Richard Quinn

Northwestern University's graduate program in healthcare quality and patient safety can be a valuable tool for hospitalists looking to meld clinical expertise with practice management skills.

So says Kevin O'Leary, MD, MS, thought to be the only hospitalist to earn the master's degree in the program's four-year history. "It's definitely important for somebody who wants to take any role in leading quality improvement (QI) either for their hospital medicine group or for the hospital," says Dr. O'Leary, associate chief of hospital medicine at Northwestern University's Feinberg School of Medicine. "A traditional residency program does not prepare, really, any physician in any specialty to take a lead in quality improvement."

Dr. O'Leary graduated from the two-year, part-time program last summer. The program, led by co-directors Kevin B. Weiss, MD, MP, and Donna Woods, EdM, PhD, offers in-depth exposure for physicians taking a leadership role at their institutions. Dr. O'Leary says the program goes beyond the introductory level available at seminars or workshops. Courses in the track include lessons on risk assessment, error theories, the development of meaningful quality metrics, and the use of health information technology. Students interact with physicians, policy makers, and researchers.

The Feinberg School also offers a certification-level program, but because of logistical constraints, both the certification and master's degree tracks attract mostly Illinois physicians. Some out-of-state doctors have taken part in the program, and the school offers a faculty development program that is not limited to Chicago-area physicians. That is one area in which Dr. O'Leary hopes to see exponential growth in the coming years.

"We all realize we have the need to teach [QI] to our trainees and our residents," he adds. "Who are the faculty who are going to teach this? First you have to train the faculty to train the residents and the medical students."

Northwestern University's graduate program in healthcare quality and patient safety can be a valuable tool for hospitalists looking to meld clinical expertise with practice management skills.

So says Kevin O'Leary, MD, MS, thought to be the only hospitalist to earn the master's degree in the program's four-year history. "It's definitely important for somebody who wants to take any role in leading quality improvement (QI) either for their hospital medicine group or for the hospital," says Dr. O'Leary, associate chief of hospital medicine at Northwestern University's Feinberg School of Medicine. "A traditional residency program does not prepare, really, any physician in any specialty to take a lead in quality improvement."

Dr. O'Leary graduated from the two-year, part-time program last summer. The program, led by co-directors Kevin B. Weiss, MD, MP, and Donna Woods, EdM, PhD, offers in-depth exposure for physicians taking a leadership role at their institutions. Dr. O'Leary says the program goes beyond the introductory level available at seminars or workshops. Courses in the track include lessons on risk assessment, error theories, the development of meaningful quality metrics, and the use of health information technology. Students interact with physicians, policy makers, and researchers.

The Feinberg School also offers a certification-level program, but because of logistical constraints, both the certification and master's degree tracks attract mostly Illinois physicians. Some out-of-state doctors have taken part in the program, and the school offers a faculty development program that is not limited to Chicago-area physicians. That is one area in which Dr. O'Leary hopes to see exponential growth in the coming years.

"We all realize we have the need to teach [QI] to our trainees and our residents," he adds. "Who are the faculty who are going to teach this? First you have to train the faculty to train the residents and the medical students."

Northwestern University's graduate program in healthcare quality and patient safety can be a valuable tool for hospitalists looking to meld clinical expertise with practice management skills.

So says Kevin O'Leary, MD, MS, thought to be the only hospitalist to earn the master's degree in the program's four-year history. "It's definitely important for somebody who wants to take any role in leading quality improvement (QI) either for their hospital medicine group or for the hospital," says Dr. O'Leary, associate chief of hospital medicine at Northwestern University's Feinberg School of Medicine. "A traditional residency program does not prepare, really, any physician in any specialty to take a lead in quality improvement."

Dr. O'Leary graduated from the two-year, part-time program last summer. The program, led by co-directors Kevin B. Weiss, MD, MP, and Donna Woods, EdM, PhD, offers in-depth exposure for physicians taking a leadership role at their institutions. Dr. O'Leary says the program goes beyond the introductory level available at seminars or workshops. Courses in the track include lessons on risk assessment, error theories, the development of meaningful quality metrics, and the use of health information technology. Students interact with physicians, policy makers, and researchers.

The Feinberg School also offers a certification-level program, but because of logistical constraints, both the certification and master's degree tracks attract mostly Illinois physicians. Some out-of-state doctors have taken part in the program, and the school offers a faculty development program that is not limited to Chicago-area physicians. That is one area in which Dr. O'Leary hopes to see exponential growth in the coming years.

"We all realize we have the need to teach [QI] to our trainees and our residents," he adds. "Who are the faculty who are going to teach this? First you have to train the faculty to train the residents and the medical students."

Hospitalized patients continue to suffer from falls despite the use of criteria to identify the highest-risk admissions, according to a study published in this month's Journal of Hospital Medicine.

The report, "Predictors of Serious Injury Among Hospitalized Patients Evaluated for Falls" (JHM. 2010;5:63-68), is a retrospective study of inpatients at 13 medical and surgical units at Mount Sinai Medical Center in New York City. A total of 513 patients experienced 636 falls during that timeframe, according to the study. The incidence rate of falls was 1.97 per 1,000 patient days. Evidence of trauma after a fall (odds ratio=24.6, P<0.001) and ambulatory status (OR=7.3, P<0.01) were found to be "independent predictors of injury being found on imaging studies."

Sara Bradley, MD, associate medical director at the Martha Stewart Center for Living, assistant professor at the Brookdale Department of Geriatrics, and assistant professor at the palliative-care department at Mount Sinai School of Medicine, says the study is the first step in trying to reduce the rate of falls. She says hospitalists are in prime position to trumpet the issue as a QI initiative, particularly as federal funding sources pull back from reimbursement for such preventable errors as falls.

"It's multifactorial, but the doctors, in many ways, are leading this charge," Dr. Bradley says. "If they think it's important and they're leading the nurses and the physical therapists and the family in seeing this as important, that's how it happens."

At Mount Sinai, a pilot program launched last fall implemented a checklist to further the identification of high-risk patients. Risk factors include cognitive status, environment, mobility, hydration, and nutrition. Future risks that may be added to the checklist include medication.

"None of this high-tech," Dr. Bradley acknowledges. "It's all about little interventions, but each of those interventions adds up."

Hospitalized patients continue to suffer from falls despite the use of criteria to identify the highest-risk admissions, according to a study published in this month's Journal of Hospital Medicine.

The report, "Predictors of Serious Injury Among Hospitalized Patients Evaluated for Falls" (JHM. 2010;5:63-68), is a retrospective study of inpatients at 13 medical and surgical units at Mount Sinai Medical Center in New York City. A total of 513 patients experienced 636 falls during that timeframe, according to the study. The incidence rate of falls was 1.97 per 1,000 patient days. Evidence of trauma after a fall (odds ratio=24.6, P<0.001) and ambulatory status (OR=7.3, P<0.01) were found to be "independent predictors of injury being found on imaging studies."

Sara Bradley, MD, associate medical director at the Martha Stewart Center for Living, assistant professor at the Brookdale Department of Geriatrics, and assistant professor at the palliative-care department at Mount Sinai School of Medicine, says the study is the first step in trying to reduce the rate of falls. She says hospitalists are in prime position to trumpet the issue as a QI initiative, particularly as federal funding sources pull back from reimbursement for such preventable errors as falls.

"It's multifactorial, but the doctors, in many ways, are leading this charge," Dr. Bradley says. "If they think it's important and they're leading the nurses and the physical therapists and the family in seeing this as important, that's how it happens."

At Mount Sinai, a pilot program launched last fall implemented a checklist to further the identification of high-risk patients. Risk factors include cognitive status, environment, mobility, hydration, and nutrition. Future risks that may be added to the checklist include medication.

"None of this high-tech," Dr. Bradley acknowledges. "It's all about little interventions, but each of those interventions adds up."

Hospitalized patients continue to suffer from falls despite the use of criteria to identify the highest-risk admissions, according to a study published in this month's Journal of Hospital Medicine.

The report, "Predictors of Serious Injury Among Hospitalized Patients Evaluated for Falls" (JHM. 2010;5:63-68), is a retrospective study of inpatients at 13 medical and surgical units at Mount Sinai Medical Center in New York City. A total of 513 patients experienced 636 falls during that timeframe, according to the study. The incidence rate of falls was 1.97 per 1,000 patient days. Evidence of trauma after a fall (odds ratio=24.6, P<0.001) and ambulatory status (OR=7.3, P<0.01) were found to be "independent predictors of injury being found on imaging studies."

Sara Bradley, MD, associate medical director at the Martha Stewart Center for Living, assistant professor at the Brookdale Department of Geriatrics, and assistant professor at the palliative-care department at Mount Sinai School of Medicine, says the study is the first step in trying to reduce the rate of falls. She says hospitalists are in prime position to trumpet the issue as a QI initiative, particularly as federal funding sources pull back from reimbursement for such preventable errors as falls.

"It's multifactorial, but the doctors, in many ways, are leading this charge," Dr. Bradley says. "If they think it's important and they're leading the nurses and the physical therapists and the family in seeing this as important, that's how it happens."

At Mount Sinai, a pilot program launched last fall implemented a checklist to further the identification of high-risk patients. Risk factors include cognitive status, environment, mobility, hydration, and nutrition. Future risks that may be added to the checklist include medication.

"None of this high-tech," Dr. Bradley acknowledges. "It's all about little interventions, but each of those interventions adds up."

A concerted effort to reduce patient falls in Minnesota hospitals culminated last year as the Gopher State reported zero fatal falls—a result heavily attributed to hospitalist efforts.

A report last month from Minnesota health officials shows that no patients died from falls in 2009. It was the first fatality-free reporting period since the state began publicly disclosing adverse events six years ago. In 2008, 10 fall-related fatalities were reported in Minnesota hospitals.

"We went through our order sets and eliminated potentially unnecessary medications across the board," says Scott Tongen, MD, a hospitalist and medical director for quality at United Hospital in St. Paul. "And we challenged hospitalists to stop prescribing those … and at the same time we had to work with the nursing staff."

Dr. Tongen says his hospital, which is part of the Allina Hospitals and Clinics system, attacked the issue of falls by emphasizing hourly rounding by the nursing staff and collaborating with HM leaders. The state also developed Minnesota Falls Prevention, an award-winning Web site that shines light on the issue of preventable falls.

"I think one of the keys to success is empowering the nursing staff to work with the hospitalist service in partnership to accomplish this goal," says hospitalist James Young, MD, who works at United and is president of SHM's Minnesota chapter. "I know that at United, our nurses are far from mute and are not bashful about telling us when a patient is at risk. We are not bashful in educating them about why sleepers aren't a great idea for elderly patients. … It’s a team effort."

A concerted effort to reduce patient falls in Minnesota hospitals culminated last year as the Gopher State reported zero fatal falls—a result heavily attributed to hospitalist efforts.

A report last month from Minnesota health officials shows that no patients died from falls in 2009. It was the first fatality-free reporting period since the state began publicly disclosing adverse events six years ago. In 2008, 10 fall-related fatalities were reported in Minnesota hospitals.

"We went through our order sets and eliminated potentially unnecessary medications across the board," says Scott Tongen, MD, a hospitalist and medical director for quality at United Hospital in St. Paul. "And we challenged hospitalists to stop prescribing those … and at the same time we had to work with the nursing staff."

Dr. Tongen says his hospital, which is part of the Allina Hospitals and Clinics system, attacked the issue of falls by emphasizing hourly rounding by the nursing staff and collaborating with HM leaders. The state also developed Minnesota Falls Prevention, an award-winning Web site that shines light on the issue of preventable falls.

"I think one of the keys to success is empowering the nursing staff to work with the hospitalist service in partnership to accomplish this goal," says hospitalist James Young, MD, who works at United and is president of SHM's Minnesota chapter. "I know that at United, our nurses are far from mute and are not bashful about telling us when a patient is at risk. We are not bashful in educating them about why sleepers aren't a great idea for elderly patients. … It’s a team effort."

A concerted effort to reduce patient falls in Minnesota hospitals culminated last year as the Gopher State reported zero fatal falls—a result heavily attributed to hospitalist efforts.

A report last month from Minnesota health officials shows that no patients died from falls in 2009. It was the first fatality-free reporting period since the state began publicly disclosing adverse events six years ago. In 2008, 10 fall-related fatalities were reported in Minnesota hospitals.

"We went through our order sets and eliminated potentially unnecessary medications across the board," says Scott Tongen, MD, a hospitalist and medical director for quality at United Hospital in St. Paul. "And we challenged hospitalists to stop prescribing those … and at the same time we had to work with the nursing staff."

Dr. Tongen says his hospital, which is part of the Allina Hospitals and Clinics system, attacked the issue of falls by emphasizing hourly rounding by the nursing staff and collaborating with HM leaders. The state also developed Minnesota Falls Prevention, an award-winning Web site that shines light on the issue of preventable falls.

"I think one of the keys to success is empowering the nursing staff to work with the hospitalist service in partnership to accomplish this goal," says hospitalist James Young, MD, who works at United and is president of SHM's Minnesota chapter. "I know that at United, our nurses are far from mute and are not bashful about telling us when a patient is at risk. We are not bashful in educating them about why sleepers aren't a great idea for elderly patients. … It’s a team effort."

In the wake of a study that showed a 70% spike in the rate of VTE in pediatric hospitals, pediatric hospitalists and others are calling for a deeper analysis of the data.

The seven-year, multicenter study measured 11,337 hospitalized patients under the age of 18. Researchers found the annual rate of VTE increased by 70%, to 58 cases from 34 cases per 10,000 (P<0.001) (Pediatrics 2009;124(4):1001-1008). Several pediatricians note that the increase looks outsized because there has been little research on the topic over the past decade. Those interviewed say they expect more research in the future to define the breadth of the problem and potential solutions.

“I don’t think we think there’s been a seven-fold increase,” says Janna Journeycake, MD, MSCS, director of the Hemophilia and Thrombosis Program at Children's Medical Center, University of Texas Southwestern Medical Center at Dallas. “It was there all along. We just didn’t know how to recognize it.”

Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and The Hospitalist's pediatric editor, attributes a large part of the study’s findings to more awareness of VTE in the pediatric community and increases in serious bone and joint infections that lead to more central lines, a risk factor for VTE. Dr. Shen also points out that as physicians learn more about pediatric VTE, it is expected that the rate of its incidence will increase. “Before, we wouldn’t look for signs of a clot unless there were physical signs of swelling, discomfort, or shortness of breath,” he adds. “Now we are much quicker to go and do an ultrasound or look for some kind of thromboembolism.”

Dr. Journeycake sees pediatric hospitalists as the vanguard in moving forward, as long as they stay vigilant to recognize the warning signs. “The job of the hospitalist is to recognize the certain medical conditions in which VTE are most likely,” she says. “They are going to be the most critically ill kids, the ones with deep-seated infection, such as osteomyelitis, mastoiditis. … Those are going to be children with central venous catheters. Hospitalists need to realize this complication exists.”

In the wake of a study that showed a 70% spike in the rate of VTE in pediatric hospitals, pediatric hospitalists and others are calling for a deeper analysis of the data.

The seven-year, multicenter study measured 11,337 hospitalized patients under the age of 18. Researchers found the annual rate of VTE increased by 70%, to 58 cases from 34 cases per 10,000 (P<0.001) (Pediatrics 2009;124(4):1001-1008). Several pediatricians note that the increase looks outsized because there has been little research on the topic over the past decade. Those interviewed say they expect more research in the future to define the breadth of the problem and potential solutions.

“I don’t think we think there’s been a seven-fold increase,” says Janna Journeycake, MD, MSCS, director of the Hemophilia and Thrombosis Program at Children's Medical Center, University of Texas Southwestern Medical Center at Dallas. “It was there all along. We just didn’t know how to recognize it.”

Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and The Hospitalist's pediatric editor, attributes a large part of the study’s findings to more awareness of VTE in the pediatric community and increases in serious bone and joint infections that lead to more central lines, a risk factor for VTE. Dr. Shen also points out that as physicians learn more about pediatric VTE, it is expected that the rate of its incidence will increase. “Before, we wouldn’t look for signs of a clot unless there were physical signs of swelling, discomfort, or shortness of breath,” he adds. “Now we are much quicker to go and do an ultrasound or look for some kind of thromboembolism.”

Dr. Journeycake sees pediatric hospitalists as the vanguard in moving forward, as long as they stay vigilant to recognize the warning signs. “The job of the hospitalist is to recognize the certain medical conditions in which VTE are most likely,” she says. “They are going to be the most critically ill kids, the ones with deep-seated infection, such as osteomyelitis, mastoiditis. … Those are going to be children with central venous catheters. Hospitalists need to realize this complication exists.”

In the wake of a study that showed a 70% spike in the rate of VTE in pediatric hospitals, pediatric hospitalists and others are calling for a deeper analysis of the data.

The seven-year, multicenter study measured 11,337 hospitalized patients under the age of 18. Researchers found the annual rate of VTE increased by 70%, to 58 cases from 34 cases per 10,000 (P<0.001) (Pediatrics 2009;124(4):1001-1008). Several pediatricians note that the increase looks outsized because there has been little research on the topic over the past decade. Those interviewed say they expect more research in the future to define the breadth of the problem and potential solutions.

“I don’t think we think there’s been a seven-fold increase,” says Janna Journeycake, MD, MSCS, director of the Hemophilia and Thrombosis Program at Children's Medical Center, University of Texas Southwestern Medical Center at Dallas. “It was there all along. We just didn’t know how to recognize it.”

Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and The Hospitalist's pediatric editor, attributes a large part of the study’s findings to more awareness of VTE in the pediatric community and increases in serious bone and joint infections that lead to more central lines, a risk factor for VTE. Dr. Shen also points out that as physicians learn more about pediatric VTE, it is expected that the rate of its incidence will increase. “Before, we wouldn’t look for signs of a clot unless there were physical signs of swelling, discomfort, or shortness of breath,” he adds. “Now we are much quicker to go and do an ultrasound or look for some kind of thromboembolism.”

Dr. Journeycake sees pediatric hospitalists as the vanguard in moving forward, as long as they stay vigilant to recognize the warning signs. “The job of the hospitalist is to recognize the certain medical conditions in which VTE are most likely,” she says. “They are going to be the most critically ill kids, the ones with deep-seated infection, such as osteomyelitis, mastoiditis. … Those are going to be children with central venous catheters. Hospitalists need to realize this complication exists.”

Hospitalists serving as attending physicians were overwhelmingly found in ICUs in hospitals where intensivists were used mostly as elective consultations, according to a study to be published in this month’s Journal of Hospital Medicine.

The report, "Characteristics of Intensive Care Units in Michigan: Not an Open and Closed Case" (JHM. 2010;5:4-9), is a cross-sectional survey of 115 ICUs in 72 Michigan hospitals. The way critical care is delivered is an issue many hospitalists pay mind to as they often are called upon to compensate for workforce shortages even though few are board-certified in critical care. The study reported that 25% of sites used a closed model of intensive care, and that those units were larger than sites with open ICUs (P<0.05). Hospitalists serving as attendings were "strongly associated with an open ICU" (odds ratio 95%; confidence interval=12.2).

"Because our study shows that hospitalists are already providing intensive care in many areas of Michigan … the best strategy [for hospitalists] would be to work within that context,” says lead researcher Robert C. Hyzy, MD, FCCM, associate professor in the Department of Internal Medicine and director of the Critical Care Medicine Unit at the University of Michigan in Ann Arbor.

Dr. Hyzy says hospitalists will "continue to play an important role" in ICU care as long as the intensivist shortage continues, even though many don’t have the extensive training to do so. Telemedicine has been used in recent years to help address the ICU physician shortage, although the debate continues as to its effectiveness on morbidity and mortality rates. In the meantime, Dr. Hyzy reports, only 20% of the sites in his study reported all attending physicians were board-certified in critical care; 60 sites had less than 50% board-certified attending physicians.

“Hospitalists can play a role in acknowledging the limitations of individuals who are not properly trained in critical care to advocate for transfer to larger centers under explicit clinical circumstances,” Dr. Hyzy says.

As a member of the Society of Critical Care Medicine’s (SCCM) fellowship program, Dr. Hyzy also urges any hospitalists who deliver critical-care services to investigate the SCCM’s certification track and to take advantage of any training opportunities available to them.

Hospitalists serving as attending physicians were overwhelmingly found in ICUs in hospitals where intensivists were used mostly as elective consultations, according to a study to be published in this month’s Journal of Hospital Medicine.

The report, "Characteristics of Intensive Care Units in Michigan: Not an Open and Closed Case" (JHM. 2010;5:4-9), is a cross-sectional survey of 115 ICUs in 72 Michigan hospitals. The way critical care is delivered is an issue many hospitalists pay mind to as they often are called upon to compensate for workforce shortages even though few are board-certified in critical care. The study reported that 25% of sites used a closed model of intensive care, and that those units were larger than sites with open ICUs (P<0.05). Hospitalists serving as attendings were "strongly associated with an open ICU" (odds ratio 95%; confidence interval=12.2).

"Because our study shows that hospitalists are already providing intensive care in many areas of Michigan … the best strategy [for hospitalists] would be to work within that context,” says lead researcher Robert C. Hyzy, MD, FCCM, associate professor in the Department of Internal Medicine and director of the Critical Care Medicine Unit at the University of Michigan in Ann Arbor.

Dr. Hyzy says hospitalists will "continue to play an important role" in ICU care as long as the intensivist shortage continues, even though many don’t have the extensive training to do so. Telemedicine has been used in recent years to help address the ICU physician shortage, although the debate continues as to its effectiveness on morbidity and mortality rates. In the meantime, Dr. Hyzy reports, only 20% of the sites in his study reported all attending physicians were board-certified in critical care; 60 sites had less than 50% board-certified attending physicians.

“Hospitalists can play a role in acknowledging the limitations of individuals who are not properly trained in critical care to advocate for transfer to larger centers under explicit clinical circumstances,” Dr. Hyzy says.

As a member of the Society of Critical Care Medicine’s (SCCM) fellowship program, Dr. Hyzy also urges any hospitalists who deliver critical-care services to investigate the SCCM’s certification track and to take advantage of any training opportunities available to them.

Hospitalists serving as attending physicians were overwhelmingly found in ICUs in hospitals where intensivists were used mostly as elective consultations, according to a study to be published in this month’s Journal of Hospital Medicine.

The report, "Characteristics of Intensive Care Units in Michigan: Not an Open and Closed Case" (JHM. 2010;5:4-9), is a cross-sectional survey of 115 ICUs in 72 Michigan hospitals. The way critical care is delivered is an issue many hospitalists pay mind to as they often are called upon to compensate for workforce shortages even though few are board-certified in critical care. The study reported that 25% of sites used a closed model of intensive care, and that those units were larger than sites with open ICUs (P<0.05). Hospitalists serving as attendings were "strongly associated with an open ICU" (odds ratio 95%; confidence interval=12.2).

"Because our study shows that hospitalists are already providing intensive care in many areas of Michigan … the best strategy [for hospitalists] would be to work within that context,” says lead researcher Robert C. Hyzy, MD, FCCM, associate professor in the Department of Internal Medicine and director of the Critical Care Medicine Unit at the University of Michigan in Ann Arbor.

Dr. Hyzy says hospitalists will "continue to play an important role" in ICU care as long as the intensivist shortage continues, even though many don’t have the extensive training to do so. Telemedicine has been used in recent years to help address the ICU physician shortage, although the debate continues as to its effectiveness on morbidity and mortality rates. In the meantime, Dr. Hyzy reports, only 20% of the sites in his study reported all attending physicians were board-certified in critical care; 60 sites had less than 50% board-certified attending physicians.

“Hospitalists can play a role in acknowledging the limitations of individuals who are not properly trained in critical care to advocate for transfer to larger centers under explicit clinical circumstances,” Dr. Hyzy says.

As a member of the Society of Critical Care Medicine’s (SCCM) fellowship program, Dr. Hyzy also urges any hospitalists who deliver critical-care services to investigate the SCCM’s certification track and to take advantage of any training opportunities available to them.

A new study questioning the efficacy of telemedicine in reducing length of stay (LOS) and improving patient care in the ICU is further proof that remote patient care only works when there is a strong support structure behind it, according to a former SHM president.

“The studies in the past have not shown that just because you have an intensivist available that you are going to get a lot of bang for the buck. You need to have a real process. … If you don’t implement something properly, you can’t expect to get results,” says Mary Jo Gorman, MD, MBA, FHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine.

Investigators at the University of Texas Health Science Center at Houston reviewed some 4,000 patients in six ICUs at five hospitals in a large U.S. healthcare system by measuring outcomes before and after implementation of a “tele-ICU” from 2003 to 2006. No statistically significant impacts were seen in mortality rates, complications, or LOS (JAMA. 2009;302[24]:2671-2678). Conversely, an accompanying editorial in the Journal of the American Medical Association argued that “tele-ICU is a potentially valuable change in ICU care, but its complexity means that ‘tele-ICU improves care’ is not a testable hypothesis.”

The use of off-site intensivists to monitor patients has been used in recent years to address the shortage of ICU physicians. Still, the study team argues that “there are few data in the peer-reviewed literature evaluating its effect on morbidity and mortality.”

Dr. Gorman suggests that HM groups looking to partner with telemedicine providers consider the importance of:

• Following the costs and intricacies of technical implementation; 
• Getting local physician buy-in;
• Creating a multidisciplinary approach that includes nurses and pharmacists; and
• Putting periodic reviews in place to measure quality metrics.

“The tool is not the problem,” Dr. Gorman adds. “It’s how do you implement the tool.”

A new study questioning the efficacy of telemedicine in reducing length of stay (LOS) and improving patient care in the ICU is further proof that remote patient care only works when there is a strong support structure behind it, according to a former SHM president.

“The studies in the past have not shown that just because you have an intensivist available that you are going to get a lot of bang for the buck. You need to have a real process. … If you don’t implement something properly, you can’t expect to get results,” says Mary Jo Gorman, MD, MBA, FHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine.

Investigators at the University of Texas Health Science Center at Houston reviewed some 4,000 patients in six ICUs at five hospitals in a large U.S. healthcare system by measuring outcomes before and after implementation of a “tele-ICU” from 2003 to 2006. No statistically significant impacts were seen in mortality rates, complications, or LOS (JAMA. 2009;302[24]:2671-2678). Conversely, an accompanying editorial in the Journal of the American Medical Association argued that “tele-ICU is a potentially valuable change in ICU care, but its complexity means that ‘tele-ICU improves care’ is not a testable hypothesis.”

The use of off-site intensivists to monitor patients has been used in recent years to address the shortage of ICU physicians. Still, the study team argues that “there are few data in the peer-reviewed literature evaluating its effect on morbidity and mortality.”

Dr. Gorman suggests that HM groups looking to partner with telemedicine providers consider the importance of:

• Following the costs and intricacies of technical implementation; 
• Getting local physician buy-in;
• Creating a multidisciplinary approach that includes nurses and pharmacists; and
• Putting periodic reviews in place to measure quality metrics.

“The tool is not the problem,” Dr. Gorman adds. “It’s how do you implement the tool.”

A new study questioning the efficacy of telemedicine in reducing length of stay (LOS) and improving patient care in the ICU is further proof that remote patient care only works when there is a strong support structure behind it, according to a former SHM president.

“The studies in the past have not shown that just because you have an intensivist available that you are going to get a lot of bang for the buck. You need to have a real process. … If you don’t implement something properly, you can’t expect to get results,” says Mary Jo Gorman, MD, MBA, FHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine.

Investigators at the University of Texas Health Science Center at Houston reviewed some 4,000 patients in six ICUs at five hospitals in a large U.S. healthcare system by measuring outcomes before and after implementation of a “tele-ICU” from 2003 to 2006. No statistically significant impacts were seen in mortality rates, complications, or LOS (JAMA. 2009;302[24]:2671-2678). Conversely, an accompanying editorial in the Journal of the American Medical Association argued that “tele-ICU is a potentially valuable change in ICU care, but its complexity means that ‘tele-ICU improves care’ is not a testable hypothesis.”

The use of off-site intensivists to monitor patients has been used in recent years to address the shortage of ICU physicians. Still, the study team argues that “there are few data in the peer-reviewed literature evaluating its effect on morbidity and mortality.”

Dr. Gorman suggests that HM groups looking to partner with telemedicine providers consider the importance of:

• Following the costs and intricacies of technical implementation; 
• Getting local physician buy-in;
• Creating a multidisciplinary approach that includes nurses and pharmacists; and
• Putting periodic reviews in place to measure quality metrics.

“The tool is not the problem,” Dr. Gorman adds. “It’s how do you implement the tool.”

The public, physician, and media fascination with the H1N1 pandemic can serve as a healthy reminder this winter for hospitalists not to overlook seasonal influenza.

The attention focused on H1N1 influenza prompted the early release by the Journal of the American Medicine Association (JAMA. 2010;303[1]:doi10.1010/JAMA.2009.1911) of a study on the effectiveness of the virus’ vaccine. The attention also has prompted many hospitals to create processes for hospitalists and other staff to communicate with primary-care physicians (PCPs), community clinicians, and local health departments, according to Rick Hilger, MD, FHM, director of resident education of hospital medicine, and medical director of care management at Regions Hospital in Saint Paul, Minn. In particular, the attention on H1N1 has helped develop “open lines of communication” with infectious-disease doctors who often are the initial stop for influenza cases, Dr. Hilger says.

“When H1N1 was peaking this fall, we were getting probably biweekly e-mail updates as to what they were seeing in the community and them making recommendations,” says Dr. Hilger, who is also an assistant professor of medicine at the University of Minnesota. “I think we were spoiled in that respect. I would highly recommend that all hospitalists try to speak with … their local infectious-disease doctors to see what’s out there this winter.”

Dr. Hilger suggests hospitalists use the focus on influenza this winter to redouble efforts to vaccinate at-risk populations and work with infectious-disease specialists when patients are admitted with clinical signs of infection. He adds that hospitalists, as front-line staffers at small and community hospitals, should be used to dealing with seasonal influenza.

“I don’t think that seasonal influenza will be a sleeper problem, in general,” Dr. Hilger says. “We all have a lot of experience with it. If anything, H1N1 will increase our awareness of it because we can’t go a day without influenza activity being talked about, whether it’s within our hospitalist group or whether it’s in administration.”

The public, physician, and media fascination with the H1N1 pandemic can serve as a healthy reminder this winter for hospitalists not to overlook seasonal influenza.

The attention focused on H1N1 influenza prompted the early release by the Journal of the American Medicine Association (JAMA. 2010;303[1]:doi10.1010/JAMA.2009.1911) of a study on the effectiveness of the virus’ vaccine. The attention also has prompted many hospitals to create processes for hospitalists and other staff to communicate with primary-care physicians (PCPs), community clinicians, and local health departments, according to Rick Hilger, MD, FHM, director of resident education of hospital medicine, and medical director of care management at Regions Hospital in Saint Paul, Minn. In particular, the attention on H1N1 has helped develop “open lines of communication” with infectious-disease doctors who often are the initial stop for influenza cases, Dr. Hilger says.

“When H1N1 was peaking this fall, we were getting probably biweekly e-mail updates as to what they were seeing in the community and them making recommendations,” says Dr. Hilger, who is also an assistant professor of medicine at the University of Minnesota. “I think we were spoiled in that respect. I would highly recommend that all hospitalists try to speak with … their local infectious-disease doctors to see what’s out there this winter.”

Dr. Hilger suggests hospitalists use the focus on influenza this winter to redouble efforts to vaccinate at-risk populations and work with infectious-disease specialists when patients are admitted with clinical signs of infection. He adds that hospitalists, as front-line staffers at small and community hospitals, should be used to dealing with seasonal influenza.

“I don’t think that seasonal influenza will be a sleeper problem, in general,” Dr. Hilger says. “We all have a lot of experience with it. If anything, H1N1 will increase our awareness of it because we can’t go a day without influenza activity being talked about, whether it’s within our hospitalist group or whether it’s in administration.”

The public, physician, and media fascination with the H1N1 pandemic can serve as a healthy reminder this winter for hospitalists not to overlook seasonal influenza.

The attention focused on H1N1 influenza prompted the early release by the Journal of the American Medicine Association (JAMA. 2010;303[1]:doi10.1010/JAMA.2009.1911) of a study on the effectiveness of the virus’ vaccine. The attention also has prompted many hospitals to create processes for hospitalists and other staff to communicate with primary-care physicians (PCPs), community clinicians, and local health departments, according to Rick Hilger, MD, FHM, director of resident education of hospital medicine, and medical director of care management at Regions Hospital in Saint Paul, Minn. In particular, the attention on H1N1 has helped develop “open lines of communication” with infectious-disease doctors who often are the initial stop for influenza cases, Dr. Hilger says.

“When H1N1 was peaking this fall, we were getting probably biweekly e-mail updates as to what they were seeing in the community and them making recommendations,” says Dr. Hilger, who is also an assistant professor of medicine at the University of Minnesota. “I think we were spoiled in that respect. I would highly recommend that all hospitalists try to speak with … their local infectious-disease doctors to see what’s out there this winter.”

Dr. Hilger suggests hospitalists use the focus on influenza this winter to redouble efforts to vaccinate at-risk populations and work with infectious-disease specialists when patients are admitted with clinical signs of infection. He adds that hospitalists, as front-line staffers at small and community hospitals, should be used to dealing with seasonal influenza.

“I don’t think that seasonal influenza will be a sleeper problem, in general,” Dr. Hilger says. “We all have a lot of experience with it. If anything, H1N1 will increase our awareness of it because we can’t go a day without influenza activity being talked about, whether it’s within our hospitalist group or whether it’s in administration.”

The latest wave of data confirming that end-of-life care is an outsized driver of healthcare costs comes with one caveat from the chair of SHM’s research committee.

“It’s not always obvious you’re providing end-of-life care when you’re providing it,” says David Meltzer, MD, PhD, FHM, FACP, chief of the section of hospital medicine and associate professor in the Department of Medicine and the Graduate School of Public Policy Studies at the University of Chicago. “You have to be really careful not to conflate age and proximity to death.”

Dr. Meltzer was one of the lead investigators who helped develop the university’s Curriculum for the Hospitalized Aging Medical Patient (CHAMP) and has studied the costs of healthcare delivery to the elderly. He cautions hospitalists against couching cost calculations in terms of the age of their patient census—and reviewing instead what would improve a patient’s quality of life.

“There are times when it’s appropriate to discuss the goals of care,” Dr. Meltzer says. “I doubt the answer to that question is defined by age.”

Accordingly, a statistical brief released last month by the federal Agency of Healthcare Research and Quality (AHRQ) focused on cost drivers, not age. The data show the inpatient death rate in 2007 was 1.9%. “However, these hospital stays ending in death were responsible for 5.2% ($20 billion) of all hospital inpatient costs,” the brief concluded. In what is probably no surprise to hospitalists, much of that cost is traced to length of stay, which averaged 8.8 days for patients who died and 4.5 days for those who lived. The data is for 2007, the latest year available.

To counter rising costs, Dr. Meltzer recommends:  

• Review a patient’s condition holistically, looking past age;

 

• Have an upfront discussion with the patient about what their expectations of care are. Avoid excess care that is not in line with the patient’s wishes; and

 

• Talk with hospital administration to ensure that your HM group has a say in care decisions, effectively giving hospitalists an opportunity to act as a change agent.

“It’s not so much measuring against cost; it’s measuring against the patient’s preferences,” Dr. Meltzer says. “Ultimately, the physician is the patient’s agent.”

The latest wave of data confirming that end-of-life care is an outsized driver of healthcare costs comes with one caveat from the chair of SHM’s research committee.

“It’s not always obvious you’re providing end-of-life care when you’re providing it,” says David Meltzer, MD, PhD, FHM, FACP, chief of the section of hospital medicine and associate professor in the Department of Medicine and the Graduate School of Public Policy Studies at the University of Chicago. “You have to be really careful not to conflate age and proximity to death.”

Dr. Meltzer was one of the lead investigators who helped develop the university’s Curriculum for the Hospitalized Aging Medical Patient (CHAMP) and has studied the costs of healthcare delivery to the elderly. He cautions hospitalists against couching cost calculations in terms of the age of their patient census—and reviewing instead what would improve a patient’s quality of life.

“There are times when it’s appropriate to discuss the goals of care,” Dr. Meltzer says. “I doubt the answer to that question is defined by age.”

Accordingly, a statistical brief released last month by the federal Agency of Healthcare Research and Quality (AHRQ) focused on cost drivers, not age. The data show the inpatient death rate in 2007 was 1.9%. “However, these hospital stays ending in death were responsible for 5.2% ($20 billion) of all hospital inpatient costs,” the brief concluded. In what is probably no surprise to hospitalists, much of that cost is traced to length of stay, which averaged 8.8 days for patients who died and 4.5 days for those who lived. The data is for 2007, the latest year available.

To counter rising costs, Dr. Meltzer recommends:  

• Review a patient’s condition holistically, looking past age;

 

• Have an upfront discussion with the patient about what their expectations of care are. Avoid excess care that is not in line with the patient’s wishes; and

 

• Talk with hospital administration to ensure that your HM group has a say in care decisions, effectively giving hospitalists an opportunity to act as a change agent.

“It’s not so much measuring against cost; it’s measuring against the patient’s preferences,” Dr. Meltzer says. “Ultimately, the physician is the patient’s agent.”

The latest wave of data confirming that end-of-life care is an outsized driver of healthcare costs comes with one caveat from the chair of SHM’s research committee.

“It’s not always obvious you’re providing end-of-life care when you’re providing it,” says David Meltzer, MD, PhD, FHM, FACP, chief of the section of hospital medicine and associate professor in the Department of Medicine and the Graduate School of Public Policy Studies at the University of Chicago. “You have to be really careful not to conflate age and proximity to death.”

Dr. Meltzer was one of the lead investigators who helped develop the university’s Curriculum for the Hospitalized Aging Medical Patient (CHAMP) and has studied the costs of healthcare delivery to the elderly. He cautions hospitalists against couching cost calculations in terms of the age of their patient census—and reviewing instead what would improve a patient’s quality of life.

“There are times when it’s appropriate to discuss the goals of care,” Dr. Meltzer says. “I doubt the answer to that question is defined by age.”

Accordingly, a statistical brief released last month by the federal Agency of Healthcare Research and Quality (AHRQ) focused on cost drivers, not age. The data show the inpatient death rate in 2007 was 1.9%. “However, these hospital stays ending in death were responsible for 5.2% ($20 billion) of all hospital inpatient costs,” the brief concluded. In what is probably no surprise to hospitalists, much of that cost is traced to length of stay, which averaged 8.8 days for patients who died and 4.5 days for those who lived. The data is for 2007, the latest year available.

To counter rising costs, Dr. Meltzer recommends:  

• Review a patient’s condition holistically, looking past age;

 

• Have an upfront discussion with the patient about what their expectations of care are. Avoid excess care that is not in line with the patient’s wishes; and

 

• Talk with hospital administration to ensure that your HM group has a say in care decisions, effectively giving hospitalists an opportunity to act as a change agent.

“It’s not so much measuring against cost; it’s measuring against the patient’s preferences,” Dr. Meltzer says. “Ultimately, the physician is the patient’s agent.”

Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is getting, well, a pretty big boost in 2010.

The pilot transitional-care program implemented at 30 sites in the past 18 months pairs SHM mentors with hospitalists to improve care via a discharge planning toolkit. Preliminary plans call for up to 45 additional sites staggered over three cohorts in the next 12 months.

Tina Budnitz, MPH, SHM senior advisor and director of Project BOOST, says the initiative also is working to create a tuition-based model, planning an educational Web-based seminar and standardized “teachback” materials. The BOOST team also is promoting an Internet listserv that hospitalists at the debut sites have used as a communal communication tool.

“It is a big jump,” Budnitz acknowledges. “We think the secret sauce that’s made it work so far will be able to scale.”

Quantifiable data from the first six sites, which were selected for the program in the summer of 2008, could be released this spring. A lack of metrics, however, has done little to stymie the initiative’s growth. Two sites—Hospital of the University of Pennsylvania in Philadelphia and St. Mary’s Health Center in St. Louis, Mo.—already have won safety awards related to the program.

One of the program’s mentors says the early success can be tied to hospitalists’ commitment to using the toolkit as the basis of a transitional-care upgrade, instead of expecting the program’s presence alone to improve care.

“It’s way more than what is BOOST and ‘how are we going to implement?’ ” says Janet Nagamine, MD, FHM, hospitalist at Kaiser Permanente in Santa Clara, Calif., SHM board member, and chair of SHM’s Hospital Quality and Patient Safety Committee. “They have really looked at their entire discharge process and done a lot of looking at their individual and specific challenges and how to overcome them.”

Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is getting, well, a pretty big boost in 2010.

The pilot transitional-care program implemented at 30 sites in the past 18 months pairs SHM mentors with hospitalists to improve care via a discharge planning toolkit. Preliminary plans call for up to 45 additional sites staggered over three cohorts in the next 12 months.

Tina Budnitz, MPH, SHM senior advisor and director of Project BOOST, says the initiative also is working to create a tuition-based model, planning an educational Web-based seminar and standardized “teachback” materials. The BOOST team also is promoting an Internet listserv that hospitalists at the debut sites have used as a communal communication tool.

“It is a big jump,” Budnitz acknowledges. “We think the secret sauce that’s made it work so far will be able to scale.”

Quantifiable data from the first six sites, which were selected for the program in the summer of 2008, could be released this spring. A lack of metrics, however, has done little to stymie the initiative’s growth. Two sites—Hospital of the University of Pennsylvania in Philadelphia and St. Mary’s Health Center in St. Louis, Mo.—already have won safety awards related to the program.

One of the program’s mentors says the early success can be tied to hospitalists’ commitment to using the toolkit as the basis of a transitional-care upgrade, instead of expecting the program’s presence alone to improve care.

“It’s way more than what is BOOST and ‘how are we going to implement?’ ” says Janet Nagamine, MD, FHM, hospitalist at Kaiser Permanente in Santa Clara, Calif., SHM board member, and chair of SHM’s Hospital Quality and Patient Safety Committee. “They have really looked at their entire discharge process and done a lot of looking at their individual and specific challenges and how to overcome them.”

Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is getting, well, a pretty big boost in 2010.

The pilot transitional-care program implemented at 30 sites in the past 18 months pairs SHM mentors with hospitalists to improve care via a discharge planning toolkit. Preliminary plans call for up to 45 additional sites staggered over three cohorts in the next 12 months.

Tina Budnitz, MPH, SHM senior advisor and director of Project BOOST, says the initiative also is working to create a tuition-based model, planning an educational Web-based seminar and standardized “teachback” materials. The BOOST team also is promoting an Internet listserv that hospitalists at the debut sites have used as a communal communication tool.

“It is a big jump,” Budnitz acknowledges. “We think the secret sauce that’s made it work so far will be able to scale.”

Quantifiable data from the first six sites, which were selected for the program in the summer of 2008, could be released this spring. A lack of metrics, however, has done little to stymie the initiative’s growth. Two sites—Hospital of the University of Pennsylvania in Philadelphia and St. Mary’s Health Center in St. Louis, Mo.—already have won safety awards related to the program.

One of the program’s mentors says the early success can be tied to hospitalists’ commitment to using the toolkit as the basis of a transitional-care upgrade, instead of expecting the program’s presence alone to improve care.

“It’s way more than what is BOOST and ‘how are we going to implement?’ ” says Janet Nagamine, MD, FHM, hospitalist at Kaiser Permanente in Santa Clara, Calif., SHM board member, and chair of SHM’s Hospital Quality and Patient Safety Committee. “They have really looked at their entire discharge process and done a lot of looking at their individual and specific challenges and how to overcome them.”

Many of the medical journals read most by hospitalists, including the New England Journal of Medicine and the Journal of the American Medical Association, are adopting a new set of guidelines for the disclosure of potential conflicts of interest, a move the journals and researchers say is a step toward further transparency of authors' competing loyalties.

"From the perspective of an investigator and an end-user of the scientific literature, this is a positive development," says Andrew Masica, MD, MSCI, FHM, director of clinical effectiveness at Baylor Health Care System in Waco, Texas. "In many cases, a work's biggest impact is at the time of its initial release. It is important to provide full information on potential conflicts of interest at this early stage, rather than having something disclosed further down the road."

The new reporting guidelines were introduced in the fall by the International Committee of Medical Journal Editors and are being phased in at member journals. Authors will be asked to disclose four types of information, according to an NEJM editorial:¹

• Financial associations tied to the study they worked on; 
  

   

• Financial ties that could have an "interest in the general area of the submitted manuscript;" 
  

   

• Similar financial associations involving spouses and children under 18 years of age; and
  

   

• Relevant nonfinancial associations.

 

The new rules "align well with the overall trend towards transparency in healthcare," says Dr. Masica, who published this year in the Journal of Hospital Medicine. "Safety and quality data at both the hospital and practitioner level are increasingly available to the public; consistency with disclosure helps move research toward that same standard."

To that end, JHM is updating its peer-review submission Web site to incorporate the new changes and expects to make an announcement on its progress in April. "Transparency is good for healthcare delivery and establishing trust with our primary focus—the care of hospitalized patients," says Mark V. Williams, MD, FACP, FHM, JHM editor-in-chief.

Download the new ICMJE disclosure form and view completed samples.

Reference

1. Glickman SW, McHutchison JG, Peterson ED, et al. Ethical and scientific implications of the globalization of clinical research. N Engl J Med. 2009;360(8):816-823.

Many of the medical journals read most by hospitalists, including the New England Journal of Medicine and the Journal of the American Medical Association, are adopting a new set of guidelines for the disclosure of potential conflicts of interest, a move the journals and researchers say is a step toward further transparency of authors' competing loyalties.

"From the perspective of an investigator and an end-user of the scientific literature, this is a positive development," says Andrew Masica, MD, MSCI, FHM, director of clinical effectiveness at Baylor Health Care System in Waco, Texas. "In many cases, a work's biggest impact is at the time of its initial release. It is important to provide full information on potential conflicts of interest at this early stage, rather than having something disclosed further down the road."

The new reporting guidelines were introduced in the fall by the International Committee of Medical Journal Editors and are being phased in at member journals. Authors will be asked to disclose four types of information, according to an NEJM editorial:¹

• Financial associations tied to the study they worked on; 
  

   

• Financial ties that could have an "interest in the general area of the submitted manuscript;" 
  

   

• Similar financial associations involving spouses and children under 18 years of age; and
  

   

• Relevant nonfinancial associations.

 

The new rules "align well with the overall trend towards transparency in healthcare," says Dr. Masica, who published this year in the Journal of Hospital Medicine. "Safety and quality data at both the hospital and practitioner level are increasingly available to the public; consistency with disclosure helps move research toward that same standard."

To that end, JHM is updating its peer-review submission Web site to incorporate the new changes and expects to make an announcement on its progress in April. "Transparency is good for healthcare delivery and establishing trust with our primary focus—the care of hospitalized patients," says Mark V. Williams, MD, FACP, FHM, JHM editor-in-chief.

Download the new ICMJE disclosure form and view completed samples.

Reference

1. Glickman SW, McHutchison JG, Peterson ED, et al. Ethical and scientific implications of the globalization of clinical research. N Engl J Med. 2009;360(8):816-823.

Many of the medical journals read most by hospitalists, including the New England Journal of Medicine and the Journal of the American Medical Association, are adopting a new set of guidelines for the disclosure of potential conflicts of interest, a move the journals and researchers say is a step toward further transparency of authors' competing loyalties.

"From the perspective of an investigator and an end-user of the scientific literature, this is a positive development," says Andrew Masica, MD, MSCI, FHM, director of clinical effectiveness at Baylor Health Care System in Waco, Texas. "In many cases, a work's biggest impact is at the time of its initial release. It is important to provide full information on potential conflicts of interest at this early stage, rather than having something disclosed further down the road."

The new reporting guidelines were introduced in the fall by the International Committee of Medical Journal Editors and are being phased in at member journals. Authors will be asked to disclose four types of information, according to an NEJM editorial:¹

• Financial associations tied to the study they worked on; 
  

   

• Financial ties that could have an "interest in the general area of the submitted manuscript;" 
  

   

• Similar financial associations involving spouses and children under 18 years of age; and
  

   

• Relevant nonfinancial associations.

 

The new rules "align well with the overall trend towards transparency in healthcare," says Dr. Masica, who published this year in the Journal of Hospital Medicine. "Safety and quality data at both the hospital and practitioner level are increasingly available to the public; consistency with disclosure helps move research toward that same standard."

To that end, JHM is updating its peer-review submission Web site to incorporate the new changes and expects to make an announcement on its progress in April. "Transparency is good for healthcare delivery and establishing trust with our primary focus—the care of hospitalized patients," says Mark V. Williams, MD, FACP, FHM, JHM editor-in-chief.

Download the new ICMJE disclosure form and view completed samples.

Reference

1. Glickman SW, McHutchison JG, Peterson ED, et al. Ethical and scientific implications of the globalization of clinical research. N Engl J Med. 2009;360(8):816-823.