sites of the Pneumonia Patient Outcome Research Team cohort study who survived at least 90 days after presentation to the hospital was compared with that among age-matched control subjects. Overall, 1419 of 1555 patients survived for >90 days, with a mean follow-up period of 5.9 years. There was significantly higher long-term mortality among patients with pneumonia than among age-matched controls. Factors significantly associated with long-term mortality were age (stratified by decade), do-not-resuscitate status, poor nutritional status, pleural effusion, glucocorticoid use, nursing home residence, high school graduation level or less, male sex, preexisting comorbid illnesses, and the lack of feverishness. This study demonstrates that there is significantly higher long-term mortality among patients with pneumonia than among age-matched controls and that long-term mortality largely is not affected by acute physiologic derangements.

Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: a randomized controlled trial

PURPOSE

Patients with pneumonia often remain hospitalized after they are stable clinically, and the duration of intravenous antibiotic therapy is a rate-limiting step for discharge. The purpose of this study was to determine whether implementation of an evidence-based guideline would reduce the duration of intravenous antibiotic therapy and length of stay for patients hospitalized with pneumonia.

METHODS

In a seven-site, cluster randomized clinical trial, we enrolled 325 control and 283 intervention patients who were admitted by one of 116 physician groups. Within site, physician groups were assigned randomly to receive a practice guideline alone (control arm) or a practice guideline that was implemented using a multifaceted strategy (intervention arm). The effectiveness of guideline implementation was measured by the duration of intravenous antibiotic therapy and length of stay; differences in the rates of discontinuation and hospital discharge were assessed with proportional hazards models. Medical outcomes were assessed at 30 days.

RESULTS

Intravenous antibiotic therapy was discontinued somewhat more quickly in the intervention group (hazard ratio [HR] =1.23; 95% confidence interval [CI]: 1.00 to 1.52; P = 0.06) than in the control group. Intervention patients were discharged more quickly, but the difference was not statistically significant (HR = 1.16; 95% CI: 0.97 to 1.38; P = 0.11). Fewer intervention (55% [157/283]) than control (63% [206/325]) patients had medical complications during the index hospitalization (P = 0.04), with no differences in other medical outcomes, including mortality, rehospitalization, and return to usual activities, between treatment arms.

CONCLUSIONS

The multifaceted guideline implementation strategy resulted in a slight reduction in the duration of intravenous antibiotic therapy and a nonsignificant reduction in length of stay, without affecting patient outcomes.

Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria

Despite careful evaluation of changes in hospital care for community-acquired pneumonia (CAP), little is known about intensive care unit (ICU) use in the treatment of this disease. There are criteria that define CAP as "severe," but evaluation of their predictive value is limited. We compared characteristics, course, and outcome of inpatients who did (n = 170) and did not (n = 1,169) receive ICU care in the Pneumonia Patient Outcomes Research Team prospective cohort. We also assessed the predictive characteristics of four prediction rules (the original and revised American Thoracic Society criteria, the British Thoracic Society criteria, and the Pneumonia Severity Index [PSI]) for ICU admission, mechanical ventilation, medical complications, and death (as proxies for severe CAP). ICU patients were more likely to be admitted from home and had more comorbid conditions. Reasons for ICU admission included respiratory failure (57%), hemodynamic monitoring (32%), and shock (16%). ICU patients incurred longer hospital stays (23.2 vs. 9.1 days, p < 0.001), higher hospital costs (21,144 dollars vs. 5,785 dollars, p < 0.001), more nonpulmonary organ dysfunction, and higher hospital mortality (18.2 vs. 5.0%, p < 0.001). Although ICU patients were sicker, 27% were of low risk (PSI Risk Classes I-III). Severity-adjusted ICU admission rates varied across institutions, but mechanical ventilation rates did not. The revised American Thoracic Society criteria rule was the best discriminator of ICU admission and mechanical ventilation (area under the receiver operating characteristic curve, 0.68 and 0.74, respectively) but none of the prediction rules were particularly good. The PSI was the best predictor of medical complications and death (area under the receiver operating characteristic curve, 0.65 and 0.75, respectively), but again, none of the prediction rules were particularly good. In conclusion, ICU use for CAP is common and expensive but admission rates are variable. Clinical prediction rules for severe CAP do not appear adequately robust to guide clinical care at the current time.

A randomized trial using computerized decision support to improve treatment of major depression in primary care

OBJECTIVE

To examine whether feedback and treatment advice for depression presented to primary care physicians (PCPs) via an electronic medical record (EMR) system can potentially improve clinical outcomes and care processes for patients with major depression.

DESIGN

Randomized controlled trial.

SETTING

Academically affiliated primary care practice in Pittsburgh, PA.

PATIENTS

Two hundred primary care patients with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD) and who met all protocol-eligibility criteria.

INTERVENTION

PCPs were randomly assigned to 1 of 3 levels of exposure to EMR feedback of guideline-based treatment advice for depression: "active care" (AC), "passive care" (PC), or "usual care" (UC).

MEASUREMENTS AND MAIN RESULTS

Patients' 3- and 6-month Hamilton Rating Scale for Depression (HRS-D) score and chart review of PCP reports of depression care in the 6 months following the depression diagnosis. Only 22% of patients recovered from their depressive episode at 6 months (HRS-D </=7). Patients' mean HRS-D score decreased regardless of their PCPs' guideline-exposure condition (20.4 to 14.2 from baseline to 6-month follow-up; P <.001). However, neither continuous (HRS-D </=7: 22% AC, 23% PC, 22% UC; P =.8) nor categorical measures of recovery (P =.2) differed by EMR exposure condition upon follow-up. Care processes for depression were also similar by PCP assignment despite exposure to repeated reminders of the depression diagnosis and treatment advice (e.g., depression mentioned in >/=3 contacts with usual PCP at 6 months: 31% AC, 31% PC, 18% UC; P =.09 and antidepressant medication suggested/prescribed or baseline regimen modified at 6 months: 59% AC, 57% PC, 52% UC; P =.3).

CONCLUSIONS

Screening for major depression, electronically informing PCPs of the diagnosis, and then exposing them to evidence-based treatment recommendations for depression via EMR has little differential impact on patients' 3- or 6-month clinical outcomes or on process measures consistent with high-quality depression care.

Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia

BACKGROUND

Investigating claims that patients are being sent home from the hospital "quicker and sicker" requires a way of objectively measuring appropriateness of hospital discharge.

OBJECTIVE

To define and validate a simple, usable measure of clinical stability on discharge for patients with community-acquired pneumonia.

METHODS

Information on daily vital signs and clinical status was collected in a prospective, multicenter, observational cohort study. Unstable factors in the 24 hours prior to discharge were temperature greater than 37.8 degrees C, heart rate greater than 100/min, respiratory rate greater than 24/min, systolic blood pressure lower than 90 mm Hg, oxygen saturation lower than 90%, inability to maintain oral intake, and abnormal mental status. Outcomes were deaths, readmissions, and failure to return to usual activities within 30 days of discharge.

RESULTS

Of the 680 patients, 19.1% left the hospital with 1 or more instabilities. Overall, 10.5% of patients with no instabilities on discharge died or were readmitted compared with 13.7% of those with 1 instability and 46.2% of those with 2 or more instabilities (P<.003). Instability on discharge (> or =1 unstable factor) was associated with higher risk-adjusted rates of death or readmission (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.8) and failure to return to usual activities (OR, 1.5; 95% CI, 1.0-2.4). Patients with 2 or more instabilities had a 5-fold greater risk-adjusted odds of death or readmission (OR, 5.4; 95% CI, 1.6-18.4).

CONCLUSIONS

Instability on discharge is associated with adverse clinical outcomes. Pneumonia guidelines and pathways should include objective criteria for judging stability on discharge to ensure that efforts to shorten length of stay do not jeopardize patient safety.

Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study

BACKGROUND

To our knowledge, no previous study has systematically examined pneumonia-related and pneumonia-unrelated mortality. This study was performed to identify the cause(s) of death and to compare the timing and risk factors associated with pneumonia-related and pneumonia-unrelated mortality.

METHODS

For all deaths within 90 days of presentation, a synopsis of all events preceding death was independently reviewed by 2 members of a 5-member review panel (C.M.C., D.E.S., T.J.M., W.N.K., and M.J.F.). The underlying and immediate causes of death and whether pneumonia had a major, a minor, or no apparent role in the death were determined using consensus. Death was defined as pneumonia related if pneumonia was the underlying or immediate cause of death or played a major role in the cause of death. Competing-risk Cox proportional hazards regression models were used to identify baseline characteristics associated with mortality.

RESULTS

Patients (944 outpatients and 1343 inpatients) with clinical and radiographic evidence of pneumonia were enrolled, and 208 (9%) died by 90 days. The most frequent immediate causes of death were respiratory failure (38%), cardiac conditions (13%), and infectious conditions (11%); the most frequent underlying causes of death were neurological conditions (29%), malignancies (24%), and cardiac conditions (14%). Mortality was pneumonia related in 110 (53%) of the 208 deaths. Pneumonia-related deaths were 7.7 times more likely to occur within 30 days of presentation compared with pneumonia-unrelated deaths. Factors independently associated with pneumonia-related mortality were hypothermia, altered mental status, elevated serum urea nitrogen level, chronic liver disease, leukopenia, and hypoxemia. Factors independently associated with pneumonia-unrelated mortality were dementia, immunosuppression, active cancer, systolic hypotension, male sex, and multilobar pulmonary infiltrates. Increasing age and evidence of aspiration were independent predictors of both types of mortality.

CONCLUSIONS

For patients with community-acquired pneumonia, only half of all deaths are attributable to their acute illness. Differences in the timing of death and risk factors for mortality suggest that future studies of community-acquired pneumonia should differentiate all-cause and pneumonia-related mortality.

Community-acquired pneumonia and do not resuscitate orders

OBJECTIVES

From a cohort of patients with community-acquired pneumonia (CAP) who required admission to hospital, to describe the subset of patients having a do not resuscitate (DNR) order and to compare them with those who did not have such an order.

DESIGN

Retrospective subset analysis of data from the pneumonia patient outcomes research team study.

SETTING

Three hospitals in the United States and one in Canada.

PARTICIPANTS

Hospitalized patients aged 18 and older with CAP.

MEASUREMENTS

Sociodemographic features, severity of illness, antibiotic therapy, length of stay, mortality, admission to special care units, and mortality attributable to pneumonia.

RESULTS

The 199 (14.9) of 1,339 inpatients with CAP who had a DNR order written within 24 hours of admission and an additional 96 (7.2) patients who had such an order written later were compared with the 1,044 who never had a DNR order. The 199 patients with an initial DNR and 96 later DNR were older (median age 81 and 78 vs 65 years, respectively; P< .001), more likely to be white (92.5 and 90.6 vs 84.8; P = .007), and more likely to have come from a nursing home or chronic care facility (53.8 and 31.3 vs 4.5; P< .001). The two DNR groups received more antibiotics for a longer time than the never DNR patients. The DNR patients had longer lengths of stay than the never DNR patients (medians 9 and 12 vs 7 days). There were 89 in-hospital deaths among the 1,339 patients, but only 11 of these were among patients who did not have a DNR order during the first 30 days (sensitivity, specificity, and positive and negative predictive values of a DNR order for in-hospital mortality were 87.6, 82.6, 26.4, and 98.9, respectively). The 90-day mortality rates were 43.2 for the initial DNR group, 61.5 in the later DNR group, and 4.7 for the never DNR group (P< .001). Pneumonia-attributable mortality accounted for most of the in-hospital deaths but did not differ by DNR status. Only 31.7 of the initial DNR patients and 24.0 of the later DNR patients were discharged home, versus 82.6 of the other patients (P< .001). In a multivariate analysis, the following were predictive of initial DNR: age, nursing home care, active cancer, dementia, neuromuscular disorders, altered mental status, low systolic blood pressure, tachypnea, abnormal hematocrit, abnormal blood urea nitrogen, and absence of alcohol or intravenous drug abuse. In similar analyses of DNR at any time, additional predictors included aspiration, low white blood count, chronic pulmonary disease, cerebrovascular disease, and congestive heart failure.

CONCLUSION

Most in-hospital pneumonia deaths occur in patients who have a DNR order. DNR orders written within 24 hours of admission primarily reflect comorbid status, whereas DNR orders written later during hospitalization reflect the futility of care plus comorbidity.

Patient satisfaction in resident and attending ambulatory care clinics

OBJECTIVE

To measure and compare patient satisfaction with care in resident and attending physician internal medicine ambulatory care clinics.

DESIGN

A cross-sectional survey using a questionnaire derived from the Visit-Specific Satisfaction Questionnaire (VSQ) and Patient Satisfaction Index (PSI) distributed from March 1998 to May 1998.

SETTING

Four clinics based at a university teaching hospital and the associated Veterans' Affairs (VA) hospital.

PARTICIPANTS

Two hundred eighty-eight patients of 76 resident and 25 attending physicians.

RESULTS

Patients of resident physicians at the university site were more likely to be African American, male, have lower socioeconomic status and have lower physical and mental health scores on the Short Form-12 than patients of university attendings. Patients of resident and attending physicians at the VA site were similar. In multivariate analyses, patients of university attending physicians were more likely to be highly satisfied than patients of university residents on the VSQ-Physician (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.8) and the PSI-Physician (OR, 10.1; 95% CI, 3.7 to 27.4) summary scores. Differences were not seen on the summary scores at the VA site. Two individual items displayed significant differences between residents and attendings at both sites: "personal manner (courtesy, respect, sensitivity, friendliness) of the doctor" (P <or= .03 at both sites) and "my doctor always treats me with the highest respect" (P < .001 at both sites).

CONCLUSIONS

After controlling for patient characteristics, patients of resident physicians were less satisfied than those of attending physicians, especially in regard to the doctor's personal manner and respect toward the patient. Medical education should continue to emphasize the importance of these aspects of the physician-patient encounter.

Arterial blood gas and pulse oximetry in initial management of patients with community-acquired pneumonia

OBJECTIVE

To identify the factors associated with the use of arterial blood gas (ABG) and pulse oximetry (PO) in the initial management of patients with community-acquired pneumonia (CAP) and arterial hypoxemia at presentation.

PARTICIPANTS

A total of 944 outpatients and 1,332 inpatients with clinical and radiographic evidence of CAP prospectively enrolled from 5 study sites in the United States and Canada.

ANALYSES

Separate multivariate logistic regression analyses were used to 1) compare measurement of ABG and PO within 48 hours of presentation across sites while controlling for patient differences, and 2) identify factors associated with arterial hypoxemia (PaO2 <60 mm Hg or SaO2 <90% for non-African Americans and <92% for African Americans) while breathing room air.

RESULTS

Range of ABG use by site was from 0% to 6.4% (P =.06) for outpatients and from 49.2% to 77.3% for inpatients (P <.001), while PO use ranged from 9.4% to 57.8% for outpatients (P <.001) and from 47.9% to 85.1% for inpatients (P <.001). Differences among sites remained after controlling for patient demographic characteristics, comorbidity, and illness severity. In patients with 1 or more measurements of oxygenation at presentation, hypoxemia was independently associated with 6 risk factors: age >30 years (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7 to 5.9), chronic obstructive pulmonary disease (OR, 1.9; 95% CI, 1.4 to 2.6), congestive heart failure (OR, 1.5; 95% CI, 1.0 to 2.1), respiratory rate >24 per minute (OR, 2.3; 95% CI, 1.8 to 3.0), altered mental status (OR, 1.6; 95% CI, 1.1 to 2.3), and chest radiographic infiltrate involving >1 lobe (OR, 2.2; 95% CI, 1.7 to 2.9). The prevalence of hypoxemia among those tested ranged from 13% for inpatients with no risk factors to 54.6% for inpatients with > or =3 risk factors. Of the 210 outpatients who had > or =2 of these risk factors, only 64 (30.5%) had either an ABG or PO performed. In the 48 outpatients tested without supplemental O2 with > or =2 risk factors 8.3% were hypoxemic.

CONCLUSIONS

In the initial management of CAP, use of ABG and PO varied widely across sites. Increasing the assessment of arterial oxygenation among patients with CAP is likely to increase the detection of arterial hypoxemia, particularly among outpatients.

Diagnostic evaluation and management of patients with syncope

This article focuses on the evaluation of patients with syncope, a symptom not a disease. Syncope is a transient loss of consciousness associated with loss of postural tone with spontaneous recovery. The authors discuss the utility of an indications for different diagnostic tests, the indications for hospital admission, and the management of patients with certain known causes of syncope, including vasovagal and arrhythmic.

The electronic medical record. A randomized trial of its impact on primary care physicians' initial management of major depression [corrected]

BACKGROUND

Inadequate treatments are reported for depressed patients cared for by primary care physicians (PCPs). Providing feedback and evidence-based treatment recommendations for depression to PCPs via electronic medical record improves the quality of interventions.

METHODS

Patients presenting to an urban academically affiliated primary care practice were screened for major depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility criteria and completed a baseline interview. They were cared for by 16 board-certified internists, who were electronically informed of their patients' diagnoses, and randomized to 1 of 3 methods of exposure to guideline-based advice for treating depression (active, passive, and usual care). Ensuing treatment patterns were assessed by medical chart review and by patient self-report at baseline and 3 months.

RESULTS

Median time for PCP response to the electronic message regarding the patient's depression diagnosis was 1 day (range, 1-95 days). Three days after notification, 120 (65%) of 186 PCP responses indicated agreement with the diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Primary care physicians who agreed with the diagnoses sooner were more likely to make a medical chart notation of depression, begin antidepressant medication therapy, or refer to a mental health specialist (P<.001). There were no differences in the agreement rate or treatments provided across guideline exposure conditions.

CONCLUSIONS

Electronic feedback of the diagnosis of major depression can affect PCP initial management of the disorder. Further study is necessary to determine whether this strategy, combined with delivery of treatment recommendations, can improve clinical outcomes in routine practice.

Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia

PURPOSE

Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia.

SUBJECTS AND METHODS

As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports.

RESULTS

The median total cost of hospitalization for all 982 inpatients was $5, 942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P <0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay.

CONCLUSIONS

Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings.

Clinical presentation, processes and outcomes of care for patients with pneumococcal pneumonia

OBJECTIVE

To describe the presentation, resolution of symptoms, processes of care, and outcomes of pneumococcal pneumonia, and to compare features of the bacteremic and nonbacteremic forms of this illness.

DESIGN

A prospective cohort study.

SETTING

Five medical institutions in 3 geographic locations.

PARTICIPANTS

Inpatients and outpatients with community-acquired pneumonia (CAP).

MEASUREMENTS

Sociodemographic characteristics, respiratory and nonrespiratory symptoms, and physical examination findings were obtained from interviews or chart review. Severity of illness was assessed using a validated prediction rule for short-term mortality in CAP. Pneumococcal pneumonia was categorized as bacteremic; nonbacteremic, pure etiology; or nonbacteremic, mixed etiology.

MAIN RESULTS

One hundred fifty-eight (6.9%) of 2,287 patients (944 outpatients, 1,343 inpatients) with CAP had pneumococcal pneumonia. Sixty-five (41%) of the 158 with pneumococcal pneumonia were bacteremic; 74 (47%) were nonbacteremic with S. pneumoniae as sole pathogen; and 19 (12%) were nonbacteremic with S. pneumoniae as one of multiple pathogens. The pneumococcal bacteremia rate for outpatients was 2.6% and for inpatients it was 6.6%. Cough, dyspnea, and pleuritic pain were common respiratory symptoms. Hemoptysis occurred in 16% to 22% of the patients. A large number of nonrespiratory symptoms were noted. Bacteremic patients were less likely than nonbacteremic patients to have sputum production and myalgias (60% vs 82% and 33% vs 57%, respectively; P <.01 for both), more likely to have elevated blood urea nitrogen and serum creatinine levels, and more likely to receive penicillin therapy. Half of bacteremic patients were in the low risk category for short-term mortality (groups I to III), similar to the nonbacteremic patients. None of the 32 bacteremic patients in risk groups I to III died, while 7 of 23 (30%) in risk group V died. Intensive care unit admissions and pneumonia-related mortality were similar between bacteremic and nonbacteremic groups, although 46% of the bacteremic group had respiratory failure compared with 32% and 37% for the other groups. The nonbacteremic pure etiology patients returned to household activities faster than bacteremic patients. Symptoms frequently persisted at 30 days: cough (50%); dyspnea (53%); sputum production (48%); pleuritic pain (13%); and fatigue (63%).

CONCLUSIONS

There were few differences in the presentation of bacteremic and nonbacteremic pneumococcal pneumonia. About half of bacteremic pneumococcal pneumonia patients were at low risk for mortality. Symptom resolution frequently was slow.

The electronic medical record: its role in disseminating depression guidelines in primary care practice

OBJECTIVE

Using the Agency for Health Care Policy and Research Depression Guideline Panel's recommendations as its focus, this article describes a step-by-step approach for disseminating a paper-based depression guideline to primary care physicians via a commercially available electronic medical record (EMR) system.

METHOD

Description of the author's approach to disseminate an evidence-based depression treatment guideline to a group of primary care physicians using a commercially available EMR system and to evaluate the results.

RESULTS

We review clinical considerations and practical barriers faced in this process with the expectation that our experiences can guide others attempting to disseminate psychiatric treatment guideline via EMR systems.

CONCLUSIONS

The EMR offers critical efficiencies in disseminating state-of-the-art clinical practice guidelines and in directing the primary care physicians' use of them. Still, well-designed, randomized controlled trials are necessary to demonstrate their effectiveness at enhancing patient outcomes for major depression in primary care settings.

Variation in length of hospital stay in patients with community-acquired pneumonia: are shorter stays associated with worse medical outcomes?

PURPOSE

To assess the variation in length of stay for patients hospitalized with community-acquired pneumonia and to determine whether patients who are treated in hospitals with shorter mean stays have worse medical outcomes.

SUBJECTS AND METHODS

We prospectively studied a cohort of 1,188 adult patients with community-acquired pneumonia who had been admitted to one community and three university teaching hospitals. We compared patients' mean length of stay, mortality, hospital readmission, return to usual activities, return to work, and pneumonia-related symptoms among the four study hospitals. All outcomes were adjusted for baseline differences in severity of illness and comorbidity.

RESULTS

Adjusted interhospital differences in mean length of stay ranged from 0.9 to 2.3 days (P <0.001). When the risk of each medical outcome was compared between patients admitted to the hospital with the shortest length of stay and those admitted to longer stay hospitals, there were no differences in mortality [relative risk (RR) = 0.7; 95% CI, 0.3 to 1.7], hospital readmission (RR = 0.8; 95% CI, 0.5 to 1.2), return to usual activities (RR = 1.1; 95% CI, 0.9 to 1.3), or return to work (RR = 1.2; 95% CI, 0.8 to 2.0) during the first 14 days after discharge, or in the mean number of pneumonia-related symptoms 30 days after admission (P = 0.54).

CONCLUSIONS

We observed substantial interhospital variation in the lengths of stay for patients hospitalized with community-acquired pneumonia. The finding that medical outcomes were similar in patients admitted to the hospital with the shortest length of stay and those admitted to hospitals with longer mean lengths of stay suggests that hospitals with longer stays may be able to reduce the mean duration of hospitalization for this disease without adversely affecting patient outcomes.

Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study

BACKGROUND

Although understanding the processes of care and medical outcomes for patients with community-acquired pneumonia is instrumental to improving the quality and cost-effectiveness of care for this illness, limited information is available on how physicians manage patients with this illness or on medical outcomes other than short-term mortality.

OBJECTIVES

To describe the processes of care and to assess a broad range of medical outcomes for ambulatory and hospitalized patients with community-acquired pneumonia.

METHODS

This prospective, observational study was conducted at 4 hospitals and 1 health maintenance organization in Pittsburgh, Pa, Boston, Mass, and Halifax, Nova Scotia. Data were collected via patient interviews and reviews of medical records for 944 outpatients and 1343 inpatients with clinical and radiographic evidence of community-acquired pneumonia. Processes of care and medical outcomes were assessed 30 days after presentation.

RESULTS

Only 29.7% of outpatients had 1 or more microbiologic tests performed, and only 5.7% had an assigned microbiologic cause. Although 95.7% of inpatients had 1 or more microbiologic tests performed, a cause was established in only 29.6%. Six outpatients (0.6%) died, and 3 of these deaths were pneumonia related. Of surviving outpatients, 8.0% had 1 or more medical complications. At 30 days, 88.9% (nonemployed) to 95.6% (employed) of the surviving outpatients had returned to usual activities, yet 76.0% of outpatients had 1 or more persisting pneumonia-related symptoms. Overall, 107 inpatients (8.0%) died, and 81 of these deaths were pneumonia related. Most surviving inpatients (69.0%) had 1 or more medical complications. At 30 days, 57.3% (non-employed) to 82.0% (employed) of surviving inpatients had returned to usual activities, and 86.1% had 1 or more persisting pneumonia-related symptoms.

CONCLUSIONS

In this study, conducted primarily at hospital sites with affiliated medical education training programs, virtually all outpatients and most inpatients had pneumonia of unknown cause. Although outpatients had an excellent prognosis, pneumonia-related symptoms often persisted at 30 days. Inpatients had substantial mortality, morbidity, and pneumonia-related symptoms at 30 days.

Do symptoms predict cardiac arrhythmias and mortality in patients with syncope?

BACKGROUND

Patients with syncope frequently present with multitude of other symptoms but their significance in predicting morbidity or mortality has not been previously studied.

OBJECTIVE

To determine if certain symptoms can be used to identify syncope patients at risk for cardiac arrhythmias, mortality, or recurrence of syncope.

PATIENTS AND METHODS

From August 1987 to February 1991, we prospectively evaluated patients with syncope from outpatient, inpatient, and emergency department services of a university medical center. These patients were interviewed, charts were reviewed, and detailed information on 19 symptoms and comorbidities was obtained. A cause of syncope was assigned using standardized diagnostic criteria. All patients were followed up at 3-month intervals for at least 1 year for recurrence of syncope and mortality. Patients in whom the cause of syncope was determined by medical history and physical examination alone were not included in our analysis.

RESULTS

History and physical examination led to the cause of syncope in 222 of 497 patients enrolled. In the remaining 275 patients, the absence of nausea and vomiting before syncope (odds ratio, 7.1) and electrocardiographic abnormalities (odds ratio, 23.5) were predictors of arrhythmic syncope. Underlying cardiac disease was the only predictor of 1-year mortality. No symptom remained as independent predictor for 1-year mortality or syncope recurrence.

CONCLUSIONS

Symptoms, although important in assigning many noncardiac causes, are not useful in risk-stratifying patients whose cause of syncope cannot be identified by other history and physical examination. Triage decisions and management plans should be based on pre-existing cardiac disease or electrocardiographic abnormalities, which are important predictors of arrhythmic syncope and mortality.

Using a tilt table to evaluate syncope

Upright tilt testing is commonly used in the evaluation of patients with syncope to provoke hypotension and/or bradycardia in the laboratory. The most common type of response is provocation of neurally mediated syndrome (vasovagal syncope). The American College of Cardiology Expert Consensus has proposed indications for tilt testing. The most common indication is recurrent syncope of unexplained cause. Upright tilt testing methods have not been standardized. The most common protocols in this country use a tilt angle of 60-80 degrees and use isoproterenol infusion after a period of drug-free tilt testing. The sensitivity of upright tilt testing is estimated to be 67-83%, and the specificity is between 75 and 100%. The reproducibility of the test has been variable. In patients with unexplained syncope, positive responses are found to be 50% without the use of isoproterenol and 64% with the use of isoproterenol. Many different treatments have been used. At this time, there is no consensus regarding the most effective treatment. Beta-blockers and fludrocortisone plus salt are the most commonly used drugs. Pacemakers have been used, but their role is ill-defined at this time.

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia

OBJECTIVES

The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia.

METHODS

Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology.

RESULTS

Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners.

CONCLUSIONS

Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.

Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines

CONTEXT

Many groups have developed guidelines to shorten hospital length of stay in pneumonia in order to decrease costs, but the length of time until a patient hospitalized with pneumonia becomes clinically stable has not been established.

OBJECTIVE

To describe the time to resolution of abnormalities in vital signs, ability to eat, and mental status in patients with community-acquired pneumonia and assess clinical outcomes after achieving stability.

DESIGN

Prospective, multicenter, observational cohort study.

SETTING

Three university and 1 community teaching hospital in Boston, Mass, Pittsburgh, Pa, and Halifax, Nova Scotia.

PATIENTS

Six hundred eighty-six adults hospitalized with community-acquired pneumonia.

MAIN OUTCOME MEASURES

Time to resolution of vital signs, ability to eat, mental status, hospital length of stay, and admission to an intensive care, coronary care, or telemetry unit.

RESULTS

The median time to stability was 2 days for heart rate (< or =100 beats/min) and systolic blood pressure (> or =90 mm Hg), and 3 days for respiratory rate (< or =24 breaths/min), oxygen saturation (> or =90%), and temperature (< or =37.2 degrees C [99 degrees F]). The median time to overall clinical stability was 3 days for the most lenient definition of stability and 7 days for the most conservative definition. Patients with more severe cases of pneumonia at presentation took longer to reach stability. Once stability was achieved, clinical deterioration requiring intensive care, coronary care, or telemetry monitoring occurred in 1% of cases or fewer. Between 65% to 86% of patients stayed in the hospital more than 1 day after reaching stability, and fewer than 29% to 46% were converted to oral antibiotics within 1 day of stability, depending on the definition of stability.

CONCLUSIONS

Our estimates of time to stability in pneumonia and explicit criteria for defining stability can provide an evidence-based estimate of optimal length of stay, and outline a clinically sensible approach to improving the efficiency of inpatient management.

Patients hospitalized after initial outpatient treatment for community-acquired pneumonia

STUDY OBJECTIVE

To determine the incidence, causes, and outcomes of patients hospitalized within 30 days of initiating outpatient treatment for community-acquired pneumonia (CAP).

DESIGN

Patients were enrolled in the Pneumonia Patient Outcomes Research Team's multicenter, prospective cohort study of CAP. All hospitalizations within 30 days of study enrollment of patients initially treated as outpatients for CAP were recorded. Two physicians used a set of predetermined definitions to independently categorize the reasons for these subsequent hospitalizations. Thirty-day mortality rate and measures of resolution of pneumonia were assessed. The setting included three university teaching hospitals, a community teaching hospital, and a staff model medical practice within a health maintenance organization.

RESULTS

Of the 944 enrollees with CAP initially treated in the outpatient setting, 71 (7.5%) were subsequently hospitalized within 30 days. The reason for subsequent hospitalization was CAP related in 40 patients and comorbidity related in 26 patients; 5 refused an initial offer of hospitalization. Ninety percent of pneumonia-related hospitalizations occurred within 10 days of initial presentation. Patients who were subsequently hospitalized required a median of 14 days to return to usual activities compared with 6 days for those who were not hospitalized (P<.0001). Patients with a subsequent hospitalization had a higher 30-day mortality rate, 4.2% compared with .3% (P<.01).

CONCLUSION

A small proportion of patients with CAP initially treated in the outpatient setting are subsequently hospitalized. Such patients face a higher risk of delayed recovery or death. However, the vast majority of outpatients, whether subsequently hospitalized or not, had a successful resolution of their illness. Subsequent hospitalization by 10 days after initial outpatient treatment seems a reasonable screening tool for potentially unsatisfactory quality of care for patients with CAP.

Community-acquired pneumonia due to Escherichia coli

OBJECTIVE: To describe the features of community-acquired Escherichia coli pneumonia and to compare these patients with patients with pneumonia caused by other etiologic agents. PATIENTS AND METHODS: This prospective study was carried out at five medical institutions in three geographic locations---Pittsburgh, PA, Boston, MA and Halifax, NS. Pneumonia etiology was assigned, based on results of microbiological investigations, by a committee consisting of five investigators using rules established prior to the study. Demographic and clinical features and outcomes of patients with E. coli pneumonia were compared with those of pneumonia due to other microorganisms. RESULTS: Nineteen patients (9 (47.4%) blood culture positive) had pneumonia due to E. coli and 430 (69 (16.0%) blood culture positive) had pneumonia caused by other etiologic agents. E. coli was the second most common cause of bacteremic pneumonia. The E. coli patients were older, and more likely to be female, from a nursing home and confused compared with patients with pneumonia due to other microbial agents. They were more severely ill as measured by a validated pneumonia specific severity of illness scoring measure. Although there was no in-hospital mortality for the patients with E. coli pneumonia, the 90-day mortality was 21%. Thirty-two (7.4%) of the patients with pneumonia due to other agents died in hospital and the 90-day mortality rate was 13.5% (p NS). Eight of the 19 patients with E. coli pneumonia were admitted from a nursing home and an additional four patients (63.2%) were discharged to such a facility. In contrast, only 44 (10.2%) of the patients with pneumonia due to other agents were discharged to a nursing home (p<0.001). CONCLUSIONS: Patients diagnosed with E. coli pneumonia are frequently bacteremic. They are older than patients with pneumonia due to other etiologies, and more likely to be female, from a nursing home and severely ill. Despite the absence of in-hospital mortality, 21% of these patients died within 90 days of presentation.

Community-acquired pneumonia: can it be defined with claims data?

The use of administrative data to study pneumonia is limited because International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM) diagnosis codes do not specify whether pneumonia is community-acquired (CAP), a key clinical distinction. We classified 212 patients discharged with a diagnosis code for pneumonia as to whether or not they had CAP, using three administrative data-based systems (Diagnosis Related Groups (DRGs) alone, principal diagnosis alone, and a complex algorithm). We examined agreement with classification by clinician chart review. We also compared the length of stay (LOS) and mortality among the CAP populations identified with different methods. Agreement between the clinical review and the three administrative data methods ranged from 86 to 80%. Classification by DRG performed least well. Populations defined by claims data had similar mortality but shorter mean LOS (9.70, 9.40, and 7.91 days for the algorithm, principal diagnosis and DRG methods, respectively) than the clinically defined population (10.85 days). We conclude that studies of CAP using populations identified by claims may underestimate LOS.