Rapid Development and Deployment of an Intensivist-Led Venovenous Extracorporeal Membrane Oxygenation Cannulation Program.

OBJECTIVES: To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program. DESIGN: A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program. SETTING: An adult ICU in a tertiary academic medical center in Camden, NJ. PATIENTS: Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation. INTERVENTIONS: Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists. MEASUREMENTS AND MAIN RESULTS: Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1). CONCLUSIONS: There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.

Analysis of Performance Trends from 2010-2019 on the American Board of Internal Medicine Nephrology Certifying Exam.

BACKGROUND: The pass rate on the American Board of Internal Medicine (ABIM) nephrology certifying exam has declined and is among the lowest of all internal medicine (IM) subspecialties. In recent years, there have also been fewer applicants for the nephrology fellowship match. METHODS: This retrospective observational study assessed how changes between 2010 and 2019 in characteristics of 4094 graduates of US ACGME-accredited nephrology fellowship programs taking the ABIM nephrology certifying exam for the first time, and how characteristics of their fellowship programs were associated with exam performance. The primary outcome measure was performance on the nephrology certifying exam. Fellowship program pass rates over the decade were also studied. RESULTS: Lower IM certifying exam score, older age, female sex, international medical graduate (IMG) status, and having trained at a smaller nephrology fellowship program were associated with poorer nephrology certifying exam performance. The mean IM certifying exam percentile score among those who subsequently took the nephrology certifying exam decreased from 56.7 (SD, 27.9) to 46.1 (SD, 28.7) from 2010 to 2019. When examining individuals with comparable IM certifying exam performance, IMGs performed less well than United States medical graduates (USMGs) on the nephrology certifying exam. In 2019, only 57% of nephrology fellowship programs had aggregate 3-year certifying exam pass rates ≥80% among their graduates. CONCLUSIONS: Changes in IM certifying exam performance, certain trainee demographics, and poorer performance among those from smaller fellowship programs explain much of the decline in nephrology certifying exam performance. IM certifying exam performance was the dominant determinant.

Gender Disparity in Evaluation of Internal Medicine Clerkship Performance.

Importance: Women studying medicine currently equal men in number, but evidence suggests that men and women might not be evaluated equally throughout their education. Objective: To examine whether there are differences associated with gender in either objective or subjective evaluations of medical students in an internal medicine clerkship. Design, Setting, and Participants: This single-center retrospective cohort study evaluated data from 277 third-year medical students completing internal medicine clerkships in the 2017 to 2018 academic year at an academic hospital and its affiliates in Pennsylvania. Data were analyzed from September to November 2020. Exposure: Gender, presumed based on pronouns used in evaluations. Main Outcomes and Measures: Likert scale evaluations of clinical skills, standardized examination scores, and written evaluations were analyzed. Univariate and multivariate linear regression were used to observe trends in measures. Word embeddings were analyzed for narrative evaluations. Results: Analyses of 277 third-year medical students completing an internal medicine clerkship (140 women [51%] with a mean [SD] age of 25.5 [2.3] years and 137 [49%] presumed men with a mean [SD] age of 25.9 [2.7] years) detected no difference in final grade distribution. However, women outperformed men in 5 of 8 domains of clinical performance, including patient interaction (difference, 0.07 [95% CI, 0.04-0.13]), growth mindset (difference, 0.08 [95% CI, 0.01-0.11]), communication (difference, 0.05 [95% CI, 0-0.12]), compassion (difference, 0.125 [95% CI, 0.03-0.11]), and professionalism (difference, 0.07 [95% CI, 0-0.11]). With no difference in examination scores or subjective knowledge evaluation, there was a positive correlation between these variables for both genders (women: r = 0.35; men: r = 0.26) but different elevations for the line of best fit (P < .001). Multivariate regression analyses revealed associations between final grade and patient interaction (women: coefficient, 6.64 [95% CI, 2.16-11.12]; P = .004; men: coefficient, 7.11 [95% CI, 2.94-11.28]; P < .001), subjective knowledge evaluation (women: coefficient, 6.66 [95% CI, 3.87-9.45]; P < .001; men: coefficient, 5.45 [95% CI, 2.43-8.43]; P < .001), reported time spent with the student (women: coefficient, 5.35 [95% CI, 2.62-8.08]; P < .001; men: coefficient, 3.65 [95% CI, 0.83-6.47]; P = .01), and communication (women: coefficient, 6.32 [95% CI, 3.12-9.51]; P < .001; men: coefficient, 4.21 [95% CI, 0.92-7.49]; P = .01). The model based on the men's data also included growth mindset as a significant variable (coefficient, 4.09 [95% CI, 0.67-7.50]; P = .02). For narrative evaluations, words in context with "he or him" and "she or her" differed, with agentic terms used in descriptions of men and personality descriptors used more often for women. Conclusions and Relevance: Despite no difference in final grade, women scored higher than men on various domains of clinical performance, and performance in these domains was associated with evaluators' suggested final grade. The content of narrative evaluations significantly differed by student gender. This work supports the hypothesis that how students are evaluated in clinical clerkships is associated with gender.

Association of diabetes with frequency and cost of hospital admissions: a retrospective cohort study.

BACKGROUND: Acute inpatient hospital admissions account for more than half of all health care costs related to diabetes. We sought to identify the most common and costly conditions leading to hospital admission among patients with diabetes compared with patients without diabetes. METHODS: We used data from the General Internal Medicine Inpatient Initiative (GEMINI) study, a retrospective cohort study, of all patients admitted to a general internal medicine service at 7 Toronto hospitals between 2010 and 2015. The Canadian Institute for Health Information (CIHI) Most Responsible Diagnosis code was used to identify the 10 most frequent reasons for admission in patients with diabetes. Cost of hospital admission was estimated using the CIHI Resource Intensity Weight. Comparisons were made between patients with or without diabetes using the Pearson χ2 test for frequency and distribution-free confidence intervals (CIs) for median cost. RESULTS: Among the 150 499 hospital admissions in our study, 41 934 (27.8%) involved patients with diabetes. Compared with patients without diabetes, hospital admissions because of soft tissue and bone infections were most frequent (2.5% v. 1.9%; prevalence ratio [PR] 1.28, 95% CI 1.19-1.37) and costly (Can$8794 v. Can$5845; cost ratio [CR] 1.50, 95% CI 1.37-1.65) among patients with diabetes. This was followed by urinary tract infections (PR 1.16, 95% CI 1.11-1.22; CR 1.23, 95% CI 1.17-1.29), stroke (PR 1.13, 95% CI 1.07-1.19; CR 1.19, 95% CI 1.14-1.25) and electrolyte disorders (PR 1.11, 95% CI 1.03-1.20; CR 1.20, 95% CI 1.08-1.34). INTERPRETATION: Soft tissue and bone infections, urinary tract infections, stroke and electrolyte disorders are associated with a greater frequency and cost of hospital admissions in patients with diabetes than in those without diabetes. Preventive strategies focused on reducing hospital admissions secondary to these disorders may be beneficial in patients with diabetes.

Nationwide Analysis of Endovascular Thrombectomy Provider Specialization for Acute Stroke.

BACKGROUND AND PURPOSE: Determine the extent of cerebrovascular expertise among the specialties of proceduralists providing endovascular thrombectomy (ET) for emergent large vessel occlusion stroke in the modern era of acute stroke among Medicare beneficiaries Methods: Retrospective cohort study using validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ET. We identified proceduralist specialty by linking the National Provider Identifier provided by Medicare to the specialty listed in the National Provider Identifier database, grouping into radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, ET team specialty composition by hospital, and number of proceduralists who performed ET at multiple hospitals. RESULTS: Forty-two percent (n=5612) of ET were performed by radiology-background proceduralists, with unclear knowledge of how many were cerebrovascular specialists. Neurosurgery- and neurology-background interventionalists performed fewer but substantial numbers of cases, accounting for 24% (n=3217) and 23% (n=3124) of total cases, respectively. ET teams included a neurology- or neurosurgery-background proceduralist at 65% (n=407) of hospitals that performed ET and included both in 26% (n=160) of teams. CONCLUSIONS: Almost two-thirds of ET teams nationwide include a neurology- or neurosurgery-background proceduralist and higher volume centers in urban areas were more likely to have neurology- or neurosurgery-background proceduralists with cerebrovascular expertise on their team. It is unclear how many radiology-background interventionalists are cerebrovascular specialists versus generalists. Significant work remains to be done to understand the impact of proceduralist specialty, training, and cerebrovascular expertise on ET outcomes.

Prediction of in-hospital mortality of patients with SARS-CoV-2 infection by comorbidity indexes: an Italian internal medicine single center study.

OBJECTIVE: Clinical outcomes in patients hospitalized for severe acute respiratory syndrome due to coronavirus (SARS-CoV-2) infection seems to be closely related with burden of comorbidities. A comorbidity score could help in clinical stratification of patients admitted to internal medicine units. Our aim was to assess a novel modified Elixhauser index (mEi) and the Charlson Comorbidity Index (CCI) for predicting in-hospital mortality (IHM) in internal medicine patients with SARS-CoV-2 infection. PATIENTS AND METHODS: This single-center retrospective study enrolled all consecutive patients discharged from internal medicine unit with confirmed SARS-CoV-2 infection. Both the mEi and CCI were easily calculated from administrative data. Comorbidity scores were tested using receiver operating characteristic (ROC) analysis, and the respective area under the curve (AUC). RESULTS: The total sample consisted of 151 individuals, and 30 (19.9%) died during their hospital stay. Deceased subjects were older (82.8±10.8 vs. 63.3±18.1 years; p<0.001) and had a higher burden of comorbidities: the mEi and CCI were 29.9±11 vs. 8.8±9.2 and 4.6±2.6 vs. 1.2±2 (p<0.001), respectively. Only the mEi was independently associated with IHM (OR 1.173), and ROC curves analysis showed that the AUCs were 0.863 and 0.918 for the CCI and for mEi, respectively. CONCLUSIONS: In patients admitted to internal medicine wards with SARS-CoV-2 infection, the mEi showed a better performance in predicting IHM than CCI.

Factors and impact of physicians' diagnostic errors in malpractice claims in Japan.

BACKGROUND: Diagnostic errors are prevalent and associated with increased economic burden; however, little is known about their characteristics at the national level in Japan. This study aimed to investigate clinical outcomes and indemnity payment in cases of diagnostic errors using Japan's largest database of national claims. METHODS: We analyzed characteristics of diagnostic error cases closed between 1961 and 2017, accessed through the national Japanese malpractice claims database. We compared diagnostic error-related claims (DERC) with non-diagnostic error-related claims (non-DERC) in terms of indemnity, clinical outcomes, and factors underlying physicians' diagnostic errors. RESULTS: All 1,802 malpractice claims were included in the analysis. The median patient age was 33 years (interquartile range = 10-54), and 54.2% were men. Deaths were the most common outcome of claims (939/1747; 53.8%). In total, 709 (39.3%, 95% CI: 37.0%-41.6%) DERC cases were observed. The adjusted total billing amount, acceptance rate, adjusted median claims payments, and proportion of deaths were significantly higher in DERC than non-DERC cases. Departments of internal medicine and surgery were 1.42 and 1.55 times more likely, respectively, to have DERC cases than others. Claims involving the emergency room (adjusted odds ratio [OR] = 5.88) and outpatient office (adjusted OR = 2.87) were more likely to be DERC than other cases. The initial diagnoses most likely to lead to diagnostic error were upper respiratory tract infection, non-bleeding digestive tract disease, and "no abnormality." CONCLUSIONS: Cases of diagnostic errors produced severe patient outcomes and were associated with high indemnity. These cases were frequently noted in general exam and emergency rooms as well as internal medicine and surgery departments and were initially considered to be common, mild diseases.

Identifying and addressing social determinants of health in outpatient practice: results of a program-wide survey of internal and family medicine residents.

BACKGROUND: Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents' competence at identifying and addressing SDOH. METHODS: Residents' perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients' challenges related to SDOH through referrals. RESULTS: The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients' challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. CONCLUSIONS: Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.

Characteristics of Office-Based Buprenorphine Prescribers for Medicare Patients.

INTRODUCTION: Opioid use disorder (OUD) is a major and growing public health concern, and Medicare patients have nearly double the proportion of OUD prevalence compared with those with commercial insurance. This study examines provider-level characteristics to delineate the wide variation behind buprenorphine provision, which is the mainstay of medication-assisted treatment for OUD. METHODS: Using Medicare Part D Public Use Files claims data from 2013 to 2016 in all states, we assessed prescribing patterns of buprenorphine formulations for the specialties of family medicine, internal medicine, psychiatry, and general practice. We incorporated data from 2013 to 2016 American Medical Association Physician Masterfile to model various provider- and area-level characteristics as predictors of buprenorphine prescriber status. RESULTS: Family medicine and internal medicine comprise nearly two-thirds of the outpatient buprenorphine prescriber population for Medicare beneficiaries. Yet, both specialties also have the lowest proportion of active buprenorphine prescribers compared with psychiatrists and general practitioners. Additional characteristics associated with buprenorphine provision include male sex, osteopathic training, Northeast region, US undergraduate medical education, more years in practice, and a higher proportion of dual-eligible patients. CONCLUSIONS: Primary care specialties, such as family medicine and internal medicine, currently comprise a significant majority of the US buprenorphine prescriber population for Medicare beneficiaries. Future policies should target specific demographics to enable greater patient access from physicians who are characteristically less likely to prescribe buprenorphine to increase overall capacity.

The employment gap: the relationship between medical student career choices and the future needs of the New Zealand medical workforce.

AIMS: To determine the career decision intentions of graduating doctors, and the relationship between these intentions and the predicted medical workforce needs in New Zealand in 10 years' time. METHODS: A workforce forecasting model developed by the Ministry of Health (MOH) has been used to predict the proportion of doctors required in each medical specialty in 2028 in New Zealand. The future work intentions of recently graduated doctors at the Universities of Auckland and Otago were collected from the Medical Student Outcomes Data (MSOD), and compared with these predicted needs. RESULTS: Between 2013 and 2017, 2,292 doctors graduated in New Zealand, of whom 1,583 completed the MSOD preferences section (response rate 69%). Of these only 50.1% had decided on a future medical specialty. The most popular were surgical specialties (26.2%), general practice (20.7%), and internal medicine (11.0%). Compared to the MOH workforce forecast model there appears to be insufficient interest in general practice at the time of graduation. CONCLUSIONS: To shape the medical workforce to meet forecast needs, multiple stakeholders will need to collaborate, with a special focus on the early postgraduate years, as many doctors have yet to decide on specialisation.

Association of Physician Characteristics With Perceptions and Experiences of Gender Equity in an Academic Internal Medicine Department.

Importance: The persistence of inequities that disadvantage women physicians remains empirically underexplained. Understanding the cultural factors that are associated with disparities in harassment, discrimination, remuneration, and career trajectory are critical to addressing inequities. Objectives: To explore how physicians perceive the climate for women physicians and compare perceptions and experiences of gender inequity among physicians based on characteristics including gender, faculty status, parental status, and years in practice. Design, Setting, and Participants: This sequential, explanatory, mixed-methods qualitative study used the Culture Conducive to Women's Academic Success (CCWAS; range 45-225, with higher scores indicating better perceived culture toward women), followed by individual semistructured interviews with physicians at the Department of Medicine of the University of Calgary. All 389 physician members of the Department of Medicine, including academic and clinical physicians and those of any gender, were invited to participate in the survey and interview phases. Main Outcomes and Measures: The culture within the department for women physicians was assessed using the CCWAS score. Scores were compared between respondents' gender and years in practice. Interviews with physicians were used to further explore findings from the CCWAS and to understand experiences and perceptions of gender disparities. Results: A total of 169 of 389 physicians completed the survey (response rate, 43.4%; 102 [59.9%] women; 65 [38.9%] men; and 2 [1.2%] who did not disclose gender); 28 participants (7.2%) elected to participate in an interview (22 [78.6%] women; 6 [21.4%] men). Women physicians perceived the culture of the department toward women as significantly worse than men physicians (median [interquartile range] CCWAS score, 137.0 [118.0-155.0] vs 164.5 [154.0-183.4]; P < .001). Physicians with more than 15 years in practice perceived the culture toward women as significantly more favorable than physicians with 15 years or less in practice (median [interquartile range] CCWAS score, 157.0 [138.8-181.3] vs 147.0 [127.5-164.3]; P = .02). Qualitative data demonstrated that experiences of junior women (ie, physicians who graduated medical school after 1996, when an equal number of men and women in medical school was achieved in Canada) and perceptions of senior men (ie, those who graduated before 1996) were most different; junior women reported high rates of discrimination and harassment, while senior men perceived that the Department of Medicine had achieved gender equity. Conclusions and Relevance: In this study, senior men physicians' perceptions of gender equity were different from lived experiences of gender inequity reported by junior women physicians. This demographic mismatch between perceptions and experiences of gender equity in medicine may explain the lack of action by leaders and decision-makers in medicine to mitigate disparities.

Physician Perceptions of Step Therapy Prescribing Requirements.

BACKGROUND: Step therapy policies that require prescribers to follow an ordered protocol for drug choices are widely used by public and private insurers to manage medication costs; however, the perceptions of prescribing physicians regarding these policies have not been studied. OBJECTIVE: To determine physician attitudes toward step therapy policies and the correlation of these beliefs with physician characteristics. METHODS: A sample of clinically active physicians specializing in internal medicine, cardiology, or endocrinology received a survey administered online or via mail. Five-point Likert scale questions assessed physicians' opinions of clinical, economic, and implementation elements of prior authorization policies; physician demographic characteristics; and the extent of their interactions with the pharmaceutical industry. RESULTS: 686 physicians (48%) responded to the survey, which was evenly divided among primary care physicians, endocrinologists, and cardiologists. Many respondents (70%) had interactions with industry, including receipt of meals or gifts and use of medication samples. Physicians reported that step therapy policies could improve the affordability of medication use (55% agree vs. 26% disagree) and its clinical appropriateness (59% agree vs. 19% disagree). By similar margins, however, physicians stated that step therapy policies were implemented inefficiently and inflexibly and often did not incorporate relevant patient-specific information. Physicians in subspecialties, especially endocrinology, and those who had interactions with the pharmaceutical industry were more likely to hold negative views of step therapy policies. CONCLUSIONS: Most physicians recognize the potential of step therapy to improve the quality and cost-effectiveness of prescribing, although interactions with industry may affect these opinions. Physician perception of ineffective implementation of these policies, however, undermines their acceptability. DISCLOSURES: The American Board of Internal Medicine (ABIM) funded the survey used in this study. The ABIM had no role in the design and conduct of the study or development and preparation of the manuscript. Survey honoraria was provided by the Consumers Union. Kesselheim and Avorn's work is funded by the Laura and John Arnold Foundation. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science, Arnold Ventures, and the Engelberg Foundation. Ross is employed by the ABIM. Fischer, Lu, and Tessema have nothing to disclose.

Cascades of Care After Incidental Findings in a US National Survey of Physicians.

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Analysis of the profitability of adult vaccination in 13 private provider practices in the United States.

Vaccination coverage among adults remains low in the United States. Understanding the barriers to provision of adult vaccination is an important step to increasing vaccination coverage and improving public health. To better understand financial factors that may affect practice decisions about adult vaccination, this study sought to understand how costs compared with payments for adult vaccinations in a sample of U.S. physician practices. We recruited a convenience sample of 19 practices in nine states in 2017. We conducted a time-motion study to assess the time costs of vaccination activities and conducted a survey of practice managers to assess materials, management, and dose costs and payments for vaccination. We received complete cost and payment data from 13 of the 19 practices. We calculated annual income from vaccination services by comparing estimated costs with payments received for vaccine doses and vaccine administration. Median annual total income from vaccination services was $90,343 at family medicine practices (range: $3968-$249,628), $28,267 at internal medicine practices (-$32,659-$141,034) and $2886 at obstetrics and gynecology practices (-$73,451-$23,820). Adult vaccination was profitable at the median of our sample, but there is wide variation in profitability due to differences in costs and payment rates across practices. This study provides evidence on the financial viability of adult vaccination and supports actions for improving financial viability. These results can help inform practices' decisions whether to provide adult vaccines and contribute to keeping adults up-to-date with the recommended vaccination schedule.

Impact of the Hospitalist System in Japan on the Quality of Care and Healthcare Economics.

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

Converting acute inpatient take to outpatient take with fast-track assessment in internal medicine wards - a before-after study.

BACKGROUND: With an extensive rise in the number of acute patients and increases in both admissions and readmissions, hospitals are at times overcrowded and under immense pressure and this may challenge patient safety. This study evaluated an innovative strategy converting acute internal medicine inpatient take to an outpatient take. Here, acute patients, following referral, underwent fast-track assessment to the needed level of medical care as outpatients, directly in internal medicine wards. METHOD: The two internal medicine wards at Diagnostic Centre, Silkeborg, Denmark, changed their take of acute patients 1st of March 2017. The intervention consisted of acute medical patients being received in medical examination chairs, going through accelerated evaluation as outpatients with assessment within one hour for either admission or another form of treatment. A before-and-after study design was used to evaluate changes in activity. All referred patients for 10 months following implementation of the intervention were compared with patients referred in corresponding months the previous year. RESULTS: A total of 5339 contacts (3632 patients) who underwent acute medical assessment (2633 contacts before and 2706 after) were included. Median hospital length-of-stay decreased from 32.6 h to 22.3 h, and the proportion of referred acute patients admitted decreased with 36.3% points from 94.5 to 58.2%. The median length-of-admission time for the admitted patients increased as expected after the intervention. The risk of being admitted, being readmitted as well as having a hospital length-of-time longer than 24 h, 72 h or 7 days, respectively, were significantly lower during the after-period in comparison to the before-period. Adverse effects, unplanned re-contacts, total contacts to general practice and mortality did not change after the intervention. CONCLUSION: Assessing referred acute patients in medical examination chairs as outpatients directly in internal medicine wards and promoting an accelerated trajectory, reduced inpatient admissions and total length-of-stay considerably. This strategy seems effective in everyday acute medical patients and has the potential to ease the increasing pressure on the acute take for wards receiving acute medical patients.

HealthPathways improving access to care.

Objective HealthPathways (HPW) is an international web-based information portal that provides health practitioners with guidelines and referral pathways to specialists and services. The present study explored usage of HPW by general practitioners (GPs) in the Barwon region, south-west Victoria, and any benefits and barriers to its use. Methods Approximately 421 GPs provide services in 86 clinics across the Barwon region, south-west Victoria and Barwon Health is the public health service providing acute, subacute, residential aged care and community health services to approximately 350000 people. The present study was a mixed-methods analysis of all GPs in the region, who were invited to complete a survey in two waves (2014 and 2016) and participate in focus groups. Data were survey/questionnaire (fixed response and free text options, analysed with descriptive statistics and content analysis), and focus groups (interview and facilitated group discussion, analysed using the principles of thematic analysis). Results Most GPs surveyed used HPW and usage increased over time from 2014 to 2016 (67% vs 77% respectively). Junior GPs used HPW more often than the more experienced practitioners. GPs reported that HPW was easy to access and navigate, improved their knowledge of local services, improved their confidence, changed their clinical management and saved them time. Main barriers to use of HPW were: GPs did not think to look at HPW, or simply did not know about it. Conclusions HPW has the potential to improve patient management and health outcomes, and use of HPW is increasing over time. What is known about the topic? Initiatives such as HPW are viewed positively by clinicians and have the potential to address challenges at the primary-secondary care interface, specifically, referral to secondary specialists. What does this paper add? Proof of concept that the ongoing availability of localised HPW for common clinical conditions improves GP usage of HPW and has increased access to HPW as the first source of clinical information. Benefits and barriers to use have been identified. What are the implications for practitioners? HPW improves knowledge of local services and provides GPs with easy access to referral pathways.