From the Director
"April fools came and went with surprisingly few pranks. Interesting! Things are starting to get busy with "end of the year" activities - board review (run by SARs but all are welcome), schedules (thanks chiefs!), advisor meetings (reminder - need one each half of the year), grant submissions, procedure log checks AND the ACGME survey!
Thanks to those who have already filled it out - please take the time to do this. It's very important to the program and to the RRC. It's anonymous and takes 10-15 minutes. Please let Jen know if your login has problems.
We will delay the "self-valuation" using reporting milestones until after the survey is done! Thanks again
Lots of great work this week - compliments came from
Ken Lyles to Tim Mercer and Nick Rohrhoff on VA gen med, to
Deanna Baker from Regina Crawford regarding care on Duke gen med and to
Jim Lefler and Ben Mouser from family med regarding transition of care from Duke gen med to clinic. Nice work!
Kevin Riggs withstood the GRC assault for an awesome chairs conference.
This week's pubmed from the program goes to
Jason Rose for his JACC article:
published in JACC: Rose JJ, Newby LK, Broderick S, Chiswell K, Van de Werf F, Armstrong PW, Mahaffey KW, Harrington RA, Ohman EM, Giugliano RP, Goodman SG, White HD, Califf, RM, Granger CB, Lopes RD. Left Bundle Branch Block in Non-ST-Segment Elevation;
Acute Coronary Syndromes: Incidence, Angiographic Characteristics, and Clinical Outcomes. J Am Coll Cardiol. 2013 Apr 2;61(13):1461-3.
I'm very excited about the upcoming
Stead Tread! Lots of hard work has gone into the planning and a record turnout would make it even better. Run fast (like Aaron Mitchell or Brian Schneider pushing a stroller), run slow (like me, watching carling Ursem and Eileen Maziarz leave me in the dust!) but definitely come out and support a great event!
Look for info soon about the house staff faculty bball game.
Have a great (spring!) week!
Aimee
QI Corner (submitted by Jon Bae, MD)
This week, QI Corner will be recognizing the ACGME Annual Survey with a brief fact sheet regarding our medicine residency Quality Improvement and Patient Safety efforts.
Medicine Residency QI Fun Facts!
Do all residents receive formal training in quality improvement and patient safety? Yes!!!
All residents are given one 1/2 day of ambulatory time to complete self-directed, online modules that provide an overview to quality measurement and methodology at least one time during their 3 year training. This ideally occurs during the intern year to set the stage for what is to come later. These modules are supplemented by QI workshops led by the Quality Chief Residents.
Additionally, we have a quality improvement and patient safety noon conference lecture series that occurs monthly. During this time, we provide updates on QI happenings around the program as well as present a core topic in quality improvement and
patient safety.
Do residents receive any training on patient safety, adverse events, or safety reporting? Yes!!!
There are lectures dedicated to patient safety and safety reporting as part of our quality noon conference lecture series. Additionally, SARs on General Medicine have a weekly, case-based discussion which focuses on patient safety cases and use of tools to analyze them.
Do residents receive data about their clinical performance? Yes!!!
Our program has a residency balanced scorecard which highlights the performance on certain measures (patient satisfaction, hand hygiene, readmissions) in areas of Duke Hospital where medicine residents work. Additionally, all residents are participants in the GME Incentive program which focuses on patient satisfaction, readmissions, catheter associated UTIs, and CMS Evidence Based Care Scores. Both of these are reviewed at our noon conference lectures and are available online.
Additionally, residents are provided performance data on their clinic panel at their continuity clinic site.
Do all residents participate in quality improvement projects? Yes!!!
All second and third year residents complete a self-directed online Sharepoint individual performance improvement project based on a program selected measure. This year, that measure has been the bundled diabetic foot exam. Next year, the project will be documentation of communication of test results to clinic patients.
There are also large resident initiated projects including our outside hospital transfer process improvement project and the DOC hospital follow-up clinic that are ongoing.
All residents have the opportunity to get involved through our medicine residency Patient Safety and Quality Council, our Quality Chiefs, or our APD for Quality Improvement.
And the whole program participated in 2 QI projects this year including 3 Good Things and our Flu Vaccination campaign.
Does our program focus on resiliency, burnout, or the culture of safety? Yes!!!
Our program completed a Safety Assessment Questionnaire to understand our culture of safety.
We also have lectures aimed at discussing patient safety, the culture of safety, fatigue/burnout, and resilience as part of our noon conference series.
Lastly, the program participated in a wide scale 3 Good Things effort this year.
Do residents get any training in Team Work? Yes!!!
All second and third year residents will have the opportunity to attend a half day training session on team work as part of the Team STEPPS training program.
GME Performance Incentive Program Update
The latest report for the GME Incentive Program has just been released with updates through February. We continue to meet targets on 2 of 4 measures with 2 periods to go!
QI Report
For full details, the report is attached and can be found (along with our resident program balanced scorecard) on the Sharepoint website.
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What Did I Read This Week
(submitted by Jon Bae, MD)
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Donze, J, et al. “Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients.” JAMA Intern Med. 2013:1-7
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Admit it. You have been anxiously awaiting another article on 30-day hospital readmissions. Well, faithful readers, you are in luck as this article was just published online in JAMA Internal Medicine. Herein, the authors describe a new prediction model to predict 30-day hospital readmissions. I say ‘new’ because there have been multiple attempts to do the same over these last several years. In fact, in 2011, JAMA published a systematic review of 26 different models designed to predict readmission (JAMA, 2011; 306 (15): 1688). Spoiler alert: none were very good and in general had poor discriminate capability. You would think providers themselves could predict readmissions fairly accurately but you would have thought wrong – a study at UCSF demonstrated interns, residents, attendings, and nurses alike could predict readmissions no better then a coin flip (JGIM, 2011; 692-698). Thus, a readmission prediction model that works is the “golden goose” for those of us interested in hospital discharge care transitions especially because of the intensity (both in cost and complexity) required to prevent a single readmission. If you have a limited number of resources, you really want to target those who need them the most. Hence, my interest in this article.
So, what did Jacques “Don’t Call me Cousteau” Donze, et al do. First, they identified 10,731 discharges (after the common exclusions of death, transfer to acute care hospital, and left AMA) from medicine service lines (medicine, cardiology, oncology, etc) from 3 hospitals within the Partners HealthCare network over the course of a year. It is noteworthy that 22.3% of these discharges resulted in a 30-day hospital readmission, a rate that is, at first blush, higher then our own (roughly 20.5%). They then sub-classified the readmissions into non-avoidable, potentially avoidable, and scheduled. There are some problems with this but more on that later. After excluding non-avoidable and scheduled readmissions, they randomly divided discharges with a potentially avoidable readmission and those without a readmission into a derivation and validation set. At this point, they performed multivariable logistic regression and identified multiple variables (hence the multivariable regression) that were independent predictors of readmission and were ultimately used to develop their HOSPITAL Score. Now I’m a sucker for a good acronym but this one is a bit of a stretch: low Hemoglobin at discharge (<12), discharge from and Oncology service, low Sodium level at discharge (<135), Procedure during hospital stay, Index admission Type (elective vs. non-elective), number of hospital Admissions during the previous year, and Length of stay (>5 days). Please refer to Table 3 in the text to see the scoring. Using the HOSPITAL score, you can divide discharges into low, intermediate, and high risk groups. High risk patients made up 24.4% of the discharges and had an estimated probability of 18.3% of potentially avoidable readmission in the derivation set and an observed probability of 18.7% in the validation set. The C-statistic was 0.69 in the derivation set and 0.71 in the validation set (for reference, 0.5 is no better then chance, 1.0 is considered perfect discrimination, and 0.8 considered strong).
So this is great, right? Not so fast. To begin, their model excludes non-avoidable readmissions. This makes complete sense but as it turns out, classifying readmissions as avoidable or non-avoidable is no easy task. The authors used a computerized algorithm to classify “avoidability” which used administrative data to make the determination. The obvious limitation here is that this determination is very subjective, hard to define, and often cannot be gleaned from administrative datasets alone. In a systematic review of the proportion of possibly preventable readmissions, the median proportion of possibly preventable readmissions was 27.1%. However, the range was 5-79%! And there was no agreed upon methodology to define how to do it. This study found 8.5% of the discharges to be avoidable and our own review of general medicine readmissions estimated ~17% to be potentially preventable. But this was done by direct provider review of the readmissions. Additionally, a C-statistic of 0.7 is ok but drops to 0.67 when all readmissions were included. So there is some discriminatory capability but the application of this score to our patients in real-time as we are actually discharging them remains a challenge, especially when it comes to the allocation of scarce resources. Using our patient population, we have 38,000 discharges per year. If we say 8.5% are potentially preventable, that is 3,200 preventable readmissions per year. But the scoring system doesn’t tell you who will be readmitted, only which patients are more likely. If 25% of our discharges fall in the high risk group, that is 9,500 discharges per year. Point being, if we were to target high cost, high intensity interventions (i.e. transition coaches, follow-up phone calls, in home follow-up visits, etc) at all of these patients, that would come at substantial cost. This would be worth it IF the interventions themselves were proven to work. They are not – please see this systematic review in Annals if you don’t believe me: Annals, 2011; 155 (8): 520-28.
Alas, I do not think this HOSPITAL score is the elusive “golden goose”. I certainly think it can be used to inform practice and help identify patients who may need greater attention to their care transitions and out of hospital needs. All told though, I believe it makes more sense to focus on improving those processes that we can control, that influence in some way the safety of a care transition, and that should be the gold standard for all patients. For example, timely, complete discharge summaries. Or accurate medication reconciliation with patient-friendly language. I do not need a randomized control trial to tell me that this is just good sense if not a gilded fowl.
From the Chief Residents
Grand Rounds
| Date |
Division |
Speaker |
Title |
| 12-Apr-13 |
Oncology |
Drs. George/Moul |
Prostate CA |
Noon Conference
| Date |
Topic |
Lecturer |
Time |
| 4/8 |
PWIM Mentoring |
Ann Brown |
12:00 |
| 4/9 |
Follow-up Rheumatologic care |
Irene Whitt |
12:00 |
| 4/10 |
Schwartz Rounds |
Lynn O'Neill, Lynn Bowlby |
12:00 |
| 4/11 |
Antiphospholipid Antibody Syndrome |
Sam Dalvi |
12:00 |
| 4/12 |
Chair's Conference |
Chiefs |
12:00 |
DoM discussion with Visiting Professor (submitted by Laura Svetkey, MD)
Please join Dr. Shane Snowdon, Director, Health & Aging Program at the Human Rights Campaign, and Founding Director of the Center for LGBT Health and Equity at UCSF. Dr Snowdon will talk with us about what our faculty and trainees need to know about medical care of the lesbian, gay, bisexual or transgender patient, and how best to teach it. AAMC is currently engaging in curriculum development, efforts that are reflected in our SoM. This discussion promises to be interesting and valuable to us all.
Time: April 19, 2:30-3:30 pm
Location: DoM Chair's Conference Room, Duke North 1103
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From the Residency Office
Smith Society Faculty Meet-and-Greet Series
The Smith Society would like to extend an invitation to the Smith Society Faculty Meet-and-Greet series which will occur generally every other month over the next year. Our first faculty member to step up to the plate is
Dr. Thomas Owens,
Chief Medical Officer for the Duke University Health System and prior VA Chief Resident. Dr. Owens will be speaking on
negotiating contracts, a topic our SARs in particular were very interested in hearing.
The Meet-and-Greet will be in the Med Res Library on Wed 4/17 from 7-8 pm. Pizza and salad dinner will be provided by the Smith Society.
Please use the following link to sign up:
https://www.surveymonkey.com/s/8ZDTS5J
Stead Tread 2012
Keep training! Just 3 weeks till RACE DAY! Details-----
- Stead Tread 2013 website for information, registration, and donations:
http://www.steadtread.org/
- Race date/time: Sunday, April 28, 2013 at 2PM
- Race location: Al Beuhler Trail, Washington Duke Inn and Golf Course (same as last year)
- Race beneficiary: Lincoln Community Health Center
- As always, your registration fee includes an official Stead Tread 2013 T-shirt
SAR Board Review Schedule
Board Review Sessions will be held in the MedRes Library, Duke North, 8th Floor. Please contact Megan Diehl or Jeff Clarke if you would like to attend. The schedule is as follows:
| Date |
Topic |
Faculty Discussants |
| Tuesday April 9 |
ID |
Dr. Zaas |
| Wednesday April 17 |
Cardiology |
Dr. Jones |
| Tuesday April 23 |
Hem/Onc |
Drs. Riedel and Diehl |
| Tuesday April 30 |
Pulmonary |
Dr. Govert |
| Wednesday May 8 |
Gastroenterology |
Drs. Choi and Desai |
| Tuesday May 14 |
Endocrine |
Dr. Matt Crowley |
| Wednesday May 22 |
Renal |
Dr. Butterly |
| Tuesday May 28 |
Neurology |
Dr. Skeen |
| Wednesday June 5 |
Dermatology/Rheumatology |
Dr. Criscione |
| Tuesday June 11 |
Mixed Bag (Medical ethics, Palliative Medicine, Psych) |
Dr. Zaas, Chiefs |
Contact Information/Opportunities
Memphis Area HOS
Upcoming Dates and Events
- April 17: Smith Society "Meet and Greet"
- April 19: Residency Program Pictures (rain date May 24)
- April 28: 2nd Annual Stead Tread
- June 4: Resident Research Conference, Searle Center
- June 8: SAR Dinner, Hope Valley Country Club
Useful links
