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Resident physicians routinely order unnecessary inpatient laboratory tests. As hospitalists face growing pressures to reduce low-value services, understanding the factors that drive residents' laboratory ordering can help steer resident training in high-value care. We conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center to describe the frequency of perceived unnecessary ordering of inpatient laboratory tests, factors contributing to that behavior, and potential interventions to change it. The sample comprised 57.0% of IM and 54.4% of GS residents. Among respondents, perceived unnecessary inpatient laboratory test ordering was self-reported by 88.2% of IM and 67.7% of GS residents, occurring on a daily basis by 43.5% and 32.3% of responding IM and GS residents, respectively. Across both specialties, residents attributed their behaviors to the health system culture, lack of transparency of the costs associated with health care services, and lack of faculty role models that celebrate restraint. Journal of Hospital Medicine 2016;11:869-872. V C 2016 Society of Hospital MedicineResident physicians routinely order inpatient laboratory tests, 1 and there is evidence to suggest that many of these tests are unnecessary 2 and potentially harmful. 3 The Society of Hospital Medicine has identified reducing the unnecessary ordering of inpatient laboratory testing as part of the Choosing Wisely campaign. 4 Hospitalists at academic medical centers face growing pressures to develop processes to reduce low-value care and train residents to be stewards of healthcare resources. 5 Studies 6-9 have described that institutional and training factors drive residents' resource utilization patterns, but, to our knowledge, none have described what factors contribute to residents' unnecessary laboratory testing. To better understand the factors associated with residents' ordering patterns, we conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center in order to describe residents' perception of the: (1) frequency of ordering unnecessary inpatient laboratory tests, (2) factors contributing to that behavior, and (3) potential interventions to change it. We also explored differences in responses by specialty and training level. METHODSIn October 2014, we surveyed all IM and GS residents at the Hospital of the University of Pennsylvania. We reviewed the literature and conducted focus groups with residents to formulate items for the survey instrument. A draft of the survey was administered to 8 residents from both specialties, and their feedback was collated and incorporated into the final version of the instrument. The final 15-question survey was comprised of 4 components: (1) training information such as specialty and postgraduate year (PGY), (2) selfreported frequency of perceived unnecessary ordering of inpatient laboratory tests, (3) perception of factors contributing to unnecessary ordering, a...

are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration.OBJECTIVE To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. DESIGN, SETTING, AND PARTICIPANTSThe Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions.INTERVENTIONS Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. MAIN OUTCOMES AND MEASURESPrimary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. RESULTSThe sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.

Residents in medicine and surgery had similar opinions about the effects of duty hours reform, including improved quality of life. However, resident opinions suggest that reduced fatigue-related errors have been offset by errors related to decreased continuity of care and that the quality of the educational experience may have declined. Quantifying the degree to which regulating duty hours affected errors related to discontinuity of care should be a focus of future research.

Status epilepticus is an emergency; however, prompt treatment of patients with status epilepticus is challenging. Clinical trials, such as the ESETT (Established Status Epilepticus Treatment Trial), compare effectiveness of antiepileptic medications, and rigorous examination of effectiveness of care delivery is similarly warranted. We reviewed the medical literature on observed deviations from guidelines, clinical significance, and initiatives to improve timely treatment. We found pervasive, substantial gaps between recommended and “real-world” practice with regard to timing, dosing, and sequence of antiepileptic therapy. Applying quality improvement methodology at the institutional level can increase adherence to guidelines and may improve patient outcomes.

Interns who received instruction on discharge summary skills improved the quality and of their discharge summaries. Adding feedback to the curriculum provided more benefit.

A longitudinal curriculum in diagnostic error and cognitive bias improved internal medicine residents' knowledge and recognition of cognitive biases as measured by a novel assessment tool. Further study is needed to refine learner assessment tools and examine optimal strategies to teach clinical reasoning and cognitive bias avoidance strategies.

Background Many hospitalized patients with complicated infections are discharged on outpatient parenteral antimicrobial therapy (OPAT). However, little is known about how to improve the postdischarge care of OPAT patients. Objective The impact of an infectious diseases transitions service (IDTS) on OPAT patient readmissions, as well as on processes of care, was evaluated. Methods We performed a controlled, quasi-experimental evaluation over 15 months in an academic medical center. Intervention-arm patients, before and after the introduction of an IDTS, were seen by the general infectious diseases consult teams, while control-arm patients (discharged on OPAT after hospitalization with bacteremia) were not. The IDTS prospectively tracked all OPAT patients and coordinated follow-up. The impact of the IDTS was calculated using a differences-in-differences approach where the interaction between time (before vs after the IDTS intervention) and study arm (intervention vs control arm) was the variable of interest. The control arm was used only in primary outcome analyses (readmissions and emergency department visits). Secondary outcomes included process of care measures and non-readmission clinical outcomes. Results Of 488 consecutive patients requiring OPAT, 362 were in the intervention arm (215 pre-intervention and 147 post-intervention) and 126 in the control arm (70 pre-intervention and 56 post-intervention). Compared to the control arm, the IDTS was not associated with changes in 60-day readmissions and/or emergency department visits (adjusted odds ratio [OR] = 0.48; 95% confidence interval [CI] = 0.13–1.79). In the intervention arm, implementation of the IDTS was associated with fewer antimicrobial therapy errors (OR = 0.062; 95% CI = 0.015–0.262), increased laboratory test receipt (OR = 27.85; 95% CI = 12.93–59.99), and improved outpatient follow-up (OR = 2.44; 95% CI = 1.50–3.97). Conclusions In a controlled evaluation, the IDTS did not affect readmissions despite improving process of care measures for targeted patients. Care coordination services may improve OPAT quality of care, but their relationship to readmissions is unclear.