The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital.

PURPOSE: To evaluate the impact of implementing a hospitalist service with a nurse discharge planner in an academic teaching hospital. SUBJECTS AND METHODS: Inpatient medicine service was provided by hospitalists, general internists, and specialists. Service personnel were identical except that the hospitalist service also had a nurse discharge planner. Hospitalists attended 4 months per year (compared with the 1 month by most other attending physicians) and had no outpatient responsibilities during the ward months. Patients were admitted alternately based on resident call schedule. Major outcomes included average costs of hospitalization, length of stay, and resource utilization. Quality measures included inpatient mortality, 30-day readmission rates, and satisfaction of patients, residents and students. RESULTS: Hospitalist-attended services had lower mean (+/- SD) inpatient costs per patient ($4289 +/- $6512) compared with specialist-staffed services ($6066 +/- $7550, P < 0.0001), with a trend toward lower costs when compared with generalist-attended services ($4850 +/- $7027, P = 0.11). Hospitalist services had shorter mean lengths of stay (4.4 +/- 4.0 days), compared with generalists (5.2 +/- 5.2 days) and specialists (6.0 +/- 5.5 days, P < 0.0001 for hospitalists vs. both groups). Readmission rates were similar in all groups. Mortality rates were higher in the specialist group [5.0% (44 of 874)] compared with hospitalists [2.2% (18 of 829)] and generalists [2.6% (20 of 761), P = 0.002 for specialists vs. both groups, P = 0.09 for generalists vs hospitalists]. Satisfaction results were uniformly high in all groups, with no significant differences. CONCLUSION: Hospitalist services with a nurse discharge planner were associated with lower average cost and shorter average length of hospital stay, without any apparent compromise in clinical outcomes or patient satisfaction.

Multidisciplinary evidence-based medicine journal clubs: curriculum design and participants' reactions.

BACKGROUND: Evidence-based medicine (EBM) is becoming an accepted educational paradigm in medical education at a variety of levels. It focuses on identifying the best evidence for medical decision making and applying that evidence to patient care. METHODS: Three EBM journal clubs were developed at the West Virginia University School of Medicine. One was for senior medical students, another for residents, and the third for primary care faculty members. In each, the sessions stressed answering clinical questions arising from actual patient-care issues. The curricular structure and development of the journal clubs are described. Participants anonymously evaluated aspects of the journal clubs regarding their educational value with Likert scale questions. RESULTS: Faculty members and residents generally gave high evaluations to all aspects of the EBM journal clubs. Student evaluations were more mixed. For each of the evaluation questions, the student means were lower than those of faculty and residents. However the differences reached statistical significance only in the responses to the usefulness of the sessions in understanding the medical literature (P < 0.01). Residents and faculty rated the EBM sessions more favorably than grand rounds or the resident lecture series. CONCLUSIONS: The establishment of evidence-based medicine journal clubs is feasible, and learners seem to value the sessions. More developed learners may gain more from the experience than those earlier in their medical education.

Appalachian perspective on modifiable risk factors in coronary artery disease: how well are we doing?

BACKGROUND: Despite recognition of modifiable risk factors and available and effective life-style and pharmacologic therapies, many individuals have unrecognized or untreated risk factors for coronary artery disease. METHODS: Using MEDLINE, we searched for relevant review articles and clinical trials related to hypertension, hyperlipidemia, diabetes mellitus, smoking, physical activity, obesity, and psychologic risk factors for coronary artery disease. We carefully reviewed the literature and statistics on modifiable risk factors and identified appropriate physician interventions. RESULTS: A large amount of information is available on coronary artery disease and modifiable risk factors. Much of the data focuses on diagnosis and treatment to goal. CONCLUSIONS: Coronary artery disease remains the number one cause of death in the United States and West Virginia, even though specific guidelines have been established for detection and treatment. The medical community needs to be more aggressive in managing modifiable risk factors.

Characteristics of West Virginians having myocardial infarction.

BACKGROUND: Prevalence of risk factors in patients having myocardial infarction (MI) have been reported in large US and international studies, but little is known about the prevalence of risk factors in West Virginians having MI. METHODS: Risk factors for MI were identified by ICD-9 codes. Logistic regression analysis was used to compute odds ratios and 95% confidence intervals. RESULTS: In this cohort (n = 727), 72% of men less than 65 years old were current smokers. Women were older and had a lower frequency of smoking and a higher frequency of diabetes mellitus and obesity than men. Women less than 65 years old had significantly more hypertension than men. CONCLUSIONS: In West Virginia, women who have MI are more likely to be nonsmoking diabetics with hypertension.

Educating residents for managed care: report on a multidisciplinary conference.

A growing number of residency programs are preparing their graduates for the realities of managed care practice. In 1996, The Cleveland Clinic Foundation, a private, nonprofit academic medical center, hosted a two-day conference on managed care education to develop innovative instructional and evaluative approaches that, where appropriate, would build on existing expertise. The conference was attended by invited national experts who had a stake in residents' education: clinical faculty, residents, medical educators, executives of managed care organizations, and representatives of other interested organizations. Participants spent much of their time in four small break out groups, each focusing on one of the following topics that were judged particularly relevant to managed care: preventive and population-based medicine, appropriate utilization of resources, clinician-patient communication, and interdisciplinary team practice. Participants shared existing materials, discussed teaching goals and objectives, and generated ideas for teaching methods, teaching materials, and evaluative methods for their respective topics. The authors summarize the recommendations from the four groups, with an overview of the issues that emerged during the conference concerning curriculum development, integration of managed care topics into existing curricula, staging of the curriculum, experiential teaching methods, negative attitudes and resistance, evaluation of trainees and profiling, program assessment, faculty development, and cooperation between academic medical centers and managed care organizations.

Evaluating cardiac risk in noncardiac surgery patients.

The cornerstones of the evaluation of cardiac risk in patients undergoing noncardiac surgery remain a thorough history and physical examination, and a resting electrocardiogram. However, new techniques to assess cardiac function allow more complete evaluation of high-risk patients.

A comparison of the effects of nifedipine and verapamil on exercise performance in patients with mild to moderate hypertension.

Twenty-four patients completed a double-blind, randomized clinical trial comparing the effects of nifedipine GITS (N) and verapamil SR (V) on blood pressure (BP) control and exercise performance. After a 2-week placebo phase, all subjects had measurements of VO2max, maximal workload, and endurance time. They were then randomized to either N (30 to 90 mg/day) or V (240 to 480 mg/day) and retested when BPs had stabilized. At rest, N lowered systolic (S) BP by 12 mm Hg (P = .02 compared to baseline) and diastolic (D) BP by 11 mm Hg (P = .001). V lowered SBP by 8 mm Hg (P = .013) and DBP by 11 mm Hg (P = .002). Neither drug affected resting heart rate. V significantly decreased resting epinephrine (P = .05) and there was a tendency for V to reduce norepinephrine (P = .07) and dopamine (P = .08). N tended to increase plasma renin activity (P = .07). During graded cycle ergometry N, compared with placebo, significantly lowered DBP at all exercise levels (P = .011), but had no significant effect on heart rate (HR), SBP, or heart rate pressure product (HRPP). Pulse pressure (PP) was significantly increased (P = .045), which was most noticeable at high exercise levels. Compared with placebo, V caused a marked reduction of exercise HR (P < .001), which was more pronounced at high levels, SBP (P = .004), DBP (P = .004), mean arterial pressure (MAP) (P = .001), and HRPP (P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

A multivariate model for the prediction of relapse after outpatient treatment of decompensated chronic obstructive pulmonary disease.

PURPOSE: To develop and validate a multivariate model for predicting relapses after treatment of decompensated chronic obstructive pulmonary disease in an emergency department. METHODS: A 5-year survey was conducted, including training and validation periods. Stepwise logistic regression was used to develop a multivariate predictive model using clinical data obtained at the time of each visit. A relapse was defined as an unscheduled return to the emergency department within 48 hours. SITE: The study was conducted in the emergency department of the Albuquerque (New Mexico) Veterans Affairs Medical Center. SUBJECTS: The subjects were 289 patients with documented chronic obstructive pulmonary disease. MEASUREMENTS AND MAIN RESULTS: During the first 3 years, there were 705 visits in which the patient was treated and released from the emergency department. Relapse occurred 82 times (11.6%). Logistic regression showed that the following variables had an effect on the risk of relapse: the relapse rate for previous visits, a previous visit within 7 days, long-term home oxygen therapy, the number of doses of nebulized bronchodilators, the administration of aminophylline, and the use of antibiotics and prednisone at the time of discharge from the emergency department. During the next 2 years, the 48-hour relapse rate was 9.9% (47 of 476 discharges). When the model was fitted to these data, all of the original variables contributed to the prediction of relapse except antibiotic use and long-term home oxygen therapy. The logistic model was used to categorize each visit during the validation phase. The relapse rate for "high-risk" visits was significantly higher than that for "low-risk" visits (18.4% vs 6.1%). The method identified 57.4% of visits that ended in relapse at 48 hours. CONCLUSIONS: A multivariate model can be used to identify patients with a poor prognosis after the outpatient treatment of decompensated chronic obstructive pulmonary disease.

A multivariate model for predicting hospital admissions for patients with decompensated chronic obstructive pulmonary disease.

PURPOSE: To develop a method for predicting hospital admissions for patients with decompensated chronic obstructive pulmonary disease treated in an emergency department. METHODS: A 4-year survey including training and validation periods was conducted. Stepwise logistic regression was used to develop a multivariate model using information from the patient's previous visits and results of baseline pulmonary function tests. MEASUREMENTS AND MAIN RESULTS: During the first 2 years, there were 693 visits to the emergency department for decompensated chronic obstructive pulmonary disease. The patient was admitted to the hospital on 210 occasions (30.3%). Logistic regression showed that the probability of admission was related to the following: the admission and relapse rates for previous visits, the proportion of previous discharges from the emergency department in which "conservative therapy" was given, the highest baseline post-bronchodilator forced expiratory volume in 1 second within 3 years of entry, and the highest baseline pre-bronchodilator forced expiratory volume in 1 second-vital capacity ratio. A relapse was defined as an unscheduled return to the emergency department within 48 hours. "Conservative therapy" was any treatment regimen that did not include parenteral medications. During the next 2 years, the model was validated with patients not previously treated at this medical center. Seventy-six (28.3%) of 269 episodes resulted in hospital admission. The logistic model was used to categorize each visit during the validation phase. "High-risk" visits had calculated probabilities of admission greater than .208, while "low-risk" visits had values that were less. The admission rate for 98 low-risk visits (8.2%) was much lower than the rate for 171 high-risk visits (39.8%). CONCLUSIONS: A multivariate model can be used to identify patients with decompensated chronic obstructive pulmonary disease who are unlikely to need hospitalization. This model could be used to select episodes of decompensated chronic obstructive pulmonary disease for treatment at home.

Treatment of decompensated chronic obstructive pulmonary disease in the emergency department--correlation between clinical features and prognosis.

STUDY OBJECTIVE: Patients with decompensated chronic obstructive pulmonary disease (COPD) are at high risk of relapse after treatment in an emergency department. The purpose of this study was to determine if the risk of relapse correlates with the clinical features of the disease. PATIENTS: Three hundred fifty-two patients with documented COPD who were treated for dyspnea in the ED of the Albuquerque Veterans Administration Medical Center over a three-year period. METHODS: We reviewed the clinical features and pulmonary function tests of the patients, who were considered to have COPD if the baseline prebronchodilator one-second forced expiratory volume (FEV1) was less than 80% predicted, and less than 80% of the forced vital capacity and inhaled bronchodilators failed to increase the FEV1 to levels of more than 80% predicted. Visits for pneumonia, pneumothorax, pleural effusion, or pulmonary emboli were excluded. A relapse was defined as an unscheduled revisit to the ED within 14 days of initial treatment. Data were entered into a microcomputer data base and analyzed by a commercial statistical package. RESULTS: Of 877 visits in which the patient was treated and released from the ED, 281 (32.0%) resulted in relapse and were considered unsuccessful Compared with successful visits, unsuccessful visits were characterized by a shorter duration of dyspnea (P = .002), a lower entry FEV1 (P = .027), a lower discharge FEV1 (P = .040), a greater number of treatments with nebulized bronchodilators (P = .009), more frequent use of parenteral adrenergic drugs (P = .006), and less frequent use of oral prednisone on discharge (P = .016). Patients with one or more relapse visits during the study period (relapsers) differed from nonrelapsers in several respects. Relapsers had a greater bronchodilator response on baseline FEV1 than nonrelapsers (P = .047). Nevertheless, relapsers required more bronchodilator treatments in the ED (P less than .001); were treated more frequently with parenteral adrenergic drugs (P less than .001), IV glucocorticoids (P less than .001), and oral prednisone (P less than .001); and recovered less of their baseline FEV1 (P less than .014). CONCLUSION: Bronchodilator response on baseline pulmonary function testing appears to identify patients with COPD who have a poor prognosis after emergency treatment. Their poor response to intensive bronchodilator treatment suggests that loss of bronchodilator response may be involved in the pathogenesis of respiratory decompensation.

Aminophylline in the outpatient management of decompensated chronic obstructive pulmonary disease.

The objective of this study was to determine if IV aminophylline reduces the risk of relapse after treatment of decompensated COPD in an ED. Forty-six visits in which IV aminophylline was given (T visits) were compared with an equal number of visits in which it was withheld (N visits) with respect to pretreatment serum theophylline level, number of treatments with nebulized bronchodilators and use of parenteral beta-adrenergic drugs, IV corticosteroids and prednisone. The difference in 48-h relapse rates for T and N visits was examined by McNemar's test. No differences were found between T and N visits with respect to vital signs, pretreatment FEV1, arterial blood gas values, hematocrit level or blood leukocyte count. The 48-h relapse rate for T visits (22.2 percent) was significantly higher than for N visits (6.7 percent; p = 0.035). Aminophylline does not appear to be beneficial for outpatients with decompensated COPD and may be harmful.

Intravenous and oral corticosteroids for the prevention of relapse after treatment of decompensated COPD. Effect on patients with a history of multiple relapses.

To determine if a regimen of intravenous and oral corticosteroids reduces the relapse rate after treatment of decompensated COPD in the ED, 30 patients were studied. Forty-five visits in which intravenous and oral corticosteroids were given (T visits) were compared with an equal number of matched visits in which they were withheld (N visits). No differences were noted between T and N visits with respect to clinical findings, laboratory results and other forms of therapy. Treatment with corticosteroids reduced the relapse rate within 24 h of discharge. At 48 h, the cumulative relapse rate for T visits (8.9 percent) was significantly lower than for N visits (33.3 percent; p = 0.005). For patients with a history of multiple relapses, a regimen consisting of intravenous and oral corticosteroids reduces the risk of relapse after ED treatment of decompensated COPD.

Ambulatory medical education: a reconsideration of sites and teachers.

This paper deals with the varied sites and teachers that can and should be used in educating residents and medical students in ambulatory care. A basic premise is that sites other than academic medical centers and teachers other than physician faculty members should be among those used. The paper describes how institutions have used non-traditional sites and teachers. Then, after emphasizing the need to choose settings according to curricular objectives, it discusses teaching sites, both hospital-based (general medical, specialty, and multidisciplinary clinics) and community-based (home care settings, rural clinics, nursing homes, and community clinics). Next it describes the array of current and potential teachers, which includes generalist and specialist physician faculty members, community physicians, residents, and allied personnel such as pharmacists and nurses. The paper also discusses forces resisting and supporting the use of new sites and teachers. It ends with general recommendations.

Use of emergency medical services by patients with decompensated obstructive lung disease.

Little information is available about the risk of relapse when patients with decompensated obstructive lung disease are treated in an emergency department for dyspnea. The purpose of our study was to determine if the risk of relapse was related to the severity and type of airway obstruction or to the time and duration of treatment. Over a period of 29 months, 496 patients with decompensated chronic obstructive pulmonary disease (COPD), asthma, or both were seen in the ED of the Albuquerque Veterans Administration Medical Center. Of 868 visits in which patients were treated and released, 244 (28.1%) were followed by a relapse within 14 days. Those who relapsed had a slightly higher one-second forced expiratory volume at baseline than those who did not (50.1 +/- 22.2% versus 45.5 +/- 20.6% predicted, P = .054). For 94 patients (group 1), asthma was the exclusive clinical diagnosis, and all available pulmonary function tests showed a bronchodilator response. For 268 patients (group 2), COPD was the exclusive diagnosis, and all tests showed no bronchodilator response. One hundred thirty-four patients (group 3) were either diagnosed as having both disorders or had varying bronchodilator response on sequential testing. The risk of relapse for group 3 patients (35.6%) was higher than for those in groups 2 (23.1%, P less than .001) or 1 (19.7%, P = .001). The frequency of relapse was higher for nighttime than daytime visits (36.1% versus 24.5%, P = .006) and for weekend than weekday visits (33.6% versus 26.6%, P = .049). Prognosis did not vary with the season or duration of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of antihypertensive medications on exercise performance: a review.

This review describes the effects of antihypertensive drugs on the performance of aerobic exercise. All available antihypertensive drugs lower blood pressure both at rest and decrease the rate of increase during exercise. However, they differ in their effects on exercise performance. The ideal antihypertensive agent should not have significant depressant effects on the myocardium, should not promote arrhythmias, should preserve the distribution of blood flow to exercising muscle, and should not interfere with substrate utilization. Diuretics, one of the most commonly prescribed class of antihypertensives, have few deleterious effects on exercise performance but have adverse metabolic effects; beta blockers have many adverse effects on exercise performance. Agents which have the least potential for adverse effects on exercise performance and metabolic effects are the converting enzyme inhibitors, calcium channel blockers, and alpha blockers, and central alpha agonists. The literature concerning each of these drugs is reviewed and recommendations are made for prescribing for the hypertensive who wishes to engage in vigorous exercise.

Nifedipine GITS and hydrochlorothiazide in essential hypertension.

Twenty-nine subjects with mild to moderate essential hypertension completed this 13 week randomized, double-blind, placebo-controlled study comparing the antihypertensive effects of nifedipine GITS (N) (30-60 mg/day), hydrochlorothiazide (H) (25-50 mg/day) and placebo (P). Nifedipine GITS is a new formulation designed for once daily administration. N lowered blood pressure 15/10 mmHg (p less than 0.0005/p less than 0.0001), H 15/8 mmHg (p less than 0.0005/p 0.05), and P 4/0 mmHg (p = NS). All patients required the larger dose of active drug to control BP. No drug affected the heart rate. For N, but not H, there was a positive correlation between age and the magnitude in reduction of SBP (r = 0.79; p less than 0.005), but not for DPB. N drug levels did not correlate with its antihypertensive effect. Epinephrine, norepinephrine, aldosterone, and plasma renin activity were not affected by N. No patients on N experienced immediate vasodilator side effects. N is a well tolerated and effective antihypertensive drug that can be given once daily. It does not cause reflex stimulation of the sympathetic nervous system.

Antihypertensive effectiveness of the nifedipine gastrointestinal therapeutic system.

The results of a multicenter trial conducted in order to determine the therapeutic efficacy of the gastrointestinal therapeutic system (GITS) formulation of nifedipine in comparison with hydrochlorothiazide and placebo in the management of mild to moderate essential hypertension are presented. During a one-week wash-out phase, antihypertensive therapy was discontinued in all patients. After a three-week single-blind placebo period, eligible patients were randomly assigned in a double-blind fashion to one of three treatment groups for a one-week titration period and a nine-week efficacy period. Patients received either nifedipine GITS, 30 or 60 mg daily; hydrochlorothiazide, 25 or 50 mg daily; or placebo. Sitting and standing blood pressures decreased by an average 11.6/10.4 and 10.8/10.8 mm Hg, respectively, with nifedipine GITS therapy, and 14.8/10.8 and 14.3/8.2 mm Hg, respectively, with hydrochlorothiazide therapy. Compared with placebo, these changes were highly significant for both sitting (p less than or equal to 0.005) and standing (p less than or equal to 0.02) measurements. Heart rate remained essentially unchanged in all three groups. It was therefore concluded that monotherapy with nifedipine GITS, at doses of 30 or 60 mg given once daily, effectively reduces blood pressure in patients with hypertension to a degree comparable with that seen in hydrochlorothiazide therapy.

The effect of nifedipine on cardiopulmonary responses during exercise in normal subjects.

We investigated the effects of a single dose of nifedipine (10 mg orally) on exercise performance during progressive incremental cycle ergometry in nine sedentary normal subjects in a double-blind, placebo-controlled crossover study. Maximum work load after nifedipine (213 +/- 42 watts; mean +/- SD) was less than after placebo (222 +/- 41 watts; p less than 0.05). Maximum oxygen consumption was unchanged. In addition, the drug decreased lactate threshold from 19.7 +/- 4.9 ml O2/min/kg to 15.5 +/- 5.5 ml O2/min/kg (p less than 0.02); gas exchange anaerobic threshold was unaffected. There were higher plasma lactate concentrations at low and intermediate exercise intensities after nifedipine compared with placebo (p less than 0.05). Systolic blood pressure was lower at high work loads (p less than 0.05) and heart rate was higher at low work loads (p less than 0.05) after nifedipine. We conclude that the short-term administration of nifedipine limits peak performance and increases plasma concentration of lactic acid in normal subjects. One or more of the following mechanisms may account for these observations: nifedipine decreases blood flow to skeletal muscle by diverting blood to nonexercising tissues; nifedipine increases catecholamine levels, thereby augmenting lactic acid production; and nifedipine decreases skeletal muscular contractility by selectively impairing fatigue-resistant fibers.