Hospitals are under great pressure to reduce readmissions of patients. Being able to reliably pre... more Hospitals are under great pressure to reduce readmissions of patients. Being able to reliably predict patients at increased risk for rehospitalization would allow for tailored interventions to be offered to them. This requires the creation of a functional predictive model specifically designed to support real-time clinical operations. A predictive model for readmissions within 30 days of discharge was developed using retrospective data from 45,924 MGH admissions between 2/1/2012 and 1/31/2013 only including factors that would be available by the day after admission. It was then validated prospectively in a real-time implementation for 3,074 MGH admissions between 10/1/2013 and 10/31/2013. The model developed retrospectively had an AUC of 0.705 with good calibration. The real-time implementation had an AUC of 0.671 although the model was overestimating readmission risk. A moderately discriminative real-time 30-day readmission predictive model can be developed and implemented in a lar...
Oral case presentations are important for patient care and clinical education. Previously publish... more Oral case presentations are important for patient care and clinical education. Previously published attempts to improve oral presentation skills have been labor intensive and have focused primarily on medical students. We created a multifaceted intervention to improve oral case presentations of medical students and internal medicine residents. Our intervention included a written handout with detailed instructions, pocket cards, model presentations, and multiple teaching sessions. The intervention was developed by consensus, supported by the department of medicine and endorsed by key faculty within the department. In addition to soliciting feedback from students and residents, we evaluated our intervention with prospectively acquired ratings of student oral case presentation skills recorded on a standardized evaluation for the internal medicine clerkship. Students, residents, and faculty gave positive feedback, although they noted some practical obstacles to effective oral case presentations. After dissemination of the guidelines, 44% of students (42/96) were rated as "excellent" in oral presentation skills on standardized evaluations of the internal medicine clerkship, compared to 30% in the previous academic year (33/111; odds ratio [OR]=1.8, 95% confidence interval=1.04-3.3; p=.036). A multifaceted intervention improved medical student oral case presentation skills. Although participants noted barriers that need further attention, we demonstrated modest improvement in student performance.
n engl j med 368;9 nejm.org february 28, 2013 873 fracture risk reporting and osteoporosis treatm... more n engl j med 368;9 nejm.org february 28, 2013 873 fracture risk reporting and osteoporosis treatment initiation. Ann Intern Med 2010;153:580-6. 5. Nguyen ND, Frost SA, Center JR, Eisman JA, Nguyen TV. Development of prognostic nomograms for individualizing 5-year and 10-year fracture risks. Osteoporos Int 2008;19:143144. 6. Ensrud KE, Lui LY, Taylor BC, et al. A comparison of prediction models for fractures in older women: is more better? Arch Intern Med 2009;169:2087-94.
Growing literature suggests that a significant proportion of rehospitalizations could be prevente... more Growing literature suggests that a significant proportion of rehospitalizations could be prevented if systems were put in place aimed at identifying and addressing some of the underlying issues that cause them. This article highlights key risk factors for unplanned rehospitalizations and illustrates a project that has successfully addressed many of the underlying issues that contribute to them. The study illustrated herein took place at an inner-city academic teaching hospital. Proactively identifying patient-, clinician-, and system-associated barriers to successful discharge transitions is critical for effective transitions of care for patients leaving the hospital setting. This process represents a culture change, requires a multidisciplinary approach to care, and mandates clear delineation of roles and responsibilities in the process, with ultimate and clear process ownership being defined. With such steps in place in a system of care, it is reasonable to expect a reduction in preventable rehospitalizations.
BACKGROUND:Little evidence exists to determine whether depression predicts hospital utilization f... more BACKGROUND:Little evidence exists to determine whether depression predicts hospital utilization following discharge among adult inpatients on a general medical service.OBJECTIVE:We aimed to determine whether a positive depression screen during hospitalization is significantly associated with an increased rate of returning for hospital services.DESIGN:A secondary analysis was performed using data from 738 English‐speaking, hospitalized adults from the Project RED randomized controlled trial (clinicaltrials.gov Identifier: NCT00252057) conducted at an urban academic safety‐net hospital.MEASUREMENTS:We used the nine‐item Patient Health Questionnaire (PHQ‐9) depression screening tool to identify patients with depressive symptoms. The primary endpoint was hospital utilization, defined as the number of emergency department (ED) visits plus readmissions within 30 days of discharge. Poisson regression was used to control for confounding variables.RESULTS:Of the 738 subjects included in the ...
Despite ongoing evidence that one quarter of HIV-infected people in the United States are unaware... more Despite ongoing evidence that one quarter of HIV-infected people in the United States are unaware of their infection, widespread implementation of the Centers for Disease Control and Prevention's 1993 recommendations regarding routine inpatient HIV testing has not occurred. This study compares two HIV testing strategies: the initial phase of inpatient HIV testing (1999-2001) utilized a physician-referral-based system. The second phase (2001-2003) included the first 2 years' experience with having trained HIV counselors directly approach inpatients regarding their willingness to undergo voluntary HIV counseling and testing (VCT) without physician referral. This latter phase was prompted by a patient attitude survey demonstrating favorable responses to unsolicited approaches by staff regarding HIV testing. Barriers to implementing the latter strategy are discussed and initial experience with rapid HIV testing on this service is also presented. Referral-based testing yielded 2.3 patient referrals (6.4% of total admissions) resulting in 1.2 HIV tests and 0.7 counseling only sessions per day. Nonreferral based testing resulted 6.2 HIV tests and another 3.0 counseling-only sessions per day. HIV VCT on an inpatient service is feasible but challenging. Most patients respond favorably to being approached for VCT. Routinely offering HIV tests to inpatients yields higher testing rates than physician referral-based systems and increases the number of patients who know their HIV status. Recommendations for implementing routing HIV testing on an inpatient service are made.
Hospitals are under great pressure to reduce readmissions of patients. Being able to reliably pre... more Hospitals are under great pressure to reduce readmissions of patients. Being able to reliably predict patients at increased risk for rehospitalization would allow for tailored interventions to be offered to them. This requires the creation of a functional predictive model specifically designed to support real-time clinical operations. A predictive model for readmissions within 30 days of discharge was developed using retrospective data from 45,924 MGH admissions between 2/1/2012 and 1/31/2013 only including factors that would be available by the day after admission. It was then validated prospectively in a real-time implementation for 3,074 MGH admissions between 10/1/2013 and 10/31/2013. The model developed retrospectively had an AUC of 0.705 with good calibration. The real-time implementation had an AUC of 0.671 although the model was overestimating readmission risk. A moderately discriminative real-time 30-day readmission predictive model can be developed and implemented in a lar...
Oral case presentations are important for patient care and clinical education. Previously publish... more Oral case presentations are important for patient care and clinical education. Previously published attempts to improve oral presentation skills have been labor intensive and have focused primarily on medical students. We created a multifaceted intervention to improve oral case presentations of medical students and internal medicine residents. Our intervention included a written handout with detailed instructions, pocket cards, model presentations, and multiple teaching sessions. The intervention was developed by consensus, supported by the department of medicine and endorsed by key faculty within the department. In addition to soliciting feedback from students and residents, we evaluated our intervention with prospectively acquired ratings of student oral case presentation skills recorded on a standardized evaluation for the internal medicine clerkship. Students, residents, and faculty gave positive feedback, although they noted some practical obstacles to effective oral case presentations. After dissemination of the guidelines, 44% of students (42/96) were rated as "excellent" in oral presentation skills on standardized evaluations of the internal medicine clerkship, compared to 30% in the previous academic year (33/111; odds ratio [OR]=1.8, 95% confidence interval=1.04-3.3; p=.036). A multifaceted intervention improved medical student oral case presentation skills. Although participants noted barriers that need further attention, we demonstrated modest improvement in student performance.
n engl j med 368;9 nejm.org february 28, 2013 873 fracture risk reporting and osteoporosis treatm... more n engl j med 368;9 nejm.org february 28, 2013 873 fracture risk reporting and osteoporosis treatment initiation. Ann Intern Med 2010;153:580-6. 5. Nguyen ND, Frost SA, Center JR, Eisman JA, Nguyen TV. Development of prognostic nomograms for individualizing 5-year and 10-year fracture risks. Osteoporos Int 2008;19:143144. 6. Ensrud KE, Lui LY, Taylor BC, et al. A comparison of prediction models for fractures in older women: is more better? Arch Intern Med 2009;169:2087-94.
Growing literature suggests that a significant proportion of rehospitalizations could be prevente... more Growing literature suggests that a significant proportion of rehospitalizations could be prevented if systems were put in place aimed at identifying and addressing some of the underlying issues that cause them. This article highlights key risk factors for unplanned rehospitalizations and illustrates a project that has successfully addressed many of the underlying issues that contribute to them. The study illustrated herein took place at an inner-city academic teaching hospital. Proactively identifying patient-, clinician-, and system-associated barriers to successful discharge transitions is critical for effective transitions of care for patients leaving the hospital setting. This process represents a culture change, requires a multidisciplinary approach to care, and mandates clear delineation of roles and responsibilities in the process, with ultimate and clear process ownership being defined. With such steps in place in a system of care, it is reasonable to expect a reduction in preventable rehospitalizations.
BACKGROUND:Little evidence exists to determine whether depression predicts hospital utilization f... more BACKGROUND:Little evidence exists to determine whether depression predicts hospital utilization following discharge among adult inpatients on a general medical service.OBJECTIVE:We aimed to determine whether a positive depression screen during hospitalization is significantly associated with an increased rate of returning for hospital services.DESIGN:A secondary analysis was performed using data from 738 English‐speaking, hospitalized adults from the Project RED randomized controlled trial (clinicaltrials.gov Identifier: NCT00252057) conducted at an urban academic safety‐net hospital.MEASUREMENTS:We used the nine‐item Patient Health Questionnaire (PHQ‐9) depression screening tool to identify patients with depressive symptoms. The primary endpoint was hospital utilization, defined as the number of emergency department (ED) visits plus readmissions within 30 days of discharge. Poisson regression was used to control for confounding variables.RESULTS:Of the 738 subjects included in the ...
Despite ongoing evidence that one quarter of HIV-infected people in the United States are unaware... more Despite ongoing evidence that one quarter of HIV-infected people in the United States are unaware of their infection, widespread implementation of the Centers for Disease Control and Prevention's 1993 recommendations regarding routine inpatient HIV testing has not occurred. This study compares two HIV testing strategies: the initial phase of inpatient HIV testing (1999-2001) utilized a physician-referral-based system. The second phase (2001-2003) included the first 2 years' experience with having trained HIV counselors directly approach inpatients regarding their willingness to undergo voluntary HIV counseling and testing (VCT) without physician referral. This latter phase was prompted by a patient attitude survey demonstrating favorable responses to unsolicited approaches by staff regarding HIV testing. Barriers to implementing the latter strategy are discussed and initial experience with rapid HIV testing on this service is also presented. Referral-based testing yielded 2.3 patient referrals (6.4% of total admissions) resulting in 1.2 HIV tests and 0.7 counseling only sessions per day. Nonreferral based testing resulted 6.2 HIV tests and another 3.0 counseling-only sessions per day. HIV VCT on an inpatient service is feasible but challenging. Most patients respond favorably to being approached for VCT. Routinely offering HIV tests to inpatients yields higher testing rates than physician referral-based systems and increases the number of patients who know their HIV status. Recommendations for implementing routing HIV testing on an inpatient service are made.
Uploads
Papers by Jeffrey Greenwald