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Objectives To investigate patterns and predictors of use of antipsychotics in hospitalized adults. Design Retrospective cohort study. Setting Academic medical center. Participants Individuals aged 18 and older hospitalized from August 2012 to August 2013, excluding those admitted to obstetrics and gynecology or psychiatry or with a psychotic disorder. Measurements Use was ascertained from pharmacy charges. Potentially excessive dosing was defined using guidelines for long-term care facilities. A review of 100 records was performed to determine reasons for use. Results The cohort included 17,775 admissions with a median age 64; individuals could have been admitted more than once during the study period. Antipsychotics were used in 9%, 55% of which were initiations. The most common reasons for initiation were delirium (53%) and probable delirium (12%). Potentially excessive dosing occurred in 16% of admissions exposed to an antipsychotic. Of admissions with antipsychotic initiation, 26% were discharged on these medications. Characteristics associated with initiation included age 75 and older (relative risk ( RR) = 1.4, 95% confidence interval ( CI) = 1.2-1.7), male sex ( RR = 1.2, 95% CI = 1.1-1.4), black race ( RR = 0.8, 95% CI = 0.6-0.96), delirium ( RR = 4.8, 95% CI = 4.2-5.7), dementia ( RR = 2.1, 95% CI = 1.7-2.6), admission to a medical service ( RR = 1.2, 95% CI = 1.1-1.4), intensive care unit stay ( RR = 2.1, 95% CI = 1.8-2.4), and mechanical ventilation ( RR = 2.0, 95% CI = 1.7-2.4). In individuals who were initiated on an antipsychotic, characteristics associated with discharge on antipsychotics were age 75 and older ( RR = 0.6, 95% CI = 0.4-0.7), discharge to any location other than home ( RR = 2.5, 95% CI = 1.8-3.3), and class of in-hospital antipsychotic exposure ( RR = 1.6, 95% CI = 1.1-2.3 for atypical vs typical; RR = 2.7, 95% CI = 1.9-3.8 for both vs typical). Conclusion Antipsychotic initiation and use were common during hospitalization, most often for delirium, and individuals were frequently discharged on these medications. Several predictors of use on discharge were identified, suggesting potential targets for decision support tools that would be used to prompt consideration of ongoing necessity. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effect of the 2008 U.S. Preventative Services Task Force recommendation against prostate-specific antigen ( PSA) screening in men aged 75 and older on frequency of PSA screening in elderly men. Design Retrospective, cross-sectional analysis. Setting Fifteen community primary care practices in western Massachusetts. Participants Men aged 65 and older with one or more annual physicals between January 1, 2006, and December 31, 2010. Measurements PSA testing was determined from the electronic health record. Mixed-effects logistic regression was used to model the rate of PSA testing over time for two age groups: 65 to 74, and 75 and older. Results Of the 7,833 men in this study, 60% were younger than 75. PSA screening rates were consistently lower in men aged 75 and older. Annual rates, adjusted for number of clinic visits, ranged from 12% to 28% in men aged 75 and older, and 37% to 49% in men aged 65 to 74. In the 2 years before the guideline was released, there was already a slow decline in screening rate in men aged 75 and older, whereas the screening rate in men aged 65 to 74 was rising. Compared to 2008, there was a 36% relative reduction in screening rate in 2009 and a 51% relative reduction in 2010 for men aged 75 and older, and a 12% relative reduction in screening rate in 2009 and a 24% relative reduction in 2010 for men aged 65 to 74. Conclusion The 2008 recommendation appeared to reduce PSA screening rates in older men in 2009 and 2010; there was a substantial reduction in men aged 75 and older and a more modest reduction in men aged 65 to 74. [ABSTRACT FROM AUTHOR]

Objectives To elicit sources of waste as viewed by hospital workers. Design Qualitative study using photo-elicitation, an ethnographic technique for prompting in-depth discussion. Setting U.S. academic tertiary care hospital. Participants Physicians, nurses, pharmacists, administrative support personnel, administrators and respiratory therapists. Methods A purposive sample of personnel at an academic tertiary care hospital was invited to take up to 10 photos of waste. Participants discussed their selections using photos as prompts during in-depth interviews. Transcripts were analysed in an iterative process using grounded theory; open and axial coding was performed, followed by selective and thematic coding to develop major themes and subthemes. Results Twenty-one participants (nine women, average number of years in field=19.3) took 159 photos. Major themes included types of waste and recommendations to reduce waste. Types of waste comprised four major categories: Time, Materials, Energy and Talent. Participants emphasised time wastage (50% of photos) over other types of waste such as excess utilisation (2.5%). Energy and Talent were novel categories of waste. Recommendations to reduce waste included interventions at the micro-level (eg, individual/ward), meso-level (eg, institution) and macro-level (eg, payor/public policy). Conclusions The waste hospital workers identified differed from previously described waste both in the types of waste described and the emphasis placed on wasted time. The findings of this study represent a possible need for education of hospital workers about known types of waste, an opportunity to assess the impact of novel types of waste described and an opportunity to intervene to reduce the waste identified. [ABSTRACT FROM AUTHOR]

Objectives To determine how well healthcare proxies ( HCPs) understand do-not-hospitalize ( DNH) orders and why they may or may not initiate them. Design Semistructured qualitative interviews. Setting Two nursing homes in western Massachusetts. Participants HCPs of nursing home residents with advanced dementia. Measurement In-depth interviews were audiotaped and transcribed verbatim. Data were qualitatively analyzed in an iterative process, and emergent concepts were conceptually ordered into explanatory categories. Pertinent demographic and clinical information was collected from the Minimum Data Set ( MDS) and patient charts. Results Sixteen of 31 eligible HCPs were interviewed. Major findings included barriers to and facilitators of initiating DNH orders. Barriers included a perceived lack of physician involvement in decision-making and limited understanding of DNH orders and the resident's prognosis. Facilitators included a HCPs' personal experience in health care, understanding the prognosis of advanced dementia, and a desire to limit resident distress. Conclusion The potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with healthcare providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes. [ABSTRACT FROM AUTHOR]

The article presents the results of a retrospective cohort study to identify outcomes of patients who presented with chest pain in a medical center in Massachusetts in 2007-2008. The review of cases of more than 2,000 patients revealed that patients underwent stress testing, with some of those who had abnormal results readmitted for other procedures due to major cardiovascular events. The article discusses the study's methodology, limitations, pertinent findings and conclusions.

Background: Morning report was initially created to meet service needs. Purpose: The objective was to improve morning report through a toolkit combining principles of learning theory with resident teaching. Methods: The toolkit consists of three parts: a guideline describing expectations, a worksheet outlining teaching plans, and a feedback form facilitating post-presentation feedback. In 2009–2010, internal medicine residents met with a chief resident before their presentations to refine teaching plans. The chief resident then supported the presenter in achieving their objectives and provided post-presentation feedback. Residents were surveyed before and 6 months after the intervention. Mean scores were compared using an unpaired t test. Results: Residents’ ratings improved in the following domains: understanding expectations (3.10 vs. 4.02, p = .0003), presentation organization (3.50 vs. 4.25, p = .005), and creating and accomplishing learning objectives (3.31 vs. 4.00, p = .002). Residents commented positively on the improved presentations. Conclusions: This toolkit, based on educational principles, improved morning report presentations. [ABSTRACT FROM AUTHOR]

Background: Internet-based social networking tools that allow users to share content have enabled a new form of public reporting of physician performance: the physician-rating website.Objective: To describe the structure and content of physician-rating websites and to assess the extent to which a patient might find them valuable.Methods: We searched Google for websites that allowed patients to review physicians in the US. We included websites that met predetermined criteria, identified common elements of these websites, and recorded website characteristics. We then searched the websites for reviews of a random sample of 300 Boston physicians. Finally, we separately analyzed quantitative and narrative reviews.Results: We identified 33 physician-rating websites, which contained 190 reviews for 81 physicians. Most reviews were positive (88%). Six percent were negative, and six percent were neutral. Generalists and subspecialists did not significantly differ in number or nature of reviews. We identified several narrative reviews that appeared to be written by the physicians themselves.Conclusion: Physician-rating websites offer patients a novel way to provide feedback and obtain information about physician performance. Despite controversy surrounding these sites, their use by patients has been limited to date, and a majority of reviews appear to be positive. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing.Objective: To determine whether recognition of CKD is associated with more appropriate treatmentDesign: Retrospective chart reviewParticipants: All patients aged >/=65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.Measurements: Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR < 60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications.Results: Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR < 60 mL/min) and 5% had severe (eGFR < 30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p = .001), a nephrology referral (58% vs 2%, p < .0001), or urine testing (75% vs 47%, p < .0001), and less likely to receive contraindicated medications (26% vs 40%, p = .013).Conclusions: Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR. [ABSTRACT FROM AUTHOR]

In 2004, we conducted a survey of physician knowledge, attitudes, and practices regarding influenza diagnosis and treatment at Baystate Medical Center in Massachusetts and Scott & White Hospital and Clinic in Texas. Of the 579 physicians we contacted, 336 completed the survey. Sixty-one percent of the respondents prescribed antivirals, and 62% used rapid testing. Prescribing practices were associated with location, practice size, use of rapid testing, and belief in the efficacy of antivirals. [ABSTRACT FROM AUTHOR]

Purpose: To identify the characteristics of successful research projects at an internal medicine residency program with an established research curriculum., Method: The authors collected data about all research projects initiated by or involving medicine residents from 2006 to 2013 at Baystate Medical Center, using departmental files and institutional review board applications. Resident and mentor characteristics were determined using personnel files and Medline searches. Using multivariable models, the authors identified predictors of successful completion of projects using adjusted prevalence ratios (PRs). The primary outcome was manuscript publication, and secondary outcome was publication or regional/national presentation. Finally, residents were surveyed to identify barriers and/or factors contributing to project completion., Results: Ninety-four research projects were identified: 52 (55.3%) projects achieved the primary outcome and 72 (76.5%) met the secondary outcome, with overlap between categories. Most study designs were cross-sectional (41; 43.6%) or retrospective cohort (30; 31.9%). After adjustment, utilization of the epidemiology/biostatistical core (PR = 2.09; 95% CI: 1.36, 3.21), established publication record of resident (PR = 1.54; 95% CI: 1.14, 2.07), and resident with U.S. medical education (PR = 1.39; 95% CI: 1.02, 1.90) were associated with successful project completion. Mentor publication record (PR = 3.13) did not retain significance because of small sample size. Most respondents (65%) cited "lack of time" as a major project barrier., Conclusions: Programs seeking to increase resident publications should consider an institutional epidemiology/biostatistical core, made available to all residency research projects, and residents should choose experienced mentors with a track record of publications.

Internal medicine residents are required to participate in scholarly activity, but conducting original research during residency is challenging. Following a poor Match at Baystate Medical Center, the authors implemented a resident research program to overcome known barriers to resident research. The multifaceted program addressed the following barriers: lack of interest, lack of time, insufficient technical support, and paucity of mentors. The program consisted of evidence-based medicine training to stimulate residents' interest in research and structural changes to support their conduct of research, including protected time for research during ambulatory blocks, a research assistant to help with tasks such as institutional review board applications and data entry, a research nurse to help with data collection, easily accessible biostatistical support, and a resident research director to provide mentorship. Following implementation in the fall of 2005, there was a steady rise in the number of resident presentations at national meetings, then in the number of resident publications. From 2001 to 2006, the department saw 3 resident publications. From 2006 to 2012, that number increased to 39 (P< .001). The department also saw more original research (29 publications) and resident first authors (12 publications) after program implementation. The percentage of residents accepted into fellowships rose from 33% before program implementation to 49% after (P = .04). This comprehensive resident research program, which focused on evidence-based medicine and was tailored to overcome specific barriers, led to a significant increase in the number of resident Medline publications and improved the reputation of the residency program.

Background: It is unknown whether there exist certain subsets of patients outside of the intensive care unit in whom the risk of nosocomial gastrointestinal bleeding is high enough that prophylactic use of acid-suppressive medication may be warranted., Objective: To identify risk factors for nosocomial gastrointestinal bleeding in a cohort of non-critically ill hospitalized patients, develop a risk scoring system, and use this system to identify patients most likely to benefit from acid suppression., Design: Cohort study., Patients: Adult patients admitted to an academic medical center from 2004 through 2007. Admissions with a principal diagnosis of gastrointestinal bleeding or a principal procedure code for cardiac catheterization were excluded., Main Measures: Medication, laboratory, and other clinical data were obtained through electronic data repositories maintained at the medical center. The main outcome measure-nosocomial gastrointestinal bleeding occurring outside of the intensive care unit-was ascertained via ICD-9-CM coding and confirmed by chart review., Key Results: Of 75,723 admissions (median age = 56 years; 40 % men), nosocomial gastrointestinal bleeding occurred in 203 (0.27 %). Independent risk factors for bleeding included age > 60 years, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulants, and coagulopathy. Risk of bleeding increased as clinical risk score derived from these factors increased. Acid-suppressive medication was utilized in > 50 % of patients in each risk stratum. Our risk scoring system identified a high risk group in whom the number-needed-to-treat with acid-suppressive medication to prevent one bleeding event was < 100., Conclusions: In this large cohort of non-critically ill hospitalized patients, we identified several independent risk factors for nosocomial gastrointestinal bleeding. With further validation at other medical centers, the risk model derived from these factors may help clinicians to direct acid-suppressive medication to those most likely to benefit.

Background: Medical residents are often responsible for leading and performing cardiopulmonary resuscitation; however, their levels of expertise and comfort as leaders of advanced cardiovascular life support (ACLS) teams vary widely. While the current American Heart Association ACLS course provides education in recommended resuscitative protocols, training in leadership skills is insufficient. In this article, we describe the design and implementation in our institution of a formative curriculum aimed at improving residents' readiness for being leaders of ACLS teams using human patient simulation. Human patient simulation refers to a variety of technologies using mannequins with realistic features, which allows learners to practice through scenarios without putting patients at risk. We discuss the limitations of the program and the challenges encountered in implementation. We also provide a description of the initiation and organization of the program. Case scenarios and assessment tools are provided., Description of the Institutional Training Program: Our simulation-based training curriculum consists of 8 simulated patient scenarios during four 1-hour sessions. Postgraduate year-2 and 3 internal medicine residents participate in this program in teams of 4. Assessment tools are utilized only for formative evaluation. Debriefing is used as a teaching strategy for the individual resident leader of the ACLS team to facilitate learning and improve performance. To evaluate the impact of the curriculum, we administered a survey before and after the intervention. The survey consisted of 10 questions answered on a 5-point Likert scale, which addressed residents' confidence in leading ACLS teams, management of the equipment, and management of cardiac rhythms. Respondents' mean presimulation (ie, baseline) and postsimulation (ie, outcome) scores were compared using a 2-sample t test. Residents' overall confidence score improved from 2.8 to 3.9 (P < 0.001; mean improvement, 1.1; 95% confidence interval, 0.7-1.6). The average score for performing and leading ACLS teams improved from 2.8 to 4 (P < 0.001; mean difference, 1.2; 95% confidence interval, 0.7-1.7). There was a uniform increase in the residents' self-confidence in their role as effective leaders of ACLS teams, and residents valued this simulation-based training program.

Background: Little is known about how pediatricians or internists manage influenza symptoms. Recent guidelines on antiviral prescribing by the Centers for Disease Control and Prevention (CDC) make almost no distinction between adults and children. Our objective was to describe how pediatricians in two large academic medical institutions manage influenza and compare them to internists., Methods: At the end of the 2003-4 influenza season, we conducted a cross sectional on-line survey of physician knowledge, attitudes and practices regarding rapid diagnostic testing and use of antiviral therapy for influenza at two large academic medical centers, one in Massachusetts and the other in Texas. We collected data on self-reported demographics, test use, prescribing practices, and beliefs about influenza and anti-influenza drugs., Results: A total of 107 pediatricians and 103 internists completed the survey (response rate of 53%). Compared to internists, pediatricians were more likely to perform rapid testing (74% vs. 47%, p < 0.0001), to use amantadine (88% vs. 48%, p < 0.0001), to restrict their prescribing to high-risk patients (86% vs. 53%, p < 0.0001), and to believe that antiviral therapy could decrease mortality (38% vs. 22%, p = 0.01). Other beliefs about antiviral therapy did not differ statistically between the specialties. Internists were more likely to be unfamiliar with rapid testing or not to have it available., Conclusion: Pediatricians and internists manage influenza differently. Evidence-based guidelines addressing the specific concerns of each group would be helpful.