Resident continuity of care experience in a Canadian general surgery training program.
(41/2057)
OBJECTIVES: To provide baseline data on resident continuity of care experience, to describe the effect of ambulatory centre surgery on continuity of care, to analyse continuity of care by level of resident training and to assess a resident-run preadmission clinic's effect on continuity of care. DESIGN: Data were prospectively collected for 4 weeks. All patients who underwent a general surgical procedure were included if a resident was present at operation. SETTING: The Division of General Surgery, Queen's University, Kingston, Ont. OUTCOME MEASURES: Preoperative, operative and inhospital postoperative involvement of each resident with each case was recorded. RESULTS: Residents assessed preoperatively (before entering the operating room) 52% of patients overall, 20% of patients at the ambulatory centre and 83% of patients who required emergency surgery. Of patients assessed by the chief resident, 94% were assessed preoperatively compared with 32% of patients assessed by other residents (p < 0.001). Of the admitted patients, 40% had complete resident continuity of care (preoperative, operative and postoperative). There was no statistical difference between this rate and that for emergency, chief-resident and non-chief-resident subgroups. Of the eligible patients, 58% were seen preoperatively by the resident on the preadmission clinic service compared with 54% on other services (p < 0.1). CONCLUSIONS: This study serves as a reference for the continuity of care experience in Canadian surgical programs. Residents assessed only 52% of patients preoperatively, and only 40% of patients had complete continuity of care. Factors such as ambulatory surgery and junior level of training negatively affected continuity experience. Such factors must be taken into account in planning surgical education. (+info)
Screening admission CT scans in patients with AIDS--a randomized trial.
(42/2057)
OBJECTIVE: To determine if the length of hospital stay could be reduced for patients with AIDS by performing screening head and abdominal-pelvic computed tomography (CT) scans within 24 hours of admission, regardless of presenting signs and symptoms. DESIGN: Randomized, prospective trial. SETTING: Tertiary, academic medical center. PATIENTS: On presentation to the emergency department, 42 patients with AIDS were identified as being eligible to participate in our study. Twenty-two patients consented to participate and were assigned to screening CT or control group. INTERVENTION: Patients assigned to the screening CT group had head and abdominal-pelvic CT scans within 24 hours of admission, regardless of presenting signs or symptoms. The findings of the screening CT scans were immediately communicated to the patient's referring physician. Patients assigned to the control group had CT studies done solely at the discretion of their physician. MAIN OUTCOME MEASURE: Length of stay for patients in the screening CT and control groups. RESULTS: The average length of stay for patients in the screening CT group was 1.3 days longer than the average length of stay for patients in the control group (95% CI, 1.4 days shorter to 4 days longer). The study was terminated after 22 patients were enrolled. CONCLUSION: Screening CT scans of the head and abdomen and pelvis at the time of hospital admission do not reduce the length of stay for patients with AIDS. (+info)
Direct admission to an extended-care facility from the emergency department.
(43/2057)
BACKGROUND: Many patients are admitted to acute-care hospitals when their medical needs might be more appropriately met in an extended-care facility (ECF). OBJECTIVE: To describe a cohort of patients who were admitted from an emergency department to an ECF. DESIGN: Observational cohort study. PARTICIPANTS: 121 enrollees of Harvard Vanguard Medical Associates who were admitted directly from an emergency department to an ECF between October 1, 1994, and December 31, 1997. OUTCOME MEASURES: Mean length of stay, charges per patient, and discharge disposition (discharged to home, discharged to a long-term-care facility, died, or transferred to an acute-care hospital within 30 days of ECF admission). RESULTS: Patients admitted directly to an ECF were generally frail and elderly (median age, 75 years). Mean length of stay in the ECF was 11 days; the mean per-patient charge was $3290. Three quarters of patients were discharged from the ECF to their homes. Six percent (seven patients) were transferred from the ECF to an acute-care hospital within 30 days of ECF admission. None of these transfers clearly suggested that the initial decision to directly admit a patient to the ECF was inappropriate. Most patients were satisfied with direct ECF admission: Of the surviving, cognitively intact patients admitted to an ECF in 1997, 71% stated that they would choose direct admission to an ECF over admission to an acute-care hospital if they were "in a similar situation in the future." CONCLUSIONS: For selected patients, direct admission to an ECF seems to be feasible, safe, and acceptable. A randomized, clinical trial is needed to fully assess the safety and cost implications of direct ECF admission. (+info)
Hospital expenditures and utilization: the impact of HMOs.
(44/2057)
OBJECTIVE: To determine whether hospital utilization and expenditures have declined more rapidly in metropolitan statistical areas (MSAs) with high health maintenance organization (HMO) penetration compared with MSAs with low HMO penetration. STUDY DESIGN: Levels and rates of change in hospital expenditures and hospital utilization in MSAs with varying levels of HMO penetration (1982 to 1996) were compared in a natural experiment. METHODS: MSAs were grouped into 4 categories based on HMO penetration rates in 1996. Levels and rates of change in hospital admission rates, hospital inpatient days, emergency room visits, total expenditures per capita, and expenditures per adjusted inpatient day from 1982 to 1996 were compared. A first-difference multivariate model was evaluated for 1993 to 1996. RESULTS: At the MSA level, the rates of change in hospital utilization and hospital expenditures varied only modestly with the level of HMO penetration. Changes in hospital admission rates did not vary systematically with HMO penetration rates except in the 1993 to 1996 period, when MSAs with the highest HMO penetration had the largest decline. Reductions in hospital days per capita and expenditures per day did not vary systematically by level of HMO penetration. Emergency room days declined most rapidly in the MSAs with the highest HMO penetration in the 1982 to 1993 period and were similar in the 1993 to 1996 period. Hospital expenditures per capita showed the greatest association with managed care penetration. They averaged 1.6% slower annual growth in MSAs with high versus low HMO penetration in the 1982 to 1996 period. CONCLUSIONS: This national study using data from 1982 to 1996 suggests that the effects of HMO penetration on hospital expenditures and hospital utilization at the MSA level are small (generally less than 1% per year). (+info)
Reliability study of the European appropriateness evaluation protocol.
(45/2057)
OBJECTIVE: To help to co-ordinate and harmonize research on utilization review in Europe, the US Appropriateness Evaluation Protocol (f inverted question markEP) was adapted for use in the European setting. The aim of this paper is to assess the reliability of the European version of the AEP (EU-AEP). DESIGN: Nineteen English-language medical records were reviewed by a physician reviewer from each of six participating countries: Austria, France, Italy, Spain, Switzerland and the UK. Each of the six reviewers was asked to assess the appropriateness of the 19 admissions and 31 hospitalization days (19 admission days and 12 randomly selected days of hospital stay, excluding days of discharge) using the revised review instrument. To evaluate inter-rater reliability, the kappa statistic was used to measure overall and pair-wise agreement for the assessment of appropriateness of admission and of day of care, respectively. RESULTS: For admission, the overall kappa statistic among the six reviewers was 0.64, with kappa values for each pair of reviewers in the range 0.46-0.86. For day of care, the kappa was 0.59, with pair-wise kappa coefficients in the range 0.25-0.95. CONCLUSION: The observed agreement could be considered substantial, especially if the fact that medical records were hand-written in a language native to only one of the reviewers is considered. Besides all the study limitations, this finding provides at least preliminary support for the application of the EU-AEP as a reliable instrument in the European setting, including application in comparative studies involving two or more countries. (+info)
A review of childhood admission with perforating ocular injuries in a hospital in north-west India.
(46/2057)
A retrospective study of perforating ocular injuries in children below the age of fifteen years was conducted. Eighty patients (eighty-nine eyes) were included in this study. Male children were more susceptible to ocular injury as compared to females (p = < 0.01). Children of the school-going age were the most affected (73.8%). Majority of the injuries occurred in the sports field (p = < 0.01). Playing with bow and arrow, and gillidanda* accounted for majority of the sport injuries (47.2%). Sixty-eight percent of the perforated eyes had no light perception at the end of treatment. Health education on the preventive aspects of ocular injuries in schools as well as through mass media should reduce the incidence of visual loss due to ocular injuries. (+info)
Six-month outcome in unstable angina patients without previous myocardial infarction according to the use of tertiary cardiologic resources. RESCATE Investigators. Recursos Empleados en el Sindrome Coronario Agudo y Tiempos de Espera.
(47/2057)
OBJECTIVES: The study assessed whether varying accessibility of patients with unstable angina (UA) to coronary angiography and revascularization determined differing usages and outcomes. BACKGROUND: The appropriate use rate of coronary angiography and revascularization procedures in UA remains to be established. METHODS: A total of 791 consecutive patients with UA without previous acute myocardial infarction (AMI) admitted to four reference teaching hospitals (one with tertiary facilities) were followed for six months. End points were six-month mortality and readmission for AMI, UA, heart failure, or severe ventricular arrhythmias. RESULTS: Patients admitted to the tertiary hospital were 3.27 (95% confidence interval [CI] 2.32 to 4.62) times more likely to undergo coronary angiography after adjustment for comorbidity and severity than were those admitted to nontertiary facilities (overall six-month use rates 70.1% and 48.3%, respectively). Revascularization procedures were performed in 36.2% of patients in the tertiary hospital and 24.6% in the others (p = 0.0007); adjusted relative risk (RR) 2.37 (95% CI 1.55 to 3.63). Median delay for urgent coronary angiography was shorter in the tertiary hospital (24 h vs. 4 days, p < 0.0002). Six-month mortality and readmission rates were similar in tertiary and nontertiary hospitals: 3.9% versus 5.3% and 16.9% versus 21.2%, respectively. Adjusted RR of death or readmission for the nontertiary hospitals was 1.23 (95% CI 0.57 to 2.67). CONCLUSIONS: The use of coronary angiography and revascularization procedures in UA patients with no previous AMI is higher in tertiary than in nontertiary hospitals, but the more selective use of these procedures in nontertiary centers does not imply worse outcome. (+info)
Preventable inpatient time: adequacy of electronic patient information systems.
(48/2057)
OBJECTIVES: This study assessed hospital electronic patient information systems (EPIS) for inclusion of variables associated with avoidable and extended hospitalization (preventable inpatient time). METHODS: We searched MEDLINE and HealthSTAR databases to identify predictors of preventable inpatient time. We then audited the admissions process and the handwritten medical record at 1 hospital, and the EPIS at all hospitals, affiliated with the Yale University School of Medicine for inclusion of the predictors. RESULTS: Whereas the written medical record included all 58 predictors, the EPIS of the 10 hospitals surveyed included an average of only 38% of the predictors. CONCLUSIONS: The conventional approach to information gathering during hospital admission is highly inefficient. Revising EPIS to include predictors of preventable inpatient time could enhance efficiency and quality, while reducing costs, of hospital care. (+info)