Editorial

It had been a turbulent year. Death and disease in the family had taken a toll on my personal life. Though I was a newlywed, life was anything but bliss. That month I was the resident in the cardiac intensive care unit (CICU); a challenging rotation, where sleep was a luxury and the long nights on call added to the strain on my relationship with my wife. It was on one of those nights that I met Mr. and Mrs. Dubinski.

Mr. Dubinski was a pleasant man who looked younger than his 75 years. He had been brought to the hospital because his implantable cardioverter defibrillator (ICD) had fired twice that night. He was in good spirits and chatting amiably with his son. I asked him how he was doing. His pleasant expression changed to a worried one. I have been rather upset for the last few days, worried about my wife, he said.

It turned out that over the last few days Mrs. Dubinski had not been feeling well. This had troubled Mr. Dubinski, and he was often preoccupied with concerns about her. The couple had been married 55 years and had never spent a day apart. They had waited to seek medical advice. Her pain was intermittent, and they thought it would pass; they had some appointments coming up, and they thought they could wait it out. That night, Mrs. Dubinski had a particularly severe episode of pain that bothered her greatly and worried Mr. Dubinski even more. He said that he felt as though he was beginning to pass out, and as he began to faint, he felt a funny feeling in his chest. He had never had a shock from the ICD before, and he didn't know what happened. He sat down to compose himself and felt the same funny feeling in his chest again and also felt lightheaded. He described it, saying, I felt like I was going to explode from the inside. Concerned about his unusual symptoms and her worsening pain, Mr. and Mrs. Dubinski decided to come to the hospital.

Mr. Dubinski's electrocardiogram revealed many premature ventricular complexes (PVCs), and I suspected that one of these had triggered a malignant arrhythmia, which resulted in the device firing. He would need monitoring, and his ICD would be interrogated in the morning to ensure that it was functioning properly. I reassured Mr. Dubinski that the device seemed to have done what it was meant to do. It had almost certainly saved his life. He was relieved to hear this but wanted me to reassure his wife that even though he was going to the CICU, he was all right and it was nothing serious.

As I was wheeling Mr. Dubinski up, I walked past the nurse taking care of his wife. She pulled me aside for a moment and said, Looks like you'll be taking her, too; her troponin just came back at 5.96.

Mrs. Dubinski was a thin, older woman who looked uncomfortable. For about a week, she had been experiencing intermittent pain in her chest and abdomen and just felt that something was not right. Tonight her chest pain did not get better spontaneously, and she had a particularly long episode of pain that radiated to her left arm. She said she felt like she was going to explode from the inside. It was uncanny how she used the same words and expressions that her husband did. I suppose after 55 years of marriage, it should not have been surprising to me, but it was. When they had gotten to the emergency room Mrs. Dubinski had told the doctor about her own complaints. He ordered an electrocardiogram, which showed subtle changes consistent with myocardial ischemia. Her lab data confirmed that she was having a heart attack.

Mrs. Dubinski asked me what was going on. I gently explained to her that she was having a small heart attack. The stuttering episodes of chest pain in the past week probably meant that it had been coming on for a few days now. We could see some evidence of heart damage in her blood tests and the subtle changes in her electrocardiogram. I expected her to ask me more questions about the heart attack or what we were going to next. Instead, she said, Please don't tell my husband. It will only worry him more. I reassured her that I understood her concerns and told her that she was also going to be admitted to the CICU. She was fine with this, more worried about her husband than herself. Once in the CICU I kept my word to Mrs. Dubinski and told Mr. Dubinski a partial truththat his wife was being admitted for observation because we were worried about her.

I was genuinely touched by the deep bond between Mr. and Mrs. Dubinski. It amazed me to see that a man's heart could be stimulated by his wife's suffering in such a way that would have taken his life if not for his ICD. One could say that Mr. Dubinski was anxious about his wife's health, which led to an increased sympathetic drive and higher catecholamine levels. But as a young man at the beginning of a relationship with my wife, I thought there was much more here. Tonight, perhaps, because he cared so deeply, a PVC occurred right during the vulnerable period of the cardiac cycle in a person with a vulnerable heart, and a potentially lethal ventricular arrhythmia had ensued. And tonight my heart was also vulnerable, and I was moved. I thought of all the storms they must have weathered in their 55 years together and the love they had forged. It gave me hope for my own fledgling marriage and made me hope that one day my wife and I would be able to look back on many years of life together like Mr. and Mrs. Dubinski could, with 2 hearts beating as 1.

I had the privilege to know this couple for only 1 call night. By the time I was back on the CICU, Mrs. Dubinski had been transferred to another facility for angioplasty, and Mr. Dubinski had been discharged. Yet that was enough time for me to take part in the care of 2 amazing people and to witness the majesty of their love.

Note: Dubinski is a fictitious name.

It had been a turbulent year. Death and disease in the family had taken a toll on my personal life. Though I was a newlywed, life was anything but bliss. That month I was the resident in the cardiac intensive care unit (CICU); a challenging rotation, where sleep was a luxury and the long nights on call added to the strain on my relationship with my wife. It was on one of those nights that I met Mr. and Mrs. Dubinski.

Mr. Dubinski was a pleasant man who looked younger than his 75 years. He had been brought to the hospital because his implantable cardioverter defibrillator (ICD) had fired twice that night. He was in good spirits and chatting amiably with his son. I asked him how he was doing. His pleasant expression changed to a worried one. I have been rather upset for the last few days, worried about my wife, he said.

It turned out that over the last few days Mrs. Dubinski had not been feeling well. This had troubled Mr. Dubinski, and he was often preoccupied with concerns about her. The couple had been married 55 years and had never spent a day apart. They had waited to seek medical advice. Her pain was intermittent, and they thought it would pass; they had some appointments coming up, and they thought they could wait it out. That night, Mrs. Dubinski had a particularly severe episode of pain that bothered her greatly and worried Mr. Dubinski even more. He said that he felt as though he was beginning to pass out, and as he began to faint, he felt a funny feeling in his chest. He had never had a shock from the ICD before, and he didn't know what happened. He sat down to compose himself and felt the same funny feeling in his chest again and also felt lightheaded. He described it, saying, I felt like I was going to explode from the inside. Concerned about his unusual symptoms and her worsening pain, Mr. and Mrs. Dubinski decided to come to the hospital.

Mr. Dubinski's electrocardiogram revealed many premature ventricular complexes (PVCs), and I suspected that one of these had triggered a malignant arrhythmia, which resulted in the device firing. He would need monitoring, and his ICD would be interrogated in the morning to ensure that it was functioning properly. I reassured Mr. Dubinski that the device seemed to have done what it was meant to do. It had almost certainly saved his life. He was relieved to hear this but wanted me to reassure his wife that even though he was going to the CICU, he was all right and it was nothing serious.

As I was wheeling Mr. Dubinski up, I walked past the nurse taking care of his wife. She pulled me aside for a moment and said, Looks like you'll be taking her, too; her troponin just came back at 5.96.

Mrs. Dubinski was a thin, older woman who looked uncomfortable. For about a week, she had been experiencing intermittent pain in her chest and abdomen and just felt that something was not right. Tonight her chest pain did not get better spontaneously, and she had a particularly long episode of pain that radiated to her left arm. She said she felt like she was going to explode from the inside. It was uncanny how she used the same words and expressions that her husband did. I suppose after 55 years of marriage, it should not have been surprising to me, but it was. When they had gotten to the emergency room Mrs. Dubinski had told the doctor about her own complaints. He ordered an electrocardiogram, which showed subtle changes consistent with myocardial ischemia. Her lab data confirmed that she was having a heart attack.

Mrs. Dubinski asked me what was going on. I gently explained to her that she was having a small heart attack. The stuttering episodes of chest pain in the past week probably meant that it had been coming on for a few days now. We could see some evidence of heart damage in her blood tests and the subtle changes in her electrocardiogram. I expected her to ask me more questions about the heart attack or what we were going to next. Instead, she said, Please don't tell my husband. It will only worry him more. I reassured her that I understood her concerns and told her that she was also going to be admitted to the CICU. She was fine with this, more worried about her husband than herself. Once in the CICU I kept my word to Mrs. Dubinski and told Mr. Dubinski a partial truththat his wife was being admitted for observation because we were worried about her.

I was genuinely touched by the deep bond between Mr. and Mrs. Dubinski. It amazed me to see that a man's heart could be stimulated by his wife's suffering in such a way that would have taken his life if not for his ICD. One could say that Mr. Dubinski was anxious about his wife's health, which led to an increased sympathetic drive and higher catecholamine levels. But as a young man at the beginning of a relationship with my wife, I thought there was much more here. Tonight, perhaps, because he cared so deeply, a PVC occurred right during the vulnerable period of the cardiac cycle in a person with a vulnerable heart, and a potentially lethal ventricular arrhythmia had ensued. And tonight my heart was also vulnerable, and I was moved. I thought of all the storms they must have weathered in their 55 years together and the love they had forged. It gave me hope for my own fledgling marriage and made me hope that one day my wife and I would be able to look back on many years of life together like Mr. and Mrs. Dubinski could, with 2 hearts beating as 1.

I had the privilege to know this couple for only 1 call night. By the time I was back on the CICU, Mrs. Dubinski had been transferred to another facility for angioplasty, and Mr. Dubinski had been discharged. Yet that was enough time for me to take part in the care of 2 amazing people and to witness the majesty of their love.

Note: Dubinski is a fictitious name.

It had been a turbulent year. Death and disease in the family had taken a toll on my personal life. Though I was a newlywed, life was anything but bliss. That month I was the resident in the cardiac intensive care unit (CICU); a challenging rotation, where sleep was a luxury and the long nights on call added to the strain on my relationship with my wife. It was on one of those nights that I met Mr. and Mrs. Dubinski.

Mr. Dubinski was a pleasant man who looked younger than his 75 years. He had been brought to the hospital because his implantable cardioverter defibrillator (ICD) had fired twice that night. He was in good spirits and chatting amiably with his son. I asked him how he was doing. His pleasant expression changed to a worried one. I have been rather upset for the last few days, worried about my wife, he said.

It turned out that over the last few days Mrs. Dubinski had not been feeling well. This had troubled Mr. Dubinski, and he was often preoccupied with concerns about her. The couple had been married 55 years and had never spent a day apart. They had waited to seek medical advice. Her pain was intermittent, and they thought it would pass; they had some appointments coming up, and they thought they could wait it out. That night, Mrs. Dubinski had a particularly severe episode of pain that bothered her greatly and worried Mr. Dubinski even more. He said that he felt as though he was beginning to pass out, and as he began to faint, he felt a funny feeling in his chest. He had never had a shock from the ICD before, and he didn't know what happened. He sat down to compose himself and felt the same funny feeling in his chest again and also felt lightheaded. He described it, saying, I felt like I was going to explode from the inside. Concerned about his unusual symptoms and her worsening pain, Mr. and Mrs. Dubinski decided to come to the hospital.

Mr. Dubinski's electrocardiogram revealed many premature ventricular complexes (PVCs), and I suspected that one of these had triggered a malignant arrhythmia, which resulted in the device firing. He would need monitoring, and his ICD would be interrogated in the morning to ensure that it was functioning properly. I reassured Mr. Dubinski that the device seemed to have done what it was meant to do. It had almost certainly saved his life. He was relieved to hear this but wanted me to reassure his wife that even though he was going to the CICU, he was all right and it was nothing serious.

As I was wheeling Mr. Dubinski up, I walked past the nurse taking care of his wife. She pulled me aside for a moment and said, Looks like you'll be taking her, too; her troponin just came back at 5.96.

Mrs. Dubinski was a thin, older woman who looked uncomfortable. For about a week, she had been experiencing intermittent pain in her chest and abdomen and just felt that something was not right. Tonight her chest pain did not get better spontaneously, and she had a particularly long episode of pain that radiated to her left arm. She said she felt like she was going to explode from the inside. It was uncanny how she used the same words and expressions that her husband did. I suppose after 55 years of marriage, it should not have been surprising to me, but it was. When they had gotten to the emergency room Mrs. Dubinski had told the doctor about her own complaints. He ordered an electrocardiogram, which showed subtle changes consistent with myocardial ischemia. Her lab data confirmed that she was having a heart attack.

Mrs. Dubinski asked me what was going on. I gently explained to her that she was having a small heart attack. The stuttering episodes of chest pain in the past week probably meant that it had been coming on for a few days now. We could see some evidence of heart damage in her blood tests and the subtle changes in her electrocardiogram. I expected her to ask me more questions about the heart attack or what we were going to next. Instead, she said, Please don't tell my husband. It will only worry him more. I reassured her that I understood her concerns and told her that she was also going to be admitted to the CICU. She was fine with this, more worried about her husband than herself. Once in the CICU I kept my word to Mrs. Dubinski and told Mr. Dubinski a partial truththat his wife was being admitted for observation because we were worried about her.

I was genuinely touched by the deep bond between Mr. and Mrs. Dubinski. It amazed me to see that a man's heart could be stimulated by his wife's suffering in such a way that would have taken his life if not for his ICD. One could say that Mr. Dubinski was anxious about his wife's health, which led to an increased sympathetic drive and higher catecholamine levels. But as a young man at the beginning of a relationship with my wife, I thought there was much more here. Tonight, perhaps, because he cared so deeply, a PVC occurred right during the vulnerable period of the cardiac cycle in a person with a vulnerable heart, and a potentially lethal ventricular arrhythmia had ensued. And tonight my heart was also vulnerable, and I was moved. I thought of all the storms they must have weathered in their 55 years together and the love they had forged. It gave me hope for my own fledgling marriage and made me hope that one day my wife and I would be able to look back on many years of life together like Mr. and Mrs. Dubinski could, with 2 hearts beating as 1.

I had the privilege to know this couple for only 1 call night. By the time I was back on the CICU, Mrs. Dubinski had been transferred to another facility for angioplasty, and Mr. Dubinski had been discharged. Yet that was enough time for me to take part in the care of 2 amazing people and to witness the majesty of their love.

Note: Dubinski is a fictitious name.

Medications are central to managing the health of older patients. In 2006, more than 93% of adults 65 years or older reported taking at least 1 medication in the last week, 58% reported taking 5 or more medications, and 18% reported taking 10 or more.1 Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered.2

Older patients, especially those who are chronically frail or acutely ill, may require special consideration when making prescribing decisions because of age‐related changes in the metabolism and clearance of medications and enhanced pharmacodynamic sensitivities.3 Thus, panels of experts in pharmacology and geriatrics have compiled lists of medications to avoid prescribing for patients 65 years of age or older. The most commonly used list is the Beers criteria, which were introduced in 1991 to serve researchers evaluating prescribing quality in nursing homes. The Beers criteria were updated in 1997 and again in 2003 to include 48 potentially inappropriate medications (PIMs) for which, according to the consensus panel, there are more effective or safer alternatives for older patients.4

Numerous studies in the last 15 years have found that PIMs continue to be used in 12% to 40% of older patients in community and nursing home settings.5 To address the continued use of PIMs, the Centers for Medicare and Medicaid Services incorporated the Beers criteria into federal safety regulations for long‐term care facilities in 1999.6 In 2006, the prescription rate of PIMs was introduced as a Health Plan and Employer Data and Information Set (HEDIS) quality measure for managed care plans.7 Despite adoption of the Beers criteria to monitor prescribing quality and safety in nursing homes and outpatient settings, there has been considerably less study of potentially inappropriate medication use in hospitalized patients.

In this issue of the Journal of Hospital Medicine, Rothberg and colleagues analyzed administrative data from nearly 400 hospitals across the United States and found that nearly half of all older patients hospitalized for 7 common conditions were prescribed at least 1 PIM.8 Thus, the incidence of PIM use in hospitalized older patients far exceeded that reported in most studies of community‐dwelling or nursing home patients. Most notable, however, was the variability found in prescribing rates based on a number of physician and hospital characteristics. For example, although hospitalists and geriatricians were found to be less likely to prescribe PIMs than cardiologists and general internists, among high‐volume cardiologists and internists, PIM prescribing rates ranged widely, from 0% to more than 90%. Similarly, hospitalwide prescribing rates varied by geographic region, and there were 7 hospitals in which not a single PIM was reportedly prescribed.

These findings raise three questions and bring to mind parallels with efforts to control inappropriate antimicrobial use. First question: Can inpatient use of PIMs truly be higher than outpatient use? Yes. The finding that more hospitalized patients are prescribed PIMs than ambulatory patients has face validity for several reasons. First, patients admitted for an acute hospitalization may have more comorbid diseases and take more medications than community‐dwelling older adults. Second, new medications are typically added to treat acutely ill patients on hospitalization. Third, previous studies estimating outpatient PIM use have typically used more narrowly defined lists of PIMs and have not captured over‐the‐counter use of PIMs, particularly antihistamines.9 Diphenhydramine alone accounted for 9% of PIM use in Rothberg's study. Finally, as Rothberg and colleagues point out, this study was limited to certain diagnoses such as acute myocardial infarction that may have protocol‐driven prescribing, which includes PIMs, that may be used only a single time such as promethazine.

Second question: Can PIM prescribing truly be so variable across regions, specialties, and individual hospitals and physicians? Yes. Using multivariable modeling, Rothberg and colleagues controlled for many patient, hospital, and physician characteristics and still found significant variation. John Wennberg and others have documented similar variations for a host of medical treatments; but although variation is interesting, it is unwarranted variation that matters for improving health care quality.10 It is not clear how much of the variation in prescribing rates of PIMs is unwarranted.

Some degree of variation in PIM prescribing rates is certainly acceptable. As the creators of the Beers criteria acknowledge, these medications are deemed only potentially inappropriate, and individual treatment decisions should be tailored to individual patients. However, others have taken the term potentially inappropriate one step further by recategorizing Beers medications as always avoid medications, rarely acceptable medications, and medications that indeed have some indications for use in older adults.8

Variation in prescribing practice may also be acceptable when there is not a clear consensus on the superiority of one practice over another. Indeed, the evidence that PIM prescribing causes large numbers of clinically significant adverse drug events and patient harm is weak and largely based on observational studies with inconsistent results. Although some studies demonstrated an epidemiological association between Beers criteria medications and general adverse outcomes (eg, hospitalizations),11 other studies did not.12 A recent systematic review concluded that Beers criteria medications were associated with some adverse health effects, but the studies analyzed were too heterogeneous to support formal meta‐analysis.13 Thus, variability in prescribing rates of Beers medications may simply reflect individual clinical judgment in the absence of conclusive outcomes data.

Third question: Can hospitalists use the findings of Rothberg and colleagues to improve the quality of medication prescribing for older adults in their institutions? Maybe. But hospitalists wishing to reduce PIM use in their institutions should draw lessons from other efforts to modify physician‐prescribing practice such as efforts to reduce inappropriate antimicrobial use. Although national data draw attention to the high frequency of potentially inappropriate medication use in hospitalized patients, the large variation in use across hospitals confirms the need for monitoring in individual facilities. For example, the National Healthcare Safety Network provides national benchmarks of antimicrobial use and resistance, but individual hospitals monitor antibiotic use and resistance in their own institutions to tailor local efforts to improve antimicrobial prescribing.14

Also, initiating a quality improvement effort targeting all 48 Beers criteria medications may be an inefficient use of resources. Using such a composite measure obscures the contribution of the component medications, each of which possesses unique and sometimes controversial profiles of efficacy and harm for older patients. Instead, a targeted intervention addressing the most commonly prescribed Beers medications that have widely accepted alternatives could be more practical. For instance, many antibiotic management programs focus on replacing a popular, extended‐spectrum antimicrobial with a narrow‐spectrum agent as soon as microbiological susceptibly results are available.

Propoxephene is a PIM that may be an attractive target for intervention. Propoxephene was the third most commonly prescribed PIM identified by Rothberg and colleagues, but meta‐analyses of controlled trials have concluded that propoxephene provides inferior analgesia for acute pain compared with that provided by other opioids with similar side effects, and has more adverse effects than nonopioid analgesics.15 Indeed, Rothberg found that just 3 of 48 PIMs (promethazine, diphenhydramine, and propoxyphene), each of which has viable alternative agents, accounted for approximately a quarter of all potentially inappropriate prescribing.

However, not all of the 48 Beers medications have alternatives with strong evidence of superiority. The Beers list includes medications (eg, amiodarone) that may not have equivalent alternative agents. On the other hand, some Beers medications have largely been supplanted (eg, ticlopidine or tripelennamine), and identifying these medications may be an inefficient use of scarce patient safety resources. As with antimicrobial stewardship programs, local surveillance of PIM use should be combined with local consensus on appropriate alternatives to target PIM interventions.

Of course, once specific PIM use is targeted for improvement, a specific intervention must be implemented. Only a handful of studies have examined the effectiveness of interventions (eg, computerized pharmacy alerts) to reduce PIM use, and most of these have focused on the outpatient setting rather than hospitalized patients.3 One study that included hospitalized patients utilized a team approach (geriatricians, nurses, social workers, and pharmacists) and demonstrated a reduction in potentially inappropriate medication use but no reduction in adverse drug reactions during hospitalization.16 In light of the scarcity of controlled intervention trials to reduce PIM use, initiatives to reduce inappropriate antimicrobial prescribing may provide useful insights into the strengths and limitations of approaches such as clinician education, formulary restrictions, pharmacist review, and computer‐based monitoring.17

Finally, any intervention to reduce PIM use should have reasonable expectations. The Beers criteria were developed to improve the effectiveness of medication therapy for older adults as well as to prevent harm, but it is unlikely that reducing PIM use in hospitalized patients will result in improvements that could be measured easily during an initial hospitalization. If preventing drug‐induced harm during the hospitalization of older patients is the primary concern, a shift in focus is required. Safety efforts should be concentrated on identifying and mitigating the most common and severe adverse drug events, rather than focusing efforts on reducing the use of PIMs. National data demonstrate that a handful of drugsinsulin, warfarin, and digoxinmost commonly cause severe adverse events in older outpatients.18 Optimizing the management of these medications may be another approach for improving drug safety in hospitalized patients. Regardless of the focus of a drug safety intervention, the experience of infection control and hospital epidemiology programs suggests that success will require dedicated professionals and the commitment of resources to examine patterns of local use, implement interventions, and monitor outcomes.

Medications are central to managing the health of older patients. In 2006, more than 93% of adults 65 years or older reported taking at least 1 medication in the last week, 58% reported taking 5 or more medications, and 18% reported taking 10 or more.1 Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered.2

Older patients, especially those who are chronically frail or acutely ill, may require special consideration when making prescribing decisions because of age‐related changes in the metabolism and clearance of medications and enhanced pharmacodynamic sensitivities.3 Thus, panels of experts in pharmacology and geriatrics have compiled lists of medications to avoid prescribing for patients 65 years of age or older. The most commonly used list is the Beers criteria, which were introduced in 1991 to serve researchers evaluating prescribing quality in nursing homes. The Beers criteria were updated in 1997 and again in 2003 to include 48 potentially inappropriate medications (PIMs) for which, according to the consensus panel, there are more effective or safer alternatives for older patients.4

Numerous studies in the last 15 years have found that PIMs continue to be used in 12% to 40% of older patients in community and nursing home settings.5 To address the continued use of PIMs, the Centers for Medicare and Medicaid Services incorporated the Beers criteria into federal safety regulations for long‐term care facilities in 1999.6 In 2006, the prescription rate of PIMs was introduced as a Health Plan and Employer Data and Information Set (HEDIS) quality measure for managed care plans.7 Despite adoption of the Beers criteria to monitor prescribing quality and safety in nursing homes and outpatient settings, there has been considerably less study of potentially inappropriate medication use in hospitalized patients.

In this issue of the Journal of Hospital Medicine, Rothberg and colleagues analyzed administrative data from nearly 400 hospitals across the United States and found that nearly half of all older patients hospitalized for 7 common conditions were prescribed at least 1 PIM.8 Thus, the incidence of PIM use in hospitalized older patients far exceeded that reported in most studies of community‐dwelling or nursing home patients. Most notable, however, was the variability found in prescribing rates based on a number of physician and hospital characteristics. For example, although hospitalists and geriatricians were found to be less likely to prescribe PIMs than cardiologists and general internists, among high‐volume cardiologists and internists, PIM prescribing rates ranged widely, from 0% to more than 90%. Similarly, hospitalwide prescribing rates varied by geographic region, and there were 7 hospitals in which not a single PIM was reportedly prescribed.

These findings raise three questions and bring to mind parallels with efforts to control inappropriate antimicrobial use. First question: Can inpatient use of PIMs truly be higher than outpatient use? Yes. The finding that more hospitalized patients are prescribed PIMs than ambulatory patients has face validity for several reasons. First, patients admitted for an acute hospitalization may have more comorbid diseases and take more medications than community‐dwelling older adults. Second, new medications are typically added to treat acutely ill patients on hospitalization. Third, previous studies estimating outpatient PIM use have typically used more narrowly defined lists of PIMs and have not captured over‐the‐counter use of PIMs, particularly antihistamines.9 Diphenhydramine alone accounted for 9% of PIM use in Rothberg's study. Finally, as Rothberg and colleagues point out, this study was limited to certain diagnoses such as acute myocardial infarction that may have protocol‐driven prescribing, which includes PIMs, that may be used only a single time such as promethazine.

Second question: Can PIM prescribing truly be so variable across regions, specialties, and individual hospitals and physicians? Yes. Using multivariable modeling, Rothberg and colleagues controlled for many patient, hospital, and physician characteristics and still found significant variation. John Wennberg and others have documented similar variations for a host of medical treatments; but although variation is interesting, it is unwarranted variation that matters for improving health care quality.10 It is not clear how much of the variation in prescribing rates of PIMs is unwarranted.

Some degree of variation in PIM prescribing rates is certainly acceptable. As the creators of the Beers criteria acknowledge, these medications are deemed only potentially inappropriate, and individual treatment decisions should be tailored to individual patients. However, others have taken the term potentially inappropriate one step further by recategorizing Beers medications as always avoid medications, rarely acceptable medications, and medications that indeed have some indications for use in older adults.8

Variation in prescribing practice may also be acceptable when there is not a clear consensus on the superiority of one practice over another. Indeed, the evidence that PIM prescribing causes large numbers of clinically significant adverse drug events and patient harm is weak and largely based on observational studies with inconsistent results. Although some studies demonstrated an epidemiological association between Beers criteria medications and general adverse outcomes (eg, hospitalizations),11 other studies did not.12 A recent systematic review concluded that Beers criteria medications were associated with some adverse health effects, but the studies analyzed were too heterogeneous to support formal meta‐analysis.13 Thus, variability in prescribing rates of Beers medications may simply reflect individual clinical judgment in the absence of conclusive outcomes data.

Third question: Can hospitalists use the findings of Rothberg and colleagues to improve the quality of medication prescribing for older adults in their institutions? Maybe. But hospitalists wishing to reduce PIM use in their institutions should draw lessons from other efforts to modify physician‐prescribing practice such as efforts to reduce inappropriate antimicrobial use. Although national data draw attention to the high frequency of potentially inappropriate medication use in hospitalized patients, the large variation in use across hospitals confirms the need for monitoring in individual facilities. For example, the National Healthcare Safety Network provides national benchmarks of antimicrobial use and resistance, but individual hospitals monitor antibiotic use and resistance in their own institutions to tailor local efforts to improve antimicrobial prescribing.14

Also, initiating a quality improvement effort targeting all 48 Beers criteria medications may be an inefficient use of resources. Using such a composite measure obscures the contribution of the component medications, each of which possesses unique and sometimes controversial profiles of efficacy and harm for older patients. Instead, a targeted intervention addressing the most commonly prescribed Beers medications that have widely accepted alternatives could be more practical. For instance, many antibiotic management programs focus on replacing a popular, extended‐spectrum antimicrobial with a narrow‐spectrum agent as soon as microbiological susceptibly results are available.

Propoxephene is a PIM that may be an attractive target for intervention. Propoxephene was the third most commonly prescribed PIM identified by Rothberg and colleagues, but meta‐analyses of controlled trials have concluded that propoxephene provides inferior analgesia for acute pain compared with that provided by other opioids with similar side effects, and has more adverse effects than nonopioid analgesics.15 Indeed, Rothberg found that just 3 of 48 PIMs (promethazine, diphenhydramine, and propoxyphene), each of which has viable alternative agents, accounted for approximately a quarter of all potentially inappropriate prescribing.

However, not all of the 48 Beers medications have alternatives with strong evidence of superiority. The Beers list includes medications (eg, amiodarone) that may not have equivalent alternative agents. On the other hand, some Beers medications have largely been supplanted (eg, ticlopidine or tripelennamine), and identifying these medications may be an inefficient use of scarce patient safety resources. As with antimicrobial stewardship programs, local surveillance of PIM use should be combined with local consensus on appropriate alternatives to target PIM interventions.

Of course, once specific PIM use is targeted for improvement, a specific intervention must be implemented. Only a handful of studies have examined the effectiveness of interventions (eg, computerized pharmacy alerts) to reduce PIM use, and most of these have focused on the outpatient setting rather than hospitalized patients.3 One study that included hospitalized patients utilized a team approach (geriatricians, nurses, social workers, and pharmacists) and demonstrated a reduction in potentially inappropriate medication use but no reduction in adverse drug reactions during hospitalization.16 In light of the scarcity of controlled intervention trials to reduce PIM use, initiatives to reduce inappropriate antimicrobial prescribing may provide useful insights into the strengths and limitations of approaches such as clinician education, formulary restrictions, pharmacist review, and computer‐based monitoring.17

Finally, any intervention to reduce PIM use should have reasonable expectations. The Beers criteria were developed to improve the effectiveness of medication therapy for older adults as well as to prevent harm, but it is unlikely that reducing PIM use in hospitalized patients will result in improvements that could be measured easily during an initial hospitalization. If preventing drug‐induced harm during the hospitalization of older patients is the primary concern, a shift in focus is required. Safety efforts should be concentrated on identifying and mitigating the most common and severe adverse drug events, rather than focusing efforts on reducing the use of PIMs. National data demonstrate that a handful of drugsinsulin, warfarin, and digoxinmost commonly cause severe adverse events in older outpatients.18 Optimizing the management of these medications may be another approach for improving drug safety in hospitalized patients. Regardless of the focus of a drug safety intervention, the experience of infection control and hospital epidemiology programs suggests that success will require dedicated professionals and the commitment of resources to examine patterns of local use, implement interventions, and monitor outcomes.

Medications are central to managing the health of older patients. In 2006, more than 93% of adults 65 years or older reported taking at least 1 medication in the last week, 58% reported taking 5 or more medications, and 18% reported taking 10 or more.1 Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered.2

Older patients, especially those who are chronically frail or acutely ill, may require special consideration when making prescribing decisions because of age‐related changes in the metabolism and clearance of medications and enhanced pharmacodynamic sensitivities.3 Thus, panels of experts in pharmacology and geriatrics have compiled lists of medications to avoid prescribing for patients 65 years of age or older. The most commonly used list is the Beers criteria, which were introduced in 1991 to serve researchers evaluating prescribing quality in nursing homes. The Beers criteria were updated in 1997 and again in 2003 to include 48 potentially inappropriate medications (PIMs) for which, according to the consensus panel, there are more effective or safer alternatives for older patients.4

Numerous studies in the last 15 years have found that PIMs continue to be used in 12% to 40% of older patients in community and nursing home settings.5 To address the continued use of PIMs, the Centers for Medicare and Medicaid Services incorporated the Beers criteria into federal safety regulations for long‐term care facilities in 1999.6 In 2006, the prescription rate of PIMs was introduced as a Health Plan and Employer Data and Information Set (HEDIS) quality measure for managed care plans.7 Despite adoption of the Beers criteria to monitor prescribing quality and safety in nursing homes and outpatient settings, there has been considerably less study of potentially inappropriate medication use in hospitalized patients.

In this issue of the Journal of Hospital Medicine, Rothberg and colleagues analyzed administrative data from nearly 400 hospitals across the United States and found that nearly half of all older patients hospitalized for 7 common conditions were prescribed at least 1 PIM.8 Thus, the incidence of PIM use in hospitalized older patients far exceeded that reported in most studies of community‐dwelling or nursing home patients. Most notable, however, was the variability found in prescribing rates based on a number of physician and hospital characteristics. For example, although hospitalists and geriatricians were found to be less likely to prescribe PIMs than cardiologists and general internists, among high‐volume cardiologists and internists, PIM prescribing rates ranged widely, from 0% to more than 90%. Similarly, hospitalwide prescribing rates varied by geographic region, and there were 7 hospitals in which not a single PIM was reportedly prescribed.

These findings raise three questions and bring to mind parallels with efforts to control inappropriate antimicrobial use. First question: Can inpatient use of PIMs truly be higher than outpatient use? Yes. The finding that more hospitalized patients are prescribed PIMs than ambulatory patients has face validity for several reasons. First, patients admitted for an acute hospitalization may have more comorbid diseases and take more medications than community‐dwelling older adults. Second, new medications are typically added to treat acutely ill patients on hospitalization. Third, previous studies estimating outpatient PIM use have typically used more narrowly defined lists of PIMs and have not captured over‐the‐counter use of PIMs, particularly antihistamines.9 Diphenhydramine alone accounted for 9% of PIM use in Rothberg's study. Finally, as Rothberg and colleagues point out, this study was limited to certain diagnoses such as acute myocardial infarction that may have protocol‐driven prescribing, which includes PIMs, that may be used only a single time such as promethazine.

Second question: Can PIM prescribing truly be so variable across regions, specialties, and individual hospitals and physicians? Yes. Using multivariable modeling, Rothberg and colleagues controlled for many patient, hospital, and physician characteristics and still found significant variation. John Wennberg and others have documented similar variations for a host of medical treatments; but although variation is interesting, it is unwarranted variation that matters for improving health care quality.10 It is not clear how much of the variation in prescribing rates of PIMs is unwarranted.

Some degree of variation in PIM prescribing rates is certainly acceptable. As the creators of the Beers criteria acknowledge, these medications are deemed only potentially inappropriate, and individual treatment decisions should be tailored to individual patients. However, others have taken the term potentially inappropriate one step further by recategorizing Beers medications as always avoid medications, rarely acceptable medications, and medications that indeed have some indications for use in older adults.8

Variation in prescribing practice may also be acceptable when there is not a clear consensus on the superiority of one practice over another. Indeed, the evidence that PIM prescribing causes large numbers of clinically significant adverse drug events and patient harm is weak and largely based on observational studies with inconsistent results. Although some studies demonstrated an epidemiological association between Beers criteria medications and general adverse outcomes (eg, hospitalizations),11 other studies did not.12 A recent systematic review concluded that Beers criteria medications were associated with some adverse health effects, but the studies analyzed were too heterogeneous to support formal meta‐analysis.13 Thus, variability in prescribing rates of Beers medications may simply reflect individual clinical judgment in the absence of conclusive outcomes data.

Third question: Can hospitalists use the findings of Rothberg and colleagues to improve the quality of medication prescribing for older adults in their institutions? Maybe. But hospitalists wishing to reduce PIM use in their institutions should draw lessons from other efforts to modify physician‐prescribing practice such as efforts to reduce inappropriate antimicrobial use. Although national data draw attention to the high frequency of potentially inappropriate medication use in hospitalized patients, the large variation in use across hospitals confirms the need for monitoring in individual facilities. For example, the National Healthcare Safety Network provides national benchmarks of antimicrobial use and resistance, but individual hospitals monitor antibiotic use and resistance in their own institutions to tailor local efforts to improve antimicrobial prescribing.14

Also, initiating a quality improvement effort targeting all 48 Beers criteria medications may be an inefficient use of resources. Using such a composite measure obscures the contribution of the component medications, each of which possesses unique and sometimes controversial profiles of efficacy and harm for older patients. Instead, a targeted intervention addressing the most commonly prescribed Beers medications that have widely accepted alternatives could be more practical. For instance, many antibiotic management programs focus on replacing a popular, extended‐spectrum antimicrobial with a narrow‐spectrum agent as soon as microbiological susceptibly results are available.

Propoxephene is a PIM that may be an attractive target for intervention. Propoxephene was the third most commonly prescribed PIM identified by Rothberg and colleagues, but meta‐analyses of controlled trials have concluded that propoxephene provides inferior analgesia for acute pain compared with that provided by other opioids with similar side effects, and has more adverse effects than nonopioid analgesics.15 Indeed, Rothberg found that just 3 of 48 PIMs (promethazine, diphenhydramine, and propoxyphene), each of which has viable alternative agents, accounted for approximately a quarter of all potentially inappropriate prescribing.

However, not all of the 48 Beers medications have alternatives with strong evidence of superiority. The Beers list includes medications (eg, amiodarone) that may not have equivalent alternative agents. On the other hand, some Beers medications have largely been supplanted (eg, ticlopidine or tripelennamine), and identifying these medications may be an inefficient use of scarce patient safety resources. As with antimicrobial stewardship programs, local surveillance of PIM use should be combined with local consensus on appropriate alternatives to target PIM interventions.

Of course, once specific PIM use is targeted for improvement, a specific intervention must be implemented. Only a handful of studies have examined the effectiveness of interventions (eg, computerized pharmacy alerts) to reduce PIM use, and most of these have focused on the outpatient setting rather than hospitalized patients.3 One study that included hospitalized patients utilized a team approach (geriatricians, nurses, social workers, and pharmacists) and demonstrated a reduction in potentially inappropriate medication use but no reduction in adverse drug reactions during hospitalization.16 In light of the scarcity of controlled intervention trials to reduce PIM use, initiatives to reduce inappropriate antimicrobial prescribing may provide useful insights into the strengths and limitations of approaches such as clinician education, formulary restrictions, pharmacist review, and computer‐based monitoring.17

Finally, any intervention to reduce PIM use should have reasonable expectations. The Beers criteria were developed to improve the effectiveness of medication therapy for older adults as well as to prevent harm, but it is unlikely that reducing PIM use in hospitalized patients will result in improvements that could be measured easily during an initial hospitalization. If preventing drug‐induced harm during the hospitalization of older patients is the primary concern, a shift in focus is required. Safety efforts should be concentrated on identifying and mitigating the most common and severe adverse drug events, rather than focusing efforts on reducing the use of PIMs. National data demonstrate that a handful of drugsinsulin, warfarin, and digoxinmost commonly cause severe adverse events in older outpatients.18 Optimizing the management of these medications may be another approach for improving drug safety in hospitalized patients. Regardless of the focus of a drug safety intervention, the experience of infection control and hospital epidemiology programs suggests that success will require dedicated professionals and the commitment of resources to examine patterns of local use, implement interventions, and monitor outcomes.

Acute atherothrombotic events associated with ischemic heart disease and stroke are the first and third most common causes of death in the United States, respectively.1 Despite an overall decrease in age‐adjusted mortality since 1970 in the United States, the worldwide prevalence of these diseases is anticipated to sharply increase by 2020.1, 2 Caring for patients with atherothrombosis is now within the purview of hospitalists to a larger extent than ever before. In recognition of the expanding role of these health care professionals and to reduce the risk of adverse cardiovascular events in the outpatient setting, the Society of Hospital Medicine held a symposium during its 10th Annual Meeting.

Rules of Engagement: The Hospitalist and Atherothrombosis took place on May 24, 2007, in Dallas, Texas. This supplement summarizes the highlights from this symposium and reviews the causes and polyvascular nature of atherothrombosis. The role of the hospitalist in managing atherothrombotic disease and evidence‐based practices for the evaluation and treatment of patients with various manifestations of atherothrombotic disease are also discussed.

ARTERIAL THROMBOSIS AND ITS POLYVASCULAR NATURE

Atherothrombosis refers to the formation of large and occlusive mural thrombi that arise from the rupture of an atherosclerotic plaque. Myocardial infarction (MI), ischemic stroke, and acute limb ischemia are the most severe manifestations of this disease.3, 4 This process begins when denuded or inflamed endothelial cells develop properties that permit platelet adhesion. At the site of endothelial dysfunction, activation of adherent platelet results in the release of inflammatory and mitogenic factors. After a series of dynamic and repetitive processes including amplified platelet activation, monocyte chemotaxis, adhesion, transmigration, and lipoprotein retention, plaque formation occurs.5 Consequently, the rupture or erosion of an atherosclerotic plaque produces a higher degree of platelet adhesion, activation, and aggregation, causing the fibrotic organization of a mural thrombus.3

The number of persons with multiple, concomitant cardiovascular disease (CAD), cerebrovascular disease (CVD), and peripheral arterial disease (PAD) accentuates the polyvascular nature of atherothrombosis (Fig. 1). The international Reduction of Atherothrombosis for Continued Health (REACH) Registry demonstrated that 1‐year incidence rates of major cardiovascular events (eg, MI, stroke, death) were high in patients with an established atherothrombotic disease and increased with the number of concomitant vascular diseases.6 These data infer that the burden on the vascular system is considered extensive on diagnosis of a single atherothrombotic disease. Thus, aggressive therapies are needed to reduce the risk of recurrent or other cardiovascular events. The management of risk factors for atherothrombosis such as hypercholesterolemia, dyslipidemia, hypertension, and diabetes mellitus fall under specific disease‐specific guidelines for patients presenting with atherothrombotic diseases.712

Figure 1

ANTIPLATELET THERAPIES

Antiplatelet therapies are used for the acute and long‐term treatment of patients after a thrombic event. Antiplatelet agents target the molecular mechanisms responsible for platelet activation and aggregation, such as the synthesis of thromboxane A₂. On platelet activation, free arachidonic acid is converted to prostaglandin H₂ (PGH₂) by cyclooxygenase‐1 (COX‐1; Fig. 2). Further metabolism of PGH₂ by thromboxane synthase produces thromboxane A₂, which induces vasoconstriction (Fig. 2). Fortunately, the ability of platelets to produce COX‐1 is limited, and irreversible inhibition of this enzyme can impair thromboxane A₂ synthesis for approximately 10 days.

Figure 2

Aspirin is a potent COX‐1 inhibitor, whose effects are evident 1 hour after dosing (Fig. 2).4, 13 Aspirin effectively prevents fatal and nonfatal vascular events in healthy individuals and in patients who present with acute MI or ischemic stroke.13 Unfortunately, a proportion of patients are aspirin resistant. Recent studies have indicated that interactions with the nonsteroidal anti‐inflammatory drug (NSAID) ibuprofen may diminish the primary and secondary protective effects of aspirin and may contribute to aspirin resistance, although the origin of this remains unclear.

The results of a post hoc subgroup analysis of 22,071 apparently healthy male physicians randomized to take aspirin or placebo for 5 years indicated that individuals who used NSAIDs for at least 60 days/year increased their risk of MI by more than 2‐fold compared with those who did not use NSAIDs.14 A second study conducted in patients following a major adverse cardiovascular event showed that the combination of aspirin plus ibuprofen increased the adjusted relative risk of cardiovascular mortality over an 8‐year period compared with aspirin alone.15 However, the effects of NSAIDS on aspirin's ability to inhibit COX‐1 are reversible and only last for the dosing interval and body clearance time of the drug.16

Adeonsine diphosphate (ADP)dependent stimulation of the P2Y₁₂ receptor is another target for antiplatelet therapy. On its release, ADP binds to the P2Y₁₂ receptor on platelets, resulting in activation and aggregation (Fig. 2). Ticlopidine and clopidogrel are thienopyridines that may irreversibly modify the P2Y₁₂ receptor (Fig. 2).13 Safety concerns associated with ticlopidine use, including severe neutropenia, have limited its administration. Conversely, clopidogrel is relatively well‐tolerated and can prevent cardiovascular events in patients with CAD, ischemic stroke, and PAD. This agent is an orally administered prodrug requiring activation by hepatic cytochrome P450 enzymes.13

Aspirin and thienopyridines do not inhibit platelet aggregation induced by the binding of fibrinogen to the platelet glycoprotein (GP) IIb/IIIa receptor (Fig. 2).4, 13 However, there are 3 commonly administered GP IIb/IIIa inhibitors: abciximab, eptifibatide, and tirofiban (Fig. 2).4 Abciximab is the fab fragment of the chimeric monoclonal antibody 7E3 and irreversibly inhibits the GP IIb/IIIa receptor. By contrast, eptifibatide is a cyclic heptapeptide, tirofiban is a nonpeptide, and both agents are reversible inhibitors. These agents are administered intravenously, and boluses are reserved for the short‐term treatment of atherothrombosis in patients undergoing percutaneous coronary intervention.13

CONCLUSIONS

Atherothrombosis is a systemic disease that often affects coronary, intracranial, and peripheral arterial beds concomitantly, which increases the probability of a thrombotic event. Aggressive treatments, including acute and long‐term antiplatelet therapies, are required to reduce the risks associated with atherothrombosis. This supplement reviews the evidence‐based approaches for managing atherothrombosis. It will provide hospitalists with the knowledge needed to treat patients with PAD, stroke, and acute coronary syndrome. First, the administration of antiplatelet therapies to patients with acute coronary syndrome will be described. Then, guidelines for the management of patients with acute ischemic stroke and the use of antiplatelet therapies to reduce mortality due to primary and secondary ischemic events will be reviewed. Finally, the role of the hospitalist in the diagnosis of PAD in asymptomatic patients and in those with confirmed atherothrombosis will be discussed.

Acute atherothrombotic events associated with ischemic heart disease and stroke are the first and third most common causes of death in the United States, respectively.1 Despite an overall decrease in age‐adjusted mortality since 1970 in the United States, the worldwide prevalence of these diseases is anticipated to sharply increase by 2020.1, 2 Caring for patients with atherothrombosis is now within the purview of hospitalists to a larger extent than ever before. In recognition of the expanding role of these health care professionals and to reduce the risk of adverse cardiovascular events in the outpatient setting, the Society of Hospital Medicine held a symposium during its 10th Annual Meeting.

Rules of Engagement: The Hospitalist and Atherothrombosis took place on May 24, 2007, in Dallas, Texas. This supplement summarizes the highlights from this symposium and reviews the causes and polyvascular nature of atherothrombosis. The role of the hospitalist in managing atherothrombotic disease and evidence‐based practices for the evaluation and treatment of patients with various manifestations of atherothrombotic disease are also discussed.

ARTERIAL THROMBOSIS AND ITS POLYVASCULAR NATURE

Atherothrombosis refers to the formation of large and occlusive mural thrombi that arise from the rupture of an atherosclerotic plaque. Myocardial infarction (MI), ischemic stroke, and acute limb ischemia are the most severe manifestations of this disease.3, 4 This process begins when denuded or inflamed endothelial cells develop properties that permit platelet adhesion. At the site of endothelial dysfunction, activation of adherent platelet results in the release of inflammatory and mitogenic factors. After a series of dynamic and repetitive processes including amplified platelet activation, monocyte chemotaxis, adhesion, transmigration, and lipoprotein retention, plaque formation occurs.5 Consequently, the rupture or erosion of an atherosclerotic plaque produces a higher degree of platelet adhesion, activation, and aggregation, causing the fibrotic organization of a mural thrombus.3

The number of persons with multiple, concomitant cardiovascular disease (CAD), cerebrovascular disease (CVD), and peripheral arterial disease (PAD) accentuates the polyvascular nature of atherothrombosis (Fig. 1). The international Reduction of Atherothrombosis for Continued Health (REACH) Registry demonstrated that 1‐year incidence rates of major cardiovascular events (eg, MI, stroke, death) were high in patients with an established atherothrombotic disease and increased with the number of concomitant vascular diseases.6 These data infer that the burden on the vascular system is considered extensive on diagnosis of a single atherothrombotic disease. Thus, aggressive therapies are needed to reduce the risk of recurrent or other cardiovascular events. The management of risk factors for atherothrombosis such as hypercholesterolemia, dyslipidemia, hypertension, and diabetes mellitus fall under specific disease‐specific guidelines for patients presenting with atherothrombotic diseases.712

Figure 1

ANTIPLATELET THERAPIES

Antiplatelet therapies are used for the acute and long‐term treatment of patients after a thrombic event. Antiplatelet agents target the molecular mechanisms responsible for platelet activation and aggregation, such as the synthesis of thromboxane A₂. On platelet activation, free arachidonic acid is converted to prostaglandin H₂ (PGH₂) by cyclooxygenase‐1 (COX‐1; Fig. 2). Further metabolism of PGH₂ by thromboxane synthase produces thromboxane A₂, which induces vasoconstriction (Fig. 2). Fortunately, the ability of platelets to produce COX‐1 is limited, and irreversible inhibition of this enzyme can impair thromboxane A₂ synthesis for approximately 10 days.

Figure 2

Aspirin is a potent COX‐1 inhibitor, whose effects are evident 1 hour after dosing (Fig. 2).4, 13 Aspirin effectively prevents fatal and nonfatal vascular events in healthy individuals and in patients who present with acute MI or ischemic stroke.13 Unfortunately, a proportion of patients are aspirin resistant. Recent studies have indicated that interactions with the nonsteroidal anti‐inflammatory drug (NSAID) ibuprofen may diminish the primary and secondary protective effects of aspirin and may contribute to aspirin resistance, although the origin of this remains unclear.

The results of a post hoc subgroup analysis of 22,071 apparently healthy male physicians randomized to take aspirin or placebo for 5 years indicated that individuals who used NSAIDs for at least 60 days/year increased their risk of MI by more than 2‐fold compared with those who did not use NSAIDs.14 A second study conducted in patients following a major adverse cardiovascular event showed that the combination of aspirin plus ibuprofen increased the adjusted relative risk of cardiovascular mortality over an 8‐year period compared with aspirin alone.15 However, the effects of NSAIDS on aspirin's ability to inhibit COX‐1 are reversible and only last for the dosing interval and body clearance time of the drug.16

Adeonsine diphosphate (ADP)dependent stimulation of the P2Y₁₂ receptor is another target for antiplatelet therapy. On its release, ADP binds to the P2Y₁₂ receptor on platelets, resulting in activation and aggregation (Fig. 2). Ticlopidine and clopidogrel are thienopyridines that may irreversibly modify the P2Y₁₂ receptor (Fig. 2).13 Safety concerns associated with ticlopidine use, including severe neutropenia, have limited its administration. Conversely, clopidogrel is relatively well‐tolerated and can prevent cardiovascular events in patients with CAD, ischemic stroke, and PAD. This agent is an orally administered prodrug requiring activation by hepatic cytochrome P450 enzymes.13

Aspirin and thienopyridines do not inhibit platelet aggregation induced by the binding of fibrinogen to the platelet glycoprotein (GP) IIb/IIIa receptor (Fig. 2).4, 13 However, there are 3 commonly administered GP IIb/IIIa inhibitors: abciximab, eptifibatide, and tirofiban (Fig. 2).4 Abciximab is the fab fragment of the chimeric monoclonal antibody 7E3 and irreversibly inhibits the GP IIb/IIIa receptor. By contrast, eptifibatide is a cyclic heptapeptide, tirofiban is a nonpeptide, and both agents are reversible inhibitors. These agents are administered intravenously, and boluses are reserved for the short‐term treatment of atherothrombosis in patients undergoing percutaneous coronary intervention.13

CONCLUSIONS

Atherothrombosis is a systemic disease that often affects coronary, intracranial, and peripheral arterial beds concomitantly, which increases the probability of a thrombotic event. Aggressive treatments, including acute and long‐term antiplatelet therapies, are required to reduce the risks associated with atherothrombosis. This supplement reviews the evidence‐based approaches for managing atherothrombosis. It will provide hospitalists with the knowledge needed to treat patients with PAD, stroke, and acute coronary syndrome. First, the administration of antiplatelet therapies to patients with acute coronary syndrome will be described. Then, guidelines for the management of patients with acute ischemic stroke and the use of antiplatelet therapies to reduce mortality due to primary and secondary ischemic events will be reviewed. Finally, the role of the hospitalist in the diagnosis of PAD in asymptomatic patients and in those with confirmed atherothrombosis will be discussed.

Acute atherothrombotic events associated with ischemic heart disease and stroke are the first and third most common causes of death in the United States, respectively.1 Despite an overall decrease in age‐adjusted mortality since 1970 in the United States, the worldwide prevalence of these diseases is anticipated to sharply increase by 2020.1, 2 Caring for patients with atherothrombosis is now within the purview of hospitalists to a larger extent than ever before. In recognition of the expanding role of these health care professionals and to reduce the risk of adverse cardiovascular events in the outpatient setting, the Society of Hospital Medicine held a symposium during its 10th Annual Meeting.

Rules of Engagement: The Hospitalist and Atherothrombosis took place on May 24, 2007, in Dallas, Texas. This supplement summarizes the highlights from this symposium and reviews the causes and polyvascular nature of atherothrombosis. The role of the hospitalist in managing atherothrombotic disease and evidence‐based practices for the evaluation and treatment of patients with various manifestations of atherothrombotic disease are also discussed.

ARTERIAL THROMBOSIS AND ITS POLYVASCULAR NATURE

Atherothrombosis refers to the formation of large and occlusive mural thrombi that arise from the rupture of an atherosclerotic plaque. Myocardial infarction (MI), ischemic stroke, and acute limb ischemia are the most severe manifestations of this disease.3, 4 This process begins when denuded or inflamed endothelial cells develop properties that permit platelet adhesion. At the site of endothelial dysfunction, activation of adherent platelet results in the release of inflammatory and mitogenic factors. After a series of dynamic and repetitive processes including amplified platelet activation, monocyte chemotaxis, adhesion, transmigration, and lipoprotein retention, plaque formation occurs.5 Consequently, the rupture or erosion of an atherosclerotic plaque produces a higher degree of platelet adhesion, activation, and aggregation, causing the fibrotic organization of a mural thrombus.3

The number of persons with multiple, concomitant cardiovascular disease (CAD), cerebrovascular disease (CVD), and peripheral arterial disease (PAD) accentuates the polyvascular nature of atherothrombosis (Fig. 1). The international Reduction of Atherothrombosis for Continued Health (REACH) Registry demonstrated that 1‐year incidence rates of major cardiovascular events (eg, MI, stroke, death) were high in patients with an established atherothrombotic disease and increased with the number of concomitant vascular diseases.6 These data infer that the burden on the vascular system is considered extensive on diagnosis of a single atherothrombotic disease. Thus, aggressive therapies are needed to reduce the risk of recurrent or other cardiovascular events. The management of risk factors for atherothrombosis such as hypercholesterolemia, dyslipidemia, hypertension, and diabetes mellitus fall under specific disease‐specific guidelines for patients presenting with atherothrombotic diseases.712

Figure 1

ANTIPLATELET THERAPIES

Antiplatelet therapies are used for the acute and long‐term treatment of patients after a thrombic event. Antiplatelet agents target the molecular mechanisms responsible for platelet activation and aggregation, such as the synthesis of thromboxane A₂. On platelet activation, free arachidonic acid is converted to prostaglandin H₂ (PGH₂) by cyclooxygenase‐1 (COX‐1; Fig. 2). Further metabolism of PGH₂ by thromboxane synthase produces thromboxane A₂, which induces vasoconstriction (Fig. 2). Fortunately, the ability of platelets to produce COX‐1 is limited, and irreversible inhibition of this enzyme can impair thromboxane A₂ synthesis for approximately 10 days.

Figure 2

Aspirin is a potent COX‐1 inhibitor, whose effects are evident 1 hour after dosing (Fig. 2).4, 13 Aspirin effectively prevents fatal and nonfatal vascular events in healthy individuals and in patients who present with acute MI or ischemic stroke.13 Unfortunately, a proportion of patients are aspirin resistant. Recent studies have indicated that interactions with the nonsteroidal anti‐inflammatory drug (NSAID) ibuprofen may diminish the primary and secondary protective effects of aspirin and may contribute to aspirin resistance, although the origin of this remains unclear.

The results of a post hoc subgroup analysis of 22,071 apparently healthy male physicians randomized to take aspirin or placebo for 5 years indicated that individuals who used NSAIDs for at least 60 days/year increased their risk of MI by more than 2‐fold compared with those who did not use NSAIDs.14 A second study conducted in patients following a major adverse cardiovascular event showed that the combination of aspirin plus ibuprofen increased the adjusted relative risk of cardiovascular mortality over an 8‐year period compared with aspirin alone.15 However, the effects of NSAIDS on aspirin's ability to inhibit COX‐1 are reversible and only last for the dosing interval and body clearance time of the drug.16

Adeonsine diphosphate (ADP)dependent stimulation of the P2Y₁₂ receptor is another target for antiplatelet therapy. On its release, ADP binds to the P2Y₁₂ receptor on platelets, resulting in activation and aggregation (Fig. 2). Ticlopidine and clopidogrel are thienopyridines that may irreversibly modify the P2Y₁₂ receptor (Fig. 2).13 Safety concerns associated with ticlopidine use, including severe neutropenia, have limited its administration. Conversely, clopidogrel is relatively well‐tolerated and can prevent cardiovascular events in patients with CAD, ischemic stroke, and PAD. This agent is an orally administered prodrug requiring activation by hepatic cytochrome P450 enzymes.13

Aspirin and thienopyridines do not inhibit platelet aggregation induced by the binding of fibrinogen to the platelet glycoprotein (GP) IIb/IIIa receptor (Fig. 2).4, 13 However, there are 3 commonly administered GP IIb/IIIa inhibitors: abciximab, eptifibatide, and tirofiban (Fig. 2).4 Abciximab is the fab fragment of the chimeric monoclonal antibody 7E3 and irreversibly inhibits the GP IIb/IIIa receptor. By contrast, eptifibatide is a cyclic heptapeptide, tirofiban is a nonpeptide, and both agents are reversible inhibitors. These agents are administered intravenously, and boluses are reserved for the short‐term treatment of atherothrombosis in patients undergoing percutaneous coronary intervention.13

CONCLUSIONS

Atherothrombosis is a systemic disease that often affects coronary, intracranial, and peripheral arterial beds concomitantly, which increases the probability of a thrombotic event. Aggressive treatments, including acute and long‐term antiplatelet therapies, are required to reduce the risks associated with atherothrombosis. This supplement reviews the evidence‐based approaches for managing atherothrombosis. It will provide hospitalists with the knowledge needed to treat patients with PAD, stroke, and acute coronary syndrome. First, the administration of antiplatelet therapies to patients with acute coronary syndrome will be described. Then, guidelines for the management of patients with acute ischemic stroke and the use of antiplatelet therapies to reduce mortality due to primary and secondary ischemic events will be reviewed. Finally, the role of the hospitalist in the diagnosis of PAD in asymptomatic patients and in those with confirmed atherothrombosis will be discussed.

Two years ago we published the first issue of the Journal of Hospital Medicine and declared, Our goal is that JHM become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.1 That first issue was just one of many steps toward this ambition. At the completion of its first year, JHM was selected for indexing and inclusion in the National Library of Medicine's Medical Literature Analysis and Retrieval System Online (MEDLINE), the primary component of PubMed. Following this huge step, we welcomed a remarkable increase in submissions and will have exceeded 300 in our second year, an approximately 50% increase from our first year!

As important, JHM quickly became a valuable benefit of membership in the Society of Hospital Medicine, and the innumerable compliments received by the staff reflect the diligent efforts of a remarkable editorial staff and work by our reviewers. With profound gratitude we list on page 86 these 325 reviewers who donated their priceless time and expertise to enhancing the quality of the manuscripts. To handle the marked increase in submissions, we are expanding and modifying our editorial staff. Please welcome Sunil Kripalani (Vanderbilt) and Daniel Brotman (Johns Hopkins), who join our previous six associate editors and all eight will now serve as JHM's deputy editors. Seven new associate editors also join our team. Among them, Tom Baudendistel (California Pacific Medical Center, San Francisco), Eric Alper (UMass Memorial Health Care, Worcester), Brian Harte (Cleveland Clinic), and Rehan Qayyum (Johns Hopkins) will all focus on optimizing content for practicing hospitalists. Paul Aronowitz will continue to develop our Images section as an associate editor. Recognizing the growing number of pediatric hospitalists, Lisa Zauotis (Childrens Hospital of Philadelphia) and Erin Stucky (Children's Hospital San Diego) join JHM as the other 2 new associate editors. Finally, we welcome new Editorial Board members Mary C. Ottolini (Children's National Medical Center), Douglas Carlson (St. Louis Children's Hospital), and Daniel Rauch (NYU Children's Hospital). The welcome addition of these nationally recognized academicians prepares us for continued growth in manuscript submissions to JHM.

Although we could not excel without the editors, reviewers and our terrific new managing editor, Phaedra McGuinness, we would not survive without the authors who submit their manuscripts to JHMthey are responsible for the caliber of the journal, and we are immensely indebted to them. Originally, we hoped to include individuals involved in all aspects of hospital care,1 and fortunately this is now happening. Complementing hospitalists are nurses and pharmacists2 who recognize the importance of teamwork in the care of hospitalized patients. I encourage all members of the hospital care team to send us the results of their research, teaching, and quality improvement efforts.

As the specialty of hospital medicine continues to evolve, now with more than 20,000 hospitalists, JHM will develop with it. I am honored and grateful to collaborate with such a remarkable group of colleagues as we build the premier journal for the fastest growing specialty in the history of medicine in the United States. On to year 3!

Two years ago we published the first issue of the Journal of Hospital Medicine and declared, Our goal is that JHM become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.1 That first issue was just one of many steps toward this ambition. At the completion of its first year, JHM was selected for indexing and inclusion in the National Library of Medicine's Medical Literature Analysis and Retrieval System Online (MEDLINE), the primary component of PubMed. Following this huge step, we welcomed a remarkable increase in submissions and will have exceeded 300 in our second year, an approximately 50% increase from our first year!

As important, JHM quickly became a valuable benefit of membership in the Society of Hospital Medicine, and the innumerable compliments received by the staff reflect the diligent efforts of a remarkable editorial staff and work by our reviewers. With profound gratitude we list on page 86 these 325 reviewers who donated their priceless time and expertise to enhancing the quality of the manuscripts. To handle the marked increase in submissions, we are expanding and modifying our editorial staff. Please welcome Sunil Kripalani (Vanderbilt) and Daniel Brotman (Johns Hopkins), who join our previous six associate editors and all eight will now serve as JHM's deputy editors. Seven new associate editors also join our team. Among them, Tom Baudendistel (California Pacific Medical Center, San Francisco), Eric Alper (UMass Memorial Health Care, Worcester), Brian Harte (Cleveland Clinic), and Rehan Qayyum (Johns Hopkins) will all focus on optimizing content for practicing hospitalists. Paul Aronowitz will continue to develop our Images section as an associate editor. Recognizing the growing number of pediatric hospitalists, Lisa Zauotis (Childrens Hospital of Philadelphia) and Erin Stucky (Children's Hospital San Diego) join JHM as the other 2 new associate editors. Finally, we welcome new Editorial Board members Mary C. Ottolini (Children's National Medical Center), Douglas Carlson (St. Louis Children's Hospital), and Daniel Rauch (NYU Children's Hospital). The welcome addition of these nationally recognized academicians prepares us for continued growth in manuscript submissions to JHM.

Although we could not excel without the editors, reviewers and our terrific new managing editor, Phaedra McGuinness, we would not survive without the authors who submit their manuscripts to JHMthey are responsible for the caliber of the journal, and we are immensely indebted to them. Originally, we hoped to include individuals involved in all aspects of hospital care,1 and fortunately this is now happening. Complementing hospitalists are nurses and pharmacists2 who recognize the importance of teamwork in the care of hospitalized patients. I encourage all members of the hospital care team to send us the results of their research, teaching, and quality improvement efforts.

As the specialty of hospital medicine continues to evolve, now with more than 20,000 hospitalists, JHM will develop with it. I am honored and grateful to collaborate with such a remarkable group of colleagues as we build the premier journal for the fastest growing specialty in the history of medicine in the United States. On to year 3!

Two years ago we published the first issue of the Journal of Hospital Medicine and declared, Our goal is that JHM become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.1 That first issue was just one of many steps toward this ambition. At the completion of its first year, JHM was selected for indexing and inclusion in the National Library of Medicine's Medical Literature Analysis and Retrieval System Online (MEDLINE), the primary component of PubMed. Following this huge step, we welcomed a remarkable increase in submissions and will have exceeded 300 in our second year, an approximately 50% increase from our first year!

As important, JHM quickly became a valuable benefit of membership in the Society of Hospital Medicine, and the innumerable compliments received by the staff reflect the diligent efforts of a remarkable editorial staff and work by our reviewers. With profound gratitude we list on page 86 these 325 reviewers who donated their priceless time and expertise to enhancing the quality of the manuscripts. To handle the marked increase in submissions, we are expanding and modifying our editorial staff. Please welcome Sunil Kripalani (Vanderbilt) and Daniel Brotman (Johns Hopkins), who join our previous six associate editors and all eight will now serve as JHM's deputy editors. Seven new associate editors also join our team. Among them, Tom Baudendistel (California Pacific Medical Center, San Francisco), Eric Alper (UMass Memorial Health Care, Worcester), Brian Harte (Cleveland Clinic), and Rehan Qayyum (Johns Hopkins) will all focus on optimizing content for practicing hospitalists. Paul Aronowitz will continue to develop our Images section as an associate editor. Recognizing the growing number of pediatric hospitalists, Lisa Zauotis (Childrens Hospital of Philadelphia) and Erin Stucky (Children's Hospital San Diego) join JHM as the other 2 new associate editors. Finally, we welcome new Editorial Board members Mary C. Ottolini (Children's National Medical Center), Douglas Carlson (St. Louis Children's Hospital), and Daniel Rauch (NYU Children's Hospital). The welcome addition of these nationally recognized academicians prepares us for continued growth in manuscript submissions to JHM.

Although we could not excel without the editors, reviewers and our terrific new managing editor, Phaedra McGuinness, we would not survive without the authors who submit their manuscripts to JHMthey are responsible for the caliber of the journal, and we are immensely indebted to them. Originally, we hoped to include individuals involved in all aspects of hospital care,1 and fortunately this is now happening. Complementing hospitalists are nurses and pharmacists2 who recognize the importance of teamwork in the care of hospitalized patients. I encourage all members of the hospital care team to send us the results of their research, teaching, and quality improvement efforts.

As the specialty of hospital medicine continues to evolve, now with more than 20,000 hospitalists, JHM will develop with it. I am honored and grateful to collaborate with such a remarkable group of colleagues as we build the premier journal for the fastest growing specialty in the history of medicine in the United States. On to year 3!

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.