Faculty Bibliography

BACKGROUND: Understanding the mechanism of unplanned hospital readmissions is necessary for accurate prediction and prevention. OBJECTIVE: To identify specific mechanisms of unplanned readmissions through medical narratives obtained from chart reviews. DESIGN: Retrospective chart review. SETTING: Urban tertiary care hospital. PATIENTS: Two hundred seventy patients accounted for 335 unplanned 7-day readmissions between July 2010 and July 2011. MEASUREMENTS: Readmissions were classified into 1 of 5 distinct categories. RESULTS: Readmitted subjects were more likely to have had a longer length of stay during the first admission compared to nonreadmitted patients. Readmissions due to unpredictable/unpreventable complications or unrelated events constituted the highest percentage at 46%. Readmissions due to patient factors such as substance abuse, signing out against medical advice, or nonadherence to the treatment plan constituted 31%. Readmissions designated as preventable accounted for 24%. Among preventable readmissions, the most common cause was incomplete management of the index diagnosis. The interobserver level of agreement across the 5 major categories was substantial. CONCLUSIONS: We found through detailed chart review of patients readmitted within 7 days to an urban teaching hospital that the majority of readmissions were not avoidable and were often due to unpredictable or unpreventable complications of the primary diagnosis from the index hospitalization or to patient behaviors that contradicted the treatment plan. These results question the value of readmissions as a valid metric of quality and support future interventions in hospital systems to reduce preventable readmissions. Journal of Hospital Medicine 2015. (c) 2015 Society of Hospital Medicine.

BACKGROUND: Deficiencies in physical examination skills among medical students, housestaff, and even faculty have been reported for decades, though specifics on how to address this deficit are lacking. METHODS: Our institution has made a commitment to improving key physical examination competencies across our general medicine faculty. Development of the Merrin Bedside Teaching Program was guided by a comprehensive needs assessment and based on a learner-centered educational model. First, selected faculty fellows achieve expertise through mentorship with a master clinician. They then develop a bedside teaching curriculum in the selected domain and conclude by delivering the curriculum to peer faculty. RESULTS: We have developed curricula in examination of the heart, shoulder, knee, and skin. Currently, curricula are being developed in the examination of the lungs, critical care bedside rounds, and motivational interviewing. Curricula are integrated with educational activities of the internal medicine residency and medical school whenever possible. CONCLUSIONS: A hospitalist-led physical examination curriculum is an innovative way to address deficits in physical exam skills at all levels of training, engenders enthusiasm for skills development from faculty and learners, offers scholarship opportunities to general medicine faculty, encourages collaboration within and between institutions, and augments the education of residents and medical students. Journal of Hospital Medicine 2012. (c) 2012 Society of Hospital Medicine.

Background: Avoidable hospital readmissions may be reflective of poor quality of inpatient healthcare and may be used as a metric to guide reimbursement rates to hospitals. Most existing risk prediction models rely on administrative databases and have poor predictive ability. Physician chart reviews are necessary to identify both the cause and preventability of a readmission. Methods: We performed a retrospective chart review of 135 patients with an unplanned (Table presented) readmission to Bellevue Hospital within 7 days of discharge from the medicine service during a six month period. Each chart was reviewed independently by two experienced attending physicians. Using an algorithm developed via a pilot study, each readmission was classified into one of five categories: (1) not medically necessary (medical necessity), (2) following a discharge against medical advice (AMA), (3) related to a deficiency in the discharge process, (4) related to poor patient adherence (patient behavior) to the discharge plan, or (5) related to a condition that was difficult to predict. The latter three categories were further subcategorized to allow for more detailed analysis. Discrepancies in classification were resolved by consensus of the four authors. Baseline demographic information was obtained for the same time frame for patients who were not readmitted within 7 days. Results: During the study period there were 265 patients who were readmitted within seven days of discharge and 3,411 patients who were not. The gender ratio was not significantly different between groups (65% male in the readmitted group versus 62% male in the not readmitted group, P = 0.47). Age was significantly lower in the readmitted group (mean = 52.9 years) as compared to the not readmitted group (56.3; P = 0.001). Median length of stay (LOS) for the initial hospitalization was longer in the readmitted group (5 days vs 3 days; P = 0.0002). For the 135 readmitted cases, there was good agreement between reviewers (84%; j 0.776). The most common category of readmission was "unpredictable" (37.8%), followed by patient behavior (22.2%), discharge process (21.5%), medical necessity (9.6%), and AMA (8.9%). Conclusions: Our novel algorithm efficiently and reproducibly classified 7-day readmissions into discreet categories. Compared to all other patients, those who were readmitted within 7 days were more likely to be younger and have a longer initial LOS. We found 62% of readmissions were attributable to physician or patient behaviors, or system failures. This categorization algorithm can be used to guide creation of risk prediction models and allows for detailed analysis of individual groups that will assist development of individualized interventions to reduce rates of avoidable readmissions