Morning Report Presentation with Literature Search Associated with Decreased Length of Hospital Stay

A Review of:
 Banks, Daniel E., Runhus Shi, Donna F. Timm, Kerri Ann Christopher, David Charles Duggar, Marianne Comegys, and Jerry McLarty. “Decreased Hospital Length of Stay Associated with Presentation of Cases at Morning Report with Librarian Support.” Journal of the Medical Library Association 95.4 (Oct. 2007): 381-87.
 
 
 Objective – To determine whether hospital charges, length of stay or 30-day re-admission rates were affected by case discussion at residents’ morning report (MR), accompanied by librarian-provided literature search results, within 24 hours of admission.
 
 Design – Case-control study and survey.
 
 Setting – Louisiana State University School of Medicine. 
 
 Subjects – MR cases presented during the study period August 2004 to March 2005 matched with one to three cases (controls) of patients who were hospitalised in the period January 2000 to July 2005. House officers who presented the MR cases during the study period were the subjects for the survey.
 
 Methods – MR cases were presented between 8:00am and 9:00am, five days a week, and only one case was presented at each MR. During the study period, August 2004 to March 2005, the presenting house officer selected independently a case for presentation at MR from patients admitted during the previous 24 hours. The selection was made without guidance as to which cases or illnesses to choose and without the knowledge or involvement of the attending physician or investigators. The term “house officer” is not defined in the article so it is not clear whether this refers to medical residents only, or if it includes interns.
 
 The faculty librarian, with clinical input from the chief resident or the chair of the Department of Medicine, conducted a search of the medical literature immediately following the MR to identify articles or citations that would answer two questions posed at the end of the presentation. The chair of the department or chief resident selected the articles that provided the most clinically sound answers to the questions. By 10:00 am, copies of the selected articles were hand-delivered to the presenting house officer and shared with members of the ward team.
 
 For the case-control component, the MR cases presented during the study period were matched against a comparison group of patients who were hospitalised in the period January 2000 to July 2005. Matching of controls to the MR cases was made on the basis of the primary International Classification of Diseases (ICD-9) diagnostic code, patient age and concomitant secondary diagnosis. MR cases with no matching control case were excluded from analysis of length of stay, costs or readmission rates. A maximum of three control cases were randomly selected where a MR case matched with more than three control cases. 
 
 Data regarding demographic information of the patient (age, sex, race, insurance coverage, marital status and number of diseases diagnosed), the length of stay, total hospitalisation charges and readmission rates within 30 days of initial discharge were extracted from the medical records of matched MR and control cases. 
 
 Statistical tests (Student T or chi-squared tests) were used to compare differences between the demographic details of patients in the MR group and the control cases. Wilcoxon signed rank test and Sign test were used to analyse nonparametric data such as length of stay and hospital charges. Median values, rather than the mean, were used for the outcome measures to reduce the influence of any extreme or outlier values. The researchers considered a p value less than p = 0.05 to be statistically significant. 
 
 For the survey component of the study, each presenting house officer was asked to complete a questionnaire for each MR case they presented during the study period, which asked them to comment on the quality of the articles located in response to the questions posed at the MR and to say whether the information would influence their treatment of the patient. A copy of the questionnaire is accessible online via a link within the article; however it is not stated who analyzed the results or how this was done.
 
 Main Results – Of the 105 cased presented at MR during the study period, 55 cases could be matched with at least one control up to a maximum of three cases, resulting in a total of 136 control cases. 
 
 Statistical analysis of the MR cases and the control cases showed no significant difference in the demographic details between the groups. 
 
 MR cases had a median length of stay of three days compared to five days for control cases. This difference was statistically significant (p = 0.0238). A logarithmic plot comparing length of stay between MR cases and controls showed a positive association that was statistically significant (p = 0.012) between presentation at MR and a reduced median length of stay. 
 
 Median hospitalisation charges were $7,045 for the MR cases and $10,663 for the control cases; however, the difference was not statistically significant (p = 0.24). A logarithmic plot for total charges showed that, in most cases, charges for MR cases were lower than controls; however, the differences did not reach statistical significance (p = 0.18).
 
 Readmission rates within thirty days of initial discharge were 16.4% for MR cases and 16.8% for controls. There was no statistically significant difference in readmission rates between the groups (p > 0.88).
 
 Analysis of the survey responses found that the house officers commented on the quality of the articles for 60 of the 105 MR cases presented. In 43 cases, the house officer commented that the articles had a positive influence on patient management. Comments for a further ten cases indicated that, although they did not alter the management of MR patient cases, the house officers believed that the articles provided good background information which may be helpful in the future. Seven other comments indicated that the articles had not influenced their patient management in any respect.
 
 Conclusion – Presentation of cases at MR accompanied by dissemination of literature search results resulted in a statistically significant shortened median length of stay and lower hospital charges compared to matched control cases. Readmission rates within 30 days of first diagnosis showed no differences between MR cases and control cases.
 
 Supplementary survey results found that the 41% of the presenting house officers believed that the literature search information provided following the MR presentation positively influenced patient management.

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