Biomedical subjects

Manish N Shah

Publications and source records attributed to Manish N Shah.

5 recordsLinked to original sources

PubMed2003

Continuity of antibiotic therapy in patients admitted from the emergency department.

STUDY OBJECTIVE: We describe discontinuities in antibiotic therapy in patients with community-acquired pneumonia admitted from the emergency department (ED) to an inpatient unit. METHODS: We performed a retrospective cohort study of patients with community-acquired pneumonia admitted from the ED to the internal medicine service at an academic tertiary care hospital between July 1997 and June 1999. We characterized the frequency of antibiotic delays after arrival on the inpatient unit in relation to antibiotic dosing intervals. We performed paired analysis on the patients treated both with an antibiotic dosed every 6 hours and an antibiotic dosed every 24 hours. RESULTS: Three hundred seventy-five patients were identified. The mean age was 61 years. Sixty-two percent were female. Five hundred fifty-one antibiotic doses were started in the ED and continued on the inpatient unit, with 177 ordered every 6 hours, and 351 ordered every 24 hours. Seventy-five percent of the antibiotics dosed every 6 hours and 19% of the antibiotics dosed every 24 hours were delayed more than 30 minutes (P <.001). Analysis of the 146 patients receiving both an antibiotic dosed every 6 and 24 hours showed that the first inpatient dose of antibiotics administered every 6 hours were 10 times more likely to be delayed than antibiotics dosed every 24 hours (95% confidence interval 5.0 to 23). The median delay for antibiotics dosed every 6 hours was 258 minutes (range 45 to 3,360 minutes), and the median delay for antibiotics dosed every 24 hours was 192 minutes (range 32 to 2,124 minutes). CONCLUSION: Discontinuous therapy, represented through a delayed first inpatient antibiotic dose, is common in patients with community-acquired pneumonia admitted from the ED. Although the effect on outcome is unknown, theoretical concerns should lead emergency physicians to consider using longer-acting antibiotics to minimize delayed therapy.

Anti-Bacterial Agents↗

PubMed2003

Efficient communication: assessment-oriented oral case presentation.

OBJECTIVE: To introduce and assess the time savings from and effectiveness of assessment-oriented (AO) oral case presentation as a model of interphysician communication. METHODS: This was a prospective, interventional study of all 10 on-site faculty and 36 residents in a postgraduate year 1 to 3 format emergency medicine residency training program. Residents were requested to perform all oral case presentations in either the traditional or AO formats. Presentations were timed, and residents and faculty rated essential measures of oral case presentation effectiveness: data content, expression of decision making, organization, and overall satisfaction. RESULTS: A total of 199 oral case presentations were sampled-112 traditional and 87 AO. Mean length of presentation for traditional presentations was 117 seconds versus 71 seconds for AO presentations (p < 0.001), a clinically significant difference, without significant differences in the essential measures of case presentation effectiveness. CONCLUSIONS: AO oral case presentation may provide a means for emergency medicine residents to "get to the point" and to communicate effectively and efficiently.

Clinical Competence↗

PubMed2003

Predictors of emergency medical services utilization by elders.

OBJECTIVE: Elders (age > or = 65 years) frequently use emergency medical services (EMS) for care. Understanding reasons for EMS use by elders may allow better management of EMS demand. To the best of the authors' knowledge, no studies have identified patient characteristics associated with EMS use by elders. This study aimed to identify patient attributes associated with elder EMS users. METHODS: This was a prospective cohort study of non-institutionalized elders presenting to an urban university hospital emergency department. Nine hundred thirty elder patients completed the survey. The authors asked patients about access to care, health beliefs, and reasons for requesting EMS assistance. Univariate and logistic regression were used to identify predictors of EMS use. RESULTS: The sample had a mean age of 76 years; 37% were male; 79% were African American. Thirty percent arrived via EMS. Sixty-five percent of those transported and 46% of those not transported by EMS were admitted to the hospital (p < 0.001). Reported reasons for using EMS transport included immobility (33%), illness (22%), request by others (21%), instruction from health care providers (10%), and lack of transportation (10%). Logistic regression identified symptom onset within four hours of seeking care (OR = 3.1), age > or = 85 years (OR = 1.63), increased deficiencies in activities of daily living (OR = 1.40 per deficiency), worse physical functioning (OR = 1.14/10 points), and worse social functioning (OR = 1.06/10 points) as factors associated with EMS use. CONCLUSIONS: Elders report using EMS because of immobility, perceived medical needs, or requests by others. Similarly, the presence of acute illness symptoms, older age, and poor social and physical function, rather than health beliefs, predict EMS use among elders. These factors must be considered when managing the demand for EMS services.

Academic Medical Centers↗

PubMed2002

Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists.

BACKGROUND: Hospitalists may decrease costs and improve outcomes in hospitalized patients, but existing evidence is limited and has not identified mechanisms for such effects. OBJECTIVE: To study the costs and outcomes for patients on an academic general medicine service assigned to teams led by hospitalists and nonhospitalists. DESIGN: Cohort study. SETTING: Academic general medicine service. PATIENTS: 6511 patients admitted to the hospital from July 1997 through June 1999. INTERVENTION: All patients admitted every fourth day were assigned to 1 of 2 hospitalists caring for inpatients 6 months each year or 1 of 58 nonhospitalists caring for inpatients 1 to 2 months each year. MEASUREMENTS: Length of stay; inpatient costs; and 30-, 60-, and 365-day mortality. RESULTS: Patients assigned to hospitalists (24.8%) and nonhospitalists (75.2%) did not differ in age, race, sex, diagnosis mix, or Charlson index score. In year 1, average adjusted length of stay was 0.29 day shorter for patients cared for by hospitalists than by nonhospitalists (95% CI, -0.66 to 0.06 day; P = 0.06); in year 2, average adjusted length of stay was 0.49 day shorter for patients cared for by hospitalists (CI, -0.79 to -0.15 day; P = 0.01). Average adjusted costs were not significantly reduced for hospitalists compared with nonhospitalists in year 1 but were reduced by $782 in year 2 (CI, -$1313 to -$187; P = 0.01). When years 1 and 2 were combined or when year 1 was analyzed alone, 30-day mortality was not significantly different for hospitalists and nonhospitalists; however, 30-day mortality was 4.2% for hospitalists compared with 6.0% for nonhospitalists in year 2 (CI for difference, 1.8 percentage points [-3.6 to -0.1 percentage points]; P = 0.04) and the adjusted relative risk was 0.65 (CI, 0.44 to 0.96; P = 0.03). In multivariate analyses, resource use decreased with the physician's cumulative experience in caring for a patient's primary diagnosis. Mortality showed a similar pattern. CONCLUSIONS: Hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience. Disease-specific physician experience may reduce resource use and improve patient outcomes; in addition, it may be an important determinant of the effectiveness of hospitalists.

Chicago↗

PubMedDate not supplied

How do residents learn? The development of practice styles in a residency program.

PURPOSE: To determine if resident interactions that occur during rotations may influence resident learning and help explain practice styles in a residency program. METHOD: We distributed clinical vignette surveys to all pediatric residents in a teaching hospital, eliciting practice styles for childhood fever without source and asthma, as well as resident demographics and learning styles. We measured residents' propensities to order tests for fever, empirically treat fever, diagnose asthma as serious, and aggressively treat asthma. For any 2 residents, we examined if similarity in propensities was associated with the number of months the residents had rotated together in the past year, controlling for demographics and learning styles. We also examined if the gender mix of each resident pair modified the association. RESULTS: Fifty-two of 62 residents (84%) responded. Practices varied across all vignettes and varied as much within as across training years. In adjusted regressions, 2 residents were 1.22 times (P =.03) and 1.30 times (P =.004) more likely to have similar propensities in fever testing and asthma diagnosis for each additional month they rotated together. By gender mix, associations were stronger for opposite-sex pairs than for same-sex pairs. CONCLUSIONS: Practice variations emerged in a residency program within a single academic year. Practice styles were more similar among residents who worked together more frequently. However, the association was not uniform across gender combinations, suggesting the importance of interpersonal dynamics in learning. This finding may have major implications for practice variations, medical education, and quality improvement.

Adult↗