Use of ecological momentary assessment to determine which structural factors impact perceived teaching quality of attending rounds.

INTRODUCTION: Providing high-quality teaching to residents during attending rounds is challenging. Reasons include structural factors that affect rounds, which are beyond the attending's teaching style and control. OBJECTIVE: To develop a new evaluation tool to identify the structural components of ward rounds that most affect teaching quality in an internal medicine (IM) residency program. METHODS: The authors developed a 10-item Ecological Momentary Assessment (EMA) tool and collected daily evaluations for 18 months from IM residents rotating on inpatient services. Residents ranked the quality of teaching on rounds that day, and questions related to their service (general medicine, medical intensive care unit, and subspecialty services), patient census, absenteeism of team members, call status, and number of teaching methods used by the attending. RESULTS: Residents completed 488 evaluation cards over 18 months. This found no association between perceived teaching quality and training level, team absenteeism, and call status. We observed differences by service (P < .001) and patient census (P  =  .009). After adjusting for type of service, census was no longer significant. Use of a larger variety of teaching methods was associated with higher perceived teaching quality, regardless of service or census (P for trend < .001). CONCLUSIONS: The EMA tool successfully identified that higher patient census was associated with lower perceived teaching quality, but the results were also influenced by the type of teaching service. We found that, regardless of census or teaching service, attendings can improve their teaching by diversifying the number of methods used in daily rounds.

Re-examination of the cost-effectiveness of surgical versus medical therapy in patients with gastroesophageal reflux disease: the value of long-term data collection.

OBJECTIVES: For patients with reflux esophagitis, long-term therapeutic options include proton pump inhibitor (PPI) therapy and/or antireflux surgery. An earlier cost-effectiveness analysis concluded that at 5 yr, medical therapy was less expensive but similarly effective to fundoplication, but the results were sensitive to estimates on quality of life and long-term medication usage, which were derived from "expert opinion." Recently, data from randomized controlled trials addressing these variables have become available. We have incorporated these new data into a revised Markov model to examine the cost-effectiveness of surgical versus medical therapy in patients with severe reflux esophagitis. METHODS: A Markov simulation model was constructed using specialized software (DATA PRO 4.0, Williamstown, MA). Total expected costs and quality-adjusted life-years were calculated for long-term medical therapy and for laparoscopic Nissen fundoplication. Probabilities were obtained from the medical literature using Medline. Procedural and hospitalization costs used were the average Medicare reimbursements at our institution. Medication costs were the average wholesale price. The analysis was extended over a 10-yr time horizon at a discount rate of 3%. RESULTS: The discounted analysis shows that medical therapy is associated with total costs of 8,798 dollars and 4.59 quality-adjusted life-years, whereas the surgical strategy is more expensive (10,475 dollars) and less effective (4.55 quality-adjusted life-years). The results were robust to most one-way sensitivity analyses. CONCLUSIONS: Long-term medical therapy with proton pump inhibitors is the preferred strategy for patients with gastroesophageal reflux disease and severe esophagitis. Our study highlights the importance of using primary, patient-derived data rather than expert opinion.

American internal medicine in the 21st century: can an Oslerian generalism survive?

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.

Do local opinion leaders augment hospital quality improvement efforts? A randomized trial to promote adherence to unstable angina guidelines.

BACKGROUND: The influence of an opinion leader intervention on adherence to Unstable Angina (UA) guidelines compared with a traditional quality improvement model was investigated. RESEARCH DESIGN: A group-randomized controlled trial with 2210 patients from 21 hospitals was designed. There were three intervention arms: (1) no intervention (NI); (2) a traditional Health Care Quality Improvement Program (HCQIP); and (3) a physician opinion leader in addition to the HCQIP model (OL). Quality indicators included: electrocardiogram within 20 minutes, antiplatelet therapy within 24 hours and at discharge, and heparin and beta-blockers during hospitalization. Hospitals could determine the specific indicators they wished to target. Potential cases of UA were identified from Medicare claims data. UA confirmation was determined by a clinical algorithm based on data abstracted from medical records. Data analyses included both hospital level analysis (analysis of variance) and patient level analysis (generalized linear models). RESULTS: The only statistically significant postintervention difference in percentage compliant was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital level (P = 0.01) and patient level analyses (P <0.05) compared with the HCQIP and NI groups. When analyses were confined to hospitals that targeted specific indicators, compared with the HCQIP hospitals, the OL hospitals showed significantly greater change in percentage compliant postintervention in both antiplatelet therapy during the first 24 hours (20.2% vs. -3.9%, P = 0.02) and heparin (31.0% vs.9.1%, P = 0.05). CONCLUSIONS: The influence of physician opinion leaders was unequivocally positive for only one of five quality indicators. To maximize adherence to best practices through physician opinion leaders, more research on how these physicians influence health care delivery in their organizations will be required.

Cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices.

OBJECTIVE: Screening for varices is recommended in patients with cirrhosis to institute primary prophylaxis to prevent variceal bleeding. Our aim was to compare the cost-effectiveness of four strategies, including no screening/no prophylaxis, universal screening and primary prophylaxis with beta-blockers, universal screening and primary prophylaxis with variceal ligation, and universal institution of primary prophylaxis with beta-blockers without screening. METHODS: We constructed a Markov simulation model in two hypothetical cohorts of 50-yr-old patients with cirrhosis (one compensated and one decompensated), who were followed for 5 yr. Transition probabilities were derived from the medical literature, and costs reflected Medicare reimbursement rates at our institution. RESULTS: In patients with compensated cirrhosis, screening and primary prophylaxis with beta-blockers is associated with an incremental cost-effectiveness ratio of $3605 per year of life saved. The results were most sensitive to the prevalence of varices and risk of variceal bleeding. In patients with decompensated liver disease, primary prophylaxis without screening was associated with an incremental cost-effectiveness ratio of $1154 per year of life saved. The results were most sensitive to the cost of beta-blockers and endoscopy. CONCLUSIONS: Screening for varices is an affordable strategy in compensated liver disease, whereas universal primary prophylaxis with beta-blockers is cost-effective in decompensated patients.

The cost-effectiveness of hepatitis A vaccination in patients with chronic hepatitis C viral infection in the United States.

OBJECTIVE: Hepatitis A vaccination is recommended for patients with chronic hepatitis C. Our aim was to analyze the cost-effectiveness of hepatitis A vaccination in these patients. The specific strategies evaluated were: no vaccination, targeted vaccination, and universal vaccination. METHODS: Clinical estimates were based on published data. Costs estimates were based on published data and institutional Medicare reimbursement rates. Health-related quality-of-life weights were derived from published data and expert estimates. The target population consisted of patients 45 yr of age with chronic hepatitis C followed every 6 months until death. We adopted a societal perspective. RESULTS: Compared with no vaccination, targeted vaccination was associated with an incremental cost-effectiveness ratio of $51,000 per quality-adjusted life-year. The incremental cost-effectiveness ratio of universal vaccination compared with targeted vaccination was $3,900,000 per quality-adjusted life-year. The results were particularly sensitive to the incidence of hepatitis A, probability of fulminant hepatic failure, and costs of hepatitis A antibody screening and vaccination. CONCLUSIONS: Targeted vaccination for hepatitis A in patients with chronic hepatitis C may be a cost-effective strategy to decrease the morbidity and mortality associated with hepatitis A superinfection. Universal vaccination is not a cost-effective alternative to targeted vaccination in this target population.