Simultaneously implementing pathways for improving asthma, pneumonia, and bronchiolitis care for hospitalized children: Protocol for a hybrid effectiveness-implementation, cluster-randomized trial.

BACKGROUND: Asthma, pneumonia, and bronchiolitis are the top causes of childhood hospitalization in the United States, leading to over 350,000 hospitalizations and ≈$2 billion in costs annually. The majority of these hospitalizations occur in general/community hospitals. Poor guideline adoption by clinicians contributes to poor health outcomes for children hospitalized with these illnesses, including longer recovery time/hospital stay, higher rates of intensive care unit transfer, and increased risk of hospital readmission. A prior single-center study at a children's hospital tested a multicondition clinical pathway intervention (simultaneous implementation of multiple pathways for multiple pediatric conditions) and demonstrated improved clinician guideline adherence and patient health outcomes. This intervention has not yet been studied in community hospitals, which face unique implementation barriers. OBJECTIVE: To study the implementation and effectiveness of a multicondition pathway intervention for children hospitalized with asthma, pneumonia, or bronchiolitis in community hospitals. METHODS: We will conduct a pragmatic, hybrid effectiveness-implementation, cluster-randomized trial in community hospitals around the United States (1:1 randomization to intervention vs. wait-list control). Our primary outcome will be the adoption of 2-3 evidence-based practices for each condition over a sustained period of 2 years. Secondary outcomes include hospital length of stay, ICU transfer, and readmission. DISCUSSION: This hybrid trial will lead to a comprehensive understanding of how to pragmatically and sustainably implement a multicondition pathway intervention in community hospitals and an assessment of its effects. Enrollment began in July 2022 and is projected to be completed in September 2024. Primary analysis completion is anticipated in March 2025, with reporting of results following.

Assessing patient work system factors for medication management during transition of care among older adults: an observational study.

OBJECTIVE: To develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults. DESIGN, SETTINGS AND PARTICIPANTS: Measures were developed and evaluated in a multisite prospective observational study of older adults (≥65 years) discharged home from medical units of two US hospitals from August 2018 to July 2019. MAIN MEASURES: Patient work system factors for managing medications were assessed during hospital stays using six capacity indicators, four task indicators and three medication management practice indicators. Main outcomes were assessed at participants' homes approximately a week after discharge for (1) Medication discrepancies between the medications taken at home and those listed in the medical record, and (2) Patient experiences with new medication regimens. RESULTS: 274 of the 376 recruited participants completed home assessment (72.8%). Among capacity indicators, most older adults (80.6%) managed medications during transition without a caregiver, 41.2% expressed low self-efficacy in managing medications and 18.3% were not able to complete basic medication administration tasks. Among task indicators, more than half (57.7%) had more than 10 discharge medications and most (94.7%) had medication regimen changes. Having more than 10 discharge medications, more than two medication regimen changes and low self-efficacy in medication management increased the risk of feeling overwhelmed (OR 2.63, 95% CI 1.08 to 6.38, OR 3.16, 95% CI 1.29 to 7.74 and OR 2.56, 95% CI 1.25 to 5.26, respectively). Low transportation independence, not having a home caregiver, low medication administration skills and more than 10 discharge medications increased the risk of medication discrepancies (incidence rate ratio 1.39, 95% CI 1.01 to 1.91, incidence rate ratio 1.73, 95% CI 1.13 to 2.66, incidence rate ratio 1.99, 95% CI 1.37 to 2.89 and incidence rate ratio 1.91, 95% CI 1.24 to 2.93, respectively). CONCLUSIONS: Patient work system factors could be assessed before discharge with indicators for increased risk of poor patient experience and medication discrepancies during older adults' care transition from hospital to home.

Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study.

BACKGROUND: Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed. OBJECTIVE: To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication. DESIGN: Prospective Type 2 Hybrid effectiveness implementation study. SETTINGS AND PARTICIPANTS: Residents from diverse specialties across 32 hospitals (12 community, 20 academic). INTERVENTION: External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews. MAIN OUTCOME AND MEASURES: Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality. RESULTS: 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).

Capturing the Rest: Inpatient Mammography for Nonadherent Hospitalized Women.

INTRODUCTION: More than a third of hospitalized women are overdue or nonadherent to breast cancer screening guidelines, and almost a third of them are also at high risk for developing breast cancer. The purpose of this study is to evaluate the feasibility of coordinating inpatient breast cancer screening mammography for these women before their discharge from the hospital. METHODS: A prospective intervention study was conducted among 101 nonadherent women aged 50-74 years who were hospitalized to a general medicine service. Sociodemographic, reproductive history, family history of breast cancer, and medical comorbidities data were collected for all patients from January 2015 to October 2016. The data were analyzed in March 2018. Fisher's exact tests and unpaired t-tests were utilized to compare the characteristics of the study population. RESULTS: Of the 101 women enrolled who were nonadherent to breast cancer screening recommendations, their mean age was 59.3 (SD=6) years, the mean 5-year Gail risk score was 1.63 (SD=0.69), and 29% of the women were African American. Almost 80% (n=79) underwent inpatient screening mammography. All women who underwent screening mammography during their inpatient stay were extremely satisfied with the experience. The convenience of having screening mammography while hospitalized was reported to be a major facilitator of completing the overdue screening. All nurses (100%) taking care of these women believed that this practice should become part of the standard of care, and most hospitalist physicians (66%) agreed that this practice is feasible. CONCLUSIONS: This study shows that it is possible to coordinate mammography for hospitalized women who were overdue for screening and at high risk for developing breast cancer. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT04164251.

Retrospective Quality Improvement Study of Insulin-Induced Hypoglycemia and Implementation of Hospital-Wide Initiatives.

BACKGROUND: Hospitalized patients who are receiving antihyperglycemic agents are at increased risk for hypoglycemia. Inpatient hypoglycemia may lead to increased risk for morbidity, mortality, prolonged hospitalization, and readmission within 30 days of discharge, which in turn may lead to increased costs. Hospital-wide initiatives targeting hypoglycemia are known to be beneficial; however, their impact on patient care and economic measures in community nonteaching hospitals are unknown. METHODS: This retrospective quality improvement study examined the effects of hospital-wide hypoglycemia initiatives on the rates of insulin-induced hypoglycemia in a community hospital setting from January 1, 2016, until September 30, 2019. The potential cost of care savings has been calculated. RESULTS: Among 49 315 total patient days, 2682 days had an instance of hypoglycemia (5.4%). Mean ± SD hypoglycemic patient days/month was 59.6 ± 16.0. The frequency of hypoglycemia significantly decreased from 7.5% in January 2016 to 3.9% in September 2019 (P = .001). Patients with type 2 diabetes demonstrated a significant decrease in the frequency of hypoglycemia (7.4%-3.8%; P < .0001), while among patients with type 1 diabetes the frequency trended downwards but did not reach statistical significance (18.5%-18.0%; P = 0.08). Based on the reduction of hypoglycemia rates, the hospital had an estimated cost of care savings of $98 635 during the study period. CONCLUSIONS: In a community hospital setting, implementation of hospital-wide initiatives targeting hypoglycemia resulted in a significant and sustainable decrease in the rate of insulin-induced hypoglycemia. These high-leverage risk reduction strategies may be translated into considerable cost savings and could be implemented at other community hospitals.

Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital.

Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown. Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR). Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models. Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048). Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.

Pilot study comparing patients' valuation of health-care services with Medicare's relative value units.

BACKGROUND AND AIMS: Physician reimbursement for services and thus income are largely determined by the Medicare Resource-Based Relative Value Scale. Patients' assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients' valuation of health-care services to Medicare's relative value unit (RVU) assessments and to discover patients' perceptions about the relative differences in incomes across physician specialties. DESIGN: Cross-sectional survey. PARTICIPANTS AND SETTING: Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. METHODS: Data collection included the use of a visual analog 'value scale' wherein participants assigned value to 10 specific physician-dependent health-care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the above-mentioned services. Comparisons of (i) the 'patient valuation RVUs' with actual Medicare RVUs, and (ii) patients' estimations of physician income with actual income were explored using t-tests. OUTCOMES: Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P<0.001) and the range in values assigned by participants was much smaller than Medicare's (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P<0.001) and the differential across specialties was thought to be much smaller (estimate: $88,225, actual: $146,769). CONCLUSION: In this pilot study, patients' estimations of the value health-care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients' valuation of services rendered by physicians may be warranted.

Physician-teacher characteristics associated with learner-centered teaching skills.

BACKGROUND: Academic institutions do not have a way to identify physician-teachers who are proficient in learner-centered teaching. AIM: To identify physician characteristics associated with being highly learner-centered. METHODS: A cohort of 363 physicians was surveyed. Measured items included personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activities. A learner-centeredness scale was developed using factor analysis. Logistic regression models were used to determine which characteristics were independently associated with scoring highly on the learner-centeredness scale. RESULTS: Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Six variables combined to form the learner-centeredness scale and the Cronbach Alpha of the scale was 0.73. The eight characteristics independently associated with high learner-centered scores for physician teachers were (i) proficiency in giving lectures or presentations (OR ;= ;5.1, 95% CI: 1.3-19.6), (ii) frequently helping learners identify resources to meet their own needs (OR ;= ;3.7, 95% CI: 1.3-10.3), (iii) proficiency in eliciting feedback from learners (OR ;= ;3.7, 95% CI: 1.7-8.5), (iv) frequently attempting to detect and discuss emotional responses of the learners (OR ;= ;2.9, 95% CI: 1.2-6.9), (v) frequently reflecting on the validity of feedback from the learners (OR ;= ;2.8, 95% CI: 1.1-7.4), (vi) frequently identifying available resources to meet the teacher's learning needs (OR ;= ;2.8, 95% CI: 1.1-7.2), (vii) having given an oral presentation related to education at a national/regional meeting (OR ;= ;2.6, 95% CI: 1.1-6.0), and (viii) frequently letting learners know how different situations affect the teacher (OR ;= ;2.5, 95% CI: 1.1-5.5). CONCLUSIONS: The clinical competence and professional growth of medical learners can be most effectively facilitated by learner-centered educational methods. It may now be possible to identify medical educators who are more learner-centered in their teaching.

Implementation of a comprehensive program to improve coordination of care in an urban academic health care system.

Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.

Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP).

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending. Design, Setting, and Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents. Interventions: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations. Main Outcomes and Measures: Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants. Results: The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings. Conclusions and Relevance: A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

A Concise Tool for Measuring Care Coordination from the Provider's Perspective in the Hospital Setting.

BACKGROUND: To support hospital efforts to improve coordination of care, a tool is needed to evaluate care coordination from the perspective of inpatient healthcare professionals. OBJECTIVES: To develop a concise tool for assessing care coordination in hospital units from the perspective of healthcare professionals, and to assess the performance of the tool in measuring dimensions of care coordination in 2 hospitals after implementation of a care coordination initiative. METHODS: We developed a survey consisting of 12 specific items and 1 global item to measure provider perceptions of care coordination across a variety of domains, including teamwork and communication, handoffs, transitions, and patient engagement. The questionnaire was distributed online between October 2015 and January 2016 to nurses, physicians, social workers, case managers, and other professionals in 2 tertiary care hospitals. RESULTS: A total of 841 inpatient care professionals completed the survey (response rate = 56.6%). Among respondents, 590 (75%) were nurses and 37 (4.7%) were physicians. Exploratory factor analysis revealed 4 subscales: (1) Teamwork, (2) Patient Engagement, (3) Handoffs, and (4) Transitions (Cronbach's alpha 0.84-0.90). Scores were fairly consistent for 3 subscales but were lower for patient engagement. There were minor differences in scores by profession, department, and hospital. CONCLUSIONS: The new tool measures 4 important aspects of inpatient care coordination with evidence for internal consistency and construct validity, indicating that the tool can be used in monitoring, evaluating, and planning care coordination activities in hospital settings.

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education duty hour requirements may affect residents' understanding and practice of professionalism. OBJECTIVE: We explored residents' perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements. DESIGN: Anonymous cross-sectional survey. PARTICIPANTS: Internal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312). MEASUREMENTS: Using Likert scales and open-ended questions, the questionnaire explored the following: residents' attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism. RESULTS: One hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing professionalism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork. CONCLUSIONS: Residents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.

Female sex: a protective role in suspected myocardial ischemia.

OBJECTIVE: Women are felt to have poor outcomes in coronary artery disease, largely on the basis of secondary observations in acute coronary syndrome trials. We sought to examine the neglected topic of sex differences in workup and outcomes in the general population presenting with chest pain. METHODS: We examined 439 consecutive patients admitted via the emergency department with ongoing chest pain. Cardiac testing was defined as any cardiac catheterization or stress test. Positive testing was defined as a 70% or greater stenosis in an epicardial coronary artery on catheterization, or a positive stress test result. Follow-up was obtained via telephone contact at 4 months following discharge. RESULTS: Further cardiac testing was deemed necessary in 68% (164/241) of women and 77% (153/198) of men (P=0.038). Among women undergoing further testing, only 21% (35/164) had positive tests, whereas 41% (62/153) of men had positive tests (P=0.002). At 4 months, women were less likely to have suffered the combined endpoint of subsequent myocardial infarction, revascularization, or death, than men (15 vs. 23%, P=0.027). Events were more likely to occur in patients who had further testing, and especially in those who had positive testing. CONCLUSIONS: These data suggest that women admitted with chest pain are less likely to have active coronary artery disease, and much less likely to have poor outcomes at 4 months than men. This apparent 'gender protection' effect warrants further study.

Insufficient treatment of hypercholesterolemia among patients hospitalized with chest pain.

BACKGROUND: Although morbidity and mortality from coronary artery disease can be improved with a variety of pharmacologic interventions, many patients remain undertreated. HYPOTHESIS: This study sought to assess whether hospitalization for possible coronary artery disease would prompt initiation of appropriate lipid-lowering therapy. METHODS: This prospective, observational study was conducted on consecutive patients with active chest pain admitted to the Emergency Department of the hospital for suspected myocardial ischemia. Elevated cholesterol, defined as low-density lipoprotein (LDL), was >100 mg/dl with a prior history or a new diagnosis of coronary artery disease, or an LDL >130 mg/dl without known coronary artery disease. Data were recorded at the time of admission, discharge, and at 4-month follow-up. RESULTS: Of the patients with hyperlipidemia, 65% men and 55% women were on medication at the time of admission (p = 0.30), while at discharge, 79% men and 60% women were on treatment (p = 0.002), with similar rates of treatment at 4-month follow-up (p = 0.030). At discharge, two variables were independently associated with patients receiving lipid-lowering therapy: age > or =65 years (odds ratio = 2.3; 95% confidence interval 1.2-4.5) and male gender (2.7; 15-5.0). CONCLUSIONS: In patients hospitalized with chest pain, particularly in women, the initiation of treatment of hyperlipidemia frequently does not happen. This oversight represents a lost opportunity for making an impact on the health of this population.

What motivates physicians throughout their careers in medicine?

Motivation provides direction and purpose in physicians' work, and motivating factors vary during different career stages. Motivation theories divide sources of motivation into those intrinsic to the work, such as the opportunity for self-expression and intellectual challenge, and those extrinsic to the work, such as salary and time. Although much attention has focused on minimizing negative extrinsic factors, the authors argue that career resilience requires that physicians reflect on and define the sources of their own intrinsic motivation. Opportunities to maximize self-awareness may allow physicians to structure their work in ways that maximize meaning and fulfillment over the long-term.

Introducing the Hospitalist Morale Index: A new tool that may be relevant for improving provider retention.

OBJECTIVE: To develop a valid instrument to assess morale and explore the relationship between morale and intent to leave employment due to unhappiness. PATIENTS AND METHODS: An expert panel identified 46 drivers of hospitalist morale. In May 2009, responders of our single-site pilot survey rated each driver in terms of current contentment and importance to their morale. With exploratory factor analysis, a 28-item/7-factor instrument emerged. In May 2011, the refined scale was distributed to 108 hospitalists from 2 academic and 3 community hospitals. Confirmatory factor analysis (CFA) was used for internal validation and refinement of the Hospitalist Morale Index. Importance ratings and contentment assessments were used to generate item scores, which were then combined to generate factor scores and personal morale scores. Results were used to validate the instrument and evaluate the relationship between hospitalist morale and intent to leave due to unhappiness. RESULTS: The 2011 response rate was 86%. The final CFA resulted in a 5-factor and 5-stand-alone-item model. Personal morale scores were normally distributed (mean = 2.79, standard deviation = 0.58). For every categorical increase on a global question that assessed overall morale, personal morale scores rose 0.23 points (P < 0.001). Each 1-point increase in personal morale score was associated with an 85% decrease (odds ratio: 0.15, 95% confidence interval: 0.05-0.41, P < 0.001) in the odds of intending to leave because of unhappiness. CONCLUSION: The Hospitalist Morale Index is a validated instrument that evaluates hospitalist morale across multiple dimensions of morale. The Hospitalist Morale Index may help program leaders monitor morale and develop customized and effective retention strategies. Journal of Hospital Medicine 2016;11:425-431. © 2016 Society of Hospital Medicine.

Chest pain relief by nitroglycerin does not predict active coronary artery disease.

BACKGROUND: The belief that chest pain relief with nitroglycerin indicates the presence of active coronary artery disease is common. However, this hypothesis has not been tested. OBJECTIVE: To define the diagnostic and prognostic value of chest pain relief with nitroglycerin. DESIGN: Prospective observational cohort study. SETTING: Urban community teaching hospital. PATIENTS: 459 consecutive patients with chest pain admitted through the emergency department who received nitroglycerin from emergency services personnel or an emergency department nurse. Follow-up was obtained by telephone contact at 4 months. MEASUREMENTS: Chest pain relief was defined as a decrease of at least 50% in patients' self-reported pain within 5 minutes of the initial dose of sublingual or spray nitroglycerin. Active coronary artery disease was defined as any elevated serum enzyme levels, coronary angiography demonstrating a 70% or greater stenosis, or a positive exercise test result. RESULTS: Nitroglycerin relieved chest pain in 39% of patients (181 of 459). In patients with active coronary artery disease as the likely cause of their chest pain, 35% (49 of 141) had chest pain relief with nitroglycerin. In contrast, in patients without active coronary artery disease, 41% (113 of 275) had chest pain relief (P > 0.2). Four-month clinical outcomes were similar in patients with or without chest pain relief with nitroglycerin (P > 0.2). CONCLUSIONS: These data suggest that, in a general population admitted for chest pain, relief of pain after nitroglycerin treatment does not predict active coronary artery disease and should not be used to guide diagnosis.

Hospitalists and Their Impact on Quality, Patient Safety, and Satisfaction.

The forces promoting the hospitalist model arose from the need for high-value care; therefore, improving quality and cost has been part of the hospitalist formula for success. The factors driving the rapid growth of generalist and subspecialty hospitalists include nationally mandated quality and safety measures, increasing age and complexity of the hospitalized patient, reduced residency duty hours, increased economic pressures to contain costs and reduce length of stay, and also primary care physicians, and specialists, relinquishing hospital privileges to focus on outpatient practices. Hospitalists are playing key roles in patient safety and quality as either leaders or practitioners in the field.

What do hospitalists think about inpatient mammography for hospitalized women who are overdue for their breast cancer screening?

BACKGROUND: A recent study showed that many hospitalized women are nonadherent with breast cancer screening recommendations, and that a majority of these women would be amenable to inpatient screening if it were offered. OBJECTIVE: Explore hospitalists' views about the appropriateness of inpatient breast cancer screening and their concerns about related matters. METHODS: A cross-sectional study was conducted among 4 hospitalist groups affiliated with Johns Hopkins Medical Institution. χ(2) and t-test statistics were used to identify hospitalist characteristics that were associated with being supportive of inpatient screening mammography. RESULTS: The response rate was 92%. Sixty-two percent of respondents believed that hospitalists should not be involved in breast cancer screening. In response to clinical scenarios describing hospitalized women who were overdue for screening, only one-third of hospitalists said that they would order a screening mammogram. Lack of follow-up on screening mammography results was cited as the most common concern related to ordering the test. CONCLUSIONS: Future studies are needed to evaluate the feasibility and potential barriers associated with inpatient screening mammography.

Prognostic usefulness of marginal troponin T elevation.

Marginal elevations of troponin T among patients with chest pain are often considered to be insignificant. We sought to define the prognostic value of marginal troponin T elevations in patients presenting to the emergency department with suspected myocardial ischemia. Four hundred twenty-eight consecutive patients presenting to the emergency department with ongoing chest pain were evaluated, followed through their hospital course, and contacted for follow-up 4 months after discharge. Two hundred ninety-nine patients had undetectable troponin T levels (<0.01 microg/L), 76 had marginal troponin T elevations (0.01 to 0.09 microg/L), and 53 had frank troponin T elevations (> or =0.1 microg/L). Patients with either marginally or frank elevated troponin levels were older and more likely to be men, but did not differ from patients with undetectable troponin levels with regard to the prevalence of coronary artery disease risk factors, history of coronary disease, or race. While in the hospital, the undetectable and marginal troponin groups were referred for cardiac testing in equal proportions (58% and 59%, respectively), whereas 87% of the elevated group underwent further testing. After adjustment for possible confounders, a significantly increased rate of death/myocardial infarction/revascularization was observed in the marginal troponin group compared with the undetectable troponin group (p = 0.004). Marginal elevations of troponin T identified a currently underevaluated high-risk subgroup of patients with suspected myocardial ischemia who are more likely to have adverse clinical outcomes than those with undetectable troponin levels.