The cost and quality of hospitalists.

The Hospitalist concept is becoming the standard of practice as managed care penetration grows. It is increasingly difficult to do a good job in the outpatient arena and this makes the old "double threat" model in which the physician speeds through inpatient rounds in the morning before clinic, during lunch, and again at night after his office closes, obsolete. There is simply too much at stake in the inpatient arena to have large periods of time in which physician coverage is minimal. Controversy exists as to whether or not the services should be "outsourced" to a Hospitalist management company or developed internally, using physicians who historically have had a significant presence in the hospital. If the services are outsourced, then it is essential that they be built around a strong local physician leader who remains active in patient care. The French author, Anais Nin wrote: "There are very few human beings who receive the truth, complete and staggering, by instant illumination. Most of them acquire it fragment by fragment, on a small scale, by successive developments, cellularly, like a laborious mosaic." Inpatient care in the United States is adequately described as a laborious mosaic in which providers of many different services surround patients with many different problems. Hospitalist programs can help to bring order to the mosaic by consistently combining the correct physician talent with the system's sickest and most expensive patients in order to achieve the best possible outcomes.

The cost and quality of hospitalists. A detailed analysis of creating and managing a hospitalist service.

HMOs and the medical groups that they contract with are increasingly developing hospitalist delivery models to assist them with their inpatient care. This article offers a case study of how not to create a hospitalist program as well as tips for success.

Localization of bronchial intraepithelial neoplastic lesions by fluorescence bronchoscopy.

BACKGROUND: In the treatment of lung cancer, the best outcome is achieved when the lesion is discovered in the intraepithelial (preinvasive) stage. However, intraepithelial neoplastic lesions are difficult to localize by conventional white-light bronchoscopy (WLB). OBJECTIVE: To determine if autofluorescence bronchoscopy, when used as an adjunct to WLB, could improve the bronchoscopist's ability to locate and remove biopsy specimens from areas suspicious of intraepithelial neoplasia as compared with WLB alone. METHOD: A multicenter clinical trial was conducted in seven institutions in the United States and Canada. WLB followed by fluorescence examination with the light-induced fluorescence endoscopy (LIFE) device was performed in 173 subjects known or suspected to have lung cancer. Biopsy specimens were taken from all areas suspicious of moderate dysplasia or worse on WLB and/or LIFE examination. In addition, random biopsy specimens were also taken from other parts of the bronchial tree. RESULTS: The relative sensitivity of WLB + LIFE vs WLB alone was 6.3 for intraepithelial neoplastic lesions and 2.71 when invasive carcinomas were also included. The positive predictive value was 0.33 and 0.39 and the negative predictive value was 0.89 and 0.83, respectively, for WLB+LIFE and WLB alone. CONCLUSION: Autofluorescence bronchoscopy, when used as an adjunct to standard WLB, enhances the bronchoscopist's ability to localize small neoplastic lesions, especially intraepithelial lesions that may have significant implication in the management of lung cancer in the future.

Subarachnoid hemorrhage: an unusual presentation of shock.

A 42-year-old woman became profoundly hypotensive shortly after arriving at our emergency medical center after a seizure. The patient's blood pressure did not respond to aggressive fluid resuscitation, administration of inotropic agents, vasopressors, or corticosteroids. After a thorough search for the cause of shock, she was found to have a subarachnoid hemorrhage (SAH). Hypotension is a rare occurrence in SAH. Several mechanisms of SAH are reviewed in this report and are invoked to explain this patient's lack of response to the standard therapies for hypotension. Emergency physicians should consider SAH in the differential diagnosis of refractory shock in patients who present with neurologic abnormalities.

Clinically occult presentation of comminuted intertrochanteric hip fractures.

Hip fractures in awake patients are rarely subtle in their clinical presentation. We report two cases of occult, comminuted, intertrochanteric hip fractures that occurred in awake, elderly patients who were brought to the emergency department for evaluation of other medical conditions. Neither patient complained of hip pain, and both were transported to the ED without spinal immobilization. Physical examination revealed no sign of hip fracture. Patient 1 was scheduled for admission and just prior to transfer out of the ED developed hip pain. Patient 2 was admitted for workup of possible transient ischemic attack and approximately 2.5 hours after admission complained of hip pain. Radiographs of both patients revealed comminuted intertrochanteric hip fractures. In an elderly, nonambulatory patient who may have fallen prior to evaluation, routine radiographs of the pelvis and hip should be performed followed by plain tomography, computed tomography, bone scan, or magnetic resonance imaging as indicated to rule out occult hip fracture. Even comminuted intertrochanteric hip fractures can present in an occult fashion; therefore, a high index of suspicion must be maintained for these injuries.

Provider continuity and quality of medical care. A retrospective analysis of prenatal and perinatal outcome.

It is often assumed that family physicians are able to provide a higher quality of medical care because of the greater degree of continuity inherent in their practices. The authors attempted to measure the association between continuity and quality of medical care using pregnancy as a tracer condition. Using a retrospective cohort study design, two groups of pregnant women were identified--those cared for in the family practice (FP) centers and those cared for in the obstetric (OB) clinics. Process and outcome of medical care were measured along with patient satisfaction. Provider continuity, as measured by the SECON value, was much higher in the FP group, and was highly correlated with the presence of an "attitudinal contract" between patient and physician. Although not statistically significant, four times as many newborns from the OB group were admitted to the neonatal intensive care unit. FP group newborn weight averaged 220 grams more than the OB group (P less than 0.05). This difference remained after control for covariates. While not reaching statistical significance, patient satisfaction scores tended to be higher for the FP group in two of three categories measured. The results suggest that continuity of care was associated with better patient outcome and satisfaction. Directions for causal interpretation and future research are discussed.

Delayed cerebral embolization of a shotgun pellet with fatal consequences.

A case of shotgun pellet embolization to the middle cerebral artery is presented. Embolization occurred approximately 36 hours following successful resuscitation of blood pressure, respirations, and neurologic function in a 21-year-old man who had sustained a massive chest wound. The diagnosis of pellet embolization was made within 8 hours of the onset of neurologic deficits; however, fatal cerebral infarction had occurred before surgery could be undertaken. Seven similar cases are briefly reviewed and it is concluded that low velocity and low kinetic energy missiles are more likely to embolize, and that left lower extremity injuries are more frequently involved in embolization. In all cases of shotgun trauma to the chest cerebral embolization of pellets should be considered at any sign of neurologic change and skull films obtained. Surgical intervention is necessary before cerebral infarction.