Diagnosis and Management of Postoperative Biliary Leaks.

Postoperative biliary leaks have become more common in the past three decades since the development of laparoscopic biliary surgery. The role of the radiologist and interventional radiologist is important in the diagnosis and treatment of such complications, and can play an adjunctive role in the definitive surgical repair. Ultrasound, computed tomography, magnetic resonance cholangiopancreatography, nuclear medicine cholescintigraphy studies, and percutaneous transhepatic cholangiograms (PTC) are the various imaging modalities used for diagnosis. Interventional radiology treatment involves percutaneous drainage of bilomas, characterization of the biliary tree and assessment of the site of ductal injury with PTC, and biliary diversion with external biliary drainage.

Cross-sectional analysis of hospitalist prevalence and quality of care in California.

BACKGROUND: Hospital leaders usually provide financial support to hospitalists groups, often with an expectation of improved performance on publicly reported quality metrics. Whether the presence of hospitalists is associated with differences in hospital-level performance is unknown. OBJECTIVE: Assess the relationship between hospitalist prevalence and quality performance. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 208 California hospitals participating in a voluntary reporting initiative. INTERVENTION: Survey of hospital personnel with knowledge of the utilization of hospitalists for patient care. MEASUREMENTS: Sixteen publicly reported quality process measures across 3 medical conditions: acute myocardial infarction (AMI); congestive heart failure (CHF); and pneumonia. Using multivariable models, we assessed the relationship between the presence of hospitalists and the percentage of missed quality opportunities for each process measure. RESULTS: Of 208 eligible hospitals, 170 (82%) had hospitalist services. After adjustment, hospitals with hospitalists had similar performance for cardiac and pneumonia measures assessed at admission and fewer missed processes for CHF measures assessed at discharge. Among sites with hospitalists, every 10% increase in the estimated percentage of patients admitted by hospitalists was associated with 0.5% fewer (P < 0.001) missed quality opportunities for AMI at admission, and 0.6% (P < 0.001), 0.5% (P = 0.004), and 1.5% (P = 0.006) fewer missed quality opportunities for AMI, CHF, and pneumonia assessed at discharge, respectively. CONCLUSIONS: The presence of hospitalists in California was associated with modest improvements in performance on publicly reported process measures. Whether hospitalists directly improve quality or simply reflect a hospital's level of investment in quality remains a subject for future study.

California hospital leaders' views of hospitalists: meeting needs of the present and future.

BACKGROUND: Hospital medicine has grown rapidly, but hospital leaders' perceptions of current and future drivers of hospitalist growth are unknown. OBJECTIVE: : To determine hospital executives' perceptions of factors leading to hospitalist implementation and their vision for hospitalists' work roles. SETTING: Nonfederal, acute care hospitals in California. PARTICIPANTS: California hospital leaders (eg, chief executive officers). INTERVENTION: Cross-sectional survey from 2006 to 2007. MEASUREMENTS: We asked California hospital leaders whether their hospitals had a hospitalist service and the prospects for growth. In addition, we examined factors responsible for implementation, scope of hospitalists' practices, and need for additional certification as perceived by hospital leaders. RESULTS: We received surveys from 179 of 334 hospitals (response rate of 54%). Of the 64% of respondents that reported the use of hospitalists, none intended to decrease the size of their hospitalist group, and 57% expected growth over 2 years. The most common reasons for implementing a hospitalist program were to care for uncovered patients (68%) and improve cost/length of stay (63%). Respondents also indicated that demand from other physicians was an important factor. Leaders reported that hospitalists provide a wide range of services, with a majority involved in quality improvement projects (72%) and medical comanagement of surgical patients (66%). Most leaders favor additional certification for hospitalists. CONCLUSIONS: There is widespread adoption of hospitalists in California hospitals, with an expectation of continued growth. The drivers of the field's growth are evolving and dynamic. In particular, attentiveness to quality performance and demand from other physicians are increasingly important reasons for implementation.