Hospital-based Physician Research Articles

Robust Artificial Intelligence Tool for Atrial Fibrillation Diagnosis: Novel Development Approach Incorporating Both Atrial Electrograms and Surface ECG and Evaluation by Head-to-Head Comparison With Hospital-Based Physician ECG Readers.

Atrial fibrillation (AF) increases risk of embolic stroke, and in postoperative patients, increases cost of care. Consequently, ECG screening for AF in high-risk patients is important but labor-intensive. Artificial intelligence (AI) may reduce AF detection workload, but AI development presents challenges. We used a novel approach to AI development for AF detection using both surface ECG recordings and atrial epicardial electrograms obtained in postoperative cardiac patients. Atrial electrograms were used only to facilitate establishing true AF for AI development; this permitted the establishment of an AI-based tool for subsequent AF detection using ECG records alone. A total of 5 million 30-second epochs from 329 patients were annotated as AF or non-AF by expert ECG readers for AI training and validation, while 5 million 30-second epochs from 330 different patients were used for AI testing. AI performance was assessed at the epoch level as well as AF burden at the patient level. AI achieved an area under the receiver operating characteristic curve of 0.932 on validation and 0.953 on testing. At the epoch level, testing results showed means of AF detection sensitivity, specificity, negative predictive value, positive predictive value, and F1 (harmonic mean of positive predictive value and sensitivity) as 0.970, 0.814, 0.976, 0.776, and 0.862, respectively, while the intraclass correlation coefficient for AF burden detection was 0.952. At the patient level, AF burden sensitivity and positive predictivity were 96.2% and 94.5%, respectively. Use of both atrial electrograms and surface ECG permitted development of a robust AI-based approach to postoperative AF recognition and AF burden assessment. This novel tool may enhance detection and management of AF, particularly in patients following operative cardiac surgery.

Cancer recurrence: Detection and diagnostic intervals in Danish primary care.

e13110 Background: Danish cancer survivors receive hospital-based, specialized follow-up care with one central aim to detect cancer recurrence (CR) at an early stage. Nevertheless, CR is frequently detected outside of scheduled follow-up visits as 40-60% of CR patients encounter and present symptoms. The family physician (FP) is presumed to facilitate most of these diagnostic pathways. However, little is known about CR detection in primary care. We aim to examine diagnostic intervals, actions taken by the FP and sub-optimal events for patients presenting symptoms of CR in primary care. Methods: We are conducting a retrospective, national cohort study based on questionnaire data linked to register data at the individual level. Patients diagnosed with CR of melanoma, lung, breast, colorectal, bladder, ovarian and endometrial cancer between Jan 2022 and May 2024 are included. Patients are identified consecutively using validated, register-based algorithms. All Danish citizens have access to free healthcare and 99% are listed with a specific FP. The affiliated FP is invited to complete a questionnaire on the diagnostic pathway utilizing the patient medical record. Danish health registers provide information on the primary cancer, CR diagnosis date, comorbidity, education, sex, and age. Results: We aim to include 3,000 CR patients and expect to receive information on 1,000 CR diagnostic pathways initiated in primary care. We will present preliminary results from the first 500 responders. The proportion of diagnostic pathways initiated in primary care was 33%, hospital-based follow-up was 44%, and another route was 23%. The FPs initiated the diagnostic pathway by referral to cancer specific urgent pathway for 31% of patients, by referral to specialized private or hospital-based physician including diagnostic imaging for 30% of patients. For 31% of diagnostic pathways, the FPs reported sub-optimal or delaying events. The most frequently reported sub-optimal event was regarding clinical decisions by the FP (12%). For patients with CR of breast cancer (n=53), the mean diagnostic interval (time from first contact to CR diagnosis) was 86 days [95% CI = 61 to 112days]. Conclusions: One third of diagnostic pathways for CR was initiated in primary care. This project will provide novel, comprehensive evidence on these diagnostic pathways to inform the efforts for early detection of CR and survivorship in primary care.

Drivers of Medicare Spending: A 20-Year Review of Radiation Oncology Charges Allowed per Person as Compared to Other Specialties

<h3>Purpose/Objective(s)</h3> The rising cost of health care is a major concern in the United States. Though radiation oncology was targeted for cost reductions based on expenditure growth, subsequent analyses suggested stabilization of radiation oncology charges. In 2019, the Centers for Medicare and Medicaid Services (CMS) proposed a new radiation oncology model aimed at further reducing Medicare expenditures while potentially improving the quality of beneficiary care. In 2020, CMS issued a final rule establishing a Radiation Oncology Alternative Payment Model to begin Jan 1, 2022, although this was delayed to Jan 1, 2023 through the Supporting Health Care Providers During the COVID-19 Pandemic Act. We examined changes in aggregate Medicare charges allowed per person served and per Part B Enrollee to provide contemporary context to proposed changes and hypothesize that radiation oncology charges remained stable from 1999 through 2019. <h3>Materials/Methods</h3> Medicare physicians/suppliers' utilization, program payments and balance billing for original Medicare beneficiaries, by physician specialty, was analyzed from 1999 to 2019 through CMS program statistics. Total allowed physician charges per person with utilization, cost per original Medicare part B enrollee, inflation adjusted charges, and percent of total charges billed per specialty were examined, including hospital-based physician charges and free-standing center global charges. We adjusted for inflation using the consumer price index for medical care from the US Bureau of Labor Statistics. <h3>Results</h3> The average allowed charges per person served went from $2,065 in 1999 to $2,260 in 2019, when adjusting for inflation. The top three specialties accounting for the most charges per person served in 2019 were Hematology-Oncology, Medical Oncology, and Radiation Oncology with $1,706, $1,485, and $1,336 charges allowed per person served, respectively. Radiation oncology charges allowed by Medicare per person served decreased by 7% from 1999 to 2004 ($1,283 to $1,199), increased by 32% from 2004 to 2009 (from $1,199 to $1,588), decreased 3% from 2009 to 2014 ($1,588 to $1,544), and decreased another 13% from 2014 to 2019 ($1,544 to $1,336), when adjusted for inflation. Radiation oncology charges allowed per original Medicare part B enrollee was $53, or 1.4% of the $3,937 total for all specialties in 2019. <h3>Conclusion</h3> Oncology charges allowed by Medicare per person served are among the highest of all specialties. Radiation oncology physician charges per person served have decreased steadily from 2009 to 2019. Charges per original Medicare Part B enrollee represent a small fraction of total Medicare fee-for-service physician/supplier expenses. Thus, the need for an alternative payment model as a method to control radiation oncology physician charges may be overstated.

Racial disparities in stage 3 lung cancer treatment.

e18574 Background: In the 1990s, it was demonstrated that Black patients were less likely to receive timely treatment for Stage 3 lung cancer than White patients. While contemporary work has found racial disparities in accessing insurance, diagnostics, and treatments, we wished to explore whether patients faced disparities once in treatment. To do this, we examined whether racial disparities were observable in a 2019 cohort of Medicare Advantage beneficiaries receiving treatment for lung cancer. Methods: This retrospective, observational study used health plan claims data to identify Black and White patients aged 18 to 89 years with a Medicare Advantage health plan in calendar year 2019 who received diagnostic imaging (computed tomography or positron emission tomography) followed by lung cancer treatment (radiation therapy [RT] or surgery claims mentioning a diagnosis of lung cancer) within 90 days. Only patients treated in 2019 were considered so that the findings would reflect the state of care immediately preceding the COVID-19 pandemic. Patients were excluded if they had a history of RT or lung surgery in the year prior to the diagnostic imaging date. Other databases were used to determine cancer stage, patient demographics, comorbidities, the urbanicity and median income of patients’ home ZIP code, and whether treatment was ordered by a hospital-based physician. A multivariate logistic model was used to examine the association between race and surgery, and a multivariate negative binomial model was used to examine the association between race and days to treatment (surgery or RT). Results: We identified 823 patients, 83.8% White (690), and 16.2% (133) Black. Surgery was received by 3.1% [4/133] of Black patients and 9.7% [61/690]) of White patients. Black patients received treatment on average 36.9 days after diagnosis, versus 35.1 days for White patients. Adjusted analysis did not find a significant association between race and receipt of surgery (P = 0.07) or race and days to treatment (P = 0.77). No covariate was significantly associated with receipt of surgery. Residence in a state with a higher obesity rate was associated with fewer days to treatment (P = 0.02). Conclusions: In a uniformly insured population that successfully received treatment, adjusted analysis found no evidence of a Black / White racial disparity in use of lung surgery for Stage 3 lung cancer or in timeliness of treatment. Given the directionality of the findings, they could potentially have been significant if the sample size had been increased by extending the enrollment period. The implication of these findings is that it may be most fruitful to address racial disparities at the frontend of the care process; working to ensure that patients have access to insurance, diagnostics, and treatments, as disparities were not observed in a population that had accessed treatment. Further research is needed to assess whether racial disparities in lung cancer treatment have dissipated over time.

Geographic Variation in Hospital-Based Physician Participation in Insurance Networks

Geographic Variation in Hospital-Based Physician Participation in Insurance Networks

Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study.

Background:Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults.Methods:We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits.Results:We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14).Interpretation:Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.

Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia.

Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia.

Les médecins prestataires à la première ligne des soins dans la ville de Kisangani en République Démocratique du Congo : vers une typologie

BackgroundIn the Democratic Republic of the Congo (DRC), for a number of years, there has been a spontaneous and growing phenomenon of physicians operating at the front line of the health system, while this role is traditionally devolved to nurse-practitioners. This phenomenon does not align with the current health policy.AimThe aim of this paper is to develop and discuss the main types of frontline physicians in the city of Kisangani.SettingWe conducted a descriptive cross-sectional study in two urban districts in the city of Kisangani.MethodsThe study population consisted of all first-line health facilities that employed at least one physician. The construction of a typology of first-line physicians consisted of three stages: identification and definition of relevant dimensions of analysis; grouping cases based on empirical data; and analysis of significant relationships and establishment of the typology itself.ResultsAn involvement of physicians in healthcare delivery at the first line was observed in 60% of all first line facilities in the two urban districts. Two main types of first-line physicians were identified: firstly, and by large the most prevalent one (96% of cases), the ‘hospital-like physician’, and secondly, the much less frequent type of the ‘supervision physician’.ConclusionThe involvement of physicians in first line healthcare is today a growing phenomenon in the DRC, especially in urban areas. The most dominant expression of this phenomenon is a transposition of the hospital-based physician model to the first line healthcare services, which thereby jeopardizing the specificity of first line healthcare.

Determinants of Hospital-based Physician Participation in Quality Improvement: A Survey of Hospitalists in British Columbia, Canada

Abstract Objective: We aimed to understand the extent of hospitalist involvement in system improvement efforts across the province of British Columbia in Canada and provide insights into determinants of such participation. Materials and Methods: We designed a web-based survey and asked about individual, programmatic, and institutional characteristics that may facilitate or impair hospitalist involvement in quality improvement (QI) activities. The survey was sent to all individuals who participated in “hospitalist care” from January 2014 to February 2015, in the province of British Columbia, Canada. We conducted both quantitative and qualitative analysis of responses. Results: We received 57 complete responses to the survey of 322 invited individuals (17.7% response rate). Of these, 15 individuals (26.3%) indicated that they had participated in QI initiatives. Respondents highlighted high clinical workload and lack of time, lack of QI skills and training, lack of access to performance data, poor support from hospital/health authority administration, and lack of financial compensation as main barriers to QI involvement. These themes were also supported in logistic regression, where QI training and the number of weeks worked as a hospitalist showed significant predictive properties for involvement in QI initiatives. Conclusion: Our study attempts to understand the various individual or organizational attributes that could facilitate involvement by hospital-based generalist physicians in QI activities. Our findings show lack of formal QI training is an important barrier for hospitalist involvement in QI, and highlight the need for formal training, dedicated time, support from physician leadership, and financial incentive as important facilitators for participation in systemic improvement efforts.

Machine Learning Predicts Acute Pulmonary Exacerbations in Cystic Fibrosis

Background: Sudden deteriorations in lung health, termed acute pulmonary exacerbations (APEs), are a major driver of mortality and morbidity in Cystic Fibrosis (CF). Accurate prediction of impending APEs would permit pre-emptive interventions and allow home monitoring to safely replace hospital-based physician consultations. Methods: We enrolled 147 adults with CF into a six-month study of home monitoring based at seven UK specialist CF Centers. Subjects were asked to undertake daily measurements of lung function, oximetry, pulse rate, weight, and activity (using sensors Bluetooth-linked to mobile phones), and provide daily self-reported symptom scores of cough frequency, general wellness, and sleep quality. Linked-anonymised data were then analysed using machine learning (ML) methods to define the profile of APEs and predict their onset. Findings: End of study questionnaires revealed that 92% of participants found home monitoring easy to use and 76% found it helpful or very helpful in tracking their health over time. Unsupervised machine learning analysis uncovered the typical signal profile of an APE and revealed three distinct classes of exacerbation. We developed a ML predictive classifier that can detect an impending APE on average 10 days earlier that current clinical practice. Interpretation: High frequency home monitoring in CF is feasible, reveals distinct types of APEs, and permits accurate prediction of future exacerbations. Trial Registration Number: NCT02416375 (ClinicalTrials.gov). Funding Statement: This study was funded through research grants from the UK Cystic Fibrosis Trust, Royal Papworth Hospital, the Wellcome Trust (Investigator Award RAF; 107032/Z/15/Z), and Microsoft Research/EPSRC (PhD scholarship DES). Declaration of Interests: Thomas Daniels has accepted speaker fees from Vertex pharmaceuticals, and consultancy fees from Chiesi Pharmaceuticals, none of which were involved in anyway at all with the submitted manuscript, nor had any influence at any stage of the work. The remaining authors have no competing interests to declare. Ethics Approval Statement: The study received National Ethical approval from the NRES Committee East of England-Norfolk (REC 14/EE/1244) and site-specific approval and monitoring from each participating Hospital R&D Department. All participants provided written informed consent before enrolment into the study.

An activity analysis of Dutch hospital-based physician assistants and nurse practitioners

BackgroundThe physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management.Study designA descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated.MethodsThe patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system.FindingsIn total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care.ConclusionsNPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

An infection control journey in hospital based practice conversion

BACKGROUND Outpatient care is provided in hospital-based (HB) outpatient clinics, non-HB clinics and physician offices, ambulatory surgical centers, and other settings. Some settings may have minimal infection control (IC) oversight based on hospital-affiliated status. Whatever the designation, it is essential that care is provided under conditions that minimize or eliminate risks of healthcare-associated infections. The project goals are to effectively bring physician based practices (PBPs) under hospital licensure, ensure safe delivery of care, and produce successful regulatory surveys. METHODS In 2016 at an urban academic medical center, a number of operational PBPs began converting to HB. They included a wide range of clinical specialties that provided a multitude of services (including urology, otolaryngology and dermatology), many of which were at high risk for transmitting infection from person to person if IC breaches occurred. During this time, IC hired a full time practitioner dedicated to PBP/ outpatient and was fully integrated into the practices. Initial assessments of each practice was done, including a full review of infection control processes. Identified needs and risks were addressed. IC presence was established through regular and continuous education, rounding, and auditing. Existing hospital policies and procedures were adjusted and adopted by the practices. RESULTS 100% of the 30 practices achieved HB status and fared well to very well during numerous regulatory activities. There has been a great improvement in following infection control expectations. Adherence to hospital policy and procedure was seen in all settings, including increased adherence to standard and isolation precautions, increased compliance to standards for low, intermediate, high level disinfection and sterilization. CONCLUSIONS The IC journey to HB conversion was successful. A collaborative approach including all levels of personnel was vital in this change. Also, leadership and staff buy-in was critical in moving forward with making and sustaining IC improvements in practice and to maintain survey readiness.

Caregiver’s attitudes, beliefs, and experiences for influenza vaccination in Australian children with medical comorbidities

BackgroundInfluenza vaccination is recommended and funded for Australian children with medical comorbidities that increase their risk of severe influenza. Despite this, influenza vaccine coverage remains low within this population. We examined caregivers’ attitudes and practices for influenza vaccination in children with medical comorbidities. MethodsCross-sectional surveys were conducted with caregivers of children (6 months to <18 years old) with medical comorbidities attending sub-speciality paediatric outpatient clinics at the Royal Children’s Hospital (Melbourne), Princess Margaret Hospital (Perth), and Leading Steps private paediatric clinic (Gold Coast). Multivariate linear regression was used to identify surveys responses predictive of receipt of influenza vaccination in 2017. ResultsFrom the 611 surveys collected, 556 were suitable for analysis. Caregiver reported 2017 influenza vaccine coverage was 52.2% in children with medical comorbidities. Caregivers who believed influenza vaccines to be ≥50% effective were more likely to vaccinate their children (adjusted Odds Ratio [aOR]:3.79 (2.41; 5.96). Those who expressed concerns about vaccine side effects were less likely to vaccinate their children (aOR: 0.49 [95% CI: 0.30; 0.80]). Influenza vaccine uptake was significantly more likely for children who had been previously recommended influenza vaccination by their hospital-based physician (aOR: 4.33 [95% CI: 2.58; 7.27]) and had previously received a hospital-based vaccination (aOR: 3.11 [95% CI 1.79; 5.40]). Hospital-based physicians were also caregivers’ most commonly reported source of trusted vaccination information (63.5%). Whilst only 29.3% of caregivers reported their child had been recommended influenza vaccination during a previous admission, 80.1% of caregivers stated they were receptive to their child receiving potential future influenza vaccinations during hospitalisations. ConclusionsReported influenza vaccination coverage in children with medical comorbidities remains inadequate. An important finding of this study is that influenza vaccination recommendation by children’s hospital physicians and previous vaccine receipt in hospital was associated with vaccine uptake. Opportunities for vaccination, especially during hospitalisation, must be examined.

Variability in Doctors' Usage Paths of Mobile Electronic Health Records Across Specialties: Comprehensive Analysis of Log Data.

BackgroundWith the emergence of mobile devices, mobile electronic health record (mEHR) systems have been utilized by health care professionals (HCPs), including doctors, nurses, and other practitioners, to improve efficiency at the point of care. Although several studies on mEHR systems were conducted, including those analyzing their effects and HCPs’ usage frequency, only a few considered the specific workflows of doctors based on their specialties in which the work process differs greatly.ObjectiveThis study aimed to investigate the differences in mEHR usage paths across clinical specialties.MethodsWe collected the log data of 974 doctors who worked from August 2016 to August 2017 and used the mEHR system at the Samsung Medical Center, one of the biggest hospitals in South Korea. The doctors were classified into 3 groups based on their specialty: the physician, the surgeon, and other hospital-based physician (OHBP) groups. We used various descriptive and visualization methods to understand and compare doctors’ usage paths of mEHRs. First, the average numbers of log-ins per day and features used per log-in were examined over different specialties and positions. Second, the number of features used by each doctor was visualized via a heat map to provide an overview of mEHR usage across feature types and doctors’ specialties. Third, we conducted a path analysis via a Sankey diagram to describe main usage paths and association rule mining to find frequent paths in mEHR usage.ResultsThe physician group logged on most frequently, whereas the OHBP group logged on least frequently. In fact, the number of log-ins per day of residents in the physician group was 4.4 times higher than that of staff members in the other groups. The heat map visualization showed a visible difference among specialty groups. The physician group used more consultation-related features, whereas the surgeon group used more surgery-related features. Generally, 50% of the doctors spent about 15 seconds at a time when using mEHRs. In the Sankey diagram, the physician group showed diverse usage patterns with higher complexity compared with the other 2 groups; in particular, their paths contained more loops, which reflected repetitive checks on multiple patients. The most frequent path included inpatient summary, which means that most users stopped at the point of summary and did not proceed to view more details.ConclusionsThe usage paths of mEHRs showed considerable differences among the specialty groups. Such differences can be accommodated into an mEHR design to enhance the efficiency of care.

Development of a points-based system for determining workload for a neonatology full-time equivalent.

Quantifying the workload for a hospital-based physician can be a challenge. We developed a novel approach to providing equity and flexibility for physicians working in a large system with heterogeneous clinical activities. In developing this points-based system, expected clinical work hours were calculated for a full-time equivalent. A point value was assigned to each clinical service based upon the hours, complexity and intensity of the work. A hypothetical work schedule was created using the expected clinical hours and translated into points needed for a full-time clinician. Faculty appreciate the flexibility and feel appropriately valued and equitably paid. Our system serves as a recruitment tool and enables the division to better understand resource needs and predict the need for additional staff. Development of a point-based model for calculating clinical work has successfully created a homogeneous system to define and measure physician work expectations in a heterogeneous clinical environment.

Recognition and management of platelet-refractory bleeding in patients with Glanzmann's thrombasthenia and other severe platelet function disorders.

Patients with rare qualitative platelet disorders or platelet function disorders (PFDs) may present to the hospital physician with severe bleeding episodes or excessive surgical bleeding. Although standard treatment consists of platelet transfusions, repeated transfusions may result in the development of antiplatelet antibodies (APA) or clinical refractoriness, rendering further platelet therapy ineffective. In such settings, an approved treatment option for patients with Glanzmann’s thrombasthenia (GT), one of the well-known rare PFDs, is recombinant activated coagulation factor VII (rFVIIa). Data regarding the efficacy of rFVIIa in patients with GT and platelet refractoriness are available from a large patient registry, an international survey, and multiple case reports and demonstrate efficacy in patients with and without refractoriness or APA. This article reviews the rFVIIa clinical data in patients with GT and platelet refractoriness and discusses clinical implications relevant to the hospital-based physician. Because uncontrolled bleeding can be life-threatening, hospital physicians should be alert to the signs of platelet refractoriness, be able to recognize continued internal or external bleeding, and know how to adapt treatment regimens for the effective management of bleeding. The management of patients who receive rFVIIa should occur in consultation with a hematologist with experience in PFDs, and patients with suspected platelet refractoriness should be referred to such a hematologist as early as possible. A critical unmet need is the development of a definition of an adequate response to platelet transfusion, which would facilitate early recognition of platelet refractoriness in patients with PFDs who exhibit a normal platelet count.

The future physician

Both hospital-based care and physician training have undergone significant changes within the past decade. Current physician training in the UK is failing to meet the needs of patients, with significant numbers of acute and general medicine posts unfilled. Building on the themes of the 2013 Shape of Training review, we propose a model that places an alternative model of generalist - the 'future hospitalist' - at the centre of patient care and medical training. The reinstatement of the general physician at the heart of hospital care will increase flexibility in both training and workforce planning, and embed active leadership, patient safety and quality improvement in care delivery.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System.

The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital. Retrospective case series. Level II trauma center. One thousand one hundred four trauma patients with orthopaedic injuries. PA involvement. Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27). Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States

We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located. We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED's location. To create a comparison nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights. We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs. In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states.

Subspecialisation in emergency medicine: A specialty at the crossroads.

Subspecialisation in emergency medicine: A specialty at the crossroads.