Faculty Bibliography

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

Background: The failure of recent generations of physicians to be proficient in physical diagnosis is well known in the medical community, and recently even the mainstream(Image presented) media have taken to reporting on the problem. However, the medical literature does not offer guidance to programs interested in improving the education of physical diagnosis. Purpose: To describe the peer-led curriculum implemented at our institution to teach cardiac physical diagnosis to hospitalists and house staff. Description: Our institution has created a peer-led curriculum to enhance the teaching of the cardiac physical examination that focuses on faculty development. The curriculum consists of a series of lectures and regular bedside rounds led by experienced hospitalists and cardiologists. Lecture topics include heart sounds, murmurs, and examination of the precordium and neck veins. Lectures on physical diagnosis are evidence based and supplemented with heart sounds played through a loudspeaker so learners can hear and see cardiac findings. Bedside teaching is enhanced with an electronic stethoscope wired for simultaneous auscultation with a group of learners and an iPod application that displays real-time phonocardiography (Fig. 1). These same tools allow for bedside teaching to be transferred easily to a variety of conference-based settings such as morning report or physical diagnosis-themed lectures. Conclusions: Implementation of a cardiac physical diagnosis curriculum aimed at hospitalists is an effective way to improve the education of faculty, house staff, and medical students, offers an opportunity for scholarship, and may improve patient care

The long-term complications of acute deep venous thrombosis (DVT) include recurrence, increased mortality, and the development of the postthrombotic syndrome. Rates of recurrent venous thromboembolism (VTE) are elevated in patients with cancer and thrombophilia. Heparin, administered either as unfractionated or low-molecular weight, is indicated for at least five days for acute DVT. Long-term treatment is currently a vitamin K antagonist with a variable duration depending on the etiology of the DVT and risk of bleeding. Novel anticoagulant agents that target factor Xa and directly inhibit thrombin are being studied in clinical trials and may one day replace vitamin K antagonists for the long-term treatment of VTE.Interventional approaches such as percutaneous mechanical thrombectomy have the potential to reduce clot burden in acute DVT with lower bleeding risks and help prevent development of the postthrombotic syndrome, a common and potentially debilitating complication of DVT

The chronic constriction injury model of mononeuropathy is a direct, partial nerve injury yielding thermal hyperalgesia. The inflammation that results from this injury is believed to contribute importantly to both the neuropathological and behavioral sequelae. This study involved administering a single dose (250 ng) of interleukin-10 (IL-10), an endogenous anti-inflammatory peptide, at the site and time of a chronic constriction injury (CCI) lesion to determine if IL-10 administration could attenuate the inflammatory response of the nerve to CCI and resulting thermal hyperalgesia. In IL-10-treated animals, thermal hyperalgesia was significantly reduced following CCI (days 3, 5 and 9). Histological sections from the peripheral nerve injury site of those animals had decreased cell profiles immunoreactive for ED-1, a marker of recruited macrophages, at both times studied (2 and 5 days post-CCI). IL-10 treatment also decreased cell profiles immunoreactive for the pro-inflammatory cytokine tumor necrosis factor alpha (TNF-alpha) at day 2, but not day 5. Qualitative light microscopic assessment of neuropathology at the lesion site did not suggest substantial differences between IL-10 and vehicle-treated sections. The authors propose that initial production of TNF-alpha and perhaps other proinflammatory cytokines at the peripheral nerve lesion site importantly influences the long-term behavioral outcome of nerve injury, and that IL-10 therapy may accomplish this by downregulating the inflammatory response of the nerve to injury.