The tension between continuity of care and specialization is not new, but may have reached a tipping point when the hospitalist movement erupted onto the American medical scene in the late 1990s. By definition, when a hospitalist cares for an inpatient, there is some fragmentation of care, which is, at least in theory, avoidableif the primary care provider (PCP) can serve as attending physician in the hospital. Literature has since emerged suggesting that clinical and economic outcomes of care by hospitalists are at least as good as that provided by PCPs, and that patients are not, in general, opposed to hospitalist care.13

However, the degree of discontinuity is not just a feature of whether a hospitalist assumes care of the hospitalized patient. Discontinuity can be exacerbated by changing attendings throughout the hospital stay. And inpatient continuity is a potential issue for both the hospitalist model and traditional model of care (in which the PCP serves as inpatient attending physician). While one might assume that the hospitalist model fosters more inpatient discontinuity because most hospitalistswhether working a 7‐on7‐off schedule or another scheduledo not commit to caring for a patient throughout an entire hospitalization the way a PCP might, this question has not previously been examined. Even if the hospitalist model is a fait accompli in many hospitals, it is worth knowing how inpatient continuity differs between the 2 models.

In this issue of the Journal, Fletcher and colleagues4 used billing data to examine trends in inpatient continuity of care over a 10‐year period ending in 2006, and sought to determine: (1) whether inpatient care has become more fragmented over time (as defined by the number of generalists caring for a patient over the course of an average hospitalization), and (2) whether inpatient care provided by hospitalists tends to be more fragmented than care provided by PCPs. They found that continuity of inpatient care has indeed decreased over time. In 1996, just over 70% of patients received care from 1 generalist; this number declined to just under 60% a decade later, despite a decrease in length‐of‐stay during that period. However, and perhaps surprisingly, patients cared for exclusively by hospitalists saw fewer generalists in the hospital (ie, fewer different hospitalists) than those cared for exclusively by outpatient providers. The authors conclude that the doctorpatient continuity over the course of a hospital stay is not worse in the hospitalist model than in the traditional model. While reassuring, it is important to remember that the patient experience does not begin at admission or end at discharge, and a more patient‐centered analysis might take into account the outpatient providers too (ie, those seeing the patient before admission and after discharge), and would probably show that the hospitalist model indeed leads to more care fragmentation. After all, there are at least 2 providers involved in every patient's care when a hospitalist model is used, whereas a large subset of patients cared for by PCPs would have only 1 provider involved.

While not the primary focus of the analysis, Fletcher and colleagues4 identified additional predictors of inpatient continuity of care. Higher socioeconomic class and white race were associated with lower continuity. This suggests that care fragmentation is not a feature of inferior, or at least cheap, care. In keeping with this observation, there was also enormous geographic variation in inpatient care continuity, marked by greater fragmentation of care in the New England and the mid‐Atlantic regions than in other areas of the country, and more fragmentation in larger hospitals serving heavily populated metropolitan areas. This pattern is strikingly similar to the cost‐of‐care patterns observed by the Dartmouth Atlas researchers.5, 6 Densely populated areas tend to have more specialists per capita and also tend to deliver more expensive carewithout demonstrably higher quality. In parallel, it is easy to see how care fragmentation might increase length‐of‐stay7 and lead to excessive diagnostic testing and consultation. More cooks in the kitchen might make costlier stew.

How hospitalists tackle the issue of inpatient continuity is not only a matter of quality of care, but also a matter of job sustainability. The simple way to maximize continuityworking many consecutive dayscan lead to burnout if taken too far. But there are creative ways to assign admissions that maximize continuity for the average inpatient while allowing providers needed time off. The CICLE initiative (Creating Incentives and Continuity Leading to Efficiency in hospital medicine) at the Johns Hopkins Bayview Medical Center, for instance, assigns physicians to 4‐day cycles of clinical work; the first day of the cycle (a long‐call day) involves admitting a large number of patients during a busy shift, with no new patients admitted on the remaining days of the cycle. Thus, all patients whose length of stay is less than 5 days will have a single attending‐of‐record. Not only does this model increase continuity, it also incentivizes providers to augment throughput: more discharged patients on Tuesday means fewer patients to see on Wednesday, without any expectation to backfill. Other less aggressive but similar approaches are used elsewhere, such as exempting hospitalists from accepting new patients on the last 1 or 2 of the consecutive days they work. We eagerly await data on the impact of these programs on quality of care, patient satisfaction, and provider satisfaction.

The impact of other providers and staff cannot be ignored. While the most important handoff in many cases may indeed be between the PCP and attending hospitalist tasked with coordinating the overall care of the patient, for some patients, there may be a specialist who has known the patient for years who is driving the plan of care. For patients with severe chronic illnesses, such as end‐stage renal disease or asthma, a well‐structured specialty clinic may even serve as a patient‐centered medical home.8 And the current inpatient team includes night coverage physicians (whether moonlighters, house staff, or covering hospitalists), and an ever‐increasing number of non‐physicians who play a critical role in hospital care (non‐physician providers, nurses, social workers, pharmacists, case managers, physical therapists, and others). While it is tempting to focus on the attending physician as the main driver of healthcare quality, continuity, and the inpatient experience, this is an oversimplification.

If there is a take‐home message, it is probably that most hospitalized patients will be cared for by multiple providers and a team of non‐physicians. The Marcus Welby practice model may not be completely dead, but if Dr. Welby were still in practice, it would be a safe bet that he would be slower at computerized order entry than the average intern, that financial pressures would make it hard for him to attend to his hospitalized patients, and that he probably would have turned over much of his inpatient practice to the physicians and non‐physician caregivers who make the hospital their primary workplace.9 Going forward, research should examine ways to optimize care coordination under the hospitalist model,1013 rather than comparing it to the traditional model of inpatient care. The ingredients for success include coordinated care by a committee of caregivers, effective handoffs (throughout hospitalization and at discharge),12, 14 focused and deliberate multidisciplinary communication, and effective patient education,15 regardless of the attending‐du‐jour.

The tension between continuity of care and specialization is not new, but may have reached a tipping point when the hospitalist movement erupted onto the American medical scene in the late 1990s. By definition, when a hospitalist cares for an inpatient, there is some fragmentation of care, which is, at least in theory, avoidableif the primary care provider (PCP) can serve as attending physician in the hospital. Literature has since emerged suggesting that clinical and economic outcomes of care by hospitalists are at least as good as that provided by PCPs, and that patients are not, in general, opposed to hospitalist care.13

However, the degree of discontinuity is not just a feature of whether a hospitalist assumes care of the hospitalized patient. Discontinuity can be exacerbated by changing attendings throughout the hospital stay. And inpatient continuity is a potential issue for both the hospitalist model and traditional model of care (in which the PCP serves as inpatient attending physician). While one might assume that the hospitalist model fosters more inpatient discontinuity because most hospitalistswhether working a 7‐on7‐off schedule or another scheduledo not commit to caring for a patient throughout an entire hospitalization the way a PCP might, this question has not previously been examined. Even if the hospitalist model is a fait accompli in many hospitals, it is worth knowing how inpatient continuity differs between the 2 models.

In this issue of the Journal, Fletcher and colleagues4 used billing data to examine trends in inpatient continuity of care over a 10‐year period ending in 2006, and sought to determine: (1) whether inpatient care has become more fragmented over time (as defined by the number of generalists caring for a patient over the course of an average hospitalization), and (2) whether inpatient care provided by hospitalists tends to be more fragmented than care provided by PCPs. They found that continuity of inpatient care has indeed decreased over time. In 1996, just over 70% of patients received care from 1 generalist; this number declined to just under 60% a decade later, despite a decrease in length‐of‐stay during that period. However, and perhaps surprisingly, patients cared for exclusively by hospitalists saw fewer generalists in the hospital (ie, fewer different hospitalists) than those cared for exclusively by outpatient providers. The authors conclude that the doctorpatient continuity over the course of a hospital stay is not worse in the hospitalist model than in the traditional model. While reassuring, it is important to remember that the patient experience does not begin at admission or end at discharge, and a more patient‐centered analysis might take into account the outpatient providers too (ie, those seeing the patient before admission and after discharge), and would probably show that the hospitalist model indeed leads to more care fragmentation. After all, there are at least 2 providers involved in every patient's care when a hospitalist model is used, whereas a large subset of patients cared for by PCPs would have only 1 provider involved.

While not the primary focus of the analysis, Fletcher and colleagues4 identified additional predictors of inpatient continuity of care. Higher socioeconomic class and white race were associated with lower continuity. This suggests that care fragmentation is not a feature of inferior, or at least cheap, care. In keeping with this observation, there was also enormous geographic variation in inpatient care continuity, marked by greater fragmentation of care in the New England and the mid‐Atlantic regions than in other areas of the country, and more fragmentation in larger hospitals serving heavily populated metropolitan areas. This pattern is strikingly similar to the cost‐of‐care patterns observed by the Dartmouth Atlas researchers.5, 6 Densely populated areas tend to have more specialists per capita and also tend to deliver more expensive carewithout demonstrably higher quality. In parallel, it is easy to see how care fragmentation might increase length‐of‐stay7 and lead to excessive diagnostic testing and consultation. More cooks in the kitchen might make costlier stew.

How hospitalists tackle the issue of inpatient continuity is not only a matter of quality of care, but also a matter of job sustainability. The simple way to maximize continuityworking many consecutive dayscan lead to burnout if taken too far. But there are creative ways to assign admissions that maximize continuity for the average inpatient while allowing providers needed time off. The CICLE initiative (Creating Incentives and Continuity Leading to Efficiency in hospital medicine) at the Johns Hopkins Bayview Medical Center, for instance, assigns physicians to 4‐day cycles of clinical work; the first day of the cycle (a long‐call day) involves admitting a large number of patients during a busy shift, with no new patients admitted on the remaining days of the cycle. Thus, all patients whose length of stay is less than 5 days will have a single attending‐of‐record. Not only does this model increase continuity, it also incentivizes providers to augment throughput: more discharged patients on Tuesday means fewer patients to see on Wednesday, without any expectation to backfill. Other less aggressive but similar approaches are used elsewhere, such as exempting hospitalists from accepting new patients on the last 1 or 2 of the consecutive days they work. We eagerly await data on the impact of these programs on quality of care, patient satisfaction, and provider satisfaction.

The impact of other providers and staff cannot be ignored. While the most important handoff in many cases may indeed be between the PCP and attending hospitalist tasked with coordinating the overall care of the patient, for some patients, there may be a specialist who has known the patient for years who is driving the plan of care. For patients with severe chronic illnesses, such as end‐stage renal disease or asthma, a well‐structured specialty clinic may even serve as a patient‐centered medical home.8 And the current inpatient team includes night coverage physicians (whether moonlighters, house staff, or covering hospitalists), and an ever‐increasing number of non‐physicians who play a critical role in hospital care (non‐physician providers, nurses, social workers, pharmacists, case managers, physical therapists, and others). While it is tempting to focus on the attending physician as the main driver of healthcare quality, continuity, and the inpatient experience, this is an oversimplification.

If there is a take‐home message, it is probably that most hospitalized patients will be cared for by multiple providers and a team of non‐physicians. The Marcus Welby practice model may not be completely dead, but if Dr. Welby were still in practice, it would be a safe bet that he would be slower at computerized order entry than the average intern, that financial pressures would make it hard for him to attend to his hospitalized patients, and that he probably would have turned over much of his inpatient practice to the physicians and non‐physician caregivers who make the hospital their primary workplace.9 Going forward, research should examine ways to optimize care coordination under the hospitalist model,1013 rather than comparing it to the traditional model of inpatient care. The ingredients for success include coordinated care by a committee of caregivers, effective handoffs (throughout hospitalization and at discharge),12, 14 focused and deliberate multidisciplinary communication, and effective patient education,15 regardless of the attending‐du‐jour.

The tension between continuity of care and specialization is not new, but may have reached a tipping point when the hospitalist movement erupted onto the American medical scene in the late 1990s. By definition, when a hospitalist cares for an inpatient, there is some fragmentation of care, which is, at least in theory, avoidableif the primary care provider (PCP) can serve as attending physician in the hospital. Literature has since emerged suggesting that clinical and economic outcomes of care by hospitalists are at least as good as that provided by PCPs, and that patients are not, in general, opposed to hospitalist care.13

However, the degree of discontinuity is not just a feature of whether a hospitalist assumes care of the hospitalized patient. Discontinuity can be exacerbated by changing attendings throughout the hospital stay. And inpatient continuity is a potential issue for both the hospitalist model and traditional model of care (in which the PCP serves as inpatient attending physician). While one might assume that the hospitalist model fosters more inpatient discontinuity because most hospitalistswhether working a 7‐on7‐off schedule or another scheduledo not commit to caring for a patient throughout an entire hospitalization the way a PCP might, this question has not previously been examined. Even if the hospitalist model is a fait accompli in many hospitals, it is worth knowing how inpatient continuity differs between the 2 models.

In this issue of the Journal, Fletcher and colleagues4 used billing data to examine trends in inpatient continuity of care over a 10‐year period ending in 2006, and sought to determine: (1) whether inpatient care has become more fragmented over time (as defined by the number of generalists caring for a patient over the course of an average hospitalization), and (2) whether inpatient care provided by hospitalists tends to be more fragmented than care provided by PCPs. They found that continuity of inpatient care has indeed decreased over time. In 1996, just over 70% of patients received care from 1 generalist; this number declined to just under 60% a decade later, despite a decrease in length‐of‐stay during that period. However, and perhaps surprisingly, patients cared for exclusively by hospitalists saw fewer generalists in the hospital (ie, fewer different hospitalists) than those cared for exclusively by outpatient providers. The authors conclude that the doctorpatient continuity over the course of a hospital stay is not worse in the hospitalist model than in the traditional model. While reassuring, it is important to remember that the patient experience does not begin at admission or end at discharge, and a more patient‐centered analysis might take into account the outpatient providers too (ie, those seeing the patient before admission and after discharge), and would probably show that the hospitalist model indeed leads to more care fragmentation. After all, there are at least 2 providers involved in every patient's care when a hospitalist model is used, whereas a large subset of patients cared for by PCPs would have only 1 provider involved.

While not the primary focus of the analysis, Fletcher and colleagues4 identified additional predictors of inpatient continuity of care. Higher socioeconomic class and white race were associated with lower continuity. This suggests that care fragmentation is not a feature of inferior, or at least cheap, care. In keeping with this observation, there was also enormous geographic variation in inpatient care continuity, marked by greater fragmentation of care in the New England and the mid‐Atlantic regions than in other areas of the country, and more fragmentation in larger hospitals serving heavily populated metropolitan areas. This pattern is strikingly similar to the cost‐of‐care patterns observed by the Dartmouth Atlas researchers.5, 6 Densely populated areas tend to have more specialists per capita and also tend to deliver more expensive carewithout demonstrably higher quality. In parallel, it is easy to see how care fragmentation might increase length‐of‐stay7 and lead to excessive diagnostic testing and consultation. More cooks in the kitchen might make costlier stew.

How hospitalists tackle the issue of inpatient continuity is not only a matter of quality of care, but also a matter of job sustainability. The simple way to maximize continuityworking many consecutive dayscan lead to burnout if taken too far. But there are creative ways to assign admissions that maximize continuity for the average inpatient while allowing providers needed time off. The CICLE initiative (Creating Incentives and Continuity Leading to Efficiency in hospital medicine) at the Johns Hopkins Bayview Medical Center, for instance, assigns physicians to 4‐day cycles of clinical work; the first day of the cycle (a long‐call day) involves admitting a large number of patients during a busy shift, with no new patients admitted on the remaining days of the cycle. Thus, all patients whose length of stay is less than 5 days will have a single attending‐of‐record. Not only does this model increase continuity, it also incentivizes providers to augment throughput: more discharged patients on Tuesday means fewer patients to see on Wednesday, without any expectation to backfill. Other less aggressive but similar approaches are used elsewhere, such as exempting hospitalists from accepting new patients on the last 1 or 2 of the consecutive days they work. We eagerly await data on the impact of these programs on quality of care, patient satisfaction, and provider satisfaction.

The impact of other providers and staff cannot be ignored. While the most important handoff in many cases may indeed be between the PCP and attending hospitalist tasked with coordinating the overall care of the patient, for some patients, there may be a specialist who has known the patient for years who is driving the plan of care. For patients with severe chronic illnesses, such as end‐stage renal disease or asthma, a well‐structured specialty clinic may even serve as a patient‐centered medical home.8 And the current inpatient team includes night coverage physicians (whether moonlighters, house staff, or covering hospitalists), and an ever‐increasing number of non‐physicians who play a critical role in hospital care (non‐physician providers, nurses, social workers, pharmacists, case managers, physical therapists, and others). While it is tempting to focus on the attending physician as the main driver of healthcare quality, continuity, and the inpatient experience, this is an oversimplification.

If there is a take‐home message, it is probably that most hospitalized patients will be cared for by multiple providers and a team of non‐physicians. The Marcus Welby practice model may not be completely dead, but if Dr. Welby were still in practice, it would be a safe bet that he would be slower at computerized order entry than the average intern, that financial pressures would make it hard for him to attend to his hospitalized patients, and that he probably would have turned over much of his inpatient practice to the physicians and non‐physician caregivers who make the hospital their primary workplace.9 Going forward, research should examine ways to optimize care coordination under the hospitalist model,1013 rather than comparing it to the traditional model of inpatient care. The ingredients for success include coordinated care by a committee of caregivers, effective handoffs (throughout hospitalization and at discharge),12, 14 focused and deliberate multidisciplinary communication, and effective patient education,15 regardless of the attending‐du‐jour.

Close supervision of residents potentially leads to fewer errors, lower patient mortality, and improved quality of care.19 An Institute of Medicine (IOM) report3 recommended improving supervision through more frequent consultations between residents and their supervisors. Although current Accreditation Council for Graduate Medical Education (ACGME) guidelines also recommend that attending physicians (attendings) supervise residents, detailed guidance about what constitutes adequate supervision and how it should be implemented is not well defined.10, 11 The ACGME stresses that supervision should promote resident autonomy in clinical care.10 However, when trainees act independently, it might lead to critical communication breakdowns and other patient safety concerns.5, 6, 1214 Although attendings can encourage (or discourage) residents from seeking advice,15, 16 residents also play important roles in asking for help (ie, initiating their own supervision).1719 Additional research is needed on how residents walk the fine line between exercising independence and seeking supervision.

Lack of resident supervision is especially problematic in high‐risk settings such as the medical intensive care unit (ICU), where medical errors are as frequent as 1.7 errors per patient per day,20, 21 and the adverse drug event rate is twice that of non‐ICU settings.22 Because medication errors are one of the most common errors residents make,23, 24 resident interactions with nursing and pharmacy staff may significantly influence medication safety in error‐prone ICUs.2529 Studies of traditional hierarchical supervision tend to overlook how interactions with other professionals influence resident training.12, 18, 30, 31

We define supervision as a process of providing trainees with monitoring, guidance, and feedback^9(p828) as they care for patients.3 Whereas traditionally, supervisors are identified by their positions of formal authority in the medical chain of command; we conceptualize supervision as a process in which professionals engaged in supervisory activities need not have formal authority over their trainees.

To examine how residents seek supervision through both the traditional medical hierarchical chain of command (including attendings, fellows and senior residents) and interprofessional communication channels (including nursing and pharmacy staff), we conducted a qualitative study of residents working in ICUs in three tertiary care hospitals. Using semi‐structured interviews, we asked residents to describe how they experienced supervision as they provided medications to patients. Two broad research questions guided data analysis:

• 1

  How do residents receive supervision from physicians in the traditional medical hierarchy?

• 2

  How do residents receive supervision from other professionals (ie, nurses, staff pharmacists, and clinical pharmacists)?

METHODS

RESULTS

Residents described how they were supervised not only by other physicians within the traditional medical hierarchy, but also by other professionals, including nurses, staff pharmacists, and clinical pharmacists, ie, interprofessional supervision (Figure 1). After presenting these results, we examine how physicians and other professionals used communication strategies during interprofessional supervision. Here we use the term residents to include trainees at all levels, from interns to upper‐level residents, and male pronouns for de‐identification.

Figure 1

DISCUSSION

We analyzed interviews of residents working in medical ICUs to understand their supervision experiences related to medication safety. Although residents espoused beliefs in seeking assistance from supervising physicians and articulated strategies for doing so, many experienced difficulties in initiating supervision through the traditional medical hierarchy. Some residents were embarrassed by their mistaken decisions; others were concerned that their questions would reflect poorly on them.

Residents also received interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Other professionals evaluated residents' decisions by comparing them to distinctive professional guidelines and routinely used deferential language when conveying their concerns. Residents, in turn, asked other professionals for assistance.

We posit that interprofessional supervision clearly meets an accepted definition of supervision.3, 9 Residents received monitoring, guidance and feedback^9(p828) from other professionals, who engaged in routine monitoring and in situation‐specific double‐checks of residents' clinical decisions, similar to those performed by supervising physicians.30 Moreover, other professionals demonstrated the ability to anticipate a doctor's strengths and weaknesses in particular clinical situations in order to maximize patient safety.^9(p829)

Our study results have implications for graduate medical education (GME) reform. First, trainees experienced supervision as a two‐way interaction.36 Residents balanced the countervailing pressures to act independently or to seek a supervising physician's advice, in part, by developing strategies for deciding when to ask questions. Kennedy et al. identified similar rhetorical strategies.18 By asking questions about their clinical decisions, residents requested that supervising physicians guide their work; thus, they proactively initiated and thereby enacted their own supervision. Fostering the conditions for initiating supervision is essential, especially given the association between lack of effective supervision and adverse outcomes.5, 6, 1214

Second, residents expressed contradictory expectations about seeking advice from supervising physicians. Some residents were wary of approaching attending physicians for fear of appearing incompetent or being ridiculed.12, 16, 18, 31 However, we found that other residents remained reluctant to seek advice despite simultaneously appreciating that attendings encouraged them to ask for assistance. Whereas the perceived approachability of supervising physicians was important,18, 19 our exploratory findings suggest that it may be a necessary, but not a sufficient, condition for creating a learning environment. Creating a supportive learning environmentin which residents feel comfortable in revealing their perceived shortcomings to supervising physicians3begins with cultural changes, such as building medical teams,6 but such changes can be slow to develop.

Third, interprofessional supervision offers a strategy for improving supervision. The ubiquitous involvement of nursing and pharmacy staff in monitoring and intervening in residents' medication‐related decisions could result in overlooking their unique contributions to resident supervision. Mindful that supervising physicians evaluate them, residents selectively sought nonjudgmental advice from professionals outside the medical hierarchy. Therefore, improving supervision could entail offering residents ready access to other professionals who can advise them, especially during late night hours when supervising physicians might not be present.17, 27

The importance of interprofessional supervision has not been adequately recognized and emphasized in GME. Our study findings, if supported by future research, highlight how interpersonal communication techniques could influence both interprofessional supervision and hierarchical supervision among physicians. Medical team training programs3739 emphasize developing skills, such as mutual performance monitoring,^40(p13) by training providers to raise and respond to potentially sensitive questions. Improving supervision by enhancing interpersonal communication skills may be important, not only when relative status differences are clear (ie, physician hierarchy), but also when status differences are ambiguous (ie, residents and other professionals). GME programs could consider incorporating these techniques into their formal curricula, as could programs for nursing and pharmacy staff.

Our study has several limitations. Because of the larger research project objectives, we focused on medication safety in medical ICU settings, where nurses and pharmacists may be especially vigilant and proactive in monitoring residents. Thus, our findings may be specific to medication issues and less relevant outside ICUs. We had a relatively small sample size and do not claim to generalize from it, although we believe it offers meaningful insights. We also did not continue enlarging our sample until reaching redundancy.^35(p202) Nevertheless, the purposeful random sample of residents produced rich information. Indeed, some study results are consistent with previous resident education research,18 adding validity to our findings. Although the interview protocol was not designed specifically to investigate supervision, the resulting interviews yielded abundant data containing residents' detailed descriptions of how they experienced supervision. Whereas we were careful to note whether particular perceptions were unique to one resident, or shared by others, we recognize that the value of residents' observations is assessed by the quality of the insights they provide, not necessarily by the number of residents who described the same experience.

In conclusion, we found that residents experienced difficulties in initiating traditional hierarchical supervision related to medication safety in the ICU. However, they reported ubiquitous interprofessional supervision, albeit limited in scope, which they relied upon for nonjudgmental guidance in their therapeutic decision‐making, especially after‐hours. In our study, interprofessional supervision proved crucial to improving medication safety in the ICU.

Close supervision of residents potentially leads to fewer errors, lower patient mortality, and improved quality of care.19 An Institute of Medicine (IOM) report3 recommended improving supervision through more frequent consultations between residents and their supervisors. Although current Accreditation Council for Graduate Medical Education (ACGME) guidelines also recommend that attending physicians (attendings) supervise residents, detailed guidance about what constitutes adequate supervision and how it should be implemented is not well defined.10, 11 The ACGME stresses that supervision should promote resident autonomy in clinical care.10 However, when trainees act independently, it might lead to critical communication breakdowns and other patient safety concerns.5, 6, 1214 Although attendings can encourage (or discourage) residents from seeking advice,15, 16 residents also play important roles in asking for help (ie, initiating their own supervision).1719 Additional research is needed on how residents walk the fine line between exercising independence and seeking supervision.

Lack of resident supervision is especially problematic in high‐risk settings such as the medical intensive care unit (ICU), where medical errors are as frequent as 1.7 errors per patient per day,20, 21 and the adverse drug event rate is twice that of non‐ICU settings.22 Because medication errors are one of the most common errors residents make,23, 24 resident interactions with nursing and pharmacy staff may significantly influence medication safety in error‐prone ICUs.2529 Studies of traditional hierarchical supervision tend to overlook how interactions with other professionals influence resident training.12, 18, 30, 31

We define supervision as a process of providing trainees with monitoring, guidance, and feedback^9(p828) as they care for patients.3 Whereas traditionally, supervisors are identified by their positions of formal authority in the medical chain of command; we conceptualize supervision as a process in which professionals engaged in supervisory activities need not have formal authority over their trainees.

To examine how residents seek supervision through both the traditional medical hierarchical chain of command (including attendings, fellows and senior residents) and interprofessional communication channels (including nursing and pharmacy staff), we conducted a qualitative study of residents working in ICUs in three tertiary care hospitals. Using semi‐structured interviews, we asked residents to describe how they experienced supervision as they provided medications to patients. Two broad research questions guided data analysis:

• 1

  How do residents receive supervision from physicians in the traditional medical hierarchy?

• 2

  How do residents receive supervision from other professionals (ie, nurses, staff pharmacists, and clinical pharmacists)?

METHODS

RESULTS

Residents described how they were supervised not only by other physicians within the traditional medical hierarchy, but also by other professionals, including nurses, staff pharmacists, and clinical pharmacists, ie, interprofessional supervision (Figure 1). After presenting these results, we examine how physicians and other professionals used communication strategies during interprofessional supervision. Here we use the term residents to include trainees at all levels, from interns to upper‐level residents, and male pronouns for de‐identification.

Figure 1

DISCUSSION

We analyzed interviews of residents working in medical ICUs to understand their supervision experiences related to medication safety. Although residents espoused beliefs in seeking assistance from supervising physicians and articulated strategies for doing so, many experienced difficulties in initiating supervision through the traditional medical hierarchy. Some residents were embarrassed by their mistaken decisions; others were concerned that their questions would reflect poorly on them.

Residents also received interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Other professionals evaluated residents' decisions by comparing them to distinctive professional guidelines and routinely used deferential language when conveying their concerns. Residents, in turn, asked other professionals for assistance.

We posit that interprofessional supervision clearly meets an accepted definition of supervision.3, 9 Residents received monitoring, guidance and feedback^9(p828) from other professionals, who engaged in routine monitoring and in situation‐specific double‐checks of residents' clinical decisions, similar to those performed by supervising physicians.30 Moreover, other professionals demonstrated the ability to anticipate a doctor's strengths and weaknesses in particular clinical situations in order to maximize patient safety.^9(p829)

Our study results have implications for graduate medical education (GME) reform. First, trainees experienced supervision as a two‐way interaction.36 Residents balanced the countervailing pressures to act independently or to seek a supervising physician's advice, in part, by developing strategies for deciding when to ask questions. Kennedy et al. identified similar rhetorical strategies.18 By asking questions about their clinical decisions, residents requested that supervising physicians guide their work; thus, they proactively initiated and thereby enacted their own supervision. Fostering the conditions for initiating supervision is essential, especially given the association between lack of effective supervision and adverse outcomes.5, 6, 1214

Second, residents expressed contradictory expectations about seeking advice from supervising physicians. Some residents were wary of approaching attending physicians for fear of appearing incompetent or being ridiculed.12, 16, 18, 31 However, we found that other residents remained reluctant to seek advice despite simultaneously appreciating that attendings encouraged them to ask for assistance. Whereas the perceived approachability of supervising physicians was important,18, 19 our exploratory findings suggest that it may be a necessary, but not a sufficient, condition for creating a learning environment. Creating a supportive learning environmentin which residents feel comfortable in revealing their perceived shortcomings to supervising physicians3begins with cultural changes, such as building medical teams,6 but such changes can be slow to develop.

Third, interprofessional supervision offers a strategy for improving supervision. The ubiquitous involvement of nursing and pharmacy staff in monitoring and intervening in residents' medication‐related decisions could result in overlooking their unique contributions to resident supervision. Mindful that supervising physicians evaluate them, residents selectively sought nonjudgmental advice from professionals outside the medical hierarchy. Therefore, improving supervision could entail offering residents ready access to other professionals who can advise them, especially during late night hours when supervising physicians might not be present.17, 27

The importance of interprofessional supervision has not been adequately recognized and emphasized in GME. Our study findings, if supported by future research, highlight how interpersonal communication techniques could influence both interprofessional supervision and hierarchical supervision among physicians. Medical team training programs3739 emphasize developing skills, such as mutual performance monitoring,^40(p13) by training providers to raise and respond to potentially sensitive questions. Improving supervision by enhancing interpersonal communication skills may be important, not only when relative status differences are clear (ie, physician hierarchy), but also when status differences are ambiguous (ie, residents and other professionals). GME programs could consider incorporating these techniques into their formal curricula, as could programs for nursing and pharmacy staff.

Our study has several limitations. Because of the larger research project objectives, we focused on medication safety in medical ICU settings, where nurses and pharmacists may be especially vigilant and proactive in monitoring residents. Thus, our findings may be specific to medication issues and less relevant outside ICUs. We had a relatively small sample size and do not claim to generalize from it, although we believe it offers meaningful insights. We also did not continue enlarging our sample until reaching redundancy.^35(p202) Nevertheless, the purposeful random sample of residents produced rich information. Indeed, some study results are consistent with previous resident education research,18 adding validity to our findings. Although the interview protocol was not designed specifically to investigate supervision, the resulting interviews yielded abundant data containing residents' detailed descriptions of how they experienced supervision. Whereas we were careful to note whether particular perceptions were unique to one resident, or shared by others, we recognize that the value of residents' observations is assessed by the quality of the insights they provide, not necessarily by the number of residents who described the same experience.

In conclusion, we found that residents experienced difficulties in initiating traditional hierarchical supervision related to medication safety in the ICU. However, they reported ubiquitous interprofessional supervision, albeit limited in scope, which they relied upon for nonjudgmental guidance in their therapeutic decision‐making, especially after‐hours. In our study, interprofessional supervision proved crucial to improving medication safety in the ICU.

Close supervision of residents potentially leads to fewer errors, lower patient mortality, and improved quality of care.19 An Institute of Medicine (IOM) report3 recommended improving supervision through more frequent consultations between residents and their supervisors. Although current Accreditation Council for Graduate Medical Education (ACGME) guidelines also recommend that attending physicians (attendings) supervise residents, detailed guidance about what constitutes adequate supervision and how it should be implemented is not well defined.10, 11 The ACGME stresses that supervision should promote resident autonomy in clinical care.10 However, when trainees act independently, it might lead to critical communication breakdowns and other patient safety concerns.5, 6, 1214 Although attendings can encourage (or discourage) residents from seeking advice,15, 16 residents also play important roles in asking for help (ie, initiating their own supervision).1719 Additional research is needed on how residents walk the fine line between exercising independence and seeking supervision.

Lack of resident supervision is especially problematic in high‐risk settings such as the medical intensive care unit (ICU), where medical errors are as frequent as 1.7 errors per patient per day,20, 21 and the adverse drug event rate is twice that of non‐ICU settings.22 Because medication errors are one of the most common errors residents make,23, 24 resident interactions with nursing and pharmacy staff may significantly influence medication safety in error‐prone ICUs.2529 Studies of traditional hierarchical supervision tend to overlook how interactions with other professionals influence resident training.12, 18, 30, 31

We define supervision as a process of providing trainees with monitoring, guidance, and feedback^9(p828) as they care for patients.3 Whereas traditionally, supervisors are identified by their positions of formal authority in the medical chain of command; we conceptualize supervision as a process in which professionals engaged in supervisory activities need not have formal authority over their trainees.

To examine how residents seek supervision through both the traditional medical hierarchical chain of command (including attendings, fellows and senior residents) and interprofessional communication channels (including nursing and pharmacy staff), we conducted a qualitative study of residents working in ICUs in three tertiary care hospitals. Using semi‐structured interviews, we asked residents to describe how they experienced supervision as they provided medications to patients. Two broad research questions guided data analysis:

• 1

  How do residents receive supervision from physicians in the traditional medical hierarchy?

• 2

  How do residents receive supervision from other professionals (ie, nurses, staff pharmacists, and clinical pharmacists)?

METHODS

RESULTS

Residents described how they were supervised not only by other physicians within the traditional medical hierarchy, but also by other professionals, including nurses, staff pharmacists, and clinical pharmacists, ie, interprofessional supervision (Figure 1). After presenting these results, we examine how physicians and other professionals used communication strategies during interprofessional supervision. Here we use the term residents to include trainees at all levels, from interns to upper‐level residents, and male pronouns for de‐identification.

Figure 1

DISCUSSION

We analyzed interviews of residents working in medical ICUs to understand their supervision experiences related to medication safety. Although residents espoused beliefs in seeking assistance from supervising physicians and articulated strategies for doing so, many experienced difficulties in initiating supervision through the traditional medical hierarchy. Some residents were embarrassed by their mistaken decisions; others were concerned that their questions would reflect poorly on them.

Residents also received interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Other professionals evaluated residents' decisions by comparing them to distinctive professional guidelines and routinely used deferential language when conveying their concerns. Residents, in turn, asked other professionals for assistance.

We posit that interprofessional supervision clearly meets an accepted definition of supervision.3, 9 Residents received monitoring, guidance and feedback^9(p828) from other professionals, who engaged in routine monitoring and in situation‐specific double‐checks of residents' clinical decisions, similar to those performed by supervising physicians.30 Moreover, other professionals demonstrated the ability to anticipate a doctor's strengths and weaknesses in particular clinical situations in order to maximize patient safety.^9(p829)

Our study results have implications for graduate medical education (GME) reform. First, trainees experienced supervision as a two‐way interaction.36 Residents balanced the countervailing pressures to act independently or to seek a supervising physician's advice, in part, by developing strategies for deciding when to ask questions. Kennedy et al. identified similar rhetorical strategies.18 By asking questions about their clinical decisions, residents requested that supervising physicians guide their work; thus, they proactively initiated and thereby enacted their own supervision. Fostering the conditions for initiating supervision is essential, especially given the association between lack of effective supervision and adverse outcomes.5, 6, 1214

Second, residents expressed contradictory expectations about seeking advice from supervising physicians. Some residents were wary of approaching attending physicians for fear of appearing incompetent or being ridiculed.12, 16, 18, 31 However, we found that other residents remained reluctant to seek advice despite simultaneously appreciating that attendings encouraged them to ask for assistance. Whereas the perceived approachability of supervising physicians was important,18, 19 our exploratory findings suggest that it may be a necessary, but not a sufficient, condition for creating a learning environment. Creating a supportive learning environmentin which residents feel comfortable in revealing their perceived shortcomings to supervising physicians3begins with cultural changes, such as building medical teams,6 but such changes can be slow to develop.

Third, interprofessional supervision offers a strategy for improving supervision. The ubiquitous involvement of nursing and pharmacy staff in monitoring and intervening in residents' medication‐related decisions could result in overlooking their unique contributions to resident supervision. Mindful that supervising physicians evaluate them, residents selectively sought nonjudgmental advice from professionals outside the medical hierarchy. Therefore, improving supervision could entail offering residents ready access to other professionals who can advise them, especially during late night hours when supervising physicians might not be present.17, 27

The importance of interprofessional supervision has not been adequately recognized and emphasized in GME. Our study findings, if supported by future research, highlight how interpersonal communication techniques could influence both interprofessional supervision and hierarchical supervision among physicians. Medical team training programs3739 emphasize developing skills, such as mutual performance monitoring,^40(p13) by training providers to raise and respond to potentially sensitive questions. Improving supervision by enhancing interpersonal communication skills may be important, not only when relative status differences are clear (ie, physician hierarchy), but also when status differences are ambiguous (ie, residents and other professionals). GME programs could consider incorporating these techniques into their formal curricula, as could programs for nursing and pharmacy staff.

Our study has several limitations. Because of the larger research project objectives, we focused on medication safety in medical ICU settings, where nurses and pharmacists may be especially vigilant and proactive in monitoring residents. Thus, our findings may be specific to medication issues and less relevant outside ICUs. We had a relatively small sample size and do not claim to generalize from it, although we believe it offers meaningful insights. We also did not continue enlarging our sample until reaching redundancy.^35(p202) Nevertheless, the purposeful random sample of residents produced rich information. Indeed, some study results are consistent with previous resident education research,18 adding validity to our findings. Although the interview protocol was not designed specifically to investigate supervision, the resulting interviews yielded abundant data containing residents' detailed descriptions of how they experienced supervision. Whereas we were careful to note whether particular perceptions were unique to one resident, or shared by others, we recognize that the value of residents' observations is assessed by the quality of the insights they provide, not necessarily by the number of residents who described the same experience.

In conclusion, we found that residents experienced difficulties in initiating traditional hierarchical supervision related to medication safety in the ICU. However, they reported ubiquitous interprofessional supervision, albeit limited in scope, which they relied upon for nonjudgmental guidance in their therapeutic decision‐making, especially after‐hours. In our study, interprofessional supervision proved crucial to improving medication safety in the ICU.

The Joint Commission (TJC) currently accredits approximately 4546 acute care, critical access, and specialty hospitals,1 accounting for approximately 82% of U.S. hospitals (representing 92% of hospital beds). Hospitals seeking to earn and maintain accreditation undergo unannounced on‐site visits by a team of Joint Commission surveyors at least once every 3 years. These surveys address a variety of domains, including the environment of care, infection prevention and control, information management, adherence to a series of national patient safety goals, and leadership.1

The survey process has changed markedly in recent years. Since 2002, accredited hospitals have been required to continuously collect and submit selected performance measure data to The Joint Commission throughout the three‐year accreditation cycle. The tracer methodology, an evaluation method in which surveyors select a patient to follow through the organization in order to assess compliance with selected standards, was instituted in 2004. Soon thereafter, on‐site surveys went from announced to unannounced in 2006.

Despite the 50+ year history of hospital accreditation in the United States, there has been surprisingly little research on the link between accreditation status and measures of hospital quality (both processes and outcomes). It is only recently that a growing number of studies have attempted to examine this relationship. Empirical support for the relationship between accreditation and other quality measures is emerging. Accredited hospitals have been shown to provide better emergency response planning2 and training3 compared to non‐accredited hospitals. Accreditation has been observed to be a key predictor of patient safety system implementation4 and the primary driver of hospitals' patient‐safety initiatives.5 Accredited trauma centers have been associated with significant reductions in patient mortality,6 and accreditation has been linked to better compliance with evidence‐based methadone and substance abuse treatment.7, 8 Accredited hospitals have been shown to perform better on measures of hospital quality in acute myocardial infarction (AMI), heart failure, and pneumonia care.9, 10 Similarly, accreditation has been associated with lower risk‐adjusted in‐hospital mortality rates for congestive heart failure (CHF), stroke, and pneumonia.11, 12 The results of such research, however, have not always been consistent. Several studies have been unable to demonstrate a relationship between accreditation and quality measures. A study of financial and cost‐related outcome measures found no relationship to accreditation,13 and a study comparing medication error rates across different types of organizations found no relationship to accreditation status.14 Similarly, a comparison of accredited versus non‐accredited ambulatory surgical organizations found that patients were less likely to be hospitalized when treated at an accredited facility for colonoscopy procedures, but no such relationship was observed for the other 4 procedures studied.15

While the research to date has been generally supportive of the link between accreditation and other measures of health care quality, the studies were typically limited to only a few measures and/or involved relatively small samples of accredited and non‐accredited organizations. Over the last decade, however, changes in the performance measurement landscape have created previously unavailable opportunities to more robustly examine the relationship between accreditation and other indicators of hospital quality.

At about the same time that The Joint Commission's accreditation process was becoming more vigorous, the Centers for Medicare and Medicaid Services (CMS) began a program of publicly reporting quality data (http://www.hospitalcompare.hhs.gov). The alignment of Joint Commission and CMS quality measures establishes a mechanism through which accredited and non‐accredited hospitals can be compared using the same nationally standardized quality measures. Therefore, we took advantage of this unique circumstancea new and more robust TJC accreditation program and the launching of public quality reportingto examine the relationship between Joint Commission accreditation status and publicly reported hospital quality measures. Moreover, by examining trends in these publicly reported measures over five years and incorporating performance data not found in the Hospital Compare Database, we assessed whether accreditation status was also linked to the pace of performance improvement over time.

By using a population of hospitals and a range of standardized quality measures greater than those used in previous studies, we seek to address the following questions: Is Joint Commission accreditation status truly associated with higher quality care? And does accreditation status help identify hospitals that are more likely to improve their quality and safety over time?

METHODS

RESULTS

For the 16 individual measures used in this study, a total of 4798 hospitals participated in Hospital Compare or reported data to The Joint Commission in 2004 or 2008. Of these, 907 were excluded because the performance data were not available for either 2004 (576 hospitals) or 2008 (331 hospitals) resulting in a missing value for the change in performance score. Therefore, 3891 hospitals (81%) were included in the final analyses. The 907 excluded hospitals were more likely to be rural (50.8% vs 17.5%), be critical access hospitals (53.9% vs 13.9%), have less than 100 beds (77.4% vs 37.6%), be government owned (34.6% vs 22.1%), be for profit (61.4% vs 49.5%), or be unaccredited (79.8% vs 45.8% in 2004; 75.6% vs 12.8% in 2008), compared with the included hospitals (P < 0.001 for all comparisons).

DISCUSSION

While accreditation has face validity and is desired by key stakeholders, it is expensive and time consuming. Stakeholders thus are justified in seeking evidence that accreditation is associated with better quality and safety. Ideally, not only would it be associated with better performance at a single point in time, it would also be associated with the pace of improvement over time.

Our study is the first, to our knowledge, to show the association of accreditation status with improvement in the trajectory of performance over a five‐year period. Taking advantage of the fact that the accreditation process changed substantially at about the same time that TJC and CMS began requiring public reporting of evidence‐based quality measures, we found that hospitals accredited by The Joint Commission had had larger improvements in hospital performance from 2004 to 2008 than non‐accredited hospitals, even though the former started with higher baseline performance levels. This accelerated improvement was broad‐based: Accredited hospitals were more likely to achieve superior performance (greater than 90% adherence to quality measures) in 2008 on 13 of 16 nationally standardized quality‐of‐care measures, three clinical area summary scores, and an overall score compared to hospitals that were not accredited. These results are consistent with other studies that have looked at both process and outcome measures and accreditation.912

It is important to note that the observed accreditation effect reflects a difference between hospitals that have elected to seek one particular self‐regulatory alternative to the more restrictive and extensive public regulatory or licensure requirements with those that have not.39 The non‐accredited hospitals that were included in this study are not considered to be sub‐standard hospitals. In fact, hospitals not accredited by The Joint Commission have also met the standards set by Medicare in the Conditions of Participation, and our study demonstrates that these hospitals achieved reasonably strong performance on publicly reported quality measures (86.8% adherence on the composite measure in 2008) and considerable improvement over the 5 years of public reporting (average improvement on composite measure from 2004 to 2008 of 11.8%). Moreover, there are many paths to improvement, and some non‐accredited hospitals achieve stellar performance on quality measures, perhaps by embracing other methods to catalyze improvement.

That said, our data demonstrate that, on average, accredited hospitals achieve superior performance on these evidence‐based quality measures, and their performance improved more strikingly over time. In interpreting these results, it is important to recognize that, while Joint Commission‐accredited hospitals must report quality data, performance on these measures is not directly factored into the accreditation decision; if this were not so, one could argue that this association is a statistical tautology. As it is, we believe that the 2 measures (accreditation and publicly reported quality measures) are two independent assessments of the quality of an organization, and, while the performance measures may not be a gold standard, a measure of their association does provide useful information about the degree to which accreditation is linked to organizational quality.

There are several potential limitations of the current study. First, while we adjusted for most of the known hospital demographic and organizational factors associated with performance, there may be unidentified factors that are associated with both accreditation and performance. This may not be relevant to a patient or payer choosing a hospital based on accreditation status (who may not care whether accreditation is simply associated with higher quality or actually helps produce such quality), but it is relevant to policy‐makers, who may weigh the value of embracing accreditation versus other maneuvers (such as pay for performance or new educational requirements) as a vehicle to promote high‐quality care.

A second limitation is that the specification of the measures can change over time due to the acquisition of new clinical knowledge, which makes longitudinal comparison and tracking of results over time difficult. There were two measures that had definitional changes that had noticeable impact on longitudinal trends: the AMI measure Primary Percutaneous Coronary Intervention (PCI) Received within 90 Minutes of Hospital Arrival (which in 2004 and 2005 used 120 minutes as the threshold), and the pneumonia measure Antibiotic Within 4 Hours of Arrival (which in 2007 changed the threshold to six hours). Other changes included adding angiotensin‐receptor blocker therapy (ARB) as an alternative to angiotensin‐converting enzyme inhibitor (ACEI) therapy in 2005 to the AMI and heart failure measures ACEI or ARB for left ventricular dysfunction. Other less significant changes have been made to the data collection methods for other measures, which could impact the interpretation of changes in performance over time. That said, these changes influenced both accredited and non‐accredited hospitals equally, and we cannot think of reasons that they would have created differential impacts.

Another limitation is that the 16 process measures provide a limited picture of hospital performance. Although the three conditions in the study account for over 15% of Medicare admissions,19 it is possible that non‐accredited hospitals performed as well as accredited hospitals on other measures of quality that were not captured by the 16 measures. As more standardized measures are added to The Joint Commission and CMS databases, it will be possible to use the same study methodology to incorporate these additional domains.

From the original cohort of 4798 hospitals reporting in 2004 or 2008, 19% were not included in the study due to missing data in either 2004 or 2008. Almost two‐thirds of the hospitals excluded from the study were missing 2004 data and, of these, 77% were critical access hospitals. The majority of these critical access hospitals (97%) were non‐accredited. This is in contrast to the hospitals missing 2008 data, of which only 13% were critical access. Since reporting of data to Hospital Compare was voluntary in 2004, it appears that critical access hospitals chose to wait later to report data to Hospital Compare, compared to acute care hospitals. Since critical access hospitals tended to have lower rates, smaller sample sizes, and be non‐accredited, the results of the study would be expected to slightly underestimate the difference between accredited and non‐accredited hospitals.

Finally, while we have argued that the publicly reported quality measures and TJC accreditation decisions provide different lenses into the quality of a given hospital, we cannot entirely exclude the possibility that there are subtle relationships between these two methods that might be partly responsible for our findings. For example, while performance measure rates do not factor directly into the accreditation decision, it is possible that Joint Commission surveyors may be influenced by their knowledge of these rates and biased in their scoring of unrelated standards during the survey process. While we cannot rule out such biases, we are aware of no research on the subject, and have no reason to believe that such biases may have confounded the analysis.

In summary, we found that Joint Commission‐accredited hospitals outperformed non‐accredited hospitals on nationally standardized quality measures of AMI, heart failure, and pneumonia. The performance gap between Joint Commission‐accredited and non‐accredited hospitals increased over the five years of the study. Future studies should incorporate more robust and varied measures of quality as outcomes, and seek to examine the nature of the observed relationship (ie, whether accreditation is simply a marker of higher quality and more rapid improvement, or the accreditation process actually helps create these salutary outcomes).

The Joint Commission (TJC) currently accredits approximately 4546 acute care, critical access, and specialty hospitals,1 accounting for approximately 82% of U.S. hospitals (representing 92% of hospital beds). Hospitals seeking to earn and maintain accreditation undergo unannounced on‐site visits by a team of Joint Commission surveyors at least once every 3 years. These surveys address a variety of domains, including the environment of care, infection prevention and control, information management, adherence to a series of national patient safety goals, and leadership.1

The survey process has changed markedly in recent years. Since 2002, accredited hospitals have been required to continuously collect and submit selected performance measure data to The Joint Commission throughout the three‐year accreditation cycle. The tracer methodology, an evaluation method in which surveyors select a patient to follow through the organization in order to assess compliance with selected standards, was instituted in 2004. Soon thereafter, on‐site surveys went from announced to unannounced in 2006.

Despite the 50+ year history of hospital accreditation in the United States, there has been surprisingly little research on the link between accreditation status and measures of hospital quality (both processes and outcomes). It is only recently that a growing number of studies have attempted to examine this relationship. Empirical support for the relationship between accreditation and other quality measures is emerging. Accredited hospitals have been shown to provide better emergency response planning2 and training3 compared to non‐accredited hospitals. Accreditation has been observed to be a key predictor of patient safety system implementation4 and the primary driver of hospitals' patient‐safety initiatives.5 Accredited trauma centers have been associated with significant reductions in patient mortality,6 and accreditation has been linked to better compliance with evidence‐based methadone and substance abuse treatment.7, 8 Accredited hospitals have been shown to perform better on measures of hospital quality in acute myocardial infarction (AMI), heart failure, and pneumonia care.9, 10 Similarly, accreditation has been associated with lower risk‐adjusted in‐hospital mortality rates for congestive heart failure (CHF), stroke, and pneumonia.11, 12 The results of such research, however, have not always been consistent. Several studies have been unable to demonstrate a relationship between accreditation and quality measures. A study of financial and cost‐related outcome measures found no relationship to accreditation,13 and a study comparing medication error rates across different types of organizations found no relationship to accreditation status.14 Similarly, a comparison of accredited versus non‐accredited ambulatory surgical organizations found that patients were less likely to be hospitalized when treated at an accredited facility for colonoscopy procedures, but no such relationship was observed for the other 4 procedures studied.15

While the research to date has been generally supportive of the link between accreditation and other measures of health care quality, the studies were typically limited to only a few measures and/or involved relatively small samples of accredited and non‐accredited organizations. Over the last decade, however, changes in the performance measurement landscape have created previously unavailable opportunities to more robustly examine the relationship between accreditation and other indicators of hospital quality.

At about the same time that The Joint Commission's accreditation process was becoming more vigorous, the Centers for Medicare and Medicaid Services (CMS) began a program of publicly reporting quality data (http://www.hospitalcompare.hhs.gov). The alignment of Joint Commission and CMS quality measures establishes a mechanism through which accredited and non‐accredited hospitals can be compared using the same nationally standardized quality measures. Therefore, we took advantage of this unique circumstancea new and more robust TJC accreditation program and the launching of public quality reportingto examine the relationship between Joint Commission accreditation status and publicly reported hospital quality measures. Moreover, by examining trends in these publicly reported measures over five years and incorporating performance data not found in the Hospital Compare Database, we assessed whether accreditation status was also linked to the pace of performance improvement over time.

By using a population of hospitals and a range of standardized quality measures greater than those used in previous studies, we seek to address the following questions: Is Joint Commission accreditation status truly associated with higher quality care? And does accreditation status help identify hospitals that are more likely to improve their quality and safety over time?

METHODS

RESULTS

For the 16 individual measures used in this study, a total of 4798 hospitals participated in Hospital Compare or reported data to The Joint Commission in 2004 or 2008. Of these, 907 were excluded because the performance data were not available for either 2004 (576 hospitals) or 2008 (331 hospitals) resulting in a missing value for the change in performance score. Therefore, 3891 hospitals (81%) were included in the final analyses. The 907 excluded hospitals were more likely to be rural (50.8% vs 17.5%), be critical access hospitals (53.9% vs 13.9%), have less than 100 beds (77.4% vs 37.6%), be government owned (34.6% vs 22.1%), be for profit (61.4% vs 49.5%), or be unaccredited (79.8% vs 45.8% in 2004; 75.6% vs 12.8% in 2008), compared with the included hospitals (P < 0.001 for all comparisons).

DISCUSSION

While accreditation has face validity and is desired by key stakeholders, it is expensive and time consuming. Stakeholders thus are justified in seeking evidence that accreditation is associated with better quality and safety. Ideally, not only would it be associated with better performance at a single point in time, it would also be associated with the pace of improvement over time.

Our study is the first, to our knowledge, to show the association of accreditation status with improvement in the trajectory of performance over a five‐year period. Taking advantage of the fact that the accreditation process changed substantially at about the same time that TJC and CMS began requiring public reporting of evidence‐based quality measures, we found that hospitals accredited by The Joint Commission had had larger improvements in hospital performance from 2004 to 2008 than non‐accredited hospitals, even though the former started with higher baseline performance levels. This accelerated improvement was broad‐based: Accredited hospitals were more likely to achieve superior performance (greater than 90% adherence to quality measures) in 2008 on 13 of 16 nationally standardized quality‐of‐care measures, three clinical area summary scores, and an overall score compared to hospitals that were not accredited. These results are consistent with other studies that have looked at both process and outcome measures and accreditation.912

It is important to note that the observed accreditation effect reflects a difference between hospitals that have elected to seek one particular self‐regulatory alternative to the more restrictive and extensive public regulatory or licensure requirements with those that have not.39 The non‐accredited hospitals that were included in this study are not considered to be sub‐standard hospitals. In fact, hospitals not accredited by The Joint Commission have also met the standards set by Medicare in the Conditions of Participation, and our study demonstrates that these hospitals achieved reasonably strong performance on publicly reported quality measures (86.8% adherence on the composite measure in 2008) and considerable improvement over the 5 years of public reporting (average improvement on composite measure from 2004 to 2008 of 11.8%). Moreover, there are many paths to improvement, and some non‐accredited hospitals achieve stellar performance on quality measures, perhaps by embracing other methods to catalyze improvement.

That said, our data demonstrate that, on average, accredited hospitals achieve superior performance on these evidence‐based quality measures, and their performance improved more strikingly over time. In interpreting these results, it is important to recognize that, while Joint Commission‐accredited hospitals must report quality data, performance on these measures is not directly factored into the accreditation decision; if this were not so, one could argue that this association is a statistical tautology. As it is, we believe that the 2 measures (accreditation and publicly reported quality measures) are two independent assessments of the quality of an organization, and, while the performance measures may not be a gold standard, a measure of their association does provide useful information about the degree to which accreditation is linked to organizational quality.

There are several potential limitations of the current study. First, while we adjusted for most of the known hospital demographic and organizational factors associated with performance, there may be unidentified factors that are associated with both accreditation and performance. This may not be relevant to a patient or payer choosing a hospital based on accreditation status (who may not care whether accreditation is simply associated with higher quality or actually helps produce such quality), but it is relevant to policy‐makers, who may weigh the value of embracing accreditation versus other maneuvers (such as pay for performance or new educational requirements) as a vehicle to promote high‐quality care.

A second limitation is that the specification of the measures can change over time due to the acquisition of new clinical knowledge, which makes longitudinal comparison and tracking of results over time difficult. There were two measures that had definitional changes that had noticeable impact on longitudinal trends: the AMI measure Primary Percutaneous Coronary Intervention (PCI) Received within 90 Minutes of Hospital Arrival (which in 2004 and 2005 used 120 minutes as the threshold), and the pneumonia measure Antibiotic Within 4 Hours of Arrival (which in 2007 changed the threshold to six hours). Other changes included adding angiotensin‐receptor blocker therapy (ARB) as an alternative to angiotensin‐converting enzyme inhibitor (ACEI) therapy in 2005 to the AMI and heart failure measures ACEI or ARB for left ventricular dysfunction. Other less significant changes have been made to the data collection methods for other measures, which could impact the interpretation of changes in performance over time. That said, these changes influenced both accredited and non‐accredited hospitals equally, and we cannot think of reasons that they would have created differential impacts.

Another limitation is that the 16 process measures provide a limited picture of hospital performance. Although the three conditions in the study account for over 15% of Medicare admissions,19 it is possible that non‐accredited hospitals performed as well as accredited hospitals on other measures of quality that were not captured by the 16 measures. As more standardized measures are added to The Joint Commission and CMS databases, it will be possible to use the same study methodology to incorporate these additional domains.

From the original cohort of 4798 hospitals reporting in 2004 or 2008, 19% were not included in the study due to missing data in either 2004 or 2008. Almost two‐thirds of the hospitals excluded from the study were missing 2004 data and, of these, 77% were critical access hospitals. The majority of these critical access hospitals (97%) were non‐accredited. This is in contrast to the hospitals missing 2008 data, of which only 13% were critical access. Since reporting of data to Hospital Compare was voluntary in 2004, it appears that critical access hospitals chose to wait later to report data to Hospital Compare, compared to acute care hospitals. Since critical access hospitals tended to have lower rates, smaller sample sizes, and be non‐accredited, the results of the study would be expected to slightly underestimate the difference between accredited and non‐accredited hospitals.

Finally, while we have argued that the publicly reported quality measures and TJC accreditation decisions provide different lenses into the quality of a given hospital, we cannot entirely exclude the possibility that there are subtle relationships between these two methods that might be partly responsible for our findings. For example, while performance measure rates do not factor directly into the accreditation decision, it is possible that Joint Commission surveyors may be influenced by their knowledge of these rates and biased in their scoring of unrelated standards during the survey process. While we cannot rule out such biases, we are aware of no research on the subject, and have no reason to believe that such biases may have confounded the analysis.

In summary, we found that Joint Commission‐accredited hospitals outperformed non‐accredited hospitals on nationally standardized quality measures of AMI, heart failure, and pneumonia. The performance gap between Joint Commission‐accredited and non‐accredited hospitals increased over the five years of the study. Future studies should incorporate more robust and varied measures of quality as outcomes, and seek to examine the nature of the observed relationship (ie, whether accreditation is simply a marker of higher quality and more rapid improvement, or the accreditation process actually helps create these salutary outcomes).

The Joint Commission (TJC) currently accredits approximately 4546 acute care, critical access, and specialty hospitals,1 accounting for approximately 82% of U.S. hospitals (representing 92% of hospital beds). Hospitals seeking to earn and maintain accreditation undergo unannounced on‐site visits by a team of Joint Commission surveyors at least once every 3 years. These surveys address a variety of domains, including the environment of care, infection prevention and control, information management, adherence to a series of national patient safety goals, and leadership.1

The survey process has changed markedly in recent years. Since 2002, accredited hospitals have been required to continuously collect and submit selected performance measure data to The Joint Commission throughout the three‐year accreditation cycle. The tracer methodology, an evaluation method in which surveyors select a patient to follow through the organization in order to assess compliance with selected standards, was instituted in 2004. Soon thereafter, on‐site surveys went from announced to unannounced in 2006.

Despite the 50+ year history of hospital accreditation in the United States, there has been surprisingly little research on the link between accreditation status and measures of hospital quality (both processes and outcomes). It is only recently that a growing number of studies have attempted to examine this relationship. Empirical support for the relationship between accreditation and other quality measures is emerging. Accredited hospitals have been shown to provide better emergency response planning2 and training3 compared to non‐accredited hospitals. Accreditation has been observed to be a key predictor of patient safety system implementation4 and the primary driver of hospitals' patient‐safety initiatives.5 Accredited trauma centers have been associated with significant reductions in patient mortality,6 and accreditation has been linked to better compliance with evidence‐based methadone and substance abuse treatment.7, 8 Accredited hospitals have been shown to perform better on measures of hospital quality in acute myocardial infarction (AMI), heart failure, and pneumonia care.9, 10 Similarly, accreditation has been associated with lower risk‐adjusted in‐hospital mortality rates for congestive heart failure (CHF), stroke, and pneumonia.11, 12 The results of such research, however, have not always been consistent. Several studies have been unable to demonstrate a relationship between accreditation and quality measures. A study of financial and cost‐related outcome measures found no relationship to accreditation,13 and a study comparing medication error rates across different types of organizations found no relationship to accreditation status.14 Similarly, a comparison of accredited versus non‐accredited ambulatory surgical organizations found that patients were less likely to be hospitalized when treated at an accredited facility for colonoscopy procedures, but no such relationship was observed for the other 4 procedures studied.15

While the research to date has been generally supportive of the link between accreditation and other measures of health care quality, the studies were typically limited to only a few measures and/or involved relatively small samples of accredited and non‐accredited organizations. Over the last decade, however, changes in the performance measurement landscape have created previously unavailable opportunities to more robustly examine the relationship between accreditation and other indicators of hospital quality.

At about the same time that The Joint Commission's accreditation process was becoming more vigorous, the Centers for Medicare and Medicaid Services (CMS) began a program of publicly reporting quality data (http://www.hospitalcompare.hhs.gov). The alignment of Joint Commission and CMS quality measures establishes a mechanism through which accredited and non‐accredited hospitals can be compared using the same nationally standardized quality measures. Therefore, we took advantage of this unique circumstancea new and more robust TJC accreditation program and the launching of public quality reportingto examine the relationship between Joint Commission accreditation status and publicly reported hospital quality measures. Moreover, by examining trends in these publicly reported measures over five years and incorporating performance data not found in the Hospital Compare Database, we assessed whether accreditation status was also linked to the pace of performance improvement over time.

By using a population of hospitals and a range of standardized quality measures greater than those used in previous studies, we seek to address the following questions: Is Joint Commission accreditation status truly associated with higher quality care? And does accreditation status help identify hospitals that are more likely to improve their quality and safety over time?

METHODS

RESULTS

For the 16 individual measures used in this study, a total of 4798 hospitals participated in Hospital Compare or reported data to The Joint Commission in 2004 or 2008. Of these, 907 were excluded because the performance data were not available for either 2004 (576 hospitals) or 2008 (331 hospitals) resulting in a missing value for the change in performance score. Therefore, 3891 hospitals (81%) were included in the final analyses. The 907 excluded hospitals were more likely to be rural (50.8% vs 17.5%), be critical access hospitals (53.9% vs 13.9%), have less than 100 beds (77.4% vs 37.6%), be government owned (34.6% vs 22.1%), be for profit (61.4% vs 49.5%), or be unaccredited (79.8% vs 45.8% in 2004; 75.6% vs 12.8% in 2008), compared with the included hospitals (P < 0.001 for all comparisons).

DISCUSSION

While accreditation has face validity and is desired by key stakeholders, it is expensive and time consuming. Stakeholders thus are justified in seeking evidence that accreditation is associated with better quality and safety. Ideally, not only would it be associated with better performance at a single point in time, it would also be associated with the pace of improvement over time.

Our study is the first, to our knowledge, to show the association of accreditation status with improvement in the trajectory of performance over a five‐year period. Taking advantage of the fact that the accreditation process changed substantially at about the same time that TJC and CMS began requiring public reporting of evidence‐based quality measures, we found that hospitals accredited by The Joint Commission had had larger improvements in hospital performance from 2004 to 2008 than non‐accredited hospitals, even though the former started with higher baseline performance levels. This accelerated improvement was broad‐based: Accredited hospitals were more likely to achieve superior performance (greater than 90% adherence to quality measures) in 2008 on 13 of 16 nationally standardized quality‐of‐care measures, three clinical area summary scores, and an overall score compared to hospitals that were not accredited. These results are consistent with other studies that have looked at both process and outcome measures and accreditation.912

It is important to note that the observed accreditation effect reflects a difference between hospitals that have elected to seek one particular self‐regulatory alternative to the more restrictive and extensive public regulatory or licensure requirements with those that have not.39 The non‐accredited hospitals that were included in this study are not considered to be sub‐standard hospitals. In fact, hospitals not accredited by The Joint Commission have also met the standards set by Medicare in the Conditions of Participation, and our study demonstrates that these hospitals achieved reasonably strong performance on publicly reported quality measures (86.8% adherence on the composite measure in 2008) and considerable improvement over the 5 years of public reporting (average improvement on composite measure from 2004 to 2008 of 11.8%). Moreover, there are many paths to improvement, and some non‐accredited hospitals achieve stellar performance on quality measures, perhaps by embracing other methods to catalyze improvement.

That said, our data demonstrate that, on average, accredited hospitals achieve superior performance on these evidence‐based quality measures, and their performance improved more strikingly over time. In interpreting these results, it is important to recognize that, while Joint Commission‐accredited hospitals must report quality data, performance on these measures is not directly factored into the accreditation decision; if this were not so, one could argue that this association is a statistical tautology. As it is, we believe that the 2 measures (accreditation and publicly reported quality measures) are two independent assessments of the quality of an organization, and, while the performance measures may not be a gold standard, a measure of their association does provide useful information about the degree to which accreditation is linked to organizational quality.

There are several potential limitations of the current study. First, while we adjusted for most of the known hospital demographic and organizational factors associated with performance, there may be unidentified factors that are associated with both accreditation and performance. This may not be relevant to a patient or payer choosing a hospital based on accreditation status (who may not care whether accreditation is simply associated with higher quality or actually helps produce such quality), but it is relevant to policy‐makers, who may weigh the value of embracing accreditation versus other maneuvers (such as pay for performance or new educational requirements) as a vehicle to promote high‐quality care.

A second limitation is that the specification of the measures can change over time due to the acquisition of new clinical knowledge, which makes longitudinal comparison and tracking of results over time difficult. There were two measures that had definitional changes that had noticeable impact on longitudinal trends: the AMI measure Primary Percutaneous Coronary Intervention (PCI) Received within 90 Minutes of Hospital Arrival (which in 2004 and 2005 used 120 minutes as the threshold), and the pneumonia measure Antibiotic Within 4 Hours of Arrival (which in 2007 changed the threshold to six hours). Other changes included adding angiotensin‐receptor blocker therapy (ARB) as an alternative to angiotensin‐converting enzyme inhibitor (ACEI) therapy in 2005 to the AMI and heart failure measures ACEI or ARB for left ventricular dysfunction. Other less significant changes have been made to the data collection methods for other measures, which could impact the interpretation of changes in performance over time. That said, these changes influenced both accredited and non‐accredited hospitals equally, and we cannot think of reasons that they would have created differential impacts.

Another limitation is that the 16 process measures provide a limited picture of hospital performance. Although the three conditions in the study account for over 15% of Medicare admissions,19 it is possible that non‐accredited hospitals performed as well as accredited hospitals on other measures of quality that were not captured by the 16 measures. As more standardized measures are added to The Joint Commission and CMS databases, it will be possible to use the same study methodology to incorporate these additional domains.

From the original cohort of 4798 hospitals reporting in 2004 or 2008, 19% were not included in the study due to missing data in either 2004 or 2008. Almost two‐thirds of the hospitals excluded from the study were missing 2004 data and, of these, 77% were critical access hospitals. The majority of these critical access hospitals (97%) were non‐accredited. This is in contrast to the hospitals missing 2008 data, of which only 13% were critical access. Since reporting of data to Hospital Compare was voluntary in 2004, it appears that critical access hospitals chose to wait later to report data to Hospital Compare, compared to acute care hospitals. Since critical access hospitals tended to have lower rates, smaller sample sizes, and be non‐accredited, the results of the study would be expected to slightly underestimate the difference between accredited and non‐accredited hospitals.

Finally, while we have argued that the publicly reported quality measures and TJC accreditation decisions provide different lenses into the quality of a given hospital, we cannot entirely exclude the possibility that there are subtle relationships between these two methods that might be partly responsible for our findings. For example, while performance measure rates do not factor directly into the accreditation decision, it is possible that Joint Commission surveyors may be influenced by their knowledge of these rates and biased in their scoring of unrelated standards during the survey process. While we cannot rule out such biases, we are aware of no research on the subject, and have no reason to believe that such biases may have confounded the analysis.

In summary, we found that Joint Commission‐accredited hospitals outperformed non‐accredited hospitals on nationally standardized quality measures of AMI, heart failure, and pneumonia. The performance gap between Joint Commission‐accredited and non‐accredited hospitals increased over the five years of the study. Future studies should incorporate more robust and varied measures of quality as outcomes, and seek to examine the nature of the observed relationship (ie, whether accreditation is simply a marker of higher quality and more rapid improvement, or the accreditation process actually helps create these salutary outcomes).

With 17 million Americans reporting heavy drinking (5 or more drinks on 5 different occasions in the last month) and 1.7 million hospital discharges in 2006 containing at least 1 alcohol‐related diagnosis, it would be hard to imagine a hospitalist who does not encounter patients with alcohol abuse.1, 2 Estimates from studies looking at the number of risky drinkers among medical inpatients vary widely2% to 60%with more detailed studies suggesting 17% to 25% prevalence.36 Yet despite the large numbers and great costs to the healthcare system, the inpatient treatment of alcohol withdrawal syndrome remains the ugly stepsister to more exciting topics, such as acute myocardial infarction, pulmonary embolism and procedures.7, 8 We hospitalists typically leave the clinical studies, research, and interest on substance abuse to addiction specialists and psychiatrists, perhaps due to our discomfort with these patients, negative attitudes, or belief that there is nothing new in the treatment of alcohol withdrawal syndrome since Dr Leo Henryk Sternbach discovered benzodiazepines in 1957.7, 9 Many of us just admit the alcoholic patient, check the alcohol‐pathway in our order entry system, and stop thinking about it.

But in this day of evidence‐based medicine and practice, what is the evidence behind the treatment of alcohol withdrawal, especially in relation to inpatient medicine? Shouldn't we hospitalists be thinking about this question? Hospitalists tend to see 2 types of inpatients with alcohol withdrawal: those solely admitted for withdrawal, and those admitted with active medical issues who then experience alcohol withdrawal. Is there a difference?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) defines early alcohol withdrawal as the first 48 hours where there is central nervous system (CNS) stimulation, adrenergic hyperactivity, and the risk of seizures. Late withdrawal, after 48 hours, includes delirium tremens (DTs) and Wernicke's encephalopathy.10 This is based on studies done in the 1950s, where researchers observed patients as they withdrew from alcohol and took notes.11, 12

The goal in treatment of alcohol withdrawal is to minimize symptoms and prevent seizures and DTs which, prior to benzodiazepines, had a mortality rate of 5% to 20%. Before the US Food and Drug Administration (FDA) approval of the first benzodiazepine in 1960 (chlordiazepoxide), physicians treated alcohol withdrawal with ethanol, antipsychotics, or paraldehyde.12 (That is why there is a P in the mnemonic MUDPILES for anion gap acidosis.) The first study to show a real benefit from benzodiazepine was published in 1969, when 537 men in a veterans detoxification unit were randomized to chlordiazepoxide (Librium), chlorpromazine (Thorazine), antihistamine, thiamine, or placebo.12 The primary outcome of DTs and seizures occurred in 10% to 16% of the patients, except for the chlordiazepoxide group where only 2% developed seizures and DTs (there was no P value calculated). Further studies published in the 1970s and early 1980s were too small to demonstrate a benefit. A 1997 meta‐analysis of all these studies, including the 1969 article,12 confirmed benzodiazepines statistically reduced seizures and DTs.13 Which benzodiazepine to use, however, is less clear. Long‐acting benzodiazepines with liver clearance (eg, chlordiazepoxide or diazepam) versus short‐acting with renal clearance (eg, oxazepam or lorazepam) is debated. While there are many strong opinions among clinicians, the same meta‐analysis did not find any difference between them, and a small 2009 study found no difference between a short‐acting and long‐acting benzodiazepine.13, 14

How much benzodiazepine to give and how frequently to dose it was looked at in 2 classic studies.15, 16 Both studies demonstrated that symptom‐triggered dosing of benzodiazepines, based on the Clinical Institute Withdrawal Assessment (CIWA) scale, performed equally well in terms of clinical outcomes, with less medication required as compared with fixed‐dose regimens. Based on these articles, many hospitals created alcohol pathways using solely symptom‐triggered dosing.

The CIWA scale is one of multiple rating scales in the assessment of alcohol withdrawal.17, 18 The CIWA‐Ar is a modified scale that was designed and validated for clinical use in inpatient detoxification centers, and excluded any active medical illness. It has gained popularity, though initial time for staff training and time for administration are limitations to its usefulness. Interestingly, vital signs, which many institutions use in their alcohol withdrawal pathways, were not strongly predictive in the CIWA study of severe withdrawal, seizures, or DTs.17

Finally, what about treatment when the patient does develop seizures or DTs? The evidence on how best to treat alcohol withdrawal seizures comes from a 1999 article which demonstrated a benefit of using lorazepam for recurrent seizures.19, 20 Unfortunately, the treatment for DTs is less clear. A 2004 meta‐analysis on the treatment of delirium tremens found benzodiazepines better than chlorpromazine (Thorazine), but benzodiazepines versus, or in addition to, newer antipsychotics have not been tested. The amount of benzodiazepine to give in DTs is only a Grade C (ie, expert opinion) recommendation: dose for light somnolence.21

All of these studies, however, come back to the basic question: Do they apply to the inpatients that hospitalists care for? A key factor to consider: All of the above‐mentioned studies, including the derivation and validation of the CIWA scale, were done in outpatient centers or inpatient detoxification centers. Patients with active medical illness or comorbidities were excluded. This data may be relevant for the patients admitted solely for alcohol withdrawal, but what about the 60 year old with diabetes, coronary artery disease, and chronic obstructive lung disease admitted for pneumonia who starts to withdraw; or the 72‐year‐old woman who breaks her hip and begins to withdraw on post‐op day 2?

There are 6 relatively recent studies that evaluate PRN (as needed) dosing of benzodiazepines on general medical inpatients.2227 While ideally these articles should apply to a hospitalist's patients, 2 of the studies excluded anyone with acute medical illness.24, 27 From the remaining 4, what do we learn? Weaver and colleagues did a randomized study on general medical patients and found less lorazepam was given with PRN versus fixed dosing.26 Unfortunately, the study was not blinded and there were statistically significant protocol errors. Comorbidity data was not given, leaving us to wonder to which inpatients this applies. Repper‐DeLisi et al. did a retrospective chart review, after implementing an alcohol pathway (not based on the CIWA scale), and did not find a statistical difference in dosing, length of stay, or delirium.25 Foy et al. looked at both medical and surgical patients, and dosed benzodiazepines based on an 18‐item CIWA scale which included vital signs.22 They found that the higher score did correlate with risk of developing severe alcohol withdrawal. However, the scale had limitations. Many patients with illness were at higher risk for severe alcohol withdrawal than their score indicated, and some high scores were believed, in part, due to illness. Jeager et al. did a pre‐comparison and post‐comparison of the implementation of a PRN CIWA protocol by chart review.23 They found a reduction in delirium in patients treated with PRN dosing, but no different in total benzodiazepine given. Because it was chart review, the authors acknowledge that defining delirium tremens was less reliable, and controlling for comorbidities was difficult. The difficult part of delirium in inpatients with alcohol abuse is that the delirium is not always just from DTs.

Two recent studies raised alarm about using a PRN CIWA pathway on patients.28, 29 A 2008 study found that 52% of patients were inappropriately put on a CIWA sliding scale when they either could not communicate or had not been recently drinking, or both.29 (The CIWA scale requires the person be able to answer symptom questions and is not applicable to non‐drinkers.) In 2005, during the implementation of an alcohol pathway at San Francisco General Hospital, an increase in mortality was noted with a PRN CIWA scale on inpatients.28

One of the conundrums for physicians is that whereas alcohol withdrawal has morbidity and mortality risks, benzodiazepine treatment itself has its own risks. Over sedation, respiratory depression, aspiration pneumonia, deconditioning from prolonged sedation, paradoxical agitation and disinhibition are the consequences of the dosing difficulties in alcohol withdrawal. Case reports on astronomical doses required to treat withdrawal (eg, 1600 mg of lorazepam in a day) raise questions of benzodiazepine resistance.30 Hence, multiple studies have been done to find alternatives for benzodiazepines. Our European counterparts lead the way in looking at: carbemazepine, gabapentin, gamma‐hydroxybuterate, corticotropin‐releasing hormone, baclofen, pregabalin, and phenobarbital. Again, the key issue for hospitalists: Are these benzodiazepine alternatives or additives applicable to our patients? These studies are done on outpatients with no concurrent medical illnesses. Yet, logic would suggest that it is the vulnerable hospitalized patients who might benefit the most from reducing the benzodiazepine amount using other agents.

In this issue of the Journal of Hospital Medicine, Lyon et al. provide a glimpse into possible ways to reduce the total benzodiazepine dose for general medical inpatients.31 They randomized inpatients withdrawing from alcohol to baclofen or placebo. Both groups still received PRN lorazepam based on their hospital's CIWA protocol. Prior outpatient studies have shown baclofen benefits patients undergoing alcohol withdrawal and the pathophysiology makes sense; baclofen acts on GABA b receptors. Lyon and collegaues' study results show significant reduction in the amount of benzodiazepine needed with no difference in CIWA scores.31

Is this a practice changer? Well, not yet. The numbers in the study are small and this is only 1 institution. These patients had only moderate alcohol withdrawal and the study was not powered to detect outcomes related to prevention of seizures and delirium tremens. However, the authors should be applauded for looking at alcohol withdrawal in medical inpatients.31 Trying to reduce the harm we cause with our benzodiazepine treatment regimens is a laudable goal. Inpatient alcohol withdrawal, especially for patients with medical comorbidities, is an area ripe for study and certainly deserves to have a spotlight shown on it.

Who better to do this than hospitalists? The Society of Hospital Medicine (SHM) core competency on Alcohol and Drug Withdrawal states, Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs‐ and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.32 Hopefully, Lyon and collegaues' work will lead to the formation of multicenter hospitalist‐initiated studies to provide us with the best evidence for the treatment of inpatient alcohol withdrawal on our patients with comorbidities.31 Given the prevalence and potential severity of alcohol withdrawal in complex inpatients, isn't it time we really knew how to treat them?