DO HOSPITALISTS FOLLOW EFFICIENCY GUIDELINES BETTER THAN NON-HOSPITALISTS? S. Freer 1 , J. Cotter 1 , C. Pugh 1 , W. Smith 1 ; 1 Virginia Commonwealth University, Richmond, VA PURPOSE: The hospitalist model of inpatient care on general medicine wards offers the potential for a more efficient use of hospital resources, but limited formal evaluation has been conducted. The ability to effectively move patients out of the hospital on day of discharge is an important indicator of the improved use of hospital resources. This is the first study we know of to examine if hospitalists, when compared to non-hospitalists, could more efficiently discharge patients. Physicians have control over the initiation but not the completion of this process. METHODS: We studied discharge orders written by 11am and completion of discharge by noon as a measure for evaluating efficiency. These efficiency guidelines were established by the institution. We evaluated compliance with these guidelines through a retrospective analysis of clinical and utilization data on 3,040 patients admitted to general medicine wards of the Medical College of Virginia Hospital at Virginia Commonwealth University. We analyzed the number and percentage of discharge orders written before 11am and the number of patients discharged by noon by hospitalist and non-hospitalist physicians using chi-square to compare proportions. RESULTS: In FYOO the percentage of discharge orders written before 11am for the hospitalist teams (44.3%) was greater than that for the non-hospitalist teams (28.2%; p < 0.0 1). Very low percentages of patients were discharged by noon from either general medicine service. CONCLUSION: Hospitalist physicians performed significantly better than did non-hospitalist physicians on entry of discharge orders by 11am, a process measure of efficiency over which they have control. There was no difference between the groups on the completion of discharge, a process measure of efficiency over which physicians have less control. METHODS: Pharmacy records for all outpatient diabetes prescriptions during 1997 were obtained at four VA hospitals. Primary care providers (PCP) were defined as writing > 50% of prescriptions, and coded as staff attendings (AT), medicine house officers (HO), nurse practitioners (NP), endocrinologists (EN), or no PCP. Patients were grouped based on whether they received oral agents only, insulin only or both. ANOVA was performed to evaluate medication costs, glucose monitoring supply costs, total costs and glycemic control by site, provider type and treatment classification, controlling for demographics. Supply costs were calculated only across patients receiving supplies; but all patients were included in total monthly costs. Chart reviews were done on a subset from 2 sites to evaluate for differences in DM severity and comorbid conditions. RESULTS: 4544 patients were identified with complete information for cost analyses ( METHODS: In December 1998 we randomized 4 of 8 outpatient health centers that participated in a local HMO to have access to an ACS. The multi-disciplinary, telephone-based ACS evaluated the appropriateness of warfarin therapy, dosed the warfarin therapy, educated the patients, and monitored their international normalized ratios (INRs). At the control sites, physicians and their staff performed these tasks. We assessed the rate of hospitalization for a hemorrhagic or thrombotic adverse event by analyzing hospital claims submitted to the HMO. Using two-sided tests of the Poisson approximation, we compared the relative rates of adverse events between control and ACS sites using an intent-to-treat approach. RESULTS: Of the approximately 1100 patients taking warfarin at the 8 centers, approximately half (N = 503) were eligible and enrolled in the ACS. The remaining patients had their warfarin monitored and dosed by their physician. Using hospital claims data through July 30, 2000, the relative risk for an adverse event was 0.71 among patients who had access to the ACS, corresponding to a significant (p < 0.05) relative risk reduction of 29% compared with patients whose warfarin was managed by their physician. CONCLUSION: The telephone-based ACS was associated with a significantly decreased rate of hospitalization for warfarin-related adverse events. This finding suggests that multidisciplinary, disease-state management programs that empower nurses and pharmacists can improve medical care. RESULTS: Baseline patient satisfaction with their doctor was quite high. The 1,270 patients interviewed gave their physician a median rating of 9 on a scale of 0 (worst doctor possible) to 10 (best doctor possible). 47% of patients rated their doctor as a``10.'' Physicians also scored highly using a validated 10-item scale to designed assess communication skills and humanistic qualities; the median score was 46 of a possible 50 points, with 35% of patients rating their doctor as`e xcellent'' on all 10 items. Patients' ratings of physicians' communication skills were a powerful independent predictor of overall patient satisfaction (p < .001). However, analysis of variance showed that attending the workshop had no significant effect on patients' rating of their doctor's communication and humanistic skills (p = 0.32) or patients' overall rating of their doctor (p = 0.33). Physicians with baseline satisfaction ratings in the lowest quartile were no more likely to show improvement in their ratings than were physicians with higher baseline satisfaction ratings. PURPOSE: In the inpatient setting, physician order entry has been shown to significantly reduce serious medication errors (MEs). However little is known about the impact of computerized prescribing systems in the ambulatory setting on MEs and adverse drug events (ADEs). We compared the frequency of these events in outpatient clinics using handwritten versus computerized prescribing. METHODS: We prospectively studied 2 sites with handwritten prescribing and 2 with basic electronic prescribing in the Boston area. The computerized sites had printed prescriptions and required fields, but no defaults and optional or non-existent checks for allergies and drug interactions. We collected copies of prescriptions written by 24 primary care providers from Sept 1999 to March 2000 (6 weeks per clinic). Prescription copies were reviewed by a pharmacist to screen for MEs and potential ADEs. In addition, patients who received prescriptions were telephoned 2 weeks after their visit to ask about problems with their medications (response rate 59%), which were then classified as ADEs or not by 2 MD reviewers. RESULTS: Of 1173 prescriptions screened during this time period, 202 (17%) were rule violations (orders that violate strict standards but are generally understood and generate no additional work), 44 (4%) were MEs, and 59 (5%) were potential ADEs. Sites with computerized prescribing were significantly less likely to have rule violations (p < .02) and ME's (p < .01), but potential ADE rates were not significantly different. Of 661 patients surveyed, 178 (27%) reported a total of 206 ADEs, of which 74 (36%) were preventable. There was no significant difference between computerized and non-computerized sites in ADE rates and preventable ADE rates (37%, 35%). Of preventable ADEs (n = 74), 45 (62%) occurred in the ordering stage, and 26 (36%) in the patient administering stage. The main types of physician error were failure to act on results of monitoring or tests (50%) and inappropriate drug choice (24%). Improved computer ordering checks would have prevented only 20% of physician errors. CONCLUSION: Errors in the drug process were common in the outpatient setting. However, while basic computerized prescribing systems were associated with lower rates of rule violations and MEs, serious error rates (potential and preventable ADEs) were similar. Monitoring for ADEs was unexpectedly important. Prescribing systems with advanced decision-support, including monitoring and communication features as well as allergy/interaction checking, may be required to substantially reduce the frequency of serious errors. PURPOSE: Despite mandates for physicians to screen for and intervene with domestic violence as they should do for HIV/STD risk, alcohol abuse, and smoking, studies show that physicians face many barriers to doing so. We wanted to know how asking and intervening with domestic violence compares to asking and intervening with patients in these other three health-risk areas. METHODS: In November 2000, we mailed a questionnaire on physicians' screening and intervention behaviors for domestic violence, HIV/STD risk, alcohol abuse, and tobacco use to a national random sample of 1200 physicians (internal medicine and family practice). Our response rate to date, prior to our final mailing, is 49%. Chi-square tests with 3 degrees of freedom (p) and Bonferroni-Holm adjusted pairwise comparisons among topics (p * ) were used to test results. RESULTS: Sixty-six percent of our physician sample reported that intervening when domestic violence is identified is an essential part of their role as a physician. In contrast, 79% reported that intervening with patients identified for HIV/STD risk is an essential part of their role; 82% with alcohol abuse; and 85% with tobacco use (Chi-square=13.8, p=.003; p * < .032 for domestic violence vs. tobacco and vs. alcohol). Regarding screening, only 10% of physicians reported that they always ask new patients about domestic violence, compared to 22% for HIV/STD risk, 72% for alcohol use, and 84% for tobacco use (Chi-square=188, p < .001; p * < .035 for all 6 pairwise comparisons). When asked about their knowledge of and confidence in screening in these areas, only 19% strongly agreed that they knew how to assess patients for the risk of domestic violence, whereas 47%, 59%, and 70% strongly agreed that they knew how to assess patients for HIV/STD risk, alcohol abuse, and tobacco use respectively (Chi-square=68.3, p < .001; p * < .001 for all 3 pairwise comparisons with domestic violence and HIV/STD vs. tobacco). When asked if they would rather refer domestic violence victims to outside resources than provide counseling themselves, 79% agreed or strongly agreed that they would. This compares with 42%, 51%, and 23% who agreed or strongly agreed that they would rather refer patients identified with HIV/STD, alcohol, and tobacco risks respectively (Chi-square = 74.7, p < .001; p * < .006 for all pairwise comparisons except HIV/STD vs. alcohol). CONCLUSION: These data suggest that, despite physicians' view that screening for domestic violence is part of their role, physicians are not prepared or able to overcome barriers to ask their patients about abuse. It is even more difficult for physicians to screen their patients for the health risk of domestic violence than to screen for the other health risks, including the risk for HIV/ STD, which is also considered a sensitive and stigmatized topic. One solution may be simplifying the physicians' role and augmenting patient care with other experts and assessment tools.