Teaching Hospitals In Boston Research Articles

Death Certificate Inaccuracy and Underreporting of Injury in Elderly People

To assess whether resident physicians (MDs) could complete a death certificate for elderly patients with injury-related fatalities and whether their abilities were related to training or other factors. A large tertiary teaching hospital in Boston, Massachusetts. Three hundred thirty-six MDs. Through an anonymous Web-based test, MDs were questioned regarding prior training and experience in completion of death certificates. The MDs read a case of an elderly patient who died from intracranial bleeding after a fall and then completed a test death certificate. Whether proper completion was associated with MD characteristics such as year of residency, self-assessment, or previous death certificate experience was examined. Almost two-thirds (63.6%) of MDs completed the test. Of participants, 52% (95% confidence interval (CI)=46-59%) filled out the death certificate with the correct primary cause of death and 10% (95% CI=6-14%) listed the three major contributing causes of death. Only 35% (95% CI=28-41%) correctly reported injury as a contributing cause of death, but 51% of the participants reported a high level of confidence in their ability to complete a death certificate accurately. Accurate completion of the sample death certificate and identification of injury was low, and MDs overrated their abilities. Death certificates completed by MDs may not be accurate and may underestimate the contribution of injury to elderly mortality.

Assessing and Managing Caregiver Stress: Development of a Teaching Tool for Medical Residents

ABSTRACT Forty medical residents from major teaching hospitals in Boston, Massachusetts, participated in small group teaching sessions about caregiver stress. A teaching tool was developed that included a teaching handout, interactive cases, standard instruments for assessing caregiver stress, peer-reviewed articles about caregiving, and a list of resources that would be useful to a caregiver. These materials and teaching format were evaluated using a pre- and posttest and a feedback form. Forty residents completed the pretest and posttest. They scored significantly higher on the posttest for questions that covered estimated cost of caregiving (p = 0.0073), physical stress from caregiving (p = 0.0196), and identifying elder abuse (p = 0.0006). Ninety percent of the residents completed the evaluation form and rated the intervention highly. Teaching medical residents about caregiver stress resulted in a significant increase in knowledge about this topic. This study makes the case for the integration of “Caregiver Stress” into the primary care residency curriculum.

Brief Motivational Intervention to Increase Self‐reported Safety Belt Use among Emergency Department Patients

Brief motivational interventions have shown promise in reducing harmful behaviors. The authors tested an intervention to increase safety belt use (SBU) among emergency department (ED) patients. From February 2006 to May 2006, the authors conducted a randomized trial of adult ED patients at a teaching hospital in Boston. ED patients were systematically sampled for self-reported SBU. Those with SBU other than "always" were asked to participate. At baseline, participants answered a 9-item series of situational SBU questions, each scored on a 5-point Likert scale. SBU was defined as a continuous variable (9-item average) and as a dichotomous variable (response of "always" across all items). Participants were randomized to an intervention or a control group. The intervention group received a 5- to 7-minute intervention, adapted from classic motivational interviewing techniques, by a trained interventionist. Participants completed a 3-month follow-up phone survey to determine changes from baseline SBU. Continuous and dichotomous SBU were analyzed via analysis of covariance and chi-square testing. Of 432 eligible patients, 292 enrolled (mean age 35 years, standard deviation [SD] +/-11 years; 61% male). At baseline, the intervention and control groups had similar mean (+/-SD) SBU scores (2.8 [+/-1.1] vs. 2.6 [+/-1.1], p = 0.31) and SBU prevalence (each 0%). At 3 months, 81% completed follow-up. The intervention group had significantly greater improvement in mean (+/-SD) SBU scores than controls (0.76 [+/-0.91] vs. 0.34 [+/-0.88], p < 0.001). Also, SBU prevalence of "always" was higher for the intervention group than controls (14.4% vs. 5.9%, p = 0.03). Participants receiving a brief motivational intervention reported higher SBU at follow-up compared to controls. An ED-based intervention may be useful to increase SBU.

Someone to watch over me

Millions of Americans are without the medical oversight and continuity of care that is provided by primary care doctors. Numerous US physician organizations have called for the development of a “medical home” model of care delivery that links patients to personal primary care physicians. These pleas have been made by, among others, the American College of Physicians, the American Academy of Pediatrics, and the American Academy of Family Physicians. They have been largely unheeded and have not led to changes in the reimbursement and administrative barriers that make primary care unattractive to US doctors. As a result, in many areas of the US the supply of primary care physicians is not adequate to meet demand. A recent Boston Globe article reported that “all, or almost all” of Massachusetts General Hospital's 178 primary care physicians are not taking new patients. “There is no ability to get anyone in except as a favor,” says one doctor (“Few doctors at Boston's teaching hospitals accepting new patients.” Boston Globe, November 12, 2006). Another describes the exodus of US doctors from primary care as “a waterfall, not a trickle.” The failings of the US primary care system detailed in this week's issue of the journal by Bindman and colleagues (doi: 10.1136/bmj.39203.658970.55) thus will come as no surprise to beleaguered US primary care doctors. The study compared the characteristics of primary care practice in the United States, Australia, and New Zealand. The US has the lowest percentage of primary care physicians, the highest percentage of population uninsured for primary care, and the lowest mean number of primary care visits per person per year. The mean annual exposure to primary care physicians in the US was only 29.7 minutes, compared with 55.5 in New Zealand and 83.4 in Australia. The authors conclude that this “severe shortfall of available time in primary care” might be one reason “the US does not have health outcomes that correspond to its overall investment in health care.” Other things also bear more watching. Susan Mayor (doi: 10.1136/bmj.39244.725810.DB) summarizes a recent study showing that survivors of early breast cancer require close monitoring for recurrence beyond the now-standard three to five years after diagnosis. Dhruv Kazi (doi: 10.1136/bmj.39245.502546.BE) reviews the latest drug safety controversy (rosiglitazone) and concludes that more care is needed in postmarketing surveillance, which currently “falls short of the standards the agencies set for themselves.” He endorses recommendations from the Institute of Medicine for a “life cycle” approach to safety monitoring that would guard against a false sense of security after a drug is released. Finally, Ben Goldacre has been watching over the British media and its reluctance to “mention the data” when reporting on dubious medical conditions such as “electromagnetic sensitivity” (doi: 10.1136/bmj.39245.510718.59). He notes the “monastic silence” of disease “lobbyists” and the press when it comes to reporting scientific evidence debunking disease claims, and considers their possible motives, none of them savory. All of this will be depressingly familiar to US readers. “Electromagnetic sensitivity” may not be as popular a disorder on the US side of the Atlantic as it is in Britain, but we have chronic Lyme disease and multiple chemical sensitivity disorder. And on both sides of the pond the apparent collusion of the popular media and disease lobbyists is dismayingly common..

Levels and correlates of alpha-fetoprotein in normal pregnancies among Caucasian and Chinese women

Alpha-fetoprotein has been suggested to have anti breast cancer properties both in adult life and in utero. We studied correlates of maternal serum alpha-fetoprotein levels in normal singleton pregnancies. This was a prospective study relying on women attending maternal units in major teaching hospitals in Boston, USA and Shanghai, China. Specifically, 212 Caucasian women in Boston, and 196 Asian women in Shanghai provided blood samples at the 16th and 27th gestational week. Maternal serum alpha-fetoprotein levels were measured and correlated with maternal and newborn parameters through multiple regression procedures, controlling for a set of potential confounders, including maternal levels of measured hormones. Alpha-fetoprotein was strongly inversely associated with maternal prepregnancy body mass index (-4.73 ng/l at the 27th week per 1 kg/m of body mass index, with 95% confidence intervals -7.09 to -2.36), whereas it was not related to parity, gender of offspring or birth weight. Duration of gestation was inversely associated with maternal alpha-fetoprotein levels, particularly among Caucasian women (-0.22 weeks per 60 ng/l of alpha-fetoprotein at the 27th week, with 95% confidence intervals -0.39 to -0.05). In normal pregnancies, maternal alpha-fetoprotein is inversely related to prepregnancy body mass index and appears to have a physiologic role on duration of gestation rather than on birth weight.

Beyond the Comfort Zone: Residents Assess Their Comfort Performing Inpatient Medical Procedures

Purpose Resident physicians learn to perform inpatient bedside procedures in a manner that is neither standardized nor rigorous. As a result, residents may be unskilled and uncomfortable performing procedures. This study characterizes residents’ comfort performing medical procedures and identifies factors associated with lack of comfort. Subjects Study subjects were internal medicine resident physicians who performed one of four medical procedures (central line, lumbar puncture, paracentesis, or thoracentesis) on adult medical inpatients between July 1, 2003, and June 30, 2004. Methods This prospective cohort study was conducted at a 556-bed Boston teaching hospital. Resident physicians evaluated their comfort with 9 aspects of 4 medical procedures, recording this information in an electronic log. We also abstracted operator characteristics and patient demographic data. We analyzed residents’ comfort with each aspect of the procedure and defined “overall comfort” as comfort with each of the 9 aspects. Results A majority of resident physicians reported lack of comfort with at least one aspect of the procedure. Residents reported lack of comfort with 37% of unsupervised procedures. They also reported lack of comfort with the prospect of managing complications in 35% of procedures. In the multivariable analysis, overall comfort was associated with the use of a dedicated medical procedure service (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.4) and inversely associated with postgraduate year 1 status (OR 0.3, CI 0.1-0.5), first time performing the procedure (OR 0.4, CI 0.2-0.8), thoracenteses (OR 0.4, CI 0.2-0.8), and emergent procedures (OR 0.6, CI 0.3-1.0). Conclusions Many resident physicians are uncomfortable performing common bedside procedures. Experience and supervision mitigate some, but not all, discomfort.

Patient-reported service quality on a medicine unit

Service quality, defined as patients' self-reported experience of care, is used as a metric for evaluating quality. Most studies rely on retrospective consumer surveys rather then more intensive data collection methods, possibly underestimating the incidence of service quality incidents. The objective of the study was to characterize patient-reported service quality deficiencies on a general medicine unit. We studied a cohort of 228 adult inpatients at a Boston teaching hospital. Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone after discharge. Physician investigators classified patients' incident reports. We calculated the rate of service incidents, characterized incident types, and used multivariable Poisson and logistic regression models to examine factors associated with patient reporting and overall rating of the hospitalization. Eighty-eight (38.6%) of 228 patients experienced 157 service quality incidents during the admission, for a rate of 68.9 incidents per 100 admissions. The most common service quality problems involved waits and delays (n = 45), problems with communication between staff and patients (n = 36), and environmental issues and amenities (n = 35). In the multivariable analysis, men (IRR 1.6, 95% CI 1.1-2.2), patients covered by hospitalists (1.5, 1.1-2.2), and patients with more medication allergies (1.1 per allergy, 1.1-1.2) reported more service incidents; patients with Medicaid or free care reported fewer (0.5, 0.3-0.9). Patients with service quality incidents were more likely to describe the hospitalization as other than excellent (adjusted OR 1.8 per incident, 95% CI 1.3-2.5). Service quality deficiencies are common among medical inpatients, and are strongly associated with patients' dissatisfaction with the hospitalization.

Hepatic Venous Pressure Gradient Predicts the Severity of Cirrhosis

Purpose: Liver biopsy is the gold standard for establishing cirrhosis, but may provide inadequate tissue in some patients. The purpose of this study was to determine whether the hepatic venous pressure gradient (HVPG) predicts the presence and severity of cirrhosis. Methods: Patients with liver disease who had undergone HVPG measurements were identified at two Boston teaching hospitals. Patients were excluded if they lacked a liver biopsy or the slides could not be obtained, if there was an elapsed time between liver biopsy and HVPG measurement of >12 months, or if the patient had undergone a shunt, TIPS or liver transplantation prior to completion of both the liver biopsy and the HVPG measurement. Clinical, laboratory, and HVPG data were collected and biopsies were staged for the degree of fibrosis using the Laennec scoring system, a modification of METAVIR, which sub-classifies cirrhosis as mild, moderate or severe. Results: A total of 32 patients met inclusion and exclusion criteria. Univariate logistic regression identified HVPG and platelet count as independent predictors of cirrhosis. When a proportional odds model was applied, the magnitude of the effect of HVPG on fibrosis score was described by the estimated OR of 1.34 (95% CI 1.12–1.61). Additionally, the model demonstrated that as the HVPG increased, so did the probability of having more histologically advanced cirrhosis. [figure 1]FigureConclusions: HVPG measurement predicts cirrhosis, with higher HVPG measurements correlating with more advanced cirrhosis. Therefore, when the diagnosis of cirrhosis is in question, an elevated HVPG measurement can support the diagnosis.Table: Laennec Scoring System of Liver Biopsies

Iatrogenic events resulting in intensive care admission: Frequency, cause, and disclosure to patients and institutions

Purpose To identify the frequency and type of iatrogenic medical events requiring admission to an intensive care unit. To assess the consequences of iatrogenic medical events for patients and institutions. To assess the prevalence of disclosure of iatrogenic medical events to patients, surrogates, and institutions. Methods The project on Care Improvement for the Critically Ill enrolled 5727 patients to 8 intensive care units at 4 Boston teaching hospitals. To determine the nature, consequences, and disclosure of iatrogenic medical events, we did a retrospective chart review on all patients whose admission to an intensive care unit was precipitated by an iatrogenic event. Results Sixty-six patients (1.2 %) were identified by an intensive care unit’s clinical team as having an iatrogenic medical event as the primary reason for admission to the unit. The majority (29, or 45%) of iatrogenic medical events were secondary to technical error, but a high percentage (21, or 33%) was due to iatrogenic drug events. Twenty-two (34%) cases were assessed by the investigators to have been preventable. In 60 (94%) cases there was no documentation in the patient’s chart of communication to the patient regarding the reason for admission to the intensive care unit. In 11 (17%) cases there was documentation of a discussion with the surrogate about the reason for admission to the unit. In only 3 (5%) cases was there documentation that the patient or surrogate was informed that an iatrogenic medical event was the reason for admission to the intensive care unit. Incident reports or malpractice claims were filed in only 4 (6 %) cases. Conclusion The frequency of iatrogenic medical events resulting in admission to intensive care units is lower than previous studies have reported. Iatrogenic drug events continue to be an important source of error. A considerable percentage of iatrogenic events may be preventable. Health care professionals rarely document disclosure of iatrogenic events to patients and surrogates.

The Impact of Methicillin Resistance in Staphylococcus aureus Bacteremia on Patient Outcomes: Mortality, Length of Stay, and Hospital Charges

To evaluate the impact of methicillin resistance in Staphylococcus aureus on mortality, length of hospitalization, and hospital charges. A cohort study of patients admitted to the hospital between July 1, 1997, and June 1, 2000, who had clinically significant S. aureus bloodstream infections. A 630-bed, urban, tertiary-care teaching hospital in Boston, Massachusetts. Three hundred forty-eight patients with S. aureus bacteremia were studied; 96 patients had methicillin-resistant S. aureus (MRSA). Patients with methicillin-susceptible S. aureus (MSSA) and MRSA were similar regarding gender, percentage of nosocomial acquisition, length of hospitalization, ICU admission, and surgery before S. aureus bacteremia. They differed regarding age, comorbidities, and illness severity score. Similar numbers of MRSA and MSSA patients died (22.9% vs 19.8%; P = .53). Both the median length of hospitalization after S. aureus bacteremia for patients who survived and the median hospital charges after S. aureus bacteremia were significantly increased in MRSA patients (7 vs 9 days, P = .045; 19,212 dollars vs 26,424 dollars, P = .008). After multivariable analysis, compared with MSSA bacteremia, MRSA bacteremia remained associated with increased length of hospitalization (1.29 fold; P = .016) and hospital charges (1.36 fold; P = .017). MRSA bacteremia had a median attributable length of stay of 2 days and a median attributable hospital charge of 6916 dollars. Methicillin resistance in S. aureus bacteremia is associated with significant increases in length of hospitalization and hospital charges.

James Mandell Becomes New Chairman for Conference of Boston Teaching Hospitals

James Mandell Becomes New Chairman for Conference of Boston Teaching Hospitals

James Mandell Becomes New Chairman for Conference of Boston Teaching Hospitals

James Mandell Becomes New Chairman for Conference of Boston Teaching Hospitals

A prospective study of pregravid oral contraceptive use in relation to fetal growth.

Because oral contraceptives are so widely used, any health consequences may have substantial public health implications. Whether pregravid oral contraceptives could affect subsequent pregnancies has not been adequately studied. The study objectives were to examine whether pregravid oral contraceptive use affects fetal growth and pregnancy hormone levels. A prospective study of pregnant women followed through pregnancy. A major teaching hospital in Boston, USA. Two hundred and sixty Caucasian pregnant women, with a mean age of 31, and a parity of no more than two. Seventy-nine percent of the women were pregravid oral contraceptive users. Exposure and covariate data were collected through structured questionnaires. Blood was drawn for hormonal analysis during the 16th and 27th gestational week. Information on pregravid oral contraceptive use included duration and recency of use, and oral contraceptive formulation. Multivariate regression models were used to examine the effect of pregravid oral contraceptive use on birth outcomes and the studied pregnancy hormones. Birthweight, placental weight, gestational age, pregnancy hormone levels of oestriol and progesterone at 16th and 27th gestational week. Adjusting for confounders, pregravid oral contraceptive use increased birthweight (mean difference =+207.3 g, 95% CI =+77.6 to +337.1) and placental weight (mean difference =+64.9 g, 95% CI =+13.0 to +116.9) compared with never use. Women with prior oral contraceptive use had higher levels of serum progesterone (P= 0.002) and oestriol (P= 0.12) at the 27th gestational week measurement. The effect on birthweight, placental weight and hormones was stronger among those using oral contraceptives in the previous year and those using a high progestin/high oestrogen potency preparation. Pregravid oral contraceptive use is positively associated with fetal growth, and this effect may be mediated through oestriol and progesterone.

Benefits of Reducing Interns' Work Hours

House officers' work hours are the stuff of legend and urban myth. Prompted by the recent mandate from the Accreditation Council for Graduate Medical Education that limits work hours for residents, researchers prospectively measured interns' work and sleep hours, attentional failures, and error rates during two different work schedules. Interns at a Boston teaching hospital worked one intensive care unit rotation on a traditional schedule (every third night …

Impact of labor induction, gestational age, and maternal age on cesarean delivery rates.

To quantify the impact of labor induction and maternal age on cesarean delivery rates in nulliparous and multiparous women between 36 and 42 weeks' gestation. We performed a retrospective cohort study on 14,409 women delivering at two teaching hospitals in metropolitan Boston during 1998 and 1999. Women who had contraindications to labor, including a prior cesarean delivery, were excluded. The risks for cesarean delivery by induction status, gestational age by completed week between 36 and 42 weeks, maternal age <35, 35-39, and >/=40 years, and stratified by parity, were calculated by logistic regression. In nulliparas, labor induction was associated with an increase in cesarean delivery from 13.7% to 24.7% (adjusted odds ratio [OR] 1.70; 95% confidence interval [CI] 1.48, 1.95]). In multiparas, induction was associated with an increase from 2.4% to 4.5% (OR 1.49; 95% CI 1.10, 2.00). Other variables that placed a nulliparous woman at increased risk for cesarean delivery included maternal age of at least 35 years and gestational ages over 40 weeks. For multiparas, only maternal age 40 years or older and gestational age of 41 weeks were associated with an increase in cesarean deliveries. Induction of labor, older maternal age, and gestational age over 40 weeks each independently increase the risk for cesarean delivery in both nulliparous and multiparous women. Although the relative risk from induction is similar in nulliparas and multiparas, the absolute magnitude of the increase is much greater in nulliparas (11% versus 2.1%).

Complications—A Surgeon's Notes on an Imperfect Science

Complications—A Surgeon's Notes on an Imperfect Science

Patient and community preferences for treatments and health states in multiple sclerosis.

To examine preferences for treatments and health states for patients with relapsing-remitting MS and members of the community. A survey was developed to evaluate health-related quality-of-life measures (utilities) for three treatments and six MS health states using a utility-elicitation software package, U-Titer II. Sixty-two MS patients at two large teaching hospitals in Boston, MA, and 67 members of the general community in San Diego, CA, completed the health-related quality-of-life survey using a computer. Assessment of quality of life decreased as disability level of MS health states increased for both respondent groups. Respondents rated less-disabled health states relatively highly (> 0.94 for patients and > 0.89 for community respondents). Quality-of-life measures for treatments in mean utilities ranged from 0.80 to 0.96. Patients assigned higher utilities for both MS health states and treatment states than community respondents; the ratings became more disparate as health states worsened. On average, respondents assigned utilities to currently available treatments for MS that are comparable to those of mild to moderate stages of the disease itself. These results underscore the importance of including preferences for health states and treatment alternatives in the decision to initiate treatment for individual patients or in the evaluation of effectiveness or cost-effectiveness of these treatments in patients with MS.

Are Daily Chest X-Rays Necessary in the ICU?

In some intensive care units (ICUs), daily chest x-rays are ordered routinely. But does this practice improve outcomes compared with a more restrictive approach to chest radiography? Researchers in the medical ICU of a Boston teaching hospital …

Outcomes in patients treated with gemtuzumab ozogamicin for relapsed acute myelogenous leukemia

The outcomes of treatment with gemtuzumab ozogamicin compared with those of conventional chemotherapy for relapse of acute myelogenous leukemia (AML) were studied. The gemtuzumab ozogamicin group consisted of 104 patients treated in 15 U.S. and 25 European centers for first relapse of AML between May 1997 and December 1998. Conventional chemotherapy recipients consisted of 22 historical control patients who received treatment for their first occurrence of AML at a Boston teaching hospital between January 1991 and December 1994 and who subsequently underwent conventional inpatient reinduction chemotherapy for relapse. Patients in the gemtuzumab ozogamicin group received a two-hour i.v. infusion of 9 mg/m2 for up to three doses with at least two weeks between doses, while the historical controls received conventional chemotherapy, usually consisting of continuous-infusion cytarabine (days 1-7) plus mitoxantrone. Outcomes evaluated included differences in survival and hospitalization (occurrence and duration) for up to six weeks. Both stratified and multivariate regression methods were used in making comparisons. Adjusting for baseline differences, six-week survival rates were similar in the two groups (95% for the historical control group versus 89% for the gemtuzumab ozogamicin group). However, gemtuzumab ozogamicin recipients had significantly fewer total hospital days (adjusted mean, 19 days, versus 35 days), which was consistent with the higher prevalence of outpatient chemotherapy in this group (43% versus 0% among the historical controls). The difference in the number of hospital days was consistent across various baseline and demographic factors. Gemtuzumab ozogamicin appeared to be associated with equivalent survival and fewer total days of hospitalization than conventional chemotherapy in adults with relapsed AML.

“MERGERS OF TEACHING HOSPITALS IN BOSTON, NEW YORK AND NORTHERN CALIFORNIA”

“MERGERS OF TEACHING HOSPITALS IN BOSTON, NEW YORK AND NORTHERN CALIFORNIA”