No abstract

PurposeWhether improving the efficiency of hospital care will worsen post-discharge outcomes is unclear. We designed this study to evaluate the General Internal Medicine (GIM) Care Transformation Initiative implemented at one of the seven teaching hospitals in the Canadian province of Alberta.MethodsControlled before–after study of GIM patients hospitalised at the University of Alberta Hospital (UAH, intervention site, n=1896) or the six other teaching hospitals in Alberta—three in Edmonton (intra-regional controls (IRC), n=4550) and three in Calgary (extra-regional controls (ERC), n=4095). The primary effectiveness outcome was risk-adjusted length of stay (LOS) and the primary safety outcome was ‘mortality during index hospitalisation or all-cause readmission or death within 30-days of discharge’.ResultsLOS for GIM patients decreased by 0.68 days at Alberta teaching hospitals between 2009 and 2012; GIM patients hospitalised at the UAH exhibited a further 20% relative decline in adjusted LOS (total reduction=1.43 days, 95% CI 0.94 to 1.92 days) from PRE to POST. Interrupted time series (ITS) confirmed that the 1.43 day reduction at the UAH was statistically significant (level change p=0.003), while the declines at the IRC (p=0.37) and ERC (p=0.45) were not. Our safety outcome did not change for UAH patients (18.4% PRE-intervention vs 17.8% POST-intervention, adjusted OR 1.02 (95%CI 0.80 to 1.31), p=0.42 on ITS), nor for those hospitalised at the IRC (p=0.33) or the ERC (p=0.73) sites.ConclusionsThe Care Transformation Initiative was associated with substantial reductions in LOS without increasing post-discharge events commonly quoted as proxies for quality.

Although neuropsychiatric manifestations are prominent in some patients with Wilson disease, there is little published information regarding the efficacy of liver transplantation for these patients. A 22-year-old male with advanced neurological impairment and prominent psychiatric manifestations due to Wilson disease who underwent liver transplantation is presented. After transplantation, the ceruloplasmin and copper studies normalized and eventually the Kayser-Fleischer rings disappeared. Neurological recovery was very slow and incomplete, and his behavioural and personality disorder was entirely unaffected. He committed suicide 43 months post-transplantation. A review of the small number of related published cases in the English language literature shows variable neurological recovery post-transplantation, but the course of psychiatric manifestations is virtually never described. This case suggests that one must be cautious regarding liver transplantation for Wilson disease in patients with prior psychiatric manifestations. Aggressive medical management is likely to be preferable in most cases.

No abstract

BackgroundThere is currently a discrepancy between Internal Medicine residents' decisions in the Canadian subspecialty fellowship match (known as the R4 match) and societal need. Some studies have been published examining factors that influence career choices. However, these were either demographic factors or factors pre-determined by the authors' opinion as possibly being important to incorporate into a survey.MethodsA qualitative study was undertaken to identify factors that determine the residents choice in the subspecialty (R4) fellowship match using focus group discussions involving third and fourth year internal medicine residentsResultsBased on content analysis of the discussion data, we identified five themes:1) Practice environment including acuity of practice, ability to do procedures, lifestyle, job prospects and income2) Exposure in rotations and to role models3) Interest in subspecialty's patient population and common diseases4) Prestige and respect of subspecialty5) Fellowship training environment including fellowship program resources and length of trainingConclusionsThere are a variety of factors that contribute to Internal Medicine residents' fellowship choice in Canada, many of which have been identified in previous survey studies. However, we found additional factors such as the resources available in a fellowship program, the prestige and respect of a subspecialty/career, and the recent trend towards a two-year General Internal Medicine fellowship in our country.

IntroductionLaboratory blood testing is one of the most high-volume medical procedures and continues to increase steadily with instances of inappropriate testing resulting in significant financial implications. Studies have suggested that the design of a standard hospital admission order form and laboratory request forms influence physician test ordering behaviour, reducing inappropriate ordering and promoting resource stewardship.Aim/methodTo redesign the standard medicine admission order form-laboratory request section to reduce inappropriate blood urea nitrogen (BUN) testing.ResultsA redesign of the standard admission order form used by general internal medicine physicians and residents in two large teaching hospitals in one health zone in Alberta, Canada led to a significant step reduction in the ordering of the BUN test on hospital admission.ConclusionsRedesigning the standard medicine admission order form-laboratory request section can have a beneficial effect on the reduction in BUN ordering altering physician ordering patterns and behaviour.

No abstract

BackgroundThere has been a decline in interest in general internal medicine that has resulted in a discrepancy between internal medicine residents’ choice in the R4 subspecialty match and societal need. Few studies have focused on the relative importance of personal goals and their impact on residents’ choice. The purpose of this study was to assess if internal medicine residents can be grouped based on their personal goals and how each group prioritizes these goals compared to each other. A secondary objective was to explore whether we could predict a resident’s desired subspecialty choice based on their constellation of personal goals.MethodsWe used Q methodology to examine how postgraduate year 1–3 internal medicine residents could be grouped based on their rankings of 36 statements (derived from our previous qualitative study). Using each groups’ defining and distinguishing statements, we predicted their subspecialties of interest. We also collected the residents’ first choice in the subspecialty match and used a kappa test to compare our predicted subspecialty group to the residents’ self-reported first choice.ResultsFifty-nine internal medicine residents at the University of Alberta participated between 2009 and 2010 with 46 Q sorts suitable for analysis. The residents loaded onto four factors (groups) based on how they ranked statements. Our prediction of each groups’ desired subspecialties with their defining and/or distinguishing statements are as follows: group 1 – general internal medicine (variety in practice); group 2 – gastroenterology, nephrology, and respirology (higher income); group 3 – cardiology and critical care (procedural, willing to entertain longer training); group 4 – rest of subspecialties (non-procedural, focused practice, and valuing more time for personal life). There was moderate agreement (kappa = 0.57) between our predicted desired subspecialty group and residents’ self-reported first choice (p < 0.001).ConclusionThis study suggests that most residents fall into four groups based on a constellation of personal goals when choosing an internal medicine subspecialty. The key goals that define and/or distinguish between these groups are breadth of practice, lifestyle, desire to do procedures, length of training, and future income potential. Using these groups, we were able to predict residents’ first subspecialty group with moderate success.