Medicolegal Issues

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi-center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and one patients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis between the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi-center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and one patients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis between the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi-center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and one patients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis between the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

SHM member David Feinbloom, MD, testified before the Massachusetts Joint Committee on Healthcare Financing and Economic Development and Emerging Technologies on May 5, 2005. Dr. Feinbloom was part of a panel of Massachusetts’ healthcare and information systems leaders advocating for additional funding of a statewide initiative to install Computerized Physician Order Entry (CPOE) systems and other advanced information technologies in each hospital across Massachusetts. Dr. Feinbloom is the director of clinical resource management, Department of Medicine, and physician liaison for Clinical Information Systems Development at Beth Israel Deaconess Medical Center in Boston. Under the leadership of John Halamka, MD, MS, and chief information office of Harvard Medical School and BIDMC, the medical center is a nationally recognized leader in medical information technology.

“The goal of the hearing was to share views about the implementation of advanced technologies like CPOE, one of a series of initiatives to create a statewide medical information technology infrastructure,” says Dr. Feinbloom. “Ultimately, this will include applications such as e-prescribing, online physician-patient communications, and regional data sharing networks, which will improve quality, patient satisfaction, and reduce costs.” He says that currently a parallel initiative for related technologies has a $50 million commitment from Blue Cross and Blue Shield. An additional $210 million is needed to bring inpatient CPOE to all of the hospitals in the state. “We wanted to make sure that the committee understood that despite the seemingly high initial outlay of capital, there is a projected savings of $275 million annually.” The dramatic savings, Dr. Feinbloom says, come from efficiencies in patient throughput, reductions in medication errors and adverse drug events, and improved utilization of inpatient resources. The Massachusetts Technology Collaborative and New England Healthcare Institute are coordinating statewide efforts to remove barriers to inpatient CPOE.

Currently, only 5% to 10% percent of hospitals nationwide have CPOE systems, but that is destined to change, says Dr. Feinbloom, especially if hospitalists lead the charge. “Hospitalists are the natural choice to champion these initiatives,” Dr. Feinbloom says. “We are the experts on inpatient care and hospital systems, and we understand how important information technology is for managing complicated patients during an acute hospitalization. In addition, these technologies have proven indispensable for communicating among care providers and managing the transition from the inpatient to the outpatient setting—a process that is notorious for errors.”

For more information on CPOE implementation or funding, contact Dr. Feinbloom at dfeinblo@bidmc.harvard.edu.

SHM member David Feinbloom, MD, testified before the Massachusetts Joint Committee on Healthcare Financing and Economic Development and Emerging Technologies on May 5, 2005. Dr. Feinbloom was part of a panel of Massachusetts’ healthcare and information systems leaders advocating for additional funding of a statewide initiative to install Computerized Physician Order Entry (CPOE) systems and other advanced information technologies in each hospital across Massachusetts. Dr. Feinbloom is the director of clinical resource management, Department of Medicine, and physician liaison for Clinical Information Systems Development at Beth Israel Deaconess Medical Center in Boston. Under the leadership of John Halamka, MD, MS, and chief information office of Harvard Medical School and BIDMC, the medical center is a nationally recognized leader in medical information technology.

“The goal of the hearing was to share views about the implementation of advanced technologies like CPOE, one of a series of initiatives to create a statewide medical information technology infrastructure,” says Dr. Feinbloom. “Ultimately, this will include applications such as e-prescribing, online physician-patient communications, and regional data sharing networks, which will improve quality, patient satisfaction, and reduce costs.” He says that currently a parallel initiative for related technologies has a $50 million commitment from Blue Cross and Blue Shield. An additional $210 million is needed to bring inpatient CPOE to all of the hospitals in the state. “We wanted to make sure that the committee understood that despite the seemingly high initial outlay of capital, there is a projected savings of $275 million annually.” The dramatic savings, Dr. Feinbloom says, come from efficiencies in patient throughput, reductions in medication errors and adverse drug events, and improved utilization of inpatient resources. The Massachusetts Technology Collaborative and New England Healthcare Institute are coordinating statewide efforts to remove barriers to inpatient CPOE.

Currently, only 5% to 10% percent of hospitals nationwide have CPOE systems, but that is destined to change, says Dr. Feinbloom, especially if hospitalists lead the charge. “Hospitalists are the natural choice to champion these initiatives,” Dr. Feinbloom says. “We are the experts on inpatient care and hospital systems, and we understand how important information technology is for managing complicated patients during an acute hospitalization. In addition, these technologies have proven indispensable for communicating among care providers and managing the transition from the inpatient to the outpatient setting—a process that is notorious for errors.”

For more information on CPOE implementation or funding, contact Dr. Feinbloom at dfeinblo@bidmc.harvard.edu.

SHM member David Feinbloom, MD, testified before the Massachusetts Joint Committee on Healthcare Financing and Economic Development and Emerging Technologies on May 5, 2005. Dr. Feinbloom was part of a panel of Massachusetts’ healthcare and information systems leaders advocating for additional funding of a statewide initiative to install Computerized Physician Order Entry (CPOE) systems and other advanced information technologies in each hospital across Massachusetts. Dr. Feinbloom is the director of clinical resource management, Department of Medicine, and physician liaison for Clinical Information Systems Development at Beth Israel Deaconess Medical Center in Boston. Under the leadership of John Halamka, MD, MS, and chief information office of Harvard Medical School and BIDMC, the medical center is a nationally recognized leader in medical information technology.

“The goal of the hearing was to share views about the implementation of advanced technologies like CPOE, one of a series of initiatives to create a statewide medical information technology infrastructure,” says Dr. Feinbloom. “Ultimately, this will include applications such as e-prescribing, online physician-patient communications, and regional data sharing networks, which will improve quality, patient satisfaction, and reduce costs.” He says that currently a parallel initiative for related technologies has a $50 million commitment from Blue Cross and Blue Shield. An additional $210 million is needed to bring inpatient CPOE to all of the hospitals in the state. “We wanted to make sure that the committee understood that despite the seemingly high initial outlay of capital, there is a projected savings of $275 million annually.” The dramatic savings, Dr. Feinbloom says, come from efficiencies in patient throughput, reductions in medication errors and adverse drug events, and improved utilization of inpatient resources. The Massachusetts Technology Collaborative and New England Healthcare Institute are coordinating statewide efforts to remove barriers to inpatient CPOE.

Currently, only 5% to 10% percent of hospitals nationwide have CPOE systems, but that is destined to change, says Dr. Feinbloom, especially if hospitalists lead the charge. “Hospitalists are the natural choice to champion these initiatives,” Dr. Feinbloom says. “We are the experts on inpatient care and hospital systems, and we understand how important information technology is for managing complicated patients during an acute hospitalization. In addition, these technologies have proven indispensable for communicating among care providers and managing the transition from the inpatient to the outpatient setting—a process that is notorious for errors.”

For more information on CPOE implementation or funding, contact Dr. Feinbloom at dfeinblo@bidmc.harvard.edu.

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Contact

Richard Rohr, MD

Milford Hospital

300 Seaside Avenue

Milford, CT 06460

Phone: 203-876-4000

richard.rohr@milfordhospital.org

Staff

Christine Chen, MD

Andrew Chow, MD

Renee Giometti, MD

Richard Rohr, MD

Michael Rudolph, MD

Keith Swan, MD

Yelena Titko, MD

The Milford Hospital Hospitalist Service program started in 1996 with 1 physician hired to provide coordination for inpatient medical care on weekdays. The hospital had previously offered only night coverage provided by moonlighting cardiology fellows. Milford Hospital has 100 beds, does not participate in any medical teaching programs, and competes with 5 teaching hospitals located within 10 miles. The community has traditionally preferred treatment in the local area, but concern about quality of medical services led many local residents to seek treatment at larger hospitals. The hospital had studied the hospitalist concept from its inception, but the medical staff did not immediately embrace the idea and feared encroachment upon their incomes. After several years of steadily increasing the role of the daytime care coordinator, the administration decided to convert the moonlighting positions in 2001 to 5 full-time employed physicians who provide 24-hour coverage in the facility. The medical staff has gradually become more comfortable with the hospitalist concept, although the internists still prefer to treat their own established patients. The community also recognizes the higher level of medical care provided, and the average daily census has nearly doubled since starting the program.

The service has been scheduled with 2 daytime physicians for 8 hours on each weekday, 1 daytime physician for 8 hours on Saturday and Sunday, and 1 physician for 16 hours every night. The staffing pattern was developed to accommodate an active joint replacement service with significant consultation needs on weekdays. The orthopedic service is expanding, and other surgeons have recognized the importance of immediate consultation, particularly as their malpractice premiums rise. The hospital administration has recognized the need for additional staffing, and the service will operate with 2 daytime physicians and 1 nighttime physician every day of the week starting in July 2005. An additional position has been created to meet the personnel needs.

The physicians are employed directly by the hospital and participate in the hospital’s benefit programs, including pension, disability insurance, life insurance, and a malpractice liability trust. There is presently no incentive plan, but the program has achieved a high level of effort from the staff. This is largely due to the culture of the hospital, which is highly collegial and patient-focused. Employees at all levels of the organization are treated well, and staff retention levels are quite high. Out of the first 10 full-time hospitalists hired, 4 are still in the program, 5 have pursued additional training, and 1 left to join her husband in California. One physician hired from a leading academic residency program found it difficult to adjust to a community hospital and resigned prior to year‘s end. The service has not experienced other personnel problems.

The program met its early staffing needs with physicians who had recently completed residency in internal medicine and were waiting to start a fellowship in 1 year. This type of staffing allowed the service to get started but required constant training in billing, continuity of care, and medical staff relations. As the program has become established in the region, it has attracted physicians who have previous experience with traditional private practice but have chosen to concentrate on inpatient care. This has allowed the program director to concentrate on advanced skill building with the staff and to spend less time on recruiting and scheduling.

Physicians are required to work 1,800 hours each year and may work additional hours for extra payment. The service admitted 600 patients (one-fourth of all medical admissions) in 2004 and provided consultation on 800 patients. The service also manages intensive care patients and handles emergencies throughout the hospital; there were 800 critical care visits last year. The staff performed a total of 6,200 billable patient visits in the past year and provided assistance to private physicians on 1,000 additional admissions. The number of billed admissions and visits has been constrained by limited weekend staffing. The service presently carries no more than 12 patients on weekends and up to 20 patients on weekdays. With the new staffing pattern, the service will round on up to 24 patients, with additional patients seen on a 1-time basis. Hospitalists normally admit patients who are not affiliated with a private physician on the hospital staff. When the hospital medicine service reaches its patient cap, private physicians must admit unaffiliated patients in rotation, as they did before the hospitalists were available. This accommodation will remain in place until the hospital medicine service is able to meet the entire demand for inpatient internal medicine services.

Postdischarge care coordination has been a major challenge. Approximately one-third of patients are discharged to nursing homes. Most of the others are affiliated with primary care physicians located in other communities who are not members of the Milford Hospital medical staff. Communication with these physicians has been improved by an electronic record management system that allows automated fax transmission of discharge summaries. Limited outpatient services are available for Medicaid patients and for those without insurance. The hospital medicine service does not provide outpatient care.

Another challenge involves care for critically ill patients. Although there are several physicians with training in pulmonary disease on the private staff, the hospital had not developed effective critical-care services. There are 2 hospitalists with critical-care training, and we have been working with the other staffers to improve their competence in critical care. The hospitalists provide 24-hour response to unstable patients throughout the hospital and have dramatically reduced unexpected mortality.

Future development will focus on improving hospitalist productivity with information technology. The hospital has undertaken installation of an integrated clinical-information system, which will include direct physician order entry and deployment of wireless technology. It is expected that many of the difficulties experienced by other hospitals with physician order entry will be ameliorated by hospitalist involvement, as the staff is comfortable with computer use. We also expect that the hospitalists will develop leadership roles within the medical staff and develop skills in quality improvement.

Contact

Richard Rohr, MD

Milford Hospital

300 Seaside Avenue

Milford, CT 06460

Phone: 203-876-4000

richard.rohr@milfordhospital.org

Staff

Christine Chen, MD

Andrew Chow, MD

Renee Giometti, MD

Richard Rohr, MD

Michael Rudolph, MD

Keith Swan, MD

Yelena Titko, MD

The Milford Hospital Hospitalist Service program started in 1996 with 1 physician hired to provide coordination for inpatient medical care on weekdays. The hospital had previously offered only night coverage provided by moonlighting cardiology fellows. Milford Hospital has 100 beds, does not participate in any medical teaching programs, and competes with 5 teaching hospitals located within 10 miles. The community has traditionally preferred treatment in the local area, but concern about quality of medical services led many local residents to seek treatment at larger hospitals. The hospital had studied the hospitalist concept from its inception, but the medical staff did not immediately embrace the idea and feared encroachment upon their incomes. After several years of steadily increasing the role of the daytime care coordinator, the administration decided to convert the moonlighting positions in 2001 to 5 full-time employed physicians who provide 24-hour coverage in the facility. The medical staff has gradually become more comfortable with the hospitalist concept, although the internists still prefer to treat their own established patients. The community also recognizes the higher level of medical care provided, and the average daily census has nearly doubled since starting the program.

The service has been scheduled with 2 daytime physicians for 8 hours on each weekday, 1 daytime physician for 8 hours on Saturday and Sunday, and 1 physician for 16 hours every night. The staffing pattern was developed to accommodate an active joint replacement service with significant consultation needs on weekdays. The orthopedic service is expanding, and other surgeons have recognized the importance of immediate consultation, particularly as their malpractice premiums rise. The hospital administration has recognized the need for additional staffing, and the service will operate with 2 daytime physicians and 1 nighttime physician every day of the week starting in July 2005. An additional position has been created to meet the personnel needs.

The physicians are employed directly by the hospital and participate in the hospital’s benefit programs, including pension, disability insurance, life insurance, and a malpractice liability trust. There is presently no incentive plan, but the program has achieved a high level of effort from the staff. This is largely due to the culture of the hospital, which is highly collegial and patient-focused. Employees at all levels of the organization are treated well, and staff retention levels are quite high. Out of the first 10 full-time hospitalists hired, 4 are still in the program, 5 have pursued additional training, and 1 left to join her husband in California. One physician hired from a leading academic residency program found it difficult to adjust to a community hospital and resigned prior to year‘s end. The service has not experienced other personnel problems.

The program met its early staffing needs with physicians who had recently completed residency in internal medicine and were waiting to start a fellowship in 1 year. This type of staffing allowed the service to get started but required constant training in billing, continuity of care, and medical staff relations. As the program has become established in the region, it has attracted physicians who have previous experience with traditional private practice but have chosen to concentrate on inpatient care. This has allowed the program director to concentrate on advanced skill building with the staff and to spend less time on recruiting and scheduling.

Physicians are required to work 1,800 hours each year and may work additional hours for extra payment. The service admitted 600 patients (one-fourth of all medical admissions) in 2004 and provided consultation on 800 patients. The service also manages intensive care patients and handles emergencies throughout the hospital; there were 800 critical care visits last year. The staff performed a total of 6,200 billable patient visits in the past year and provided assistance to private physicians on 1,000 additional admissions. The number of billed admissions and visits has been constrained by limited weekend staffing. The service presently carries no more than 12 patients on weekends and up to 20 patients on weekdays. With the new staffing pattern, the service will round on up to 24 patients, with additional patients seen on a 1-time basis. Hospitalists normally admit patients who are not affiliated with a private physician on the hospital staff. When the hospital medicine service reaches its patient cap, private physicians must admit unaffiliated patients in rotation, as they did before the hospitalists were available. This accommodation will remain in place until the hospital medicine service is able to meet the entire demand for inpatient internal medicine services.

Postdischarge care coordination has been a major challenge. Approximately one-third of patients are discharged to nursing homes. Most of the others are affiliated with primary care physicians located in other communities who are not members of the Milford Hospital medical staff. Communication with these physicians has been improved by an electronic record management system that allows automated fax transmission of discharge summaries. Limited outpatient services are available for Medicaid patients and for those without insurance. The hospital medicine service does not provide outpatient care.

Another challenge involves care for critically ill patients. Although there are several physicians with training in pulmonary disease on the private staff, the hospital had not developed effective critical-care services. There are 2 hospitalists with critical-care training, and we have been working with the other staffers to improve their competence in critical care. The hospitalists provide 24-hour response to unstable patients throughout the hospital and have dramatically reduced unexpected mortality.

Future development will focus on improving hospitalist productivity with information technology. The hospital has undertaken installation of an integrated clinical-information system, which will include direct physician order entry and deployment of wireless technology. It is expected that many of the difficulties experienced by other hospitals with physician order entry will be ameliorated by hospitalist involvement, as the staff is comfortable with computer use. We also expect that the hospitalists will develop leadership roles within the medical staff and develop skills in quality improvement.

Contact

Richard Rohr, MD

Milford Hospital

300 Seaside Avenue

Milford, CT 06460

Phone: 203-876-4000

richard.rohr@milfordhospital.org

Staff

Christine Chen, MD

Andrew Chow, MD

Renee Giometti, MD

Richard Rohr, MD

Michael Rudolph, MD

Keith Swan, MD

Yelena Titko, MD

The Milford Hospital Hospitalist Service program started in 1996 with 1 physician hired to provide coordination for inpatient medical care on weekdays. The hospital had previously offered only night coverage provided by moonlighting cardiology fellows. Milford Hospital has 100 beds, does not participate in any medical teaching programs, and competes with 5 teaching hospitals located within 10 miles. The community has traditionally preferred treatment in the local area, but concern about quality of medical services led many local residents to seek treatment at larger hospitals. The hospital had studied the hospitalist concept from its inception, but the medical staff did not immediately embrace the idea and feared encroachment upon their incomes. After several years of steadily increasing the role of the daytime care coordinator, the administration decided to convert the moonlighting positions in 2001 to 5 full-time employed physicians who provide 24-hour coverage in the facility. The medical staff has gradually become more comfortable with the hospitalist concept, although the internists still prefer to treat their own established patients. The community also recognizes the higher level of medical care provided, and the average daily census has nearly doubled since starting the program.

The service has been scheduled with 2 daytime physicians for 8 hours on each weekday, 1 daytime physician for 8 hours on Saturday and Sunday, and 1 physician for 16 hours every night. The staffing pattern was developed to accommodate an active joint replacement service with significant consultation needs on weekdays. The orthopedic service is expanding, and other surgeons have recognized the importance of immediate consultation, particularly as their malpractice premiums rise. The hospital administration has recognized the need for additional staffing, and the service will operate with 2 daytime physicians and 1 nighttime physician every day of the week starting in July 2005. An additional position has been created to meet the personnel needs.

The physicians are employed directly by the hospital and participate in the hospital’s benefit programs, including pension, disability insurance, life insurance, and a malpractice liability trust. There is presently no incentive plan, but the program has achieved a high level of effort from the staff. This is largely due to the culture of the hospital, which is highly collegial and patient-focused. Employees at all levels of the organization are treated well, and staff retention levels are quite high. Out of the first 10 full-time hospitalists hired, 4 are still in the program, 5 have pursued additional training, and 1 left to join her husband in California. One physician hired from a leading academic residency program found it difficult to adjust to a community hospital and resigned prior to year‘s end. The service has not experienced other personnel problems.

The program met its early staffing needs with physicians who had recently completed residency in internal medicine and were waiting to start a fellowship in 1 year. This type of staffing allowed the service to get started but required constant training in billing, continuity of care, and medical staff relations. As the program has become established in the region, it has attracted physicians who have previous experience with traditional private practice but have chosen to concentrate on inpatient care. This has allowed the program director to concentrate on advanced skill building with the staff and to spend less time on recruiting and scheduling.

Physicians are required to work 1,800 hours each year and may work additional hours for extra payment. The service admitted 600 patients (one-fourth of all medical admissions) in 2004 and provided consultation on 800 patients. The service also manages intensive care patients and handles emergencies throughout the hospital; there were 800 critical care visits last year. The staff performed a total of 6,200 billable patient visits in the past year and provided assistance to private physicians on 1,000 additional admissions. The number of billed admissions and visits has been constrained by limited weekend staffing. The service presently carries no more than 12 patients on weekends and up to 20 patients on weekdays. With the new staffing pattern, the service will round on up to 24 patients, with additional patients seen on a 1-time basis. Hospitalists normally admit patients who are not affiliated with a private physician on the hospital staff. When the hospital medicine service reaches its patient cap, private physicians must admit unaffiliated patients in rotation, as they did before the hospitalists were available. This accommodation will remain in place until the hospital medicine service is able to meet the entire demand for inpatient internal medicine services.

Postdischarge care coordination has been a major challenge. Approximately one-third of patients are discharged to nursing homes. Most of the others are affiliated with primary care physicians located in other communities who are not members of the Milford Hospital medical staff. Communication with these physicians has been improved by an electronic record management system that allows automated fax transmission of discharge summaries. Limited outpatient services are available for Medicaid patients and for those without insurance. The hospital medicine service does not provide outpatient care.

Another challenge involves care for critically ill patients. Although there are several physicians with training in pulmonary disease on the private staff, the hospital had not developed effective critical-care services. There are 2 hospitalists with critical-care training, and we have been working with the other staffers to improve their competence in critical care. The hospitalists provide 24-hour response to unstable patients throughout the hospital and have dramatically reduced unexpected mortality.

Future development will focus on improving hospitalist productivity with information technology. The hospital has undertaken installation of an integrated clinical-information system, which will include direct physician order entry and deployment of wireless technology. It is expected that many of the difficulties experienced by other hospitals with physician order entry will be ameliorated by hospitalist involvement, as the staff is comfortable with computer use. We also expect that the hospitalists will develop leadership roles within the medical staff and develop skills in quality improvement.

Worker claims therapist disclosed confidential information

Cook County (IL) Circuit Court

A public works employee in Illinois received psychotherapy through his city’s wellness program. After the man left his position, he claimed in court that the treating therapist met with his former co-workers, disclosed his receipt of therapy to them, and told them he was unstable and capable of harming himself or others. The former employee argued that the disclosures violated Illinois law, caused him emotional distress, and made him unable to trust mental health professionals.

The defense denied that the therapist had violated the law or had made any disclosures. Instead, the defense argued that the co-workers—not the therapist—had voiced concern about the plaintiff. The defense maintained that the co-workers were confused about who had discussed the plaintiff, and that the therapist had not discussed him.

• The jury found for the defense.
  

Dr. Grant’s observations

The courts have recognized and protected the fundamental importance of confidentiality in the therapist/patient relationship.^{How to avoid ‘foreseeable’ harm,” Current Psychiatry, March 2005, at www.currentpsychiatry.com).}

Here, the request for consultation might suggest that an honest error in judgment occurred—the psychiatrist was simply puzzled by the patient’s medical symptoms. Although several doctors failed to diagnose NMS, shouldn’t the psychiatrists have been able to diagnose it?

NMS is a side-effect risk of atypical and conventional neuroleptics,^{Pearls: Identifying NMS with FEVER,”).}

The psychiatrists in this case did not conform to the standard of care, and consulting with another doctor did not absolve them of liability.

Worker claims therapist disclosed confidential information

Cook County (IL) Circuit Court

A public works employee in Illinois received psychotherapy through his city’s wellness program. After the man left his position, he claimed in court that the treating therapist met with his former co-workers, disclosed his receipt of therapy to them, and told them he was unstable and capable of harming himself or others. The former employee argued that the disclosures violated Illinois law, caused him emotional distress, and made him unable to trust mental health professionals.

The defense denied that the therapist had violated the law or had made any disclosures. Instead, the defense argued that the co-workers—not the therapist—had voiced concern about the plaintiff. The defense maintained that the co-workers were confused about who had discussed the plaintiff, and that the therapist had not discussed him.

• The jury found for the defense.
  

Dr. Grant’s observations

The courts have recognized and protected the fundamental importance of confidentiality in the therapist/patient relationship.^{How to avoid ‘foreseeable’ harm,” Current Psychiatry, March 2005, at www.currentpsychiatry.com).}

Here, the request for consultation might suggest that an honest error in judgment occurred—the psychiatrist was simply puzzled by the patient’s medical symptoms. Although several doctors failed to diagnose NMS, shouldn’t the psychiatrists have been able to diagnose it?

NMS is a side-effect risk of atypical and conventional neuroleptics,^{Pearls: Identifying NMS with FEVER,”).}

The psychiatrists in this case did not conform to the standard of care, and consulting with another doctor did not absolve them of liability.

Worker claims therapist disclosed confidential information

Cook County (IL) Circuit Court

A public works employee in Illinois received psychotherapy through his city’s wellness program. After the man left his position, he claimed in court that the treating therapist met with his former co-workers, disclosed his receipt of therapy to them, and told them he was unstable and capable of harming himself or others. The former employee argued that the disclosures violated Illinois law, caused him emotional distress, and made him unable to trust mental health professionals.

The defense denied that the therapist had violated the law or had made any disclosures. Instead, the defense argued that the co-workers—not the therapist—had voiced concern about the plaintiff. The defense maintained that the co-workers were confused about who had discussed the plaintiff, and that the therapist had not discussed him.

• The jury found for the defense.
  

Dr. Grant’s observations

The courts have recognized and protected the fundamental importance of confidentiality in the therapist/patient relationship.^{How to avoid ‘foreseeable’ harm,” Current Psychiatry, March 2005, at www.currentpsychiatry.com).}

Here, the request for consultation might suggest that an honest error in judgment occurred—the psychiatrist was simply puzzled by the patient’s medical symptoms. Although several doctors failed to diagnose NMS, shouldn’t the psychiatrists have been able to diagnose it?

NMS is a side-effect risk of atypical and conventional neuroleptics,^{Pearls: Identifying NMS with FEVER,”).}

The psychiatrists in this case did not conform to the standard of care, and consulting with another doctor did not absolve them of liability.

Coronary-Artery Revascularization Before Elective Major Vascular Sugery

McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2861-3.

Cardiac risk stratification and treatment prior to non-cardiac surgery is a frequent reason for medical consultation, and yet the optimal approach to managing these patients remains controversial. National guidelines, based on expert opinion and inferred from published data, suggest that preoperative cardiac revascularization be reserved for patients with unstable coronary syndromes or for whom coronary artery bypass grad ing has been shown to improve mortality. Despite these recommendations, there remains considerable variability in clinical practice, which is compounded by a paucity of prospective randomized trials to validate one approach over another.

In this multicenter randomized controlled trial, McFalls et al. studied whether coronary artery revascularization prior to elective vascular surgery would reduce mortality among a cohort of patients with angiographically documented stable coronary artery disease. The investigators evaluated 5859 patients from 18 centers scheduled for abdominal aortic aneurysm or lower extremity vascular surgery. Patients felt to be at high risk for perioperative cardiac complications based on cardiology consultation, established clinical criteria, or the presence of ischemia on stress imaging studies were referred for coronary angiography. Of this cohort, 4669 (80%) were excluded due to subsequent determination of insufficient cardiac risk (28%), urgent need for vascular surgery (18%), severe comorbid illness (13%), patient preference (11%), or prior revascularization without new ischemia (11%). Of the 1190 patients who underwent angiography, 680 were excluded due to protocol criteria including: the absence of obstructive coronary artery disease (54%), coronary disease not amenable to revascularization (32%), led main artery stenosis ≥ 50% (8%), led ventricular ejection fraction <20% (2%), or severe aortic stenosis (AVA<1.0 cm²) (1%).

Of the 510 patients who remained, 252 were randomized to proceed with vascular surgery with optimal medical management, of which 9 crossed over due to the need for urgent cardiac revascularization. Two hundred fifty-eight patients were randomized to elective preoperative revascularization; 99 underwent CABG, 141 underwent PCI, and 18 were excluded due to need for urgent vascular surgery, patient preference, or in one case, stroke. Both groups were similar with respect to baseline clinical variables, including the incidence of previous myocardial infarction, congestive heart failure, diabetes mellitus, led ventricular ejection fraction, and 3vessel coronary artery disease. They were also similar in the use of perioperative betablockers (~ 85%), statins, and aspirin.

At 2.7 years after randomization, mortality was 22% in the revascularization group and 22% in the medical management group, the relative risk was 0.98 (95% CI 0.7-1.37; p=.92), which was not statistically significant. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the medical management group not undergoing revascularization (p<.001). Although not designed to address short-term outcomes, there were no differences in the rates of early postoperative myocardial infarction, death, or hospital length of stay. It is also worth noting that 316 of the 510 patients who were ultimately randomized had undergone nuclear imaging studies, of which 226 (72%) had moderate to large reversible perfusion defects detected. These outcome data suggest that the presence of reversible perfusions defects is not in itself a reason for preoperative revascularization.

This well-designed study demonstrates that in the absence of unstable coronary syndromes, led main disease, severe aortic stenosis, or severely depressed led ventricular ejection fraction, there is no morbidity or mortality benefit to revascularization among patients with stable coronary artery disease prior to vascular surgery. Because vascular surgery is the highest risk category among non-cardiac procedures, it may be reasonable to extend these findings to lower risk surgeries as well, and in this sense this study is particularly relevant to consultative practice. While this study provides clear evidence on how to manage this cohort of patients, it remains unclear what the optimal strategy is to identify and manage those patients who were excluded from the trial. (DF)

Amiodarone or a Implantable Cardioverter-Defibrilator for Congestive Heart Failure

Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005 20;352:225-37.

Ventricular arrhythmias are the leading cause of sudden cardiac death in patients with systolic heart failure. Treatment with antiarrhythmic drug therapy has failed to improve survival in these patients, due to their proarrhythmic effects. Unlike other antiarrhythmics, amiodarone is a drug with low proarrhythmic effects. Some studies have suggested that amiodarone may be beneficial in patients with systolic heart failure. Conversely, several primary and secondary prevention trials have demonstrated that placement of an implantable cardioverter-defibrillator (ICD) confers a survival benefit in patients with ischemic cardiomyopathy. However, the role of ICDs in nonischemic heart failure remained unproven.

Bardy and colleagues developed the Sudden Cardiac Death in Heart Failure Trial (SCDHeFT) to evaluate the hypothesis that treatment with amiodarone or a shock-only, single-lead ICD would decrease death from any cause in a population of patients with mild to moderate heart failure. They randomly assigned 2521 patients with New York Heart Association (NYHA) class II or II heart failure (and a led ventricular ejection fraction (LVEF) of 35% or less to conventional medical therapy plus placebo, conventional therapy plus treatment with amiodarone or conventional therapy plus a conservatively programmed, shock-only, single-lead ICD.

Fifty-two percent of patients had ischemic heart failure and 48% had nonischemic heart failure. Placebo and amiodarone were given in double-blind fashion. The primary endpoint was death from any cause with a median followup of 45.5 months. The results were as follows:

Placebo Group - 244 deaths (29% Death Rate)

Amiodarone Group - 240 deaths (28% Death Rate)

ICD Group - 182 deaths (22% Death Rate)

Patients treated with amiodarone had a similar risk of death as those who received placebo (hazard ratio, 1.06; 97.5% CI: 0.86–1.30; p=0.53). Patients implanted with an ICD had a 23% decreased risk of death when compared with those who received placebo (0.77; 97.5% CI: 0.62–0.96; p=.007). This resulted in an absolute risk reduction of 7.2% at 5 years. The authors concluded that in patients with NYHA class II or III heart failure and a LVEF of 35% or less, implantation of a single-lead, shock-only ICD reduced overall mortality by 23%, while treatment with amiodarone had no effect on survival. The benefit of ICD placement reached or approached significance in both the ischemic (hazard ratio .79, CI: 0.60–1.04, p= .05) and nonischemic (hazard ratio 0.73, CI: 0.50–1.07, p= 0.06) subgroups.

It is important to note that an additional subgroup analysis showed that ICD therapy had a significant survival benefit only in NYHA class II patients but not in NYHA class III patients. Amiodarone therapy had no benefit in class II patients and actually decreased survival in class III patients compared to those receiving placebo. In light of results from previous trials that demonstrated a greater survival benefit from ICD placement with worsening ejection fraction in patients with ischemic heart failure, the authors were unable to explain whether the differences in subclasses were biologically plausible.

This study is important for several reasons. First, it suggested that patients with systolic heart failure due to either ischemic or non ischemic causes would benefit from placement of an ICD. Second, these results support the conclusions of previous trials that demonstrate a survival advantage of ICD placement in patients with ischemic heart failure. Finally, this study also demonstrates that amiodarone therapy offers no survival benefit in this population of patients. (JL)

Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding

Chan F, Ching J, Hung L, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005;352:238-44.

The optimal choice of antiplatelet therapy for patients with coronary heart disease who have had a recent upper gastrointestinal hemorrhage has not been well studied. Clopidogrel has been shown to cause fewer episodes of gastrointestinal hemorrhage than aspirin, but it is unknown whether clopidogrel monotherapy is in fact superior to aspirin plus a protonpump inhibitor. In this prospective, randomized, doubleblind trial, Chan and colleagues hypothesize that clopidogrel monotherapy would “not be inferior” to aspirin plus esomeprazole in a population of patients who had recovered from aspirin-induced hemorrhagic ulcers.

The study population was drawn from patients taking aspirin who were evaluated for an upper gastrointestinal bleed and had ulcer disease documented on endoscopy. Patients with documented Helicobacter pylori infection were treated with a 1-week course of a standard triple-drug regimen. All subjects, regardless of H. pylori status, were treated with an 8-week course of proton-pump inhibitors (PPI). Inclusion criteria included endoscopic confirmation of ulcer healing and successful eradication of H. pylori, if it was present. The location of the ulcers was not specified in the study.

Exclusion criteria included use of nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors, anticoagulant drugs, corticosteroids, or other anti-platelet agents; history of gastric surgery; presence of erosive esophagitis; gastric outlet obstruction; cancer; need for dialysis; or terminal illness.

Subjects who met the inclusion criteria were randomized to receive either 75 mg of clopidogrel and placebo or 80 mg of aspirin daily plus 20 mg of esomeprazole twice a day for a 12 months. Patients returned for evaluation every 3 months during the 1-year study period. The primary endpoint was recurrence of ulcer bleeding, which was predefined as clinical or laboratory evidence of gastrointestinal hemorrhage with a documented recurrence of ulcers on endoscopy. Lower gastrointestinal bleeding was a secondary endpoint.

Of 492 consecutive patients who were evaluated, 320 met inclusion criteria and were evenly divided into the clopidogrel plus placebo or the aspirin plus esomeprazole arms. Only 3 patients were lost to followup. During the study period, 34 cases of suspected gastrointestinal hemorrhage (defined as hematemesis, melena, or 2 g/dL decrease of hemoglobin) were identified. During endoscopy,14 cases were confirmed to be due to recurrent ulcer bleeding. Of these, 13 ulcers were in the clopidogrel arm (6 gastric ulcers, 5 duodenal, and 2 both) and 1 ulcer (duodenal) in the aspirin plus esomeprazole arm, a statistically significant difference (p=.001).

Fourteen patients were determined to have a lower gastrointestinal hemorrhage. Interestingly, these cases were evenly divided between the clopidogrel group (7 cases) and the aspirin plus esomeprazole (7 cases). This finding suggests the effect of esomeprazole in this study may be specific in preventing recurrent upper gastrointestinal ulcer formation and hemorrhage. The 2 groups had equivalent rates of recurrent ischemic events.

This study addresses an important clinical question, frequently encountered by hospitalists. The recommendation that clopidogrel be used instead of aspirin in patients who require antiplatelet therapy but have a history of upper gastrointestinal hemorrhage is based on studies using high-dose (325 mg) aspirin and excluded patients on acid-suppressing therapy. However, this study failed to prove noninferiority of clopidogrel to aspirin and esomeprazole for this indication. Although this study was not designed to show superiority of aspirin and esomeprazole over clopidogrel, these results indicate that this may be the case, and such a study would be timely. (CG)

Coronary-Artery Revascularization Before Elective Major Vascular Sugery

McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2861-3.

Cardiac risk stratification and treatment prior to non-cardiac surgery is a frequent reason for medical consultation, and yet the optimal approach to managing these patients remains controversial. National guidelines, based on expert opinion and inferred from published data, suggest that preoperative cardiac revascularization be reserved for patients with unstable coronary syndromes or for whom coronary artery bypass grad ing has been shown to improve mortality. Despite these recommendations, there remains considerable variability in clinical practice, which is compounded by a paucity of prospective randomized trials to validate one approach over another.

In this multicenter randomized controlled trial, McFalls et al. studied whether coronary artery revascularization prior to elective vascular surgery would reduce mortality among a cohort of patients with angiographically documented stable coronary artery disease. The investigators evaluated 5859 patients from 18 centers scheduled for abdominal aortic aneurysm or lower extremity vascular surgery. Patients felt to be at high risk for perioperative cardiac complications based on cardiology consultation, established clinical criteria, or the presence of ischemia on stress imaging studies were referred for coronary angiography. Of this cohort, 4669 (80%) were excluded due to subsequent determination of insufficient cardiac risk (28%), urgent need for vascular surgery (18%), severe comorbid illness (13%), patient preference (11%), or prior revascularization without new ischemia (11%). Of the 1190 patients who underwent angiography, 680 were excluded due to protocol criteria including: the absence of obstructive coronary artery disease (54%), coronary disease not amenable to revascularization (32%), led main artery stenosis ≥ 50% (8%), led ventricular ejection fraction <20% (2%), or severe aortic stenosis (AVA<1.0 cm²) (1%).

Of the 510 patients who remained, 252 were randomized to proceed with vascular surgery with optimal medical management, of which 9 crossed over due to the need for urgent cardiac revascularization. Two hundred fifty-eight patients were randomized to elective preoperative revascularization; 99 underwent CABG, 141 underwent PCI, and 18 were excluded due to need for urgent vascular surgery, patient preference, or in one case, stroke. Both groups were similar with respect to baseline clinical variables, including the incidence of previous myocardial infarction, congestive heart failure, diabetes mellitus, led ventricular ejection fraction, and 3vessel coronary artery disease. They were also similar in the use of perioperative betablockers (~ 85%), statins, and aspirin.

At 2.7 years after randomization, mortality was 22% in the revascularization group and 22% in the medical management group, the relative risk was 0.98 (95% CI 0.7-1.37; p=.92), which was not statistically significant. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the medical management group not undergoing revascularization (p<.001). Although not designed to address short-term outcomes, there were no differences in the rates of early postoperative myocardial infarction, death, or hospital length of stay. It is also worth noting that 316 of the 510 patients who were ultimately randomized had undergone nuclear imaging studies, of which 226 (72%) had moderate to large reversible perfusion defects detected. These outcome data suggest that the presence of reversible perfusions defects is not in itself a reason for preoperative revascularization.

This well-designed study demonstrates that in the absence of unstable coronary syndromes, led main disease, severe aortic stenosis, or severely depressed led ventricular ejection fraction, there is no morbidity or mortality benefit to revascularization among patients with stable coronary artery disease prior to vascular surgery. Because vascular surgery is the highest risk category among non-cardiac procedures, it may be reasonable to extend these findings to lower risk surgeries as well, and in this sense this study is particularly relevant to consultative practice. While this study provides clear evidence on how to manage this cohort of patients, it remains unclear what the optimal strategy is to identify and manage those patients who were excluded from the trial. (DF)

Amiodarone or a Implantable Cardioverter-Defibrilator for Congestive Heart Failure

Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005 20;352:225-37.

Ventricular arrhythmias are the leading cause of sudden cardiac death in patients with systolic heart failure. Treatment with antiarrhythmic drug therapy has failed to improve survival in these patients, due to their proarrhythmic effects. Unlike other antiarrhythmics, amiodarone is a drug with low proarrhythmic effects. Some studies have suggested that amiodarone may be beneficial in patients with systolic heart failure. Conversely, several primary and secondary prevention trials have demonstrated that placement of an implantable cardioverter-defibrillator (ICD) confers a survival benefit in patients with ischemic cardiomyopathy. However, the role of ICDs in nonischemic heart failure remained unproven.

Bardy and colleagues developed the Sudden Cardiac Death in Heart Failure Trial (SCDHeFT) to evaluate the hypothesis that treatment with amiodarone or a shock-only, single-lead ICD would decrease death from any cause in a population of patients with mild to moderate heart failure. They randomly assigned 2521 patients with New York Heart Association (NYHA) class II or II heart failure (and a led ventricular ejection fraction (LVEF) of 35% or less to conventional medical therapy plus placebo, conventional therapy plus treatment with amiodarone or conventional therapy plus a conservatively programmed, shock-only, single-lead ICD.

Fifty-two percent of patients had ischemic heart failure and 48% had nonischemic heart failure. Placebo and amiodarone were given in double-blind fashion. The primary endpoint was death from any cause with a median followup of 45.5 months. The results were as follows:

Placebo Group - 244 deaths (29% Death Rate)

Amiodarone Group - 240 deaths (28% Death Rate)

ICD Group - 182 deaths (22% Death Rate)

Patients treated with amiodarone had a similar risk of death as those who received placebo (hazard ratio, 1.06; 97.5% CI: 0.86–1.30; p=0.53). Patients implanted with an ICD had a 23% decreased risk of death when compared with those who received placebo (0.77; 97.5% CI: 0.62–0.96; p=.007). This resulted in an absolute risk reduction of 7.2% at 5 years. The authors concluded that in patients with NYHA class II or III heart failure and a LVEF of 35% or less, implantation of a single-lead, shock-only ICD reduced overall mortality by 23%, while treatment with amiodarone had no effect on survival. The benefit of ICD placement reached or approached significance in both the ischemic (hazard ratio .79, CI: 0.60–1.04, p= .05) and nonischemic (hazard ratio 0.73, CI: 0.50–1.07, p= 0.06) subgroups.

It is important to note that an additional subgroup analysis showed that ICD therapy had a significant survival benefit only in NYHA class II patients but not in NYHA class III patients. Amiodarone therapy had no benefit in class II patients and actually decreased survival in class III patients compared to those receiving placebo. In light of results from previous trials that demonstrated a greater survival benefit from ICD placement with worsening ejection fraction in patients with ischemic heart failure, the authors were unable to explain whether the differences in subclasses were biologically plausible.

This study is important for several reasons. First, it suggested that patients with systolic heart failure due to either ischemic or non ischemic causes would benefit from placement of an ICD. Second, these results support the conclusions of previous trials that demonstrate a survival advantage of ICD placement in patients with ischemic heart failure. Finally, this study also demonstrates that amiodarone therapy offers no survival benefit in this population of patients. (JL)

Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding

Chan F, Ching J, Hung L, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005;352:238-44.

The optimal choice of antiplatelet therapy for patients with coronary heart disease who have had a recent upper gastrointestinal hemorrhage has not been well studied. Clopidogrel has been shown to cause fewer episodes of gastrointestinal hemorrhage than aspirin, but it is unknown whether clopidogrel monotherapy is in fact superior to aspirin plus a protonpump inhibitor. In this prospective, randomized, doubleblind trial, Chan and colleagues hypothesize that clopidogrel monotherapy would “not be inferior” to aspirin plus esomeprazole in a population of patients who had recovered from aspirin-induced hemorrhagic ulcers.

The study population was drawn from patients taking aspirin who were evaluated for an upper gastrointestinal bleed and had ulcer disease documented on endoscopy. Patients with documented Helicobacter pylori infection were treated with a 1-week course of a standard triple-drug regimen. All subjects, regardless of H. pylori status, were treated with an 8-week course of proton-pump inhibitors (PPI). Inclusion criteria included endoscopic confirmation of ulcer healing and successful eradication of H. pylori, if it was present. The location of the ulcers was not specified in the study.

Exclusion criteria included use of nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors, anticoagulant drugs, corticosteroids, or other anti-platelet agents; history of gastric surgery; presence of erosive esophagitis; gastric outlet obstruction; cancer; need for dialysis; or terminal illness.

Subjects who met the inclusion criteria were randomized to receive either 75 mg of clopidogrel and placebo or 80 mg of aspirin daily plus 20 mg of esomeprazole twice a day for a 12 months. Patients returned for evaluation every 3 months during the 1-year study period. The primary endpoint was recurrence of ulcer bleeding, which was predefined as clinical or laboratory evidence of gastrointestinal hemorrhage with a documented recurrence of ulcers on endoscopy. Lower gastrointestinal bleeding was a secondary endpoint.

Of 492 consecutive patients who were evaluated, 320 met inclusion criteria and were evenly divided into the clopidogrel plus placebo or the aspirin plus esomeprazole arms. Only 3 patients were lost to followup. During the study period, 34 cases of suspected gastrointestinal hemorrhage (defined as hematemesis, melena, or 2 g/dL decrease of hemoglobin) were identified. During endoscopy,14 cases were confirmed to be due to recurrent ulcer bleeding. Of these, 13 ulcers were in the clopidogrel arm (6 gastric ulcers, 5 duodenal, and 2 both) and 1 ulcer (duodenal) in the aspirin plus esomeprazole arm, a statistically significant difference (p=.001).

Fourteen patients were determined to have a lower gastrointestinal hemorrhage. Interestingly, these cases were evenly divided between the clopidogrel group (7 cases) and the aspirin plus esomeprazole (7 cases). This finding suggests the effect of esomeprazole in this study may be specific in preventing recurrent upper gastrointestinal ulcer formation and hemorrhage. The 2 groups had equivalent rates of recurrent ischemic events.

This study addresses an important clinical question, frequently encountered by hospitalists. The recommendation that clopidogrel be used instead of aspirin in patients who require antiplatelet therapy but have a history of upper gastrointestinal hemorrhage is based on studies using high-dose (325 mg) aspirin and excluded patients on acid-suppressing therapy. However, this study failed to prove noninferiority of clopidogrel to aspirin and esomeprazole for this indication. Although this study was not designed to show superiority of aspirin and esomeprazole over clopidogrel, these results indicate that this may be the case, and such a study would be timely. (CG)

Coronary-Artery Revascularization Before Elective Major Vascular Sugery

McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2861-3.

Cardiac risk stratification and treatment prior to non-cardiac surgery is a frequent reason for medical consultation, and yet the optimal approach to managing these patients remains controversial. National guidelines, based on expert opinion and inferred from published data, suggest that preoperative cardiac revascularization be reserved for patients with unstable coronary syndromes or for whom coronary artery bypass grad ing has been shown to improve mortality. Despite these recommendations, there remains considerable variability in clinical practice, which is compounded by a paucity of prospective randomized trials to validate one approach over another.

In this multicenter randomized controlled trial, McFalls et al. studied whether coronary artery revascularization prior to elective vascular surgery would reduce mortality among a cohort of patients with angiographically documented stable coronary artery disease. The investigators evaluated 5859 patients from 18 centers scheduled for abdominal aortic aneurysm or lower extremity vascular surgery. Patients felt to be at high risk for perioperative cardiac complications based on cardiology consultation, established clinical criteria, or the presence of ischemia on stress imaging studies were referred for coronary angiography. Of this cohort, 4669 (80%) were excluded due to subsequent determination of insufficient cardiac risk (28%), urgent need for vascular surgery (18%), severe comorbid illness (13%), patient preference (11%), or prior revascularization without new ischemia (11%). Of the 1190 patients who underwent angiography, 680 were excluded due to protocol criteria including: the absence of obstructive coronary artery disease (54%), coronary disease not amenable to revascularization (32%), led main artery stenosis ≥ 50% (8%), led ventricular ejection fraction <20% (2%), or severe aortic stenosis (AVA<1.0 cm²) (1%).

Of the 510 patients who remained, 252 were randomized to proceed with vascular surgery with optimal medical management, of which 9 crossed over due to the need for urgent cardiac revascularization. Two hundred fifty-eight patients were randomized to elective preoperative revascularization; 99 underwent CABG, 141 underwent PCI, and 18 were excluded due to need for urgent vascular surgery, patient preference, or in one case, stroke. Both groups were similar with respect to baseline clinical variables, including the incidence of previous myocardial infarction, congestive heart failure, diabetes mellitus, led ventricular ejection fraction, and 3vessel coronary artery disease. They were also similar in the use of perioperative betablockers (~ 85%), statins, and aspirin.

At 2.7 years after randomization, mortality was 22% in the revascularization group and 22% in the medical management group, the relative risk was 0.98 (95% CI 0.7-1.37; p=.92), which was not statistically significant. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the medical management group not undergoing revascularization (p<.001). Although not designed to address short-term outcomes, there were no differences in the rates of early postoperative myocardial infarction, death, or hospital length of stay. It is also worth noting that 316 of the 510 patients who were ultimately randomized had undergone nuclear imaging studies, of which 226 (72%) had moderate to large reversible perfusion defects detected. These outcome data suggest that the presence of reversible perfusions defects is not in itself a reason for preoperative revascularization.

This well-designed study demonstrates that in the absence of unstable coronary syndromes, led main disease, severe aortic stenosis, or severely depressed led ventricular ejection fraction, there is no morbidity or mortality benefit to revascularization among patients with stable coronary artery disease prior to vascular surgery. Because vascular surgery is the highest risk category among non-cardiac procedures, it may be reasonable to extend these findings to lower risk surgeries as well, and in this sense this study is particularly relevant to consultative practice. While this study provides clear evidence on how to manage this cohort of patients, it remains unclear what the optimal strategy is to identify and manage those patients who were excluded from the trial. (DF)

Amiodarone or a Implantable Cardioverter-Defibrilator for Congestive Heart Failure

Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005 20;352:225-37.

Ventricular arrhythmias are the leading cause of sudden cardiac death in patients with systolic heart failure. Treatment with antiarrhythmic drug therapy has failed to improve survival in these patients, due to their proarrhythmic effects. Unlike other antiarrhythmics, amiodarone is a drug with low proarrhythmic effects. Some studies have suggested that amiodarone may be beneficial in patients with systolic heart failure. Conversely, several primary and secondary prevention trials have demonstrated that placement of an implantable cardioverter-defibrillator (ICD) confers a survival benefit in patients with ischemic cardiomyopathy. However, the role of ICDs in nonischemic heart failure remained unproven.

Bardy and colleagues developed the Sudden Cardiac Death in Heart Failure Trial (SCDHeFT) to evaluate the hypothesis that treatment with amiodarone or a shock-only, single-lead ICD would decrease death from any cause in a population of patients with mild to moderate heart failure. They randomly assigned 2521 patients with New York Heart Association (NYHA) class II or II heart failure (and a led ventricular ejection fraction (LVEF) of 35% or less to conventional medical therapy plus placebo, conventional therapy plus treatment with amiodarone or conventional therapy plus a conservatively programmed, shock-only, single-lead ICD.

Fifty-two percent of patients had ischemic heart failure and 48% had nonischemic heart failure. Placebo and amiodarone were given in double-blind fashion. The primary endpoint was death from any cause with a median followup of 45.5 months. The results were as follows:

Placebo Group - 244 deaths (29% Death Rate)

Amiodarone Group - 240 deaths (28% Death Rate)

ICD Group - 182 deaths (22% Death Rate)

Patients treated with amiodarone had a similar risk of death as those who received placebo (hazard ratio, 1.06; 97.5% CI: 0.86–1.30; p=0.53). Patients implanted with an ICD had a 23% decreased risk of death when compared with those who received placebo (0.77; 97.5% CI: 0.62–0.96; p=.007). This resulted in an absolute risk reduction of 7.2% at 5 years. The authors concluded that in patients with NYHA class II or III heart failure and a LVEF of 35% or less, implantation of a single-lead, shock-only ICD reduced overall mortality by 23%, while treatment with amiodarone had no effect on survival. The benefit of ICD placement reached or approached significance in both the ischemic (hazard ratio .79, CI: 0.60–1.04, p= .05) and nonischemic (hazard ratio 0.73, CI: 0.50–1.07, p= 0.06) subgroups.

It is important to note that an additional subgroup analysis showed that ICD therapy had a significant survival benefit only in NYHA class II patients but not in NYHA class III patients. Amiodarone therapy had no benefit in class II patients and actually decreased survival in class III patients compared to those receiving placebo. In light of results from previous trials that demonstrated a greater survival benefit from ICD placement with worsening ejection fraction in patients with ischemic heart failure, the authors were unable to explain whether the differences in subclasses were biologically plausible.

This study is important for several reasons. First, it suggested that patients with systolic heart failure due to either ischemic or non ischemic causes would benefit from placement of an ICD. Second, these results support the conclusions of previous trials that demonstrate a survival advantage of ICD placement in patients with ischemic heart failure. Finally, this study also demonstrates that amiodarone therapy offers no survival benefit in this population of patients. (JL)

Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding

Chan F, Ching J, Hung L, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005;352:238-44.

The optimal choice of antiplatelet therapy for patients with coronary heart disease who have had a recent upper gastrointestinal hemorrhage has not been well studied. Clopidogrel has been shown to cause fewer episodes of gastrointestinal hemorrhage than aspirin, but it is unknown whether clopidogrel monotherapy is in fact superior to aspirin plus a protonpump inhibitor. In this prospective, randomized, doubleblind trial, Chan and colleagues hypothesize that clopidogrel monotherapy would “not be inferior” to aspirin plus esomeprazole in a population of patients who had recovered from aspirin-induced hemorrhagic ulcers.

The study population was drawn from patients taking aspirin who were evaluated for an upper gastrointestinal bleed and had ulcer disease documented on endoscopy. Patients with documented Helicobacter pylori infection were treated with a 1-week course of a standard triple-drug regimen. All subjects, regardless of H. pylori status, were treated with an 8-week course of proton-pump inhibitors (PPI). Inclusion criteria included endoscopic confirmation of ulcer healing and successful eradication of H. pylori, if it was present. The location of the ulcers was not specified in the study.

Exclusion criteria included use of nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors, anticoagulant drugs, corticosteroids, or other anti-platelet agents; history of gastric surgery; presence of erosive esophagitis; gastric outlet obstruction; cancer; need for dialysis; or terminal illness.

Subjects who met the inclusion criteria were randomized to receive either 75 mg of clopidogrel and placebo or 80 mg of aspirin daily plus 20 mg of esomeprazole twice a day for a 12 months. Patients returned for evaluation every 3 months during the 1-year study period. The primary endpoint was recurrence of ulcer bleeding, which was predefined as clinical or laboratory evidence of gastrointestinal hemorrhage with a documented recurrence of ulcers on endoscopy. Lower gastrointestinal bleeding was a secondary endpoint.

Of 492 consecutive patients who were evaluated, 320 met inclusion criteria and were evenly divided into the clopidogrel plus placebo or the aspirin plus esomeprazole arms. Only 3 patients were lost to followup. During the study period, 34 cases of suspected gastrointestinal hemorrhage (defined as hematemesis, melena, or 2 g/dL decrease of hemoglobin) were identified. During endoscopy,14 cases were confirmed to be due to recurrent ulcer bleeding. Of these, 13 ulcers were in the clopidogrel arm (6 gastric ulcers, 5 duodenal, and 2 both) and 1 ulcer (duodenal) in the aspirin plus esomeprazole arm, a statistically significant difference (p=.001).

Fourteen patients were determined to have a lower gastrointestinal hemorrhage. Interestingly, these cases were evenly divided between the clopidogrel group (7 cases) and the aspirin plus esomeprazole (7 cases). This finding suggests the effect of esomeprazole in this study may be specific in preventing recurrent upper gastrointestinal ulcer formation and hemorrhage. The 2 groups had equivalent rates of recurrent ischemic events.

This study addresses an important clinical question, frequently encountered by hospitalists. The recommendation that clopidogrel be used instead of aspirin in patients who require antiplatelet therapy but have a history of upper gastrointestinal hemorrhage is based on studies using high-dose (325 mg) aspirin and excluded patients on acid-suppressing therapy. However, this study failed to prove noninferiority of clopidogrel to aspirin and esomeprazole for this indication. Although this study was not designed to show superiority of aspirin and esomeprazole over clopidogrel, these results indicate that this may be the case, and such a study would be timely. (CG)

Contact

Mark Kulaga, MD

Associate Program Director

Internal Medicine Residency

Norwalk Hospital

Norwalk, CT 06856

Mark.Kulaga@norwalkhealth.org

Physician Staff

Pamela Charney, MD

Joseph Cleary, MD

Mark Kulaga, MD

Eric Mazur, MD

Stephen O’Mahony, MD

Jason Orlinick, MD, PhD

Andrea Peterson, MD

Other Staff

Michael Marotta, PA

Start Up

July 1999

Hospital Setting

Norwalk Hospital, Norwalk, CT

Academic Community Hospital with 250 beds

Affiliated with Yale University

Patient Population

Our patient population is wonderfully diverse, both economically and socially. Located in the heart of affluent Fairfield County, Norwalk is nevertheless a true small city and home to vibrant communities of African Americans, Latinos, and multiple other immigrant groups. The Hospitalist Clinician-Educator program was originally created to provide inpatient care for indigent patients (who predominantly attend the Norwalk Community Health Center) and for those patients without a local primary care physician. In recent years, as more community internists have chosen to use the hospital medicine service, our payer mix has substantially changed to include many more patients with private insurance and/or Medicare.

Employer

All physicians are general internists employed by the Norwalk Hospital.

Organization/Management

Dr. Eric Mazur, Chairman of the Department of Internal Medicine, is the program founder and administrative leader. He serves as the primary liaison between the hospitalists and the Chief Executive and Operating Officers of the hospital.

Total Number of Patients Served Each Year

On average, each hospitalist admits 350 patients per year. When this threshold is exceeded, a new hospitalist has been added to the group. In the first few years of service, our hospitalists covered 20-25% of the total number of medical admissions to the Norwalk Hospital. As use of the service by local internists has increased, this percentage has grown to 40–45%. It is projected that the Norwalk Hospital hospital medicine service will admit over 2200 patients this year.

Compensation/Schedules

All hospitalists receive a fixed annual salary. The hospital subsidizes 50% of each Hospitalist Clinician Educator position and bills the faculty practice income for the remaining 50%. Faculty practice income is generated through direct patient billing facilitated by a billing agency not affiliated with the hospital. The hospital also provides an annual stipend to the faculty practice for the indigent care supplied by the hospital medicine group. Our compensation model does not utilize an incentive bonus system, although yearly bonuses derived from surplus faculty practice revenue are provided at the discretion of the Chairman.

All hospitalists admit and co-manage patients with resident teams who provide 24/7 in-house coverage. Each hospitalist typically works Monday through Friday from approximately 7–8 a.m. until 5:30–6:30 p.m. depending on patient census. Hospitalists, along with other members of the full time faculty, provide nighttime backup coverage from home for the residents. Weekend coverage responsibilities are also shared with other members of the teaching faculty. Weekend moonlighters, all of whom are board-certified or board-eligible internists from nearby communities, assist full-time faculty members with coverage on Saturdays and Sundays.

Communication Strategies/Role in Education

All of our hospitalists are highly rated by medical residents for their effectiveness as teachers and supervisors. For many, they also serve as important mentors and role models. In addition to traditional educational roles on the inpatient service, our hospitalists have developed several innovative teaching conferences, which include: teaching skills workshops; weekly medical informatics sessions; a monthly medical quiz game incorporating content from core educational conferences; a multidisciplinary Morbidity and Mortality Conference in which residents from the internal medicine and radiology departments are key participants; and a series of conferences in which end-of-life issues and physician professional development are explored in great depth.

Our hospitalists have also established a formal medical consultation service with a specially designed curriculum for the residents. We have also developed a hospital medicine elective where medical residents experience what being a hospitalist is “really like.” This elective has also been used to remediate struggling residents. Our hospitalists also have prominent administrative hospital roles; one is the Director of Graduate Medical Education, and 2 others serve as Associate Program Directors for the Internal Medicine residency. In addition, they have presented their academic work at regional and national meetings of the American College of Physicians and the Society of General Internal Medicine.

Challenges Now and in the Future

Our biggest challenge can be summed up with one word: growth. Up to this point in time, a major strength of our program is that it has been able to grow incrementally and deliberately. We have never “rushed” the hiring of new hospitalists and thus have been able to recruit physicians with similar academic backgrounds and career goals. This has resulted in a cohesive group of hospitalists who support each other in every way and work extremely well together.

A major concern in hospitalist medicine is the concept of “hospitalist burnout.” We have successfully addressed this issue by limiting the number of hospitalist admissions and weekends on call, actively participating in medical education with resident physicians, and serving in important administrative roles within the hospital. As we expand to meet the growing demand for our inpatient care services by primary care physicians, we are finding it more difficult to strike a balance between our service duties and academic interests. We are working closely with our department chairman, who is a true advocate of “hospitalist career building,” to find creative ways to achieve this goal. We believe that it is the balance between service and education that has allowed us to attain a hospitalist retention rate of 100% since the inception of the group.

Goals of Hospital Medicine Group

In addition to providing outstanding patient care and resident teaching, the goals of our group are commensurate with many of the current trends affecting the field of medicine and include:

1. Quality. As quality moves to the forefront of medicine, we believe that hospitalists are the logical champions and effectors of inpatient quality care. Our hospitalists have been involved in a number of quality improvement projects, such as the establishment of multidisciplinary patient rounds, which serve to advance care and achieve high levels of core measure compliance; stroke center development; and the design of inpatient diabetes management protocols. Our hospitalists have also been heavily involved in the implementation of computerized physician order entry at the Norwalk Hospital and have written numerous order sets for specific diagnoses. We expect these projects to result in demonstrably improved quality beyond the improvements in length-of-stay and core-measures adherence already achieved. We believe that our involvement in quality, both now and in the future, adds value to our role as hospitalists from the point of view of hospital administrators. It also provides us with enhanced job satisfaction and multiple opportunities for career development.
2. Patient safety. This is another “hot topic” in the field of medicine where we feel that hospitalists can and should have a substantial impact. As mentioned before, our hospitalists have played prominent roles in the successful implementation of computerized physician order entry, a process that has been shown to result in major improvements in patient safety. Our hospitalists also serve on the patient safety committee and are an important link between residents and ancillary staff when housestaff raise safety concerns. In the future, our hospitalists hope to have an even greater role in such important safety areas as infection control, management of delirium in the elderly, venous thromboembolism prophylaxis in the medical inpatient, and the prevention of patient falls.
3. Research. Clinically and educationally oriented research is encouraged among all full-time hospitalist faculty. We recently published data on the financial and educational benefits of our hospitalist model in the April 2004 issue of the Journal of General Internal Medicine, but we feel that more needs to be done. In particular, we plan to better quantify how hospitalists achieve the reported cost-saving benefits. We also plan to further assess the roles of hospitalists in the education of medical residents in the community setting, a topic that is vastly underrepresented in the medical literature. Hospitalist faculty will also participate in a formal evaluation of the Multidisciplinary Rounds Process and will mentor residents in their personal research projects.

Contact

Mark Kulaga, MD

Associate Program Director

Internal Medicine Residency

Norwalk Hospital

Norwalk, CT 06856

Mark.Kulaga@norwalkhealth.org

Physician Staff

Pamela Charney, MD

Joseph Cleary, MD

Mark Kulaga, MD

Eric Mazur, MD

Stephen O’Mahony, MD

Jason Orlinick, MD, PhD

Andrea Peterson, MD

Other Staff

Michael Marotta, PA

Start Up

July 1999

Hospital Setting

Norwalk Hospital, Norwalk, CT

Academic Community Hospital with 250 beds

Affiliated with Yale University

Patient Population

Our patient population is wonderfully diverse, both economically and socially. Located in the heart of affluent Fairfield County, Norwalk is nevertheless a true small city and home to vibrant communities of African Americans, Latinos, and multiple other immigrant groups. The Hospitalist Clinician-Educator program was originally created to provide inpatient care for indigent patients (who predominantly attend the Norwalk Community Health Center) and for those patients without a local primary care physician. In recent years, as more community internists have chosen to use the hospital medicine service, our payer mix has substantially changed to include many more patients with private insurance and/or Medicare.

Employer

All physicians are general internists employed by the Norwalk Hospital.

Organization/Management

Dr. Eric Mazur, Chairman of the Department of Internal Medicine, is the program founder and administrative leader. He serves as the primary liaison between the hospitalists and the Chief Executive and Operating Officers of the hospital.

Total Number of Patients Served Each Year

On average, each hospitalist admits 350 patients per year. When this threshold is exceeded, a new hospitalist has been added to the group. In the first few years of service, our hospitalists covered 20-25% of the total number of medical admissions to the Norwalk Hospital. As use of the service by local internists has increased, this percentage has grown to 40–45%. It is projected that the Norwalk Hospital hospital medicine service will admit over 2200 patients this year.

Compensation/Schedules

All hospitalists receive a fixed annual salary. The hospital subsidizes 50% of each Hospitalist Clinician Educator position and bills the faculty practice income for the remaining 50%. Faculty practice income is generated through direct patient billing facilitated by a billing agency not affiliated with the hospital. The hospital also provides an annual stipend to the faculty practice for the indigent care supplied by the hospital medicine group. Our compensation model does not utilize an incentive bonus system, although yearly bonuses derived from surplus faculty practice revenue are provided at the discretion of the Chairman.

All hospitalists admit and co-manage patients with resident teams who provide 24/7 in-house coverage. Each hospitalist typically works Monday through Friday from approximately 7–8 a.m. until 5:30–6:30 p.m. depending on patient census. Hospitalists, along with other members of the full time faculty, provide nighttime backup coverage from home for the residents. Weekend coverage responsibilities are also shared with other members of the teaching faculty. Weekend moonlighters, all of whom are board-certified or board-eligible internists from nearby communities, assist full-time faculty members with coverage on Saturdays and Sundays.

Communication Strategies/Role in Education

All of our hospitalists are highly rated by medical residents for their effectiveness as teachers and supervisors. For many, they also serve as important mentors and role models. In addition to traditional educational roles on the inpatient service, our hospitalists have developed several innovative teaching conferences, which include: teaching skills workshops; weekly medical informatics sessions; a monthly medical quiz game incorporating content from core educational conferences; a multidisciplinary Morbidity and Mortality Conference in which residents from the internal medicine and radiology departments are key participants; and a series of conferences in which end-of-life issues and physician professional development are explored in great depth.

Our hospitalists have also established a formal medical consultation service with a specially designed curriculum for the residents. We have also developed a hospital medicine elective where medical residents experience what being a hospitalist is “really like.” This elective has also been used to remediate struggling residents. Our hospitalists also have prominent administrative hospital roles; one is the Director of Graduate Medical Education, and 2 others serve as Associate Program Directors for the Internal Medicine residency. In addition, they have presented their academic work at regional and national meetings of the American College of Physicians and the Society of General Internal Medicine.

Challenges Now and in the Future

Our biggest challenge can be summed up with one word: growth. Up to this point in time, a major strength of our program is that it has been able to grow incrementally and deliberately. We have never “rushed” the hiring of new hospitalists and thus have been able to recruit physicians with similar academic backgrounds and career goals. This has resulted in a cohesive group of hospitalists who support each other in every way and work extremely well together.

A major concern in hospitalist medicine is the concept of “hospitalist burnout.” We have successfully addressed this issue by limiting the number of hospitalist admissions and weekends on call, actively participating in medical education with resident physicians, and serving in important administrative roles within the hospital. As we expand to meet the growing demand for our inpatient care services by primary care physicians, we are finding it more difficult to strike a balance between our service duties and academic interests. We are working closely with our department chairman, who is a true advocate of “hospitalist career building,” to find creative ways to achieve this goal. We believe that it is the balance between service and education that has allowed us to attain a hospitalist retention rate of 100% since the inception of the group.

Goals of Hospital Medicine Group

In addition to providing outstanding patient care and resident teaching, the goals of our group are commensurate with many of the current trends affecting the field of medicine and include:

1. Quality. As quality moves to the forefront of medicine, we believe that hospitalists are the logical champions and effectors of inpatient quality care. Our hospitalists have been involved in a number of quality improvement projects, such as the establishment of multidisciplinary patient rounds, which serve to advance care and achieve high levels of core measure compliance; stroke center development; and the design of inpatient diabetes management protocols. Our hospitalists have also been heavily involved in the implementation of computerized physician order entry at the Norwalk Hospital and have written numerous order sets for specific diagnoses. We expect these projects to result in demonstrably improved quality beyond the improvements in length-of-stay and core-measures adherence already achieved. We believe that our involvement in quality, both now and in the future, adds value to our role as hospitalists from the point of view of hospital administrators. It also provides us with enhanced job satisfaction and multiple opportunities for career development.
2. Patient safety. This is another “hot topic” in the field of medicine where we feel that hospitalists can and should have a substantial impact. As mentioned before, our hospitalists have played prominent roles in the successful implementation of computerized physician order entry, a process that has been shown to result in major improvements in patient safety. Our hospitalists also serve on the patient safety committee and are an important link between residents and ancillary staff when housestaff raise safety concerns. In the future, our hospitalists hope to have an even greater role in such important safety areas as infection control, management of delirium in the elderly, venous thromboembolism prophylaxis in the medical inpatient, and the prevention of patient falls.
3. Research. Clinically and educationally oriented research is encouraged among all full-time hospitalist faculty. We recently published data on the financial and educational benefits of our hospitalist model in the April 2004 issue of the Journal of General Internal Medicine, but we feel that more needs to be done. In particular, we plan to better quantify how hospitalists achieve the reported cost-saving benefits. We also plan to further assess the roles of hospitalists in the education of medical residents in the community setting, a topic that is vastly underrepresented in the medical literature. Hospitalist faculty will also participate in a formal evaluation of the Multidisciplinary Rounds Process and will mentor residents in their personal research projects.

Contact

Mark Kulaga, MD

Associate Program Director

Internal Medicine Residency

Norwalk Hospital

Norwalk, CT 06856

Mark.Kulaga@norwalkhealth.org

Physician Staff

Pamela Charney, MD

Joseph Cleary, MD

Mark Kulaga, MD

Eric Mazur, MD

Stephen O’Mahony, MD

Jason Orlinick, MD, PhD

Andrea Peterson, MD

Other Staff

Michael Marotta, PA

Start Up

July 1999

Hospital Setting

Norwalk Hospital, Norwalk, CT

Academic Community Hospital with 250 beds

Affiliated with Yale University

Patient Population

Our patient population is wonderfully diverse, both economically and socially. Located in the heart of affluent Fairfield County, Norwalk is nevertheless a true small city and home to vibrant communities of African Americans, Latinos, and multiple other immigrant groups. The Hospitalist Clinician-Educator program was originally created to provide inpatient care for indigent patients (who predominantly attend the Norwalk Community Health Center) and for those patients without a local primary care physician. In recent years, as more community internists have chosen to use the hospital medicine service, our payer mix has substantially changed to include many more patients with private insurance and/or Medicare.

Employer

All physicians are general internists employed by the Norwalk Hospital.

Organization/Management

Dr. Eric Mazur, Chairman of the Department of Internal Medicine, is the program founder and administrative leader. He serves as the primary liaison between the hospitalists and the Chief Executive and Operating Officers of the hospital.

Total Number of Patients Served Each Year

On average, each hospitalist admits 350 patients per year. When this threshold is exceeded, a new hospitalist has been added to the group. In the first few years of service, our hospitalists covered 20-25% of the total number of medical admissions to the Norwalk Hospital. As use of the service by local internists has increased, this percentage has grown to 40–45%. It is projected that the Norwalk Hospital hospital medicine service will admit over 2200 patients this year.

Compensation/Schedules

All hospitalists receive a fixed annual salary. The hospital subsidizes 50% of each Hospitalist Clinician Educator position and bills the faculty practice income for the remaining 50%. Faculty practice income is generated through direct patient billing facilitated by a billing agency not affiliated with the hospital. The hospital also provides an annual stipend to the faculty practice for the indigent care supplied by the hospital medicine group. Our compensation model does not utilize an incentive bonus system, although yearly bonuses derived from surplus faculty practice revenue are provided at the discretion of the Chairman.

All hospitalists admit and co-manage patients with resident teams who provide 24/7 in-house coverage. Each hospitalist typically works Monday through Friday from approximately 7–8 a.m. until 5:30–6:30 p.m. depending on patient census. Hospitalists, along with other members of the full time faculty, provide nighttime backup coverage from home for the residents. Weekend coverage responsibilities are also shared with other members of the teaching faculty. Weekend moonlighters, all of whom are board-certified or board-eligible internists from nearby communities, assist full-time faculty members with coverage on Saturdays and Sundays.

Communication Strategies/Role in Education

All of our hospitalists are highly rated by medical residents for their effectiveness as teachers and supervisors. For many, they also serve as important mentors and role models. In addition to traditional educational roles on the inpatient service, our hospitalists have developed several innovative teaching conferences, which include: teaching skills workshops; weekly medical informatics sessions; a monthly medical quiz game incorporating content from core educational conferences; a multidisciplinary Morbidity and Mortality Conference in which residents from the internal medicine and radiology departments are key participants; and a series of conferences in which end-of-life issues and physician professional development are explored in great depth.

Our hospitalists have also established a formal medical consultation service with a specially designed curriculum for the residents. We have also developed a hospital medicine elective where medical residents experience what being a hospitalist is “really like.” This elective has also been used to remediate struggling residents. Our hospitalists also have prominent administrative hospital roles; one is the Director of Graduate Medical Education, and 2 others serve as Associate Program Directors for the Internal Medicine residency. In addition, they have presented their academic work at regional and national meetings of the American College of Physicians and the Society of General Internal Medicine.

Challenges Now and in the Future

Our biggest challenge can be summed up with one word: growth. Up to this point in time, a major strength of our program is that it has been able to grow incrementally and deliberately. We have never “rushed” the hiring of new hospitalists and thus have been able to recruit physicians with similar academic backgrounds and career goals. This has resulted in a cohesive group of hospitalists who support each other in every way and work extremely well together.

A major concern in hospitalist medicine is the concept of “hospitalist burnout.” We have successfully addressed this issue by limiting the number of hospitalist admissions and weekends on call, actively participating in medical education with resident physicians, and serving in important administrative roles within the hospital. As we expand to meet the growing demand for our inpatient care services by primary care physicians, we are finding it more difficult to strike a balance between our service duties and academic interests. We are working closely with our department chairman, who is a true advocate of “hospitalist career building,” to find creative ways to achieve this goal. We believe that it is the balance between service and education that has allowed us to attain a hospitalist retention rate of 100% since the inception of the group.

Goals of Hospital Medicine Group

In addition to providing outstanding patient care and resident teaching, the goals of our group are commensurate with many of the current trends affecting the field of medicine and include:

1. Quality. As quality moves to the forefront of medicine, we believe that hospitalists are the logical champions and effectors of inpatient quality care. Our hospitalists have been involved in a number of quality improvement projects, such as the establishment of multidisciplinary patient rounds, which serve to advance care and achieve high levels of core measure compliance; stroke center development; and the design of inpatient diabetes management protocols. Our hospitalists have also been heavily involved in the implementation of computerized physician order entry at the Norwalk Hospital and have written numerous order sets for specific diagnoses. We expect these projects to result in demonstrably improved quality beyond the improvements in length-of-stay and core-measures adherence already achieved. We believe that our involvement in quality, both now and in the future, adds value to our role as hospitalists from the point of view of hospital administrators. It also provides us with enhanced job satisfaction and multiple opportunities for career development.
2. Patient safety. This is another “hot topic” in the field of medicine where we feel that hospitalists can and should have a substantial impact. As mentioned before, our hospitalists have played prominent roles in the successful implementation of computerized physician order entry, a process that has been shown to result in major improvements in patient safety. Our hospitalists also serve on the patient safety committee and are an important link between residents and ancillary staff when housestaff raise safety concerns. In the future, our hospitalists hope to have an even greater role in such important safety areas as infection control, management of delirium in the elderly, venous thromboembolism prophylaxis in the medical inpatient, and the prevention of patient falls.
3. Research. Clinically and educationally oriented research is encouraged among all full-time hospitalist faculty. We recently published data on the financial and educational benefits of our hospitalist model in the April 2004 issue of the Journal of General Internal Medicine, but we feel that more needs to be done. In particular, we plan to better quantify how hospitalists achieve the reported cost-saving benefits. We also plan to further assess the roles of hospitalists in the education of medical residents in the community setting, a topic that is vastly underrepresented in the medical literature. Hospitalist faculty will also participate in a formal evaluation of the Multidisciplinary Rounds Process and will mentor residents in their personal research projects.

1. Carratala J, FernandezSabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142: 165-72.

The appropriate triage and management of patients with community-acquired pneumonia (CAP) has important implications for patient outcomes and the allocation of health care resources. Despite the availability of validated risk stratification tools significant variability in clinical practice which results in hospitalization rates that are often inconsistent with the severity of illness. In this unblinded, randomized controlled trial, 224 patients with CAP and a low-risk pneumonia severity index (PSI) score between 51 and 90 (class II and III) were randomized to outpatient oral levofloxacin therapy versus inpatient sequential intravenous and oral levofloxacin therapy. Exclusion criteria included quinolone allergy or use within the previous 3 months, PaO₂ < 60 mm Hg, complicated pleural effusion, lung abscess, metastatic infection, inability to maintain oral intake, and severe psychosocial problems precluding outpatient therapy. In an intention-to-treat analysis, the primary endpoints, of cure of pneumonia (resolution of signs, symptoms, and radiographic changes at 30 days), absence of adverse drug reactions, medical complications, or need for hospitalization at 30 days were achieved in 83.6% of outpatients and in 80.7% of hospitalized patients. For the secondary endpoint of patient satisfaction, 91.2% of outpatients versus 79.1% of hospitalized patients (p=.03) were satisfied, but there were no differences between groups with respect to the secondary endpoint of health-related quality of life. Mortality was similar between the 2 groups, and although the study was not sufficiently powered to address this outcome, and interestingly there was trend toward increased medical complications in the hospitalized patients.

Limitations of this study include lack of blinding by investigators and questions about whether the results can be generalized given the geographic variation in microbial susceptibility to quinolone antibiotics. As the authors suggest, this study also highlights limitations in the PSI scoring system, given that patients with clinical findings and comorbidities who would never be treated in the outpatient setting may in fact fall into low-risk PSI categories. These concerns notwithstanding, this study adds to our ability to identify an additional subset of patients with CAP who can be safely managed as outpatients.

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care.Ann Intern Med. 2005;142:260-73.

Early in the hospital medicine movement, when it was clear that hospitalists provided more efficient care than their colleagues, experience was cited as a reason for this difference. If, for example, a hospitalist cares for patients with community-acquired pneumonia daily, he or she is more likely to make the transition to oral antibiotics sooner, resulting in a shorter length of stay. Everyone recognized the hospitalists were younger, but is it plausible their “inexperience” explained the difference in care?

Choudhry and colleagues explored the available data surrounding clinical experience and quality of care delivered by physicians. They found few studies that specifically evaluated the effects of experience on quality of care. They did find articles that looked at quality of care and included experience or age as part of the physician characteristics

that possibly explained the differences. They reviewed 59 articles, available on MEDLINE, published since 1966. Forty-five studies found an inverse relationship between increasing experience and performance. For example, physicians more recently out of training programs were more familiar with evidence-based therapies for myocardial infarction and more familiar with NIH recommendations for treatment of breast cancer. Experienced physicians were less likely to screen for hypertension and more likely to prescribe inappropriate medications for elderly patients. This led them to the unexpected conclusion that experienced physicians may be at risk for providing lower-quality care and may need improvement interventions. An accompanying editorial by Drs. Weinberger, Duffy, and Cassel of the American Board of Internal Medicine stated, “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care.” They urged all physicians to “embrace the concepts behind maintenance of (board) certification.”

The image of Marcus Welby, MD, would lead one to believe that experience promotes higher quality care. But don’t ask a hospitalist: Many aren’t old enough to remember seeing him on television.

3. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969-77.

March was DVT (deep vein thrombosis) Awareness Month. Despite the availability of numerous guidelines, providers fail to consistently prescribe prophylactic measures against venous thromboembolism (VTE) for their hospitalized patients who meet criteria for prophylaxis.

Kucher and colleagues tested an innovative approach to remind providers to undertake such measures for their patients. They designed a computer program to identify hospitalized patients at increased risk for VTE who were not presently receiving VTE prophylaxis. The program reviewed the records of inpatients on the medical and surgical services and assigned a VTE risk score for each patient based on their history (i.e., history of cancer, hypercoagulability, etc.) and their present medical treatment (i.e., hormone therapy, prescribed bed rest, etc.). For patients considered “high risk” for VTE, the computer reviewed orders to identify ongoing use of VTE prophylactic measures. High-risk patients not receiving prophylactic therapies were randomized into 2 groups. The responsible physician in the intervention group received an electronic alert about the risk of VTE in their patient. No alerts were sent to the physicians in the control group. Physicians who received the alerts were forced to acknowledge the alert by either actively withholding prophylaxis or ordering prophylaxis (mechanical or pharmacologic measures). Patients were followed for 90 days with a primary endpoint of clinically diagnosed, objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). The primary endpoint occurred in 8.2% of the control group versus 4.9% in the invention group (p<.001). The alert reduced the risk of DVT or PE at 90 days by 41% (p=.001).

The results of the study are interesting. The authors acknowledged that many physicians had patients in both groups. So receiving 1 alert may have affected their use of prophylaxis in both groups. They also could not eliminate the possibility of diagnostic bias. Prophylaxis was not blinded and VTE testing was not routinely performed. Would physicians be more likely to order an imaging study for symptomatic patients on no prophylaxis than patients on prophylaxis? Nevertheless, for hospitals that have sufficient computer resources, implementation of such alerts can elevate physician awareness about VTE and other clinical conditions.

4. Lau DT, Kasper JD, Pofer DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165: 68-74.

Lau and colleagues studied the impact of potentially inappropriate medications among residents of longtermcare facilities. They used information from a 1996 national survey of home residents. The sample included 3372 residents, 65 years and older, who lived in a nursing home for 3 months or longer. Over half of the residents were older than 85 years old and 75% were female. Only 10% were black. Nearly two thirds had dementia or other mental disorders. The study used the Beers Criteria to define potentially inappropriate medications. The potential errors in medications were categorized as 1 of 3 types:

1. inappropriate choice of medication
2. excessive medication dosage
3. drug–disease interactions

Residents were considered to have a potentially inappropriate medication if their medication administration records revealed any of the above findings.

A univariate analysis showed that the risk of hospitalization was almost 30% higher among residents who received potentially inappropriate medications in the preceding month and 33% higher among residents who received potentially inappropriate medications for 2 consecutive months, compared with residents with no inappropriate medication exposure. The odds of death in any month were 21% higher among residents who had inappropriate medication exposure during the month of death or the preceeding month, compared with those with no inappropriate medication exposure.

These findings can be generalized to the inpatient setting, where hospitalists have the opportunity to influence and modify prescribing practices in the elderly population.

5. Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triplelumen catheter in the right internal jugular vein, using the anterior approach? Chest. 2005;127:220-3.

The routine use of chest radiography to confirm proper triplelumen catheter (TLC) placement may be an unnecessary and costly intervention. Lessnau conducted a prospective observational study of 100 consecutive patients over a 4-month period who required non-urgent TLC placement. The primary operators of the procedure included 18 medical residents, 3 pulmonary fellows, and a pulmonary attending with supervision provided for more junior clinicians. Operators followed a standardized approach to TLC placement utilizing the anterior approach to the right internal jugular vein. Complicated procedures were predefined as any procedure that required more than 3 needle passes, resulted in hemorrhage or hematoma formation (where there was concern for pneumothorax), or an absence of blood return in any of the TLC’s lumens. All subjects underwent routine post-procedure chest radiography to determine proper placement of the catheter and to exclude pneumothorax. A blinded radiologist reviewed these images.

Ninety-eight of the 100 catheters were in proper position. One malpositioned catheter was 7 cm above the right atrium in a patient who was 215 cm (>7 feet) tall. The second was noted to be in an S-shaped position on chest radiography. This procedure had required 20 needle passes and 5 slides of the catheter; additionally, blood return was inadequate in 2 lumens of the catheter. An operator reported a possible complication in 10 other procedures, but the only clinical finding in these cases was the development of a local hematoma in 1 patient. Eighty-eight patients had uncomplicated insertions and had normal chest radiographs. There were no pneumothoraces.

This study demonstrates that in carefully controlled and supervised situations, as described in the study, routine chest radiography may be omitted if the insertion goes smoothly. It is important to note that these results are specific to the technique described in the study (using the anterior approach to the right internal jugular, using a short finder needle to initially locate the vein) and cannot be extrapolated to other methods of TLC insertion. Important limitations of the study include the sample size of only 100 patients and the use of only a single anatomic approach to TLC insertion. These findings, although an important first step, will need to be reproduced on a larger scale before we can recommend the cessation of routine chest radiography after TLC placement on a more widespread basis.

6. Safdar N, Fine JP, Maki DG. Metaanalysis: methods for diagnosing intravascular devicerelated bloodstream infection. Ann Intern Med. 2005;142:451-66.

Intravascular device (IVD)–related blood stream infections are a frequent cause of morbidity and mortality, and yet there is lack of a clear consensus on the most accurate method to make this diagnosis.

In this metaanalysis, Safdar et al. reviewed 185 studies, including 8 different diagnostic tests, for the detection of IVD-related bloodstream infections, of which 51 studies met the inclusion criteria. Tests were divided into IVD-sparing and those requiring IVD removal. Pooled sensitivity and specificity, summary measures of accuracy, and the mean log odds ratio were determined. The most accurate IVD-sparing test was paired quantitative blood cultures (simultaneous blood cultures from the IVD and a peripheral site, with a positive result defined as an IVD-site microorganism concentration 3–5 times greater than peripheral site) with a sensitivity of 0.87 (95% CI: 0.83–0.91) and specificity of 0.98 (95% CI: 0.97–0.99). This was followed by quantitative IVD-drawn blood cultures alone (positive result defined as growth of ≥100 CFU), with a sensitivity of 0.77 (95% CI: 0.69–0.85) and a specificity of 0.90 (95% CI: 0.88–0.92). IVD-drawn qualitative blood cultures had a sensitivity of 0.87 (95% CI: 0.80–0.94) and a specificity of 0.83 (95% CI: 0.78–0.88), and IVD- and peripheral-drawn qualitative blood cultures with differential time to positivity had a sensitivity of 0.85 (95% CI: 0.78–0.92) and specificity of 0.81 (95% CI: 0.81–0.97).

The most accurate test requiring IVD removal was quantitative catheter segment culture (segment of catheter is flushed or sonicated and plated, positive if ≥1000 CFU), with sensitivity of 0.83 (95% CI: 0.78–0.88) and specificity of 0.87 (95% CI: 0.85–0.89), followed by semi-quantitative catheter segment culture (5cm segment plated, positive if ≥ 15 CFU) with sensitivity of 0.82 (95% CI: 0.81–0.89) and specificity of 0.82 (95% CI: 0.80–0.84). The least accurate was qualitative catheter segment culture (positive if any growth) with a sensitivity of 0.90 (95% CI: 0.83–0.97) and specificity of 0.72 (95% CI: 0.66–0.78).

The limitations of this study include heterogeneity of study design, including limited data on the use of antibiotics before culture data was obtained and the baseline prevalence of bacteremia in the study populations. In addition, all data was obtained prior to the widespread use of antibiotic-coated catheters. While these results support the catheter-tip quantitative culture techniques that are already widely in use, they are less applicable to blood culture testing techniques, because quantitative assays are rarely used. Fortunately, all of these assays have a high negative predictive value, and false-positive results can be minimized by reserving testing for patients in whom there is moderate-to-high pretest probability of IVD related bloodstream infection.

7. Sopena N, Sabria M, Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest. 2005;127:213-9.

A growing body of literature exists on hospital-acquired pneumonia (HAP) in the ICU setting. Sopena and colleagues extend the HAP literature to the non-ICU setting in a multicenter cross-sectional study. Cases of HAP were identified if clinical or radiographic evidence of pneumonia developed 72 hours after admission or within 10 days of a previous discharge. Patients who developed pneumonia in the ICU were excluded from analysis.

During an 18-month study period, 165 cases were identified with complete clinical and microbiologic data. The incidence of HAP was 3.1 ± 1.4 per 1000 hospital admissions. Ninety-eight (59.4%) patients diagnosed with HAP had severe underlying diseases that were classified as fatal (<1 year) or ultimately fatal (in 5 years). Extrinsic risk factors observed in patients with HAP included concurrent steroid use (29%), antibiotic therapy (53.3%), use of H2 blockers (37%), and hospitalization greater than 5 days (76%). Microbiologic data were positive in 60 (36.4%) cases. Streptococcus pneumoniae was diagnosed in 16 cases (9.7%), enterobacteriaceae in 8 (4.8%), Legionella pneumophila in 7 (4.2%), Aspergillus sp in 7 (4.2%), Pseudomonas aeruginosa in 7 (4.2%). Four cases of Staphylococcus aureus were diagnosed (3%), only one of which was methicillin resistant.

Complications of HAP occurred in 52.1% of cases and included respiratory failure (34.5%), pleural effusion (20.6%), septic shock (9.6%), renal failure (4.8%), and empyema (2.4%). Forty-three (26%) patients died during the hospitalization; 23 of these cases were directly attributed to HAP.

A limitation of the study is that the incidence of HAP was somewhat lower than reported in the literature and thus might represent an unintended sampling bias. Moreover, the study demonstrated underlying factors seen in patients with HAP, but these are not necessarily causative. Results useful to hospitalists include a higher than expected rate of Legionella and Aspergillus sp causing HAP in this population. A Legionella outbreak was not the explanation, as these cases were diagnosed in 5 different hospitals. The high frequency of adverse outcomes associated with HAP should alert hospitalists to the risk of nosocomial pneumonia in the non-ICU setting.

1. Carratala J, FernandezSabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142: 165-72.

The appropriate triage and management of patients with community-acquired pneumonia (CAP) has important implications for patient outcomes and the allocation of health care resources. Despite the availability of validated risk stratification tools significant variability in clinical practice which results in hospitalization rates that are often inconsistent with the severity of illness. In this unblinded, randomized controlled trial, 224 patients with CAP and a low-risk pneumonia severity index (PSI) score between 51 and 90 (class II and III) were randomized to outpatient oral levofloxacin therapy versus inpatient sequential intravenous and oral levofloxacin therapy. Exclusion criteria included quinolone allergy or use within the previous 3 months, PaO₂ < 60 mm Hg, complicated pleural effusion, lung abscess, metastatic infection, inability to maintain oral intake, and severe psychosocial problems precluding outpatient therapy. In an intention-to-treat analysis, the primary endpoints, of cure of pneumonia (resolution of signs, symptoms, and radiographic changes at 30 days), absence of adverse drug reactions, medical complications, or need for hospitalization at 30 days were achieved in 83.6% of outpatients and in 80.7% of hospitalized patients. For the secondary endpoint of patient satisfaction, 91.2% of outpatients versus 79.1% of hospitalized patients (p=.03) were satisfied, but there were no differences between groups with respect to the secondary endpoint of health-related quality of life. Mortality was similar between the 2 groups, and although the study was not sufficiently powered to address this outcome, and interestingly there was trend toward increased medical complications in the hospitalized patients.

Limitations of this study include lack of blinding by investigators and questions about whether the results can be generalized given the geographic variation in microbial susceptibility to quinolone antibiotics. As the authors suggest, this study also highlights limitations in the PSI scoring system, given that patients with clinical findings and comorbidities who would never be treated in the outpatient setting may in fact fall into low-risk PSI categories. These concerns notwithstanding, this study adds to our ability to identify an additional subset of patients with CAP who can be safely managed as outpatients.

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care.Ann Intern Med. 2005;142:260-73.

Early in the hospital medicine movement, when it was clear that hospitalists provided more efficient care than their colleagues, experience was cited as a reason for this difference. If, for example, a hospitalist cares for patients with community-acquired pneumonia daily, he or she is more likely to make the transition to oral antibiotics sooner, resulting in a shorter length of stay. Everyone recognized the hospitalists were younger, but is it plausible their “inexperience” explained the difference in care?

Choudhry and colleagues explored the available data surrounding clinical experience and quality of care delivered by physicians. They found few studies that specifically evaluated the effects of experience on quality of care. They did find articles that looked at quality of care and included experience or age as part of the physician characteristics

that possibly explained the differences. They reviewed 59 articles, available on MEDLINE, published since 1966. Forty-five studies found an inverse relationship between increasing experience and performance. For example, physicians more recently out of training programs were more familiar with evidence-based therapies for myocardial infarction and more familiar with NIH recommendations for treatment of breast cancer. Experienced physicians were less likely to screen for hypertension and more likely to prescribe inappropriate medications for elderly patients. This led them to the unexpected conclusion that experienced physicians may be at risk for providing lower-quality care and may need improvement interventions. An accompanying editorial by Drs. Weinberger, Duffy, and Cassel of the American Board of Internal Medicine stated, “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care.” They urged all physicians to “embrace the concepts behind maintenance of (board) certification.”

The image of Marcus Welby, MD, would lead one to believe that experience promotes higher quality care. But don’t ask a hospitalist: Many aren’t old enough to remember seeing him on television.

3. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969-77.

March was DVT (deep vein thrombosis) Awareness Month. Despite the availability of numerous guidelines, providers fail to consistently prescribe prophylactic measures against venous thromboembolism (VTE) for their hospitalized patients who meet criteria for prophylaxis.

Kucher and colleagues tested an innovative approach to remind providers to undertake such measures for their patients. They designed a computer program to identify hospitalized patients at increased risk for VTE who were not presently receiving VTE prophylaxis. The program reviewed the records of inpatients on the medical and surgical services and assigned a VTE risk score for each patient based on their history (i.e., history of cancer, hypercoagulability, etc.) and their present medical treatment (i.e., hormone therapy, prescribed bed rest, etc.). For patients considered “high risk” for VTE, the computer reviewed orders to identify ongoing use of VTE prophylactic measures. High-risk patients not receiving prophylactic therapies were randomized into 2 groups. The responsible physician in the intervention group received an electronic alert about the risk of VTE in their patient. No alerts were sent to the physicians in the control group. Physicians who received the alerts were forced to acknowledge the alert by either actively withholding prophylaxis or ordering prophylaxis (mechanical or pharmacologic measures). Patients were followed for 90 days with a primary endpoint of clinically diagnosed, objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). The primary endpoint occurred in 8.2% of the control group versus 4.9% in the invention group (p<.001). The alert reduced the risk of DVT or PE at 90 days by 41% (p=.001).

The results of the study are interesting. The authors acknowledged that many physicians had patients in both groups. So receiving 1 alert may have affected their use of prophylaxis in both groups. They also could not eliminate the possibility of diagnostic bias. Prophylaxis was not blinded and VTE testing was not routinely performed. Would physicians be more likely to order an imaging study for symptomatic patients on no prophylaxis than patients on prophylaxis? Nevertheless, for hospitals that have sufficient computer resources, implementation of such alerts can elevate physician awareness about VTE and other clinical conditions.

4. Lau DT, Kasper JD, Pofer DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165: 68-74.

Lau and colleagues studied the impact of potentially inappropriate medications among residents of longtermcare facilities. They used information from a 1996 national survey of home residents. The sample included 3372 residents, 65 years and older, who lived in a nursing home for 3 months or longer. Over half of the residents were older than 85 years old and 75% were female. Only 10% were black. Nearly two thirds had dementia or other mental disorders. The study used the Beers Criteria to define potentially inappropriate medications. The potential errors in medications were categorized as 1 of 3 types:

1. inappropriate choice of medication
2. excessive medication dosage
3. drug–disease interactions

Residents were considered to have a potentially inappropriate medication if their medication administration records revealed any of the above findings.

A univariate analysis showed that the risk of hospitalization was almost 30% higher among residents who received potentially inappropriate medications in the preceding month and 33% higher among residents who received potentially inappropriate medications for 2 consecutive months, compared with residents with no inappropriate medication exposure. The odds of death in any month were 21% higher among residents who had inappropriate medication exposure during the month of death or the preceeding month, compared with those with no inappropriate medication exposure.

These findings can be generalized to the inpatient setting, where hospitalists have the opportunity to influence and modify prescribing practices in the elderly population.

5. Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triplelumen catheter in the right internal jugular vein, using the anterior approach? Chest. 2005;127:220-3.

The routine use of chest radiography to confirm proper triplelumen catheter (TLC) placement may be an unnecessary and costly intervention. Lessnau conducted a prospective observational study of 100 consecutive patients over a 4-month period who required non-urgent TLC placement. The primary operators of the procedure included 18 medical residents, 3 pulmonary fellows, and a pulmonary attending with supervision provided for more junior clinicians. Operators followed a standardized approach to TLC placement utilizing the anterior approach to the right internal jugular vein. Complicated procedures were predefined as any procedure that required more than 3 needle passes, resulted in hemorrhage or hematoma formation (where there was concern for pneumothorax), or an absence of blood return in any of the TLC’s lumens. All subjects underwent routine post-procedure chest radiography to determine proper placement of the catheter and to exclude pneumothorax. A blinded radiologist reviewed these images.

Ninety-eight of the 100 catheters were in proper position. One malpositioned catheter was 7 cm above the right atrium in a patient who was 215 cm (>7 feet) tall. The second was noted to be in an S-shaped position on chest radiography. This procedure had required 20 needle passes and 5 slides of the catheter; additionally, blood return was inadequate in 2 lumens of the catheter. An operator reported a possible complication in 10 other procedures, but the only clinical finding in these cases was the development of a local hematoma in 1 patient. Eighty-eight patients had uncomplicated insertions and had normal chest radiographs. There were no pneumothoraces.

This study demonstrates that in carefully controlled and supervised situations, as described in the study, routine chest radiography may be omitted if the insertion goes smoothly. It is important to note that these results are specific to the technique described in the study (using the anterior approach to the right internal jugular, using a short finder needle to initially locate the vein) and cannot be extrapolated to other methods of TLC insertion. Important limitations of the study include the sample size of only 100 patients and the use of only a single anatomic approach to TLC insertion. These findings, although an important first step, will need to be reproduced on a larger scale before we can recommend the cessation of routine chest radiography after TLC placement on a more widespread basis.

6. Safdar N, Fine JP, Maki DG. Metaanalysis: methods for diagnosing intravascular devicerelated bloodstream infection. Ann Intern Med. 2005;142:451-66.

Intravascular device (IVD)–related blood stream infections are a frequent cause of morbidity and mortality, and yet there is lack of a clear consensus on the most accurate method to make this diagnosis.

In this metaanalysis, Safdar et al. reviewed 185 studies, including 8 different diagnostic tests, for the detection of IVD-related bloodstream infections, of which 51 studies met the inclusion criteria. Tests were divided into IVD-sparing and those requiring IVD removal. Pooled sensitivity and specificity, summary measures of accuracy, and the mean log odds ratio were determined. The most accurate IVD-sparing test was paired quantitative blood cultures (simultaneous blood cultures from the IVD and a peripheral site, with a positive result defined as an IVD-site microorganism concentration 3–5 times greater than peripheral site) with a sensitivity of 0.87 (95% CI: 0.83–0.91) and specificity of 0.98 (95% CI: 0.97–0.99). This was followed by quantitative IVD-drawn blood cultures alone (positive result defined as growth of ≥100 CFU), with a sensitivity of 0.77 (95% CI: 0.69–0.85) and a specificity of 0.90 (95% CI: 0.88–0.92). IVD-drawn qualitative blood cultures had a sensitivity of 0.87 (95% CI: 0.80–0.94) and a specificity of 0.83 (95% CI: 0.78–0.88), and IVD- and peripheral-drawn qualitative blood cultures with differential time to positivity had a sensitivity of 0.85 (95% CI: 0.78–0.92) and specificity of 0.81 (95% CI: 0.81–0.97).

The most accurate test requiring IVD removal was quantitative catheter segment culture (segment of catheter is flushed or sonicated and plated, positive if ≥1000 CFU), with sensitivity of 0.83 (95% CI: 0.78–0.88) and specificity of 0.87 (95% CI: 0.85–0.89), followed by semi-quantitative catheter segment culture (5cm segment plated, positive if ≥ 15 CFU) with sensitivity of 0.82 (95% CI: 0.81–0.89) and specificity of 0.82 (95% CI: 0.80–0.84). The least accurate was qualitative catheter segment culture (positive if any growth) with a sensitivity of 0.90 (95% CI: 0.83–0.97) and specificity of 0.72 (95% CI: 0.66–0.78).

The limitations of this study include heterogeneity of study design, including limited data on the use of antibiotics before culture data was obtained and the baseline prevalence of bacteremia in the study populations. In addition, all data was obtained prior to the widespread use of antibiotic-coated catheters. While these results support the catheter-tip quantitative culture techniques that are already widely in use, they are less applicable to blood culture testing techniques, because quantitative assays are rarely used. Fortunately, all of these assays have a high negative predictive value, and false-positive results can be minimized by reserving testing for patients in whom there is moderate-to-high pretest probability of IVD related bloodstream infection.

7. Sopena N, Sabria M, Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest. 2005;127:213-9.

A growing body of literature exists on hospital-acquired pneumonia (HAP) in the ICU setting. Sopena and colleagues extend the HAP literature to the non-ICU setting in a multicenter cross-sectional study. Cases of HAP were identified if clinical or radiographic evidence of pneumonia developed 72 hours after admission or within 10 days of a previous discharge. Patients who developed pneumonia in the ICU were excluded from analysis.

During an 18-month study period, 165 cases were identified with complete clinical and microbiologic data. The incidence of HAP was 3.1 ± 1.4 per 1000 hospital admissions. Ninety-eight (59.4%) patients diagnosed with HAP had severe underlying diseases that were classified as fatal (<1 year) or ultimately fatal (in 5 years). Extrinsic risk factors observed in patients with HAP included concurrent steroid use (29%), antibiotic therapy (53.3%), use of H2 blockers (37%), and hospitalization greater than 5 days (76%). Microbiologic data were positive in 60 (36.4%) cases. Streptococcus pneumoniae was diagnosed in 16 cases (9.7%), enterobacteriaceae in 8 (4.8%), Legionella pneumophila in 7 (4.2%), Aspergillus sp in 7 (4.2%), Pseudomonas aeruginosa in 7 (4.2%). Four cases of Staphylococcus aureus were diagnosed (3%), only one of which was methicillin resistant.

Complications of HAP occurred in 52.1% of cases and included respiratory failure (34.5%), pleural effusion (20.6%), septic shock (9.6%), renal failure (4.8%), and empyema (2.4%). Forty-three (26%) patients died during the hospitalization; 23 of these cases were directly attributed to HAP.

A limitation of the study is that the incidence of HAP was somewhat lower than reported in the literature and thus might represent an unintended sampling bias. Moreover, the study demonstrated underlying factors seen in patients with HAP, but these are not necessarily causative. Results useful to hospitalists include a higher than expected rate of Legionella and Aspergillus sp causing HAP in this population. A Legionella outbreak was not the explanation, as these cases were diagnosed in 5 different hospitals. The high frequency of adverse outcomes associated with HAP should alert hospitalists to the risk of nosocomial pneumonia in the non-ICU setting.

1. Carratala J, FernandezSabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142: 165-72.

The appropriate triage and management of patients with community-acquired pneumonia (CAP) has important implications for patient outcomes and the allocation of health care resources. Despite the availability of validated risk stratification tools significant variability in clinical practice which results in hospitalization rates that are often inconsistent with the severity of illness. In this unblinded, randomized controlled trial, 224 patients with CAP and a low-risk pneumonia severity index (PSI) score between 51 and 90 (class II and III) were randomized to outpatient oral levofloxacin therapy versus inpatient sequential intravenous and oral levofloxacin therapy. Exclusion criteria included quinolone allergy or use within the previous 3 months, PaO₂ < 60 mm Hg, complicated pleural effusion, lung abscess, metastatic infection, inability to maintain oral intake, and severe psychosocial problems precluding outpatient therapy. In an intention-to-treat analysis, the primary endpoints, of cure of pneumonia (resolution of signs, symptoms, and radiographic changes at 30 days), absence of adverse drug reactions, medical complications, or need for hospitalization at 30 days were achieved in 83.6% of outpatients and in 80.7% of hospitalized patients. For the secondary endpoint of patient satisfaction, 91.2% of outpatients versus 79.1% of hospitalized patients (p=.03) were satisfied, but there were no differences between groups with respect to the secondary endpoint of health-related quality of life. Mortality was similar between the 2 groups, and although the study was not sufficiently powered to address this outcome, and interestingly there was trend toward increased medical complications in the hospitalized patients.

Limitations of this study include lack of blinding by investigators and questions about whether the results can be generalized given the geographic variation in microbial susceptibility to quinolone antibiotics. As the authors suggest, this study also highlights limitations in the PSI scoring system, given that patients with clinical findings and comorbidities who would never be treated in the outpatient setting may in fact fall into low-risk PSI categories. These concerns notwithstanding, this study adds to our ability to identify an additional subset of patients with CAP who can be safely managed as outpatients.

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care.Ann Intern Med. 2005;142:260-73.

Early in the hospital medicine movement, when it was clear that hospitalists provided more efficient care than their colleagues, experience was cited as a reason for this difference. If, for example, a hospitalist cares for patients with community-acquired pneumonia daily, he or she is more likely to make the transition to oral antibiotics sooner, resulting in a shorter length of stay. Everyone recognized the hospitalists were younger, but is it plausible their “inexperience” explained the difference in care?

Choudhry and colleagues explored the available data surrounding clinical experience and quality of care delivered by physicians. They found few studies that specifically evaluated the effects of experience on quality of care. They did find articles that looked at quality of care and included experience or age as part of the physician characteristics

that possibly explained the differences. They reviewed 59 articles, available on MEDLINE, published since 1966. Forty-five studies found an inverse relationship between increasing experience and performance. For example, physicians more recently out of training programs were more familiar with evidence-based therapies for myocardial infarction and more familiar with NIH recommendations for treatment of breast cancer. Experienced physicians were less likely to screen for hypertension and more likely to prescribe inappropriate medications for elderly patients. This led them to the unexpected conclusion that experienced physicians may be at risk for providing lower-quality care and may need improvement interventions. An accompanying editorial by Drs. Weinberger, Duffy, and Cassel of the American Board of Internal Medicine stated, “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care.” They urged all physicians to “embrace the concepts behind maintenance of (board) certification.”

The image of Marcus Welby, MD, would lead one to believe that experience promotes higher quality care. But don’t ask a hospitalist: Many aren’t old enough to remember seeing him on television.

3. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969-77.

March was DVT (deep vein thrombosis) Awareness Month. Despite the availability of numerous guidelines, providers fail to consistently prescribe prophylactic measures against venous thromboembolism (VTE) for their hospitalized patients who meet criteria for prophylaxis.

Kucher and colleagues tested an innovative approach to remind providers to undertake such measures for their patients. They designed a computer program to identify hospitalized patients at increased risk for VTE who were not presently receiving VTE prophylaxis. The program reviewed the records of inpatients on the medical and surgical services and assigned a VTE risk score for each patient based on their history (i.e., history of cancer, hypercoagulability, etc.) and their present medical treatment (i.e., hormone therapy, prescribed bed rest, etc.). For patients considered “high risk” for VTE, the computer reviewed orders to identify ongoing use of VTE prophylactic measures. High-risk patients not receiving prophylactic therapies were randomized into 2 groups. The responsible physician in the intervention group received an electronic alert about the risk of VTE in their patient. No alerts were sent to the physicians in the control group. Physicians who received the alerts were forced to acknowledge the alert by either actively withholding prophylaxis or ordering prophylaxis (mechanical or pharmacologic measures). Patients were followed for 90 days with a primary endpoint of clinically diagnosed, objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). The primary endpoint occurred in 8.2% of the control group versus 4.9% in the invention group (p<.001). The alert reduced the risk of DVT or PE at 90 days by 41% (p=.001).

The results of the study are interesting. The authors acknowledged that many physicians had patients in both groups. So receiving 1 alert may have affected their use of prophylaxis in both groups. They also could not eliminate the possibility of diagnostic bias. Prophylaxis was not blinded and VTE testing was not routinely performed. Would physicians be more likely to order an imaging study for symptomatic patients on no prophylaxis than patients on prophylaxis? Nevertheless, for hospitals that have sufficient computer resources, implementation of such alerts can elevate physician awareness about VTE and other clinical conditions.

4. Lau DT, Kasper JD, Pofer DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165: 68-74.

Lau and colleagues studied the impact of potentially inappropriate medications among residents of longtermcare facilities. They used information from a 1996 national survey of home residents. The sample included 3372 residents, 65 years and older, who lived in a nursing home for 3 months or longer. Over half of the residents were older than 85 years old and 75% were female. Only 10% were black. Nearly two thirds had dementia or other mental disorders. The study used the Beers Criteria to define potentially inappropriate medications. The potential errors in medications were categorized as 1 of 3 types:

1. inappropriate choice of medication
2. excessive medication dosage
3. drug–disease interactions

Residents were considered to have a potentially inappropriate medication if their medication administration records revealed any of the above findings.

A univariate analysis showed that the risk of hospitalization was almost 30% higher among residents who received potentially inappropriate medications in the preceding month and 33% higher among residents who received potentially inappropriate medications for 2 consecutive months, compared with residents with no inappropriate medication exposure. The odds of death in any month were 21% higher among residents who had inappropriate medication exposure during the month of death or the preceeding month, compared with those with no inappropriate medication exposure.

These findings can be generalized to the inpatient setting, where hospitalists have the opportunity to influence and modify prescribing practices in the elderly population.

5. Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triplelumen catheter in the right internal jugular vein, using the anterior approach? Chest. 2005;127:220-3.

The routine use of chest radiography to confirm proper triplelumen catheter (TLC) placement may be an unnecessary and costly intervention. Lessnau conducted a prospective observational study of 100 consecutive patients over a 4-month period who required non-urgent TLC placement. The primary operators of the procedure included 18 medical residents, 3 pulmonary fellows, and a pulmonary attending with supervision provided for more junior clinicians. Operators followed a standardized approach to TLC placement utilizing the anterior approach to the right internal jugular vein. Complicated procedures were predefined as any procedure that required more than 3 needle passes, resulted in hemorrhage or hematoma formation (where there was concern for pneumothorax), or an absence of blood return in any of the TLC’s lumens. All subjects underwent routine post-procedure chest radiography to determine proper placement of the catheter and to exclude pneumothorax. A blinded radiologist reviewed these images.

Ninety-eight of the 100 catheters were in proper position. One malpositioned catheter was 7 cm above the right atrium in a patient who was 215 cm (>7 feet) tall. The second was noted to be in an S-shaped position on chest radiography. This procedure had required 20 needle passes and 5 slides of the catheter; additionally, blood return was inadequate in 2 lumens of the catheter. An operator reported a possible complication in 10 other procedures, but the only clinical finding in these cases was the development of a local hematoma in 1 patient. Eighty-eight patients had uncomplicated insertions and had normal chest radiographs. There were no pneumothoraces.

This study demonstrates that in carefully controlled and supervised situations, as described in the study, routine chest radiography may be omitted if the insertion goes smoothly. It is important to note that these results are specific to the technique described in the study (using the anterior approach to the right internal jugular, using a short finder needle to initially locate the vein) and cannot be extrapolated to other methods of TLC insertion. Important limitations of the study include the sample size of only 100 patients and the use of only a single anatomic approach to TLC insertion. These findings, although an important first step, will need to be reproduced on a larger scale before we can recommend the cessation of routine chest radiography after TLC placement on a more widespread basis.

6. Safdar N, Fine JP, Maki DG. Metaanalysis: methods for diagnosing intravascular devicerelated bloodstream infection. Ann Intern Med. 2005;142:451-66.

Intravascular device (IVD)–related blood stream infections are a frequent cause of morbidity and mortality, and yet there is lack of a clear consensus on the most accurate method to make this diagnosis.

In this metaanalysis, Safdar et al. reviewed 185 studies, including 8 different diagnostic tests, for the detection of IVD-related bloodstream infections, of which 51 studies met the inclusion criteria. Tests were divided into IVD-sparing and those requiring IVD removal. Pooled sensitivity and specificity, summary measures of accuracy, and the mean log odds ratio were determined. The most accurate IVD-sparing test was paired quantitative blood cultures (simultaneous blood cultures from the IVD and a peripheral site, with a positive result defined as an IVD-site microorganism concentration 3–5 times greater than peripheral site) with a sensitivity of 0.87 (95% CI: 0.83–0.91) and specificity of 0.98 (95% CI: 0.97–0.99). This was followed by quantitative IVD-drawn blood cultures alone (positive result defined as growth of ≥100 CFU), with a sensitivity of 0.77 (95% CI: 0.69–0.85) and a specificity of 0.90 (95% CI: 0.88–0.92). IVD-drawn qualitative blood cultures had a sensitivity of 0.87 (95% CI: 0.80–0.94) and a specificity of 0.83 (95% CI: 0.78–0.88), and IVD- and peripheral-drawn qualitative blood cultures with differential time to positivity had a sensitivity of 0.85 (95% CI: 0.78–0.92) and specificity of 0.81 (95% CI: 0.81–0.97).

The most accurate test requiring IVD removal was quantitative catheter segment culture (segment of catheter is flushed or sonicated and plated, positive if ≥1000 CFU), with sensitivity of 0.83 (95% CI: 0.78–0.88) and specificity of 0.87 (95% CI: 0.85–0.89), followed by semi-quantitative catheter segment culture (5cm segment plated, positive if ≥ 15 CFU) with sensitivity of 0.82 (95% CI: 0.81–0.89) and specificity of 0.82 (95% CI: 0.80–0.84). The least accurate was qualitative catheter segment culture (positive if any growth) with a sensitivity of 0.90 (95% CI: 0.83–0.97) and specificity of 0.72 (95% CI: 0.66–0.78).

The limitations of this study include heterogeneity of study design, including limited data on the use of antibiotics before culture data was obtained and the baseline prevalence of bacteremia in the study populations. In addition, all data was obtained prior to the widespread use of antibiotic-coated catheters. While these results support the catheter-tip quantitative culture techniques that are already widely in use, they are less applicable to blood culture testing techniques, because quantitative assays are rarely used. Fortunately, all of these assays have a high negative predictive value, and false-positive results can be minimized by reserving testing for patients in whom there is moderate-to-high pretest probability of IVD related bloodstream infection.

7. Sopena N, Sabria M, Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest. 2005;127:213-9.

A growing body of literature exists on hospital-acquired pneumonia (HAP) in the ICU setting. Sopena and colleagues extend the HAP literature to the non-ICU setting in a multicenter cross-sectional study. Cases of HAP were identified if clinical or radiographic evidence of pneumonia developed 72 hours after admission or within 10 days of a previous discharge. Patients who developed pneumonia in the ICU were excluded from analysis.

During an 18-month study period, 165 cases were identified with complete clinical and microbiologic data. The incidence of HAP was 3.1 ± 1.4 per 1000 hospital admissions. Ninety-eight (59.4%) patients diagnosed with HAP had severe underlying diseases that were classified as fatal (<1 year) or ultimately fatal (in 5 years). Extrinsic risk factors observed in patients with HAP included concurrent steroid use (29%), antibiotic therapy (53.3%), use of H2 blockers (37%), and hospitalization greater than 5 days (76%). Microbiologic data were positive in 60 (36.4%) cases. Streptococcus pneumoniae was diagnosed in 16 cases (9.7%), enterobacteriaceae in 8 (4.8%), Legionella pneumophila in 7 (4.2%), Aspergillus sp in 7 (4.2%), Pseudomonas aeruginosa in 7 (4.2%). Four cases of Staphylococcus aureus were diagnosed (3%), only one of which was methicillin resistant.

Complications of HAP occurred in 52.1% of cases and included respiratory failure (34.5%), pleural effusion (20.6%), septic shock (9.6%), renal failure (4.8%), and empyema (2.4%). Forty-three (26%) patients died during the hospitalization; 23 of these cases were directly attributed to HAP.

A limitation of the study is that the incidence of HAP was somewhat lower than reported in the literature and thus might represent an unintended sampling bias. Moreover, the study demonstrated underlying factors seen in patients with HAP, but these are not necessarily causative. Results useful to hospitalists include a higher than expected rate of Legionella and Aspergillus sp causing HAP in this population. A Legionella outbreak was not the explanation, as these cases were diagnosed in 5 different hospitals. The high frequency of adverse outcomes associated with HAP should alert hospitalists to the risk of nosocomial pneumonia in the non-ICU setting.

The Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary programs focused on improving the quality of care and quality of life for beneficiaries with multiple chronic illnesses. These Chronic Care Improvement Programs (CCIPs) represent the first large-scale chronic care improvement initiative under the Medicare fee-for-service (FFS) program. The programs also may represent an opportunity for SHM members to partner with the selected organizations.

CMS selected organizations that will offer self-care guidance and support to chronically ill beneficiaries. These organizations will help beneficiaries manage their health, adhere to their physicians’ plans of care, and assure that they seek or obtain medical care as needed to reduce their health risks. Chronic conditions are currently a leading cause of illness, disability, and death among beneficiaries and account for a disproportionate share of health care expenditures.

Each selected organization may design its own program, with the potential for a variety of unique models. Some vendors are partnering with physician groups and others may reach out to physicians in their regions. The selected regions and respective vendors are:

• Brooklyn and Queens in New York City (Visiting Nurse Service of New York in partnership with United-Healthcare Services, Inc.–Evercare)
• Chicago (Aetna Health Management)
• District of Columbia and Maryland (American Healthways, Inc.)
• Central Florida (Humana, Inc.)
• Georgia (CIGNA HealthCare)
• Mississippi (McKesson Health Solutions)
• Oklahoma (LifeMasters Supported SelfCare, Inc.)
• Pennsylvania (Health Dialog Services Corporation)
• Tennessee (XLHealth)

Performance-based contracting is one of the most important features of the CCIP design. The CCIPs will be paid based on achieving measurable improvements in clinical and financial outcomes, as well as satisfaction levels across their assigned populations. Payment is not based on services provided. CCIP organizations will be paid monthly fees, but those fees will be fully at risk. The organizations will be required to refund some or all of their fees to the federal government if they do not meet agreed-upon standards for quality improvement, savings to Medicare, and increased beneficiary satisfaction levels.

Phase I programs will collectively serve 150,000 to 300,000 chronically ill beneficiaries who are enrolled in traditional fee-for-service Medicare. This is the phase currentlyunder development, with the first programs expected to begin implementation in spring 2005. The programs are intended to help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications and comorbidities. With attention to reducing hospital costs, hospitalists may play an important role in CCIPs.

CCIPs include collaboration with participants’ providers to improve communication regarding relevant clinical information. The programs are being designed to assist beneficiaries in managing all of their health problems (not just a single disease). The programs to be tested vary in types of interventions to be used to improve outcomes. Across all programs, payments will be based on performance results.

Patient participation will be entirely voluntary. Eligible beneficiaries do not have to change plans or providers to participate, and there is no charge to the beneficiaries to participate. Once the program begins, beneficiaries may stop participating at any time. These programs may not restrict access to care. CMS will use historical claims data to identify beneficiaries by geographic area and screen them for eligibility. The selected beneficiaries will be assigned randomly to either an intervention group or a control group. Those in the intervention group will be notified of the opportunity to participate via a letter from the Medicare program. The letter will describe the CCIP and give the beneficiary the opportunity to decline to participate.

Phase II, which is the expansion of successful CCIPs, may begin within 2 to 31/2 years after Phase I. Entire CCIPs, or components of programs, may be expanded either regionally or nationally. SHM will continue to track the progress of the CCIPs and to encourage members to participate in the development and implementation of this exciting new chapter of Medicare services.

Please check the list above. If you are interested in partnering with any of the organizations, please email Lillian Higgins at lhiggins@hospitalistmedicine.org. She will provide you with contact information for the CCIP vendor.

The Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary programs focused on improving the quality of care and quality of life for beneficiaries with multiple chronic illnesses. These Chronic Care Improvement Programs (CCIPs) represent the first large-scale chronic care improvement initiative under the Medicare fee-for-service (FFS) program. The programs also may represent an opportunity for SHM members to partner with the selected organizations.

CMS selected organizations that will offer self-care guidance and support to chronically ill beneficiaries. These organizations will help beneficiaries manage their health, adhere to their physicians’ plans of care, and assure that they seek or obtain medical care as needed to reduce their health risks. Chronic conditions are currently a leading cause of illness, disability, and death among beneficiaries and account for a disproportionate share of health care expenditures.

Each selected organization may design its own program, with the potential for a variety of unique models. Some vendors are partnering with physician groups and others may reach out to physicians in their regions. The selected regions and respective vendors are:

• Brooklyn and Queens in New York City (Visiting Nurse Service of New York in partnership with United-Healthcare Services, Inc.–Evercare)
• Chicago (Aetna Health Management)
• District of Columbia and Maryland (American Healthways, Inc.)
• Central Florida (Humana, Inc.)
• Georgia (CIGNA HealthCare)
• Mississippi (McKesson Health Solutions)
• Oklahoma (LifeMasters Supported SelfCare, Inc.)
• Pennsylvania (Health Dialog Services Corporation)
• Tennessee (XLHealth)

Performance-based contracting is one of the most important features of the CCIP design. The CCIPs will be paid based on achieving measurable improvements in clinical and financial outcomes, as well as satisfaction levels across their assigned populations. Payment is not based on services provided. CCIP organizations will be paid monthly fees, but those fees will be fully at risk. The organizations will be required to refund some or all of their fees to the federal government if they do not meet agreed-upon standards for quality improvement, savings to Medicare, and increased beneficiary satisfaction levels.

Phase I programs will collectively serve 150,000 to 300,000 chronically ill beneficiaries who are enrolled in traditional fee-for-service Medicare. This is the phase currentlyunder development, with the first programs expected to begin implementation in spring 2005. The programs are intended to help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications and comorbidities. With attention to reducing hospital costs, hospitalists may play an important role in CCIPs.

CCIPs include collaboration with participants’ providers to improve communication regarding relevant clinical information. The programs are being designed to assist beneficiaries in managing all of their health problems (not just a single disease). The programs to be tested vary in types of interventions to be used to improve outcomes. Across all programs, payments will be based on performance results.

Patient participation will be entirely voluntary. Eligible beneficiaries do not have to change plans or providers to participate, and there is no charge to the beneficiaries to participate. Once the program begins, beneficiaries may stop participating at any time. These programs may not restrict access to care. CMS will use historical claims data to identify beneficiaries by geographic area and screen them for eligibility. The selected beneficiaries will be assigned randomly to either an intervention group or a control group. Those in the intervention group will be notified of the opportunity to participate via a letter from the Medicare program. The letter will describe the CCIP and give the beneficiary the opportunity to decline to participate.

Phase II, which is the expansion of successful CCIPs, may begin within 2 to 31/2 years after Phase I. Entire CCIPs, or components of programs, may be expanded either regionally or nationally. SHM will continue to track the progress of the CCIPs and to encourage members to participate in the development and implementation of this exciting new chapter of Medicare services.

Please check the list above. If you are interested in partnering with any of the organizations, please email Lillian Higgins at lhiggins@hospitalistmedicine.org. She will provide you with contact information for the CCIP vendor.

The Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary programs focused on improving the quality of care and quality of life for beneficiaries with multiple chronic illnesses. These Chronic Care Improvement Programs (CCIPs) represent the first large-scale chronic care improvement initiative under the Medicare fee-for-service (FFS) program. The programs also may represent an opportunity for SHM members to partner with the selected organizations.

CMS selected organizations that will offer self-care guidance and support to chronically ill beneficiaries. These organizations will help beneficiaries manage their health, adhere to their physicians’ plans of care, and assure that they seek or obtain medical care as needed to reduce their health risks. Chronic conditions are currently a leading cause of illness, disability, and death among beneficiaries and account for a disproportionate share of health care expenditures.

Each selected organization may design its own program, with the potential for a variety of unique models. Some vendors are partnering with physician groups and others may reach out to physicians in their regions. The selected regions and respective vendors are:

• Brooklyn and Queens in New York City (Visiting Nurse Service of New York in partnership with United-Healthcare Services, Inc.–Evercare)
• Chicago (Aetna Health Management)
• District of Columbia and Maryland (American Healthways, Inc.)
• Central Florida (Humana, Inc.)
• Georgia (CIGNA HealthCare)
• Mississippi (McKesson Health Solutions)
• Oklahoma (LifeMasters Supported SelfCare, Inc.)
• Pennsylvania (Health Dialog Services Corporation)
• Tennessee (XLHealth)

Performance-based contracting is one of the most important features of the CCIP design. The CCIPs will be paid based on achieving measurable improvements in clinical and financial outcomes, as well as satisfaction levels across their assigned populations. Payment is not based on services provided. CCIP organizations will be paid monthly fees, but those fees will be fully at risk. The organizations will be required to refund some or all of their fees to the federal government if they do not meet agreed-upon standards for quality improvement, savings to Medicare, and increased beneficiary satisfaction levels.

Phase I programs will collectively serve 150,000 to 300,000 chronically ill beneficiaries who are enrolled in traditional fee-for-service Medicare. This is the phase currentlyunder development, with the first programs expected to begin implementation in spring 2005. The programs are intended to help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications and comorbidities. With attention to reducing hospital costs, hospitalists may play an important role in CCIPs.

CCIPs include collaboration with participants’ providers to improve communication regarding relevant clinical information. The programs are being designed to assist beneficiaries in managing all of their health problems (not just a single disease). The programs to be tested vary in types of interventions to be used to improve outcomes. Across all programs, payments will be based on performance results.

Patient participation will be entirely voluntary. Eligible beneficiaries do not have to change plans or providers to participate, and there is no charge to the beneficiaries to participate. Once the program begins, beneficiaries may stop participating at any time. These programs may not restrict access to care. CMS will use historical claims data to identify beneficiaries by geographic area and screen them for eligibility. The selected beneficiaries will be assigned randomly to either an intervention group or a control group. Those in the intervention group will be notified of the opportunity to participate via a letter from the Medicare program. The letter will describe the CCIP and give the beneficiary the opportunity to decline to participate.

Phase II, which is the expansion of successful CCIPs, may begin within 2 to 31/2 years after Phase I. Entire CCIPs, or components of programs, may be expanded either regionally or nationally. SHM will continue to track the progress of the CCIPs and to encourage members to participate in the development and implementation of this exciting new chapter of Medicare services.

Please check the list above. If you are interested in partnering with any of the organizations, please email Lillian Higgins at lhiggins@hospitalistmedicine.org. She will provide you with contact information for the CCIP vendor.