Teaching Hospitals In California Research Articles

Learning Lessons from the COVID-19 Pandemic-A Qualitative Assessment of the Experiences of Pregnant Latinas Infected with COVID-19 and Their Perspectives on Vaccination.

To examine the experiences of pregnant Hispanic/Latine people with COVID-19, as well as their perspectives on COVID-19 vaccination in pregnancy. We interviewed birthing parents who received care from a teaching hospital in California and tested positive for COVID-19 during pregnancy or delivery. We analyzed transcripts using the constant comparative method for analyzing data to using a phenomological epidemiological approach. We used root cause analysis to identify consistent themes across interviews and assess relationships between social determinants of health and COVID-19 infectivity. We interviewed 14 women from November 2021 to June 2022. Participants reported COVID-19 adversely impacted their clinical care and well-being during pregnancy or postpartum. Impacts among Spanish-speaking participants included unexpected financial hardships, challenges navigating in-patient experiences, and difficulty securing reliable childcare. While most participants were at least partially vaccinated, participants also described doubts and concerns about the vaccine. Our findings suggest that Spanish-speaking Hispanic/Latine patients could benefit from receiving more information about COVID-19 in pregnancy from their healthcare providers. Leveraging familial and social networks, providing reliable information in people's preferred language, and increasing communication through trusted partners may also help combat vaccine hesitancy.

Seroprevalence of SARS-CoV-2 in 1186 Equids Presented to a Veterinary Medical Teaching Hospital in California from 2020 to 2022.

While some companion animals have been shown to be susceptible to SARS-CoV-2, their role in the COVID-19 pandemic has remained poorly investigated. Equids are susceptible to SARS-CoV-2 based on the similarity of the human ACE-2 receptor and reports of infection. Clinical disease and prevalence factors associated with SARS-CoV-2 infection in equids have not yet been investigated. The aim of this study was to determine the seroprevalence of SARS-CoV-2 and selected prevalence factors in 1186 equids presented for various conditions to a Veterinary Medical Teaching Hospital over a two-year period. Blood samples were tested for SARS-CoV-2 antibodies using an ELISA targeting the receptor binding domain (RBD) of the SARS-CoV-2 spike protein. Further, selected prevalence factors (season, age, breed, sex, presenting complaint) were retrieved from the medical records. No information was available on whether the horses had come into contact with COVID-19-positive individuals. Among the study animals, 42/1186 (3.5%) horses had detectable SARS-CoV-2 antibodies. Amongst the prevalence factors investigated, only seasonality (spring) was associated with a greater frequency of seropositivity to SARS-CoV-2. Horses with medical and surgical complaints were more likely to test seropositive to SARS-CoV-2 compared to horses presented for routine health care procedures, suggesting more frequent and/or longer interactions with individuals with COVID-19. While horses can become infected with SARS-CoV-2 via the occasional spillover from COVID-19 individuals, clinical disease expression remains subclinical, making horses an unlikely contributor to the spread of SARS-CoV-2.

Genetic testing costs and compliance with clinical best practices.

We sought to determine the costs of genetic testing and compliance with published guidelines and clinical best practices at our institution. A cost analysis was performed comparing the costs of ordered tests to the cost of the recommended testing. This was an approved quality improvement project at a tertiary teaching hospital in California. We identified charts associated with the genetic testing billing codes for common genetic tests through our contracted laboratory (cystic fibrosis genotyping, Breast cancer susceptibility gene (BRCA 1&2), Methylenetetrahydrofolate reductase (MTHFR), factor V Leiden (FVL), prothrombin gene pathogenic variant, alpha-thalassemia, hemochromatosis, and cell-free fetal DNA). Charts were reviewed retrospectively by a licensed, certified genetic counselor to assess the compliance with published clinical practice guidelines identified on GeneReviews and the American College of Obstetricians and Gynecologists (ACOG). Tests were classified as: appropriate, misordered/not indicated, misordered/false reassurance, and misordered/inadequate. We performed a cost analysis for the recommended test changes. We reviewed 114 charts over a three-month period. Forty-four (38.6%) of the tests were misordered based on published clinical practice guidelines: 24 (21%) were misordered/not indicated, 8 (7%) were misordered/false reassurance, and 12 (10.5%) were misordered/inadequate. Costs of ordered testing ($75,177) were compared to recommended testing after review ($54,265), with a total cost savings of $20,912. In clinical practice, over one-third of genetic tests reviewed were misordered. As these tests are a small fraction of all genetic tests at our institution, future studies should broaden the scope of testing evaluated to understand the magnitude of this problem and potential cost savings. Genetic counselor review and involvement in genetic test ordering can decrease inappropriate healthcare expenditures and improve patient care.

The impact of Hospital Elder Life Program interventions, on 30-day readmission Rates of older hospitalized patients

ObjectiveThis study investigated the impact of the Hospital Elder Life Program (HELP), a geriatric intervention program targeted at reducing delirium, on readmission rates. Secondary goals were to review HELP’s impact on average length of stay (ALOS), discharge to the home, and falls. DesignThis retrospective 3-year study reviewed inpatients age 70 and older, with one or more of six impairments: functional, renal, cognitive, sleep, visual and hearing. Patients were from a 784 bed teaching hospital in California with admissions between January 1, 2014 and December 31, 2016. This was compared to a matched cohort of patients who did not receive any interventions from HELP volunteers or a HELP geriatric nurse practitioner. Data was also reviewed for impact on goals in age groups 70–85 and 85 + . Results2146 HELP patients with an average age of 82.1 showed improvement in 30-day readmission rates, with a readmission rate of 11.3% in the HELP group and 13.5% in the control group (n = 2704, mean 82.5). Detailed age data noted statistical significance only in the 70–85 population for readmission. ALOS was 5.6 and 6.2 days respectively in the HELP and non-HELP population. ALOS was also statistically significant across 70–85 and 85 + . Neither rates of discharge to home nor falls showed any significant improvement. Both control and intervention groups had a disproportionate number of whites and females. ConclusionThis study shows hospitals can improve patient outcomes and financial burden from 30-day readmissions and length of stay, particularly in the 70–85 age group, by implementing the Hospital Elder Life Program.

Canine demodicosis: a retrospective study of a veterinary hospital population in California, USA (2000-2016).

Demodex spp. are cutaneous mites that cause clinical disease when present in increased numbers. There is an association in some dogs with underlying systemic disease or immunosuppressive medications. Retrospective study to document breed predisposition, identify any concurrent diseases or underlying immunosuppressive conditions, and to determine the frequency of demodicosis recurrence after treatment completion. There were 431 dogs with demodicosis presented to a veterinary teaching hospital in California, USA, from 2000 to 2016. Inclusion in this study required a diagnosis of demodicosis based on direct demonstration of the mite. Records were reviewed for signalment, disease history, potential underlying aetiologies, diagnosed concurrent diseases, medications and demodicosis treatment. Analyses were performed to evaluate for potential breed predispositions and because of the large number of dogs with allergic dermatoses, analyses for this diagnosis as a disease associated with demodicosis was also performed. E-mailed surveys and follow-up telephone calls were used to assess for information about disease recurrence. The pit bull terrier group and West Highland white terrier, based on calculated odds ratio, were breeds predisposed to developing demodicosis. For dogs with demodicosis, allergic dermatoses was an associated disease. Relapse or recurrence of disease after treatment was uncommon, affecting 11% of the dogs with long-term follow-up. This study identified, in dogs attending the institution based in California, USA, breed predilections for canine demodicosis and associated concomitant diseases. It also revealed a low occurrence of disease relapse, recurrence or persistence.

A descriptive qualitative study of the roles of family members in older men's depression treatment from the perspectives of older men and primary care providers.

The aim of this study is to describe the roles of family members in older men's depression treatment from the perspectives of older men and primary care physicians (PCPs). Cross-sectional, descriptive qualitative study conducted from 2008-2011 in primary care clinics in an academic medical center and a safety-net county teaching hospital in California's Central Valley. Participants in this study were the following: (1) 77 age ≥ 60, noninstitutionalized men with a 1-year history of clinical depression and/or depression treatment who were identified through screening in primary care clinics and (2) a convenience sample of 15 PCPs from the same recruitment sites. Semi-structured and in-depth qualitative interviews were conducted and audiotaped then transcribed and analyzed thematically. Treatment-promoting roles of family included providing an emotionally supportive home environment, promoting depression self-management and facilitating communication about depression during primary care visits. Treatment-impeding roles of family included triggering or worsening men's depression, hindering depression care during primary care visits, discouraging depression treatment and being unavailable to assist men with their depression care. Overall, more than 90% of the men and the PCPs described one or more treatment-promoting roles of family and over 75% of men and PCPs described one or more treatment-impeding roles of family. Families play important roles in older men's depression treatment with the potential to promote as well as impede care. Interventions and services need to carefully assess the ongoing roles and attitudes of family members and to tailor treatment approaches to build on the positive aspects and mitigate the negative aspects of family support.

Rapid Response Teams: Qualitative Analysis of Their Effectiveness

Multidisciplinary rapid response teams focus on patients' emergent needs and manage critical situations to prevent avoidable deaths. Although research has focused primarily on outcomes, studies of the actual team effectiveness within the teams from multiple perspectives have been limited. To describe effectiveness of rapid response teams in a large teaching hospital in California that had been using such teams for 5 years. The grounded-theory method was used to discover if substantive theory might emerge from interview and/or observational data. Purposeful sampling was used to conduct in-person semistructured interviews with 17 key informants. Convenience sampling was used for the 9 observed events that involved a rapid response team. Analysis involved use of a concept or indicator model to generate empirical results from the data. Data were coded, compared, and contrasted, and, when appropriate, relationships between concepts were formed. Results Dimensions of effective team performance included the concepts of organizational culture, team structure, expertise, communication, and teamwork. Professionals involved reported that rapid response teams functioned well in managing patients at risk or in crisis; however, unique challenges were identified. Teams were loosely coupled because of the inconsistency of team members from day to day. Team members had little opportunity to develop relationships or team skills. The need for team training may be greater than that among teams that work together regularly under less time pressure to perform. Communication between team members and managing a crisis were critical aspects of an effective response team.

Do physicians disclose uncertainty when discussing prognosis in grave critical illness?

Even when critically ill patients are almost certain to die from their illnesses, there is generally an element of prognostic uncertainty. Little is known about how physicians handle this uncertainty in conversations with surrogate decision makers. We sought to evaluate whether and how physicians discuss prognostic uncertainty with surrogate decision makers of patients who are highly likely, but not certain, to die. We audiotaped and transcribed discussions between clinicians and surrogate decision makers at two major California teaching hospitals from 2006 through 2008. Physicians completed a questionnaire addressing their prognostic estimates for patients' survival to hospital discharge. We included physicians and surrogates of 12 incapacitated, critically ill patients. We analyzed transcripts of discussions in which physicians' estimates of patients' chances of hospital survival were 1% to 5%; we coded whether physicians disclosed the prognostic uncertainty and, if so, how they conveyed that death was highly likely but not certain. Physicians' estimates of short-term survival were 1% to 5% for 12 of the 70 patients enrolled in the original study. In 8 of 12 cases, physicians conveyed prognostic uncertainty by using probabilistic language or by an explicit mention of uncertainty. In four cases, physicians made at least one statement that either implied or was ambiguous about whether death was certain. We observed variability in how physicians handle prognostic uncertainty in their discussions with surrogates of patients who are highly likely, but not certain, to die, including some circumstances in which physicians stated or implied that death was certain.

Payment Policy Based on Measurement of Health Care Spending and Outcomes

MEASURING VARIATION IN SPENDING AND OUTcomes is a critical component of reforming physician and hospital payment policy. Analysis of area and hospital variations has a storied history and is increasingly common in media reports. If higher spending does not lead to better outcomes, health care could be delivered far more cost-effectively. But if approaches to measuring costs and outcomes are flawed, reductions in spending might yield worse outcomes. The 2 perspectives—look back and look forward—in measuringhospitaloutcomesandhospital resourceuse haveconceptual shortcomings inassessinghospitalperformance.Both approachesalsodistractfromtheoriginalpopulation-basedperspective first proposed in early work by the Dartmouth Atlas founder and central to the related analyses. Considering this community-basedperspectiveinconjunctionwithhospital-based perspectivescanavoidbiases in themeasurementofhealthsystem performance and thus better inform payment policy. The discussion on measurement methods matters for policy because different techniques may lead to divergent findings. The look back analyses have consistently demonstrated that spending variations are not correlated with outcomes. A variant of the Dartmouth Atlas technique has found instead that higher end of life treatment intensity in Pennsylvania was associated with small mortality benefits. A major look forward analysis showed that teaching hospitals in California with higher resource use had lower heart failure mortality. Dartmouth investigators counter that using the look forward approach for all Medicare inpatients with a diagnosis of acute myocardial infarction shows that higher resource use hospitals had modestly worse 1-year mortality. Both the look back and the look forward perspectives count costs and outcomes in different ways for different patients, as patients and their physicians decide on more conservative care in the community or more intensive care in the hospital. TheDartmouthAtlashospital-specific end-of-lifemeasures startwithaseriesofdecedentsandcountexpendituresforthem, whether treated conservatively outside of hospitals or intensively in hospitals. This approach excludes survivors, who benefited from resources used in their treatment, but includes conservatively treateddecedents. Because theDartmouthAtlas considers only fee-for-service Medicare decedents, spending among non-Medicare patients who did not die during the period may not correlate well with measured spending. The different lookforwardmethodhastheoppositefeatures. Itstarts withan indexadmissionandmeasuresoutcomes for thosepatients who lived or died. It misses patients treated outside the hospital when their cohort peers were admitted, but includes survivors of the index admission (FIGURE). These differences matter. The sample studied retrospectively is technically conditioned on an endogenous outcome (death). The sample studied prospectively is conditioned on a potentially endogenous event (the decision to admit). In consequence, neither approach may allow unbiased inferences of hospital performance; separately, neither may permit accurate inferences of community performance. Hospital performance measurement will be most biased if thedecision toadmitvaries systematicallyacrosshospitals and regions. Such variation may reflect greater illness levels in the population. However, higher utilization also may be due to a lower threshold for admission, driven for example by higher per capita supply of specialists and hospital beds. In such hospitals, sufficient slack capacity allows physicians to work “downanappropriatenesscurve” in theiradmissiondecisions. Oncepatientswhoareverysickhavebeenadmitted, suchhospitals may tend to admit patients in better general health with anexpectedgoodresponse to treatment.Suchselectionmeans theseadmittedpatientsaremore likely todowell andconsume fewerresourcesonaverage. Inanotherhospital,ahigherthreshold foradmissionwould lead to theoppositephenomenon.Selection now makes it more likely that those patients who are admitted tend to do poorly and consume more costly care. As a result, the first hospital appears to be a more careful steward of resources and a better performer than the other hospital. Looking forward sees lower costs and better outcomes after an index admission, because of better selection of hospitalized patients. Looking back sees lower end-of-life spending for all local decedents, because proportionately more decedents did not consume hospital-based intensive care or other expensive services. Hospitals do appear to be ranked similarly on spending regardless of which approach is used.

Looking Forward, Looking Back

Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined. A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission ("Looking Forward"). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death ("Looking Back"). "Looking Forward" risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were -0.68 between mortality and hospital days, and -0.93 between mortality and indexed total direct costs. "Looking Back" risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences. California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.

Defining postoperative values for successful resection of prolactinomas.

On retrospective review of a series of tumors treated at the University of Southern California teaching hospitals, we have found that the immediate postoperative prolactin level may be predictive of late recurrence of hyperprolactinemia.[4] It is our routine to ascertain prolactin levels at 3 days and 6 weeks postoperatively. Of 133 patients undergoing microadenomectomy who had 3-day postoperative prolactin levels of less than 10 μg/L (the vast majority of these were less than 3 μg/L), 132 or 99% had prolactin levels of less than 20 μg/L at their 6-week follow-up examination. At 5 years postoperatively, 130 (98%) of the original 133 patients still had normal prolactin levels. However, of 43 patients who had 3-day postoperative prolactin levels in the range of 10 to 20 μg/L, only 32 (74%) had prolactin levels in the normal range at 6 weeks postoperatively, and only five (16%) of this group of 32 patients had normal prolactin levels at 5-year follow-up review. Therefore, although 18% of patients who have a normal postoperative prolactin level at 6 weeks will develop recurrent hyperprolactinemia when followed for 5 years, only three (7%) of 41 represent patients with immediate prolactin levels of less than 10 μg/L, whereas the remainder were in the group with immediate postoperative prolactin levels in the 10 to 20 μg/L range.

Prospective validation of artificial neural network trained to identify acute myocardial infarction

SummaryBackground Artificial neural networks apply non-linear statistics to pattern recognition problems. One such problem is acute myocardial infarction (AMI), a diagnosis which, in a patient presenting as an emergency, can be difficult to confirm. We report here a prospective comparison of the diagnostic accuracy of a network and that of physicians, on the same patients with suspected AMI.Methods Emergency department physicians who evaluated 1070 patients 18 years or older presenting to the emergency department of a teaching hospital in California, USA with anterior chest pain indicated whether they thought these patients had sustained a myocardial infarction. The network analysed the patient data collected by the physicians during their evaluations and also generated a diagnosis.Findings The physicians had a diagnostic sensitivity and specificity for myocardial infarction of 73·3% (95% confidence interval 63·3-83·3%) and 81·1% (78·7-83·5%), respectively, while the network had a diagnostic sensitivity and specificity of 96·0% (91·2-100%) and 96·0% (94·8-97·2%), respectively. Only 7% of patients had had an AMI, a low frequency but typical for anterior chest pain.Interpretation The application of non-linear neural computational analysis via an artificial neural network to the clinical diagnosis of myocardial infarction appears to have significant potential.

Using patient reports to assess health-related quality of life after total hip replacement.

Data on disease severity, co-morbidity, and process of care were obtained from the medical records of 356 patients without rheumatoid arthritis undergoing a first unilateral total hip replacement at four teaching hospitals in California and Massachusetts. Socio-demographic characteristics, functional status prior and subsequent to hospitalization, and improvement in health status were measured with a patient questionnaire 12 months after discharge. Completed questionnaires were received from 284 patients, a response rate of 79.8%. The questionnaire was acceptable to patients, reliable, and had good construct validity. The data indicate substantial benefits from hip arthroplasty. As expected, pre-surgical functioning was a strong predictor of outcomes 1 year after surgery. Controlling for pre-surgical functioning, age was not related to outcomes.

The Importance of Co-existent Disease in the Occurrence of Postoperative Complications and One-Year Recovery in Patients Undergoing Total Hip Replacement

Co-existent or comorbid diseases are appreciated as prognostic factors in studies of quality and effectiveness of care when mortality is the end point. The need to measure and adjust for comorbidity in studies of postoperative hospital complications or long-term recovery from surgery has not been documented. In this study, we determined the impact of co-existent disease on post-operative complications and 1-year health-related quality of life in patients hospitalized for a total hip replacement. The study population consisted of a cohort of 356 patients who were hospitalized in four teaching hospitals in California and Massachusetts for a total hip replacement. Patients' medical records were reviewed to collect information regarding severity of illness, co-existent disease, and postoperative complications. The kind and amount of baseline preoperative co-existent disease was measured from medical record information at admission using a four level Index of co-existent Disease (ICED). Approximately 12 months after hospital discharge, 283 (80%) of the patients were surveyed by questionnaire. The presence and amount of co-existent disease were significant predictors of postoperative complications. The complication rates ranged from 3% to 41% between the lowest and highest levels of the ICED. Patients treated at the four study hospitals differed in functional outcomes 1 year after surgery. Functional outcomes were strongly related to ICED scores: patients in Level 4 ICED scored 26.8 points lower in instrumental activities of daily living than patients in Level 1. After controlling for gender, age, education, and marital status, ICED remained a significant predictor of functional status at 1 year. Furthermore, differences among hospitals in functional outcomes disappeared when the ICED was included in the model to adjust for patient characteristics at the time of surgery. A measure of co-existent disease was crucial in explaining differences among hospitals in recovery from total hip replacement patients.

Assessing quality of life after surgery

Researchers and clinicians increasingly are recognizing the importance of assessing a wide range of outcomes when evaluating the efficacy of medical therapies or procedures. We developed and evaluated a set of self-report scales that assessed both generic and condition-specific aspects of health-related quality of life before and after surgery. We report data from a study of patients having one of four types of surgery at six teaching hospitals in California and Massachusetts. The four surgical conditions studied were: total hip replacement, transurethral prostatectomy, cholecystectomy, and coronary artery bypass graft surgery. All the outcome scales, except for those assessing cognitive functioning and fatigue, had internal consistencies greater than 0.70. The pattern of correlations between the scales and other measures of health status are similar to those reported in other studies and provide evidence of their construct validity. The scales also appeared to be sensitive to differences between presurgical and postsurgical health-related quality of life. The results suggest that the scales used were easy to administer, reliable, valid, and offered important information about outcomes of surgery that is not provided by more traditional clinical indicators.

Variations in Length of Stay and Outcomes for Six Medical and Surgical Conditions in Massachusetts and California

--To determine the extent to which interinstitutional variations in length of stay are explained by differences in patient characteristics and to determine whether patients in hospitals with shorter lengths of stay had worse outcomes. --We reviewed patients' medical records and surveyed patients between 3 and 12 months after hospital discharge using a questionnaire. --Six teaching hospitals in California and Massachusetts. --A cohort of 2484 selected patients who had been hospitalized for acute myocardial infarction or to rule out acute myocardial infarction, coronary artery bypass graft surgery, total hip replacement, cholecystectomy, or transurethral prostatectomy. Between 73% and 84% of the patients with each condition completed a follow-up questionnaire. --In-hospital complications, deaths, length of stay, functional status after hospital discharge, readmission, and patient satisfaction with hospital care were analyzed. --Significant interinstitutional differences in length of stay were noted for all conditions except rule-out acute myocardial infarction. Statistical adjustment for case-mix differences accounted for most of the interinstitutional differences in length of stay for total hip replacement but explained little of the differences in the other conditions. When we controlled statistically for other predictors, length of stay did not have a significant impact on deaths, functional status after hospital discharge, the probability of readmission, or patient satisfaction with hospital care. --More research is needed to determine the medical practices that are related to variations in lengths of stay. Routinely available outcome data may help preserve quality in the face of efforts to decrease costs by effecting more standardized practices of care.

Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California

<h3>Objectives.</h3> —To determine the extent to which interinstitutional variations in length of stay are explained by differences in patient characteristics and to determine whether patients in hospitals with shorter lengths of stay had worse outcomes. <h3>Design.</h3> —We reviewed patients' medical records and surveyed patients between 3 and 12 months after hospital discharge using a questionnaire. <h3>Setting.</h3> —Six teaching hospitals in California and Massachusetts. <h3>Patients.</h3> —A cohort of 2484 selected patients who had been hospitalized for acute myocardial infarction or to rule out acute myocardial infarction, coronary artery bypass graft surgery, total hip replacement, cholecystectomy, or transurethral prostatectomy. Between 73% and 84% of the patients with each condition completed a follow-up questionnaire. <h3>Outcome Measures.</h3> —In-hospital complications, deaths, length of stay, functional status after hospital discharge, readmission, and patient satisfaction with hospital care were analyzed. <h3>Results.</h3> —Significant interinstitutional differences in length of stay were noted for all conditions except rule-out acute myocardial infarction. Statistical adjustment for case-mix differences accounted for most of the interinstitutional differences in length of stay for total hip replacement but explained little of the differences in the other conditions. When we controlled statistically for other predictors, length of stay did not have a significant impact on deaths, functional status after hospital discharge, the probability of readmission, or patient satisfaction with hospital care. <h3>Conclusion.</h3> —More research is needed to determine the medical practices that are related to variations in lengths of stay. Routinely available outcome data may help preserve quality in the face of efforts to decrease costs by effecting more standardized practices of care. (<i>JAMA</i>. 1991;266:73-79)

Reduction in work hours during a period of reduced patient census

Implementation of and experience with a temporary reduction in hours worked at a large teaching hospital in California are described. During a period of reduced patient census, the hospital administration ordered a 20% reduction in the number of hours worked by employees in all departments for three months. Employees were required to take one extra day off per week as paid vacation or holiday time or as leave without pay. During this period, pharmacy staff members averaged seven extra days off. Pharmacy personnel were unable to complete some routine responsibilities, and their involvement in interdisciplinary patient rounds and inservice education decreased. The temporary cutback in work hours allowed the work force to be preserved. Departmental managers should keep staff members informed about potential changes in staffing patterns that may be required for cost containment.