Triplicate publication, not an epidemic.
Explore the source record for details and available documents.
Duplicate Publications as Topic↗
Biomedical subjects
Lee Goldman
Publications and source records attributed to Lee Goldman.
Passing the clinical baton: 6 principles to guide the hospitalist.
Hospitalist systems make it increasingly common for responsibility for a patient to be passed from one physician to another. During such transfers, patients' outcomes and satisfaction can benefit from better communication between hospitalists and the primary care physicians whose patients they care for. We propose 6 principles to guide such communication, to ensure that critical information about patients is not lost and to optimize the quality of care. We also discuss special considerations for patients discharged to a skilled nursing facility or to home with home care.
Communication↗
Critical pathways for patients with acute chest pain at low risk.
Critical pathways are predefined protocols that define the crucial steps in evaluating and treating a clinical problem to improve quality of patient care, reduce variability and enhance efficiency. Critical pathways have proliferated for a variety of diagnoses, including evaluation of patients with chest pain, a common and costly complaint. This review will outline the development, implementation, and assessment of critical pathways using as a paradigm our experience with a pathway for patients presenting to the Emergency Department with acute chest pain who are at low risk of myocardial ischemia. The goals of the pathway were to expedite evaluation of low-risk patients and reduce admission rates among these patients and in the cohort overall without compromising outcomes. The pathway was developed by a multidisciplinary team in an iterative process that considered published literature, as well as the experience and consensus of local opinion leaders. Patients at least 30 years old presenting to the Emergency Department of an urban teaching hospital who were pain-free without heart failure or ischemic changes on EKG, but who were not considered appropriate for discharge by the treating physician, were eligible for the critical pathway. The pathway involved one set of creatine kinase-MB enzymes drawn at least 4 hours after pain, a 6 hour observation period after the last episode of pain and exercise testing. Outcomes during evaluation and admission rates were assessed. Clinical outcomes at 7 days and 6 months after evaluation and patient satisfaction at 7 days were also measured. Of 1363 patient visits, 145 (10.6%) were triaged by the pathway: 131 (90.3%) were discharged, 14 (9.7%) were admitted. The overall admission rate decreased from 63% (2898/4595) to 60% (819/1363) [p < 0.05] in comparison to a cohort studied prior to pathway implementation. Pathway patients reported low rates of subsequent cardiac procedures. No deaths or myocardial infarctions were recorded. At 7 days, only 2 respondents (2%) reported going to an Emergency Department since their evaluation. Most respondents (83%) rated their care as very good or excellent. Critical pathways designed to enhance efficiency, reduce variability, and improve the quality of care are becoming increasingly common. Our pathway for evaluation of patients with chest pain at low risk of myocardial ischemia was feasible and safe and was associated with a decline in absolute admission rates. Because of the possibility of concomitant secular trends and the effects of a changing medical environment, further rigorous research on the efficacy of individual pathways is needed.
Acute Disease↗
Cost effectiveness of aggressive care for patients with nontraumatic coma.
OBJECTIVE: To estimate the cost effectiveness of aggressive care for patients with nontraumatic coma. DESIGN: Cost-effectiveness analysis. SETTING: Five academic medical centers. PATIENTS: Patients with nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Patients with reversible metabolic causes of coma such as diabetic ketoacidosis or uremia were excluded. MEASUREMENTS: We calculated the incremental cost effectiveness of continuing aggressive care vs. withholding cardiopulmonary resuscitation and ventilatory support after day 3 of coma. We estimated life expectancy based on up to 4.6 yrs of follow-up. Utilities (quality-of-life weights) were estimated using time-tradeoff questions. Costs were based on hospital fiscal data and Medicare data. Separate analyses were conducted for two prognostic groups based on five risk factors assessed on day 3 of coma: age > or = 70 yrs, abnormal brainstem response, absent verbal response, absent withdrawal to pain, and serum creatinine > or = 132.6 micromol/L (1.5 mg/dL). RESULTS: For the 596 patients studied, the median (25th, 75th percentile) age was 67 yrs (range, 55-77), and 52% were female. By 2 months after enrollment, 69% had died, 19% were severely disabled, 7% had survived without severe disability, and 4% had survived with unknown functional status. The incremental cost effectiveness of the more aggressive care strategy was $140,000 (1998 dollars) per quality-adjusted life year (QALY) for high-risk patients (3-5 risk factors, 93% 2-month mortality) and $87,000/QALY for low-risk patients (0-2 risk factors, 49% mortality). In sensitivity analyses, the incremental cost per QALY did not fall below $50,000/QALY, even with wide variation in our baseline estimates. CONCLUSIONS: Continuing aggressive care after day 3 of nontraumatic coma is associated with a high cost per QALY gained, especially for patients at high risk for poor outcomes. Earlier decisions to withhold life-sustaining treatments for patients with very poor prognoses may yield considerable cost savings.
Activities of Daily Living↗
Health values before and after pacemaker implantation.
BACKGROUND: Health value or utility is the abstracted magnitude of a person's preference for quality and quantity of life. It reflects how much lifetime with the patient's current health condition a patient is willing to exchange for a life in excellent health. Health values are used in cost-effectiveness analysis as a means of calculating quality-adjusted years of life. OBJECTIVE: This study assessed the health values of elderly patients before and after pacemaker implantation. METHODS: We prospectively examined 398 patients from the Pacemaker Selection in the Elderly study, in which patients were randomized to either VVIR or DDDR mode. Health values were estimated with the time tradeoff method before implantation and at 3, 9, and 18 months after implantation. RESULTS: The mean age of patients was 76 +/- 6 years; 234 patients (59%) were male. At baseline, patients were, on average, willing to exchange 5 years of current health for approximately 4 years in perfect health (value 0.76 +/- 0.06). There was no difference in baseline health values with implant diagnosis (sinus node dysfunction n = 172, 0.72, atrioventricular block n = 227, 0.75, other diagnoses n = 39, 0.78, P = not significant). The overall improvement in health values at 3 months after pacemaker implantation was 0.165 +/- 0.4 (P =.0001). The improvement in health values was independent of pacing mode (P =.6). The time tradeoff score was modestly correlated with other measurements of health-related quality of life. The change in time tradeoff score with time was not influenced by demographic characteristics such as age and sex, diagnoses, pacing mode, employment status, or history of angina. Patients with a lower functional class at enrollment (III or IV on the Specific Activity Scale) demonstrated an absolute improvement of 23% in their health values, whereas patients in class I or II improved only by 12%, (P =.03). CONCLUSIONS: Permanent pacemaker implantation for standard indications improves health values and descriptive health status measures. The values reported here may be used as a means of calculating the cost-effectiveness of different pacing modalities.
Aged↗
The hospitalist movement 5 years later.
CONTEXT: We originally described the hospitalist model of inpatient care in 1996; since then, the model has experienced tremendous growth. This growth has important clinical, financial, educational, and policy implications. OBJECTIVES: To review data regarding the effect of hospitalists on resource use, quality of care, satisfaction, and teaching; and to analyze the impact of hospitalists on the health care system and frame key issues facing the movement. DATA SOURCES AND STUDY SELECTION: We searched MEDLINE, BIOSIS, EMBASE, and the Cochrane Library from 1996 to September 2001 for studies comparing hospitalist care with an appropriate control group in terms of resource use, quality, or satisfaction outcomes. DATA EXTRACTION: We extracted information regarding study design, nature of hospitalist and control groups, analytical strategies, and key outcomes. DATA SYNTHESIS: Most studies found that implementation of hospitalist programs was associated with significant reductions in resource use, usually measured as hospital costs (average decrease, 13.4%) or average length of stay (average decrease, 16.6%). The few studies that failed to demonstrate reductions usually used atypical control groups. Although several studies found improved outcomes, such as inpatient mortality and readmission rates, these results were inconsistent. Patient satisfaction was generally preserved, while limited data supported positive effects on teaching. Although concerns about inpatient-outpatient information transfer remain, recent physician surveys indicate general acceptance of the model. CONCLUSIONS: Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction. Education may be improved. In part catalyzed by these data, the clinical use of hospitalists is growing rapidly, and hospitalists are also assuming prominent roles as teachers, researchers, and quality leaders. The hospitalist field has now achieved many of the attributes of traditional medical specialties and seems destined to continue to grow.
Health Services Research↗