Exit Survey of Senior Residents: Cost Conscious but Uninformed

Background Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness. Objective We sought to assess senior resident self-perceived cost awareness and cost knowledge. Methods In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale-New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price. Results We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%. Conclusions In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.

An Atypical Case of Hemoptysis

Hemoptysis, a common sign of diffuse alveolar hemorrhage, can be caused by multiple factors, both infectious and noninfectious. A 45-year-old male with hypertension, obstructive sleep apnea, and stage IV pulmonary sarcoidosis with cardiac involvement, presented with a two-month history of cough and acute nonmassive hemoptysis with hypoxia. A chest CT showed ground glass consolidation and interlobular septal thickening, concerning for diffuse alveolar hemorrhage. Flexible bronchoscopy confirmed diffuse alveolar hemorrhage; microbiological analyses of bronchoalveolar washings did not reveal a causative organism. Mycoplasma pneumoniae-specific IgM in serum studies was consistent with mycoplasma pneumonia as the most likely etiology of this patient's diffuse alveolar hemorrhage and resultant hemoptysis. This report points to the need to consider atypical mycoplasma pneumonia as a possible etiology of hemoptysis in patients with underlying sarcoidosis.

Addressing outpatient continuity for ambulatory training: A novel tool for longitudinal primary care sign out

BACKGROUND

We created a tool to improve communication among health professional trainees in the ambulatory setting. The tool was devised to both inform practice partner teams about high-risk patients and assign patient follow-up issues to team members. Team members were internal medicine residents and nurse practitioner fellows in the VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE), an interprofessional training model in primary care.

METHODS

We used a combination of Likert scale response questions and open ended questions to evaluate trainee attitudes before and after the implementation of the tool, as well as solicited feedback to improve the tool.

RESULTS

After using the primary care sign out tool, trainees expressed greater confidence that they could identify high-risk patients that had been cared for by other trainees and that important patient care issues would be followed up by others when they were not in clinic. In terms of areas for improvement, respondents wanted to have the sign out tool posted online.

DISCUSSION

Our sign out tool offers a strategy that others can use to improve communication and knowledge of shared patients within teams comprised of interprofessional trainees.

A Logic Model for Understanding and Reducing Preventable Hospitalizations

Identifying and understanding the root causes of preventable hospitalization (PH) is important for improving health outcomes and reducing unnecessary healthcare costs. Thus far, however, the desire to address this issue has been impeded by a general lack of research on factors associated with PH. To begin to address this gap, we propose an evidence-based logic model of individual, environmental, and systemic factors related to PH. We aim to use this logic model to design public health interventions to reduce PH in the State of Rhode Island and to stimulate an industry-wide discussion of the problem and its possible solutions.

Development and Validation of an Algorithm to Identify Planned Readmissions From Claims Data

BACKGROUND

It is desirable not to include planned readmissions in readmission measures because they represent deliberate, scheduled care.

OBJECTIVES

To develop an algorithm to identify planned readmissions, describe its performance characteristics, and identify improvements.

DESIGN

Consensus-driven algorithm development and chart review validation study at 7 acute-care hospitals in 2 health systems.

PATIENTS

For development, all discharges qualifying for the publicly reported hospital-wide readmission measure. For validation, all qualifying same-hospital readmissions that were characterized by the algorithm as planned, and a random sampling of same-hospital readmissions that were characterized as unplanned.

MEASUREMENTS

We calculated weighted sensitivity and specificity, and positive and negative predictive values of the algorithm (version 2.1), compared to gold standard chart review.

RESULTS

In consultation with 27 experts, we developed an algorithm that characterizes 7.8% of readmissions as planned. For validation we reviewed 634 readmissions. The weighted sensitivity of the algorithm was 45.1% overall, 50.9% in large teaching centers and 40.2% in smaller community hospitals. The weighted specificity was 95.9%, positive predictive value was 51.6%, and negative predictive value was 94.7%. We identified 4 minor changes to improve algorithm performance. The revised algorithm had a weighted sensitivity 49.8% (57.1% at large hospitals), weighted specificity 96.5%, positive predictive value 58.7%, and negative predictive value 94.5%. Positive predictive value was poor for the 2 most common potentially planned procedures: diagnostic cardiac catheterization (25%) and procedures involving cardiac devices (33%).

CONCLUSIONS

An administrative claims-based algorithm to identify planned readmissions is feasible and can facilitate public reporting of primarily unplanned readmissions.

CD147 interacts with NDUFS6 in regulating mitochondrial complex I activity and the mitochondrial apoptotic pathway in human malignant melanoma cells

Malignant melanoma (MM) is one of the most lethal tumors and is characterized by high invasiveness, frequent metastasis, and resistance to chemotherapy. The risk of metastatic MM is accompanied by disordered energy metabolism involving the oxidative phosphorylation (OXPHOS) process, which is largely carried out in mitochondrial complexes. Complex I is the first and largest mitochondrial enzyme complex associated with this process. CD147 is a transmembrane glycoprotein mainly expressed on the cell surface, and also appears in the cytoplasm in some tumors. We found that CD147 is often translocated to the cytoplasm in metastatic MM specimens as compared to primary MM. We also demonstrated high expression of CD147 in isolated mitochondrial fractions of A375 cells. The yeast two-hybrid (Y2H) assay identified NDUFS6 (which encodes a subunit of mitochondrial respiratory chain complex I) as a candidate that interacts with CD147 and depletion of CD147 in A375 cells significantly decreased complex I enzyme activity. We also showed that CD147 increased the viability of A375 cells exposed to berberine-induced mitochondrial damage, and protected them from apoptosis through a mitochondrial-dependent pathway. This finding was confirmed by adding exogenous Bcl-2 to A375 cell cultures. In summary, our results identify the existence of CD147 in human melanoma cell mitochondria. They indicate that CD147 appears to regulate complex I activity and apoptosis in MM by interacting with mitochondrial NDUFS6. Our findings provide new insight into the function of CD147 and identify it as a promising therapeutic target in melanoma through disruption of the energy metabolism.

Effects of Fatigue on Driving Safety: A Comparison of Brake Reaction Times in Night Float and Postcall Physicians in Training

BACKGROUND

Concerns about duty hour and resident safety have fostered discussion about postshift fatigue and driving impairment.

OBJECTIVE

We assessed how converting to a night float schedule for overnight coverage affected driving safety for trainees.

METHODS

Brake reaction times were measured for internal medicine and orthopaedic surgery resident volunteers after a traditional 28-hour call shift and after a night float shift. We conducted matched paired t tests of preshift and postshift reaction time means. Participants also completed the Epworth Sleepiness Scale pre- and postshift.

RESULTS

From June to July 2013, we enrolled 58 interns and residents (28 orthopaedic surgery, 30 internal medicine). We included 24 (41%) trainees on night float rotations and 34 (59%) trainees on traditional 28-hour call shifts. For all residents on night float rotations, there was no significant difference pre- and postshift. An increase in reaction times was noted among trainees on 28-hour call rotations. This included no effect on reaction times for internal medicine trainees pre- and postshift, and an increase in reaction times for orthopaedic trainees. For both night float and traditional call groups, there were significant increases in the Epworth Sleepiness Scale.

CONCLUSIONS

Trainees on traditional 28-hour call rotations had significantly worse postshift brake reaction times, whereas trainees on night float rotations had no difference. Orthopaedic trainees had significant differences in brake reaction times after a traditional call shift.

Expanding Health Policy and Advocacy Education for Graduate Trainees

BACKGROUND

Education in health policy and advocacy is recognized as an important component of health professional training. To date, curricula have only been assessed at the medical school level.

OBJECTIVE

We sought to address the gap in these curricula for residents and other health professionals in primary care.

INNOVATION

We created a health policy and advocacy curriculum for the VA Connecticut Healthcare System, Center of Excellence in Primary Care Education, an interprofessional, ambulatory-based, training program that includes internal medicine residents, nurse practitioner fellows, health psychology fellows, and pharmacy residents. The policy module focuses on health care finance and delivery, and the advocacy module emphasizes negotiation skills and opinion-based writing. Trainee attitudes were surveyed before and after the course, and using the Wilcoxon signed rank test, relative change was determined. Knowledge acquisition was evaluated with precourse and postcourse examinations using a paired sample t test.

RESULTS

From July 2011 through June 2013, 16 trainees completed the course. In the postcourse survey, trainees demonstrated improved comfort with understanding health law and the American health care system (Likert mean increased from 2.1 to 3.0, P  =  .01), as well as with associated advocacy skills (Likert mean increased from 2.0 to 2.9, P  =  .04). Knowledge-based test scores also showed significant improvement (increasing from 55% to 78% correct, P ≤ .001).

CONCLUSIONS

Our curriculum integrating core health policy knowledge with advocacy skills represents a novel approach in postgraduate health professional education and resulted in sustained improvement in knowledge and comfort with health policy and advocacy.

CD147 promotes melanoma progression through hypoxia-induced MMP2 activation

Hypoxia enhances MMP2 expression and the invasion and metastatic potential of melanoma cells. CD147 has been shown to induce MMP2 in multiple cancers. To investigate the role of CD147 in hypoxiainduced MMP2 activation, we performed immunohistochemistry (IHC) staining in 206 normal and melanoma tissue samples, and analyzed the correlation between HIF1α and CD147. ChIP (chromosome Immunoprecipitation) in melanoma cell lines supports that HIF1α directly binds to CD147 promoter. Moreover, we made a series of deletion mutants of CD147 promoter, and identified a conserved HIF1α binding site. Point mutation in this site significantly decreased CD147 response to hypoxia. Importantly, knocking down CD147 attenuates MMP2 response to hypoxia in melanoma cell lines. MMP2 could not be efficiently activated by hypoxia in CD147 depletion cells. ELISA data showed that MMP2 secretion was reduced in CD147 depletion cells than control under hypoxia condition. To verify the data from cell culture model, we performed in vivo mouse xenograft experiment. IHC staining showed reduced MMP2 level in CD147 depleted xenografts compared to the control group, with the HIF1α level being comparable. Our study demonstrates a novel pathway mediated by CD147 to promote the MMP2 activation induced by hypoxia, and helps to understand the interplay between hypoxia and melanoma progression.

Continuity in a VA patient-centered medical home reduces emergency department visits

Background

One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED).

Objective

To characterize continuity under the Veterans Health Administration’s PCMH model – the Patient Aligned Care Team (PACT), at one large Veterans Affair’s (VA’s) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits.

Design

Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012.

Patients

The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011.

Main Measures

Our exposure variable was continuity of care –a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit.

Results

The patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care – at least one visit with their assigned PCP – had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (p = 0.001). Compared to patients with low continuity (<33% of visits), individuals with medium (33–50%) and high (>50%) continuity were less likely to utilize the ED.

Conclusions

Strong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services.

Resident and fellow assessment of health policy attitudes and advocacy priorities

BACKGROUND

House staff physicians (medical residents and fellows) represent a significant proportion of the physician workforce in the U.S. and are a potentially important force in health care transformation, but little is known about house staff health policy attitudes or priorities.

METHODS

We conducted a cross-sectional survey of all house staff at Yale-New Haven Hospital (YNHH) and the University of Connecticut Health Center (UCHC). We calculated means of Likert-scale attitude response scores and rankings of health policy priorities. We then performed linear regression of postgraduate year (PGY) and surgical specialty on health policy priorities.

RESULTS

We received back 308 surveys (response rate of 19%). One hundred thirty-five responses (44%) were from UCHC and 173 responses were from YNHH (56%). Eighty-nine percent agreed that health policy was important to them, but only 21% felt confident in their knowledge of health policy. Thirty-two percent felt they had a good understanding of the Affordable Care Act. In terms of health policy priorities, malpractice reform and future salary were ranked the highest. There was a statistically significant positive association between PGY and malpractice reform as well as a negative association with Medicaid expansion and PGY after adjusting for surgical specialty.

CONCLUSION

House staff physicians feel that health policy is important to them, but they are not confident in their knowledge of health policy. Malpractice reform and future salary are policy priorities for house staff, and malpractice reform is increasingly important to house staff as they advance through their postgraduate training.

Skin-to-skin contact: multicultural perspectives on birth fluids and birth 'dirt'

Aim

To explore the experiences of women from three population groups of immediate skin-to-skin contact (SSC) with their newborn babies.

Method

A mixed methods approach was adopted in a phenomenological study to elicit the experiences of English, Pakistani and Bangladeshi women. Audiotaped diaries, semi-structured interviews, photographs and video recordings were employed. Concept mapping was central to data analysis.

Results

This paper reports novel findings that women contextualized and accepted secretions and bodily fluids from birth. This contradicts the beliefs of midwives that Asian women find bodily secretions abhorrent and culturally unacceptable. All participants reported positive experiences of SSC despite varying degrees of soiling from birth fluids.

Limitations

The study was conducted in a single setting, and participants may not have been representative of others in their cultural groups. Third-party translation may have added an unsought layer of interpretation. The imposition of cultural expectations by peers in the recruitment process excluded some potential participants.

Conclusion

Stereotypical assumptions about cultural background often characterize professional responses. When this stereotyping was put aside, women of all three cultures, whether breastfeeding or bottle-feeding, were able to enjoy SSC with their babies.

Implications for Nursing and Health Policy

The findings suggest that changes will be needed in professional practice to be more open to women's expressed preferences, in local policy to ensure that choices are made clear and are available, and in national strategic direction to ensure widespread adoption of positive practices for opportunities to increase breastfeeding, promote parent–child bonding and support patient choice to be realized.