Literature at a Glance

A guide to this month’s studies.

• Score predicts risk of intracerebral hemorrhage after thrombolysis.
• Trigylcerides and stroke-risk predictors.
• PPI use and risk of community-acquired pneumonia.
• Clopidogrel before coronary intervention might improve outcomes.
• High-dose clopidogrel after coronary intervention is beneficial.
• B-type natriuretic peptide level and sepsis.
• Thrombolytic use in pulmonary embolism.
• Hospitalists and ED patient flow.

Simple Clinical Score Predicts Intracerebral Hemorrhage after Thrombolysis

Clinical question: Is there a simple scoring tool that will predict the risk of intracerebral hemorrhage (ICH) following IV tissue-plasminogen activator (t-PA) in ischemic strokes?

Background: The use of t-PA in acute ischemic stroke (AIS) is about 2% to 4%, due in part to fear of conversion of an ischemic event to an ICH. Several studies using t-PA after AIS have identified risk factors for ICH; however, none has looked at the cumulative risk and prognosis for an individual candidate based on these factors.

Study design: Retrospective, observational cohort study.

Setting: The National Institute of Neurological Disorders and Stroke Trials 1 and 2, and consecutive patients treated at Beth Israel Deaconess Medical Center, Boston.

Synopsis: After an extensive literature review, a five-point scale to determine the risk of hemorrhage after t-PA (HAT) was developed using the top four predictive factors based on odds ratios. These included the National Institutes of Health Stroke Scale (NIHSS), presence and extent of hypodensity on initial CT scan, history of diabetes, and high baseline serum glucose. The predictive value of this scale was tested against two independent cohorts of patients with AIS treated with IV t-PA. The HAT scale was able to reasonably predict both the risk of ICH following t-PA and the functional outcome at 90 days. Higher scores on the scale tended to do worse, especially scores of three or more. Its retrospective nature and small number of patients experiencing ICH limit this study.

Bottom line: The HAT score is a quick bedside tool that can help in the counseling of patients and families in conjunction with the risks and benefits of t-PA after ischemic stroke.

Citation: Lou M, Safdar A, Mehdiratta M, et al. The HAT Score: a simple grading scale for predicting hemorrhage after thrombolysis. Neurology. 2008;71:1417-1423.

Nonfasting Triglycerides Predict Stroke Risk

Clinical question: Is there a correlation between nonfasting triglyceride levels and ischemic stroke?

Background: Most individuals are in a nonfasting state, with the exception of several hours prior to breakfast. Fasting cholesterol levels exclude most remnant lipoproteins, which might play a role in early atherosclerotic disease. Increased levels of triglycerides in a nonfasting state indicate the presence of these remnants.

Study design: Prospective, population-based cohort study.

Setting: The Copenhagen City Heart Study.

Synopsis: The study included 13,956 individuals between the ages of 20 and 93 with a follow-up period of up to 31 years. Cholesterol levels were checked during four evaluation periods: 1976-1978, 1981-1983, 1991-1994, and 2001-2003. Eighty-two percent of the participants had eaten a meal within three hours of the blood draw; the other 18% had eaten more than three hours prior to the draw. The study showed an association between increasing nonfasting triglyceride levels and a step-wise increase in the risk of ischemic stroke. The highest risk came in individuals with nonfasting triglyceride levels > 443mg/dl, which was associated with a three- to fourfold greater risk of ischemic stroke. The study was limited in that it evaluated a homogenous group of individuals, which may not reflect other racial or ethnic populations.

Bottom line: Increasing levels of nonfasting triglycerides are associated with an increased risk of ischemic stroke.

Citation: Freiberg J, Tybjaerg-Hansen A, Jensen JS, Nordestgaard BG. Nonfasting triglycerides and risk of ischemic stroke in the general population. JAMA. 2008;300(18):2142-2152.

Proton-Pump Inhibitor (PPI) Use Increases the Risk of Community-Acquired Pneumonia (CAP)

Clinical question: Is there an association between PPI use and CAP?

Background: CAP is associated with significant morbidity, annually accounting for billions of healthcare dollars. Proton-pump inhibitors (PPI) are a mainstay treatment for gastric acid suppression. Previous studies have suggested using PPIs may increase the risk of developing CAP.

Study design: Nested case control study.

Setting: Outpatient general practices, United Kingdom.

Synopsis: The association between PPI use and CAP was evaluated in a cohort of more than 7 million patients using the UK’s general-practice research database. Eligible participants were divided into two groups: case patients and control patients. Initial results indicated an increased risk of CAP with PPI use. After adjusting for confounding variables, the use of a PPI was strongly associated with CAP development when used within 30 days prior of the diagnosis, and most notably within 48 hours of diagnosis. It also was noted that the risk of developing CAP with longer-term PPI use was much lower. This inverse temporal relationship was noted in two previous studies. The limitations of this study were related to presumed adherence and compliance with PPI therapy. There also was no radiographic data to support the diagnosis of pneumonia in these cases, both of which could bias the results.

Bottom line: There appears to be an increased risk of CAP with PPI use. This risk is most notable within 48 hours. However, long-term, chronic PPI use was not associated with an increased risk of CAP.

Citation: Sarkar M, Hennessy S, Yang YX. Proton-pump inhibitor use and the risk for community-acquired pneumonia. Ann Intern Med. 2008;149:391-398.

Clopidogrel Prior to Percutaneous Intervention (PCI) Might Improve Outcomes in Patients with Acute ST-Elevation Myocardial Infarction (STEMI)

Clinical question: Does pretreatment with clopidogrel prior to PCI in acute STEMI improve outcomes?

Background: Extant guidelines for early utilization of clopidogrel in STEMI patients are based on results of studies of patients with non-ST-elevation acute coronary syndromes or treatment with thrombolytics.

Study design: Systematic review.

Setting: MEDLINE and Cochrane Controlled Trials Register of randomized controlled trials.

Synopsis: The authors selected 38 treatment groups, including 8,429 patients with STEMI who underwent primary PCI. They found a statistically significant difference in initial patency, and further found clopidogrel pretreatment was an independent predictor of early reperfusion and improved clinical outcome. This study suggests a benefit to pretreatment with clopidogrel but likely is not sufficient to establish such pretreatment as the standard of care. The limitations of this study were a retrospective review/meta-analysis, as the ability to limit the influence of confounding variables is reduced.

Bottom line: Pretreatment with clopidogrel in patients with acute STEMI undergoing primary PCI appears beneficial based on the results of this review of available evidence.

Citation: Vlaar PJ, Svilaas T, Damman K, et al. Impact of pretreatment with clopidogrel on initial patency and outcomes in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review. Circulation. 2008;118:1828-1836.

High-Dose Clopidogrel after PCI Is Beneficial

Clinical question: Does high-dose clopidogrel improve patient outcome following PCI?

Background: Studies have shown antiplatelet resistance after PCI is associated with an increased risk of cardiovascular events, including in-stent thrombosis and death. Other studies have shown the benefit of high-dose clopidogrel by the inhibition of platelet aggregation. Limited information is available regarding the applicability to patients after PCI.

Study design: Retrospective study of 2,954 consecutive patients divided into two groups, low-dose and high-dose clopidogrel use.

Setting: Single hospital in France.

Synopsis: The low-dose study group undergoing PCI was pretreated with 300 mg clopidogrel, followed by ASA 75 mg and clopidogrel 75 mg daily for two months. The second group undergoing PCI was pretreated with 600 mg clopidogrel followed by ASA 75 mg and clopidogrel 150 mg for 15 days, then maintained on ASA 75 mg and clopidogrel 75 mg. Patients received follow-up at two months and were evaluated for in-stent thrombosis, myocardial infarction (MI), death, and hemorrhagic complications. The two groups were matched one-to-one using propensity scoring and the nearest-pair-matching method blinded to patient outcome.

The high-dose clopidogrel group showed a decreased incidence of MI, in-stent thrombosis, and death. This benefit confirms the importance of achieving early and adequate antiplatelet therapy. However, the study authors noted a higher percentage of major bleeding and minor bleeding, although the increase was not statistically significant (2.8% vs. 3.5%, P=0.379, and 7.4% vs. 8.2%, P=0.699, respectively).

Bottom line: High-dose clopidogrel before and within the first 15 days after PCI decreases the risk of MI, in-stent thrombosis, and death, with no statistical increase in bleeding complications. Long-range studies beyond the two-month interval might be beneficial.

Citation: Lemesle G, Delhaye C, Sudre A, et al. Impact of high loading and maintenance dose of clopidogrel within the first 15 days after percutaneous coronary intervention on patient outcome. Am Heart J. 2008;10:1-8.

B-Type Natriuretic Peptide (BNP) Identifies Patients Developing Sepsis-Induced Myocardial Depression

Clinical question: Can plasma BNP be used as a marker to identify patients at risk for sepsis-induced depression of myocardial function?

Background: Previous studies have established BNP levels are increased in patients with septic shock but have not examined the relationship between plasma BNP concentration and left ventricular (LV) systolic dysfunction.

Study design: Prospective cohort.

Setting: Academic medical center.

Synopsis: The authors divided 93 prospectively selected ICU patients with severe sepsis into two groups: one with normal left ventricular (LV) function and a group with LV systolic dysfunction. Comparison of the plasma BNP concentrations between these two groups demonstrated a significant positive correlation between the BNP level and the degree of LV systolic dysfunction, suggesting BNP is a reasonable marker for identification of septic patients with sepsis-induced myocardial depression.

Further, the study’s results suggest BNP measurements early in the course of septic shock might be useful prognostic indicators. However, it is unclear to what extent the knowledge gained from such measurements would alter care management, or how BNP compares to echocardiography in terms of diagnostic and prognostic utility. Thus, these results might not be adequate to justify the routine measurement of BNP in patients with severe sepsis.

Bottom line: Elevated BNP in septic patients is associated with the presence or risk of sepsis-induced myocardial depression, and might be a negative prognostic indicator.

Citation: Post F, Weilemann LS, Messow CM, Sinning C, Munzel T. B-type natriuretic peptide as a marker for sepsis-induced myocardial depression in intensive care patients. Crit Care Med. 2008;36:3030–3037.

High Risk of Death with Thrombolytic Use in Low-Risk Pulmonary Embolism (PE)

Clinical question: Is there an advantage to thrombolytic therapy in the treatment of acute PE versus treatment with unfractionated or low-molecular-weight (LMW) heparin?

Background: Given the high mortality linked to PE, consistent indications for thrombolytic therapy in acute PE are needed. An assessment of the prevalence of thrombolytic therapy and mortality, as compared with standard anticoagulation, has been described inconsistently.

Study design: Retrospective cohort study.

Setting: 186 acute-care hospitals in Pennsylvania.

Synopsis: Using a database of ICD-9 codes, 15,116 patients were reviewed. Logistic regression was used to evaluate the association between thrombolytic therapy and 30-day mortality. Poisson regression was used to evaluate the association between thrombolytic therapy and in-hospital mortality. For those receiving thrombolysis and considered unlikely candidates for the therapy based on documentation at presentation (low predicted probability), the in-hospital mortality and overall 30-day mortality rate were higher when compared with those who did not receive thrombolysis. An exception to this was a group of patients with high predicted probability of receiving thrombolysis. In this group, thrombolysis was not associated with increased risk. Limitations to the study include lack of assessment of right ventricular function, changes in condition after presentation, lack of long-term outcomes, and lack of exact cause of death.

Bottom line: Thrombolytic therapy is associated with higher mortality in patients with hemodynamically uncomplicated PE, and therefore not indicated. Thrombolytic therapy in a subgroup of patients with hemodynamic instability or right ventricular dysfunction improves the clinical course and outcome.

Citation: Ibrahim SA, Stone RA, Obrosky S, Geng M, Fine MJ, Aujesky D. Thrombolytic therapy and mortality in patients with acute pulmonary embolism. Arch Intern Med. 2008;168(20):2183-2190.

Hospitalists Improve Patient Flow in the ED

Clinical question: Can active-bed management by hospitalists reduce ED throughput times and diversionary status?

Background: ED overcrowding leads to ambulance diversion, which has been associated with increased mortality. A primary cause of ED crowding is inpatient boarding, which can reduce patient satisfaction and quality of care. Previous studies targeting the ED have had little impact on throughput and ambulance diversion.

Study design: Pre-post case study in a single institution.

Setting: Academic teaching hospital in Baltimore.

Synopsis: ED throughput times and ambulance diversion hours were measured for all adult patients registered in the department from November 2005 to February 2006 (control period) and November 2006 to February 2007 (intervention period). Active-bed management was defined as appointing a hospitalist to assess bed availability in real time and assigning department of medicine admissions to the appropriate clinical setting, as well as the creation of a bed director. Although the ED census was 8.8% higher during the intervention period, throughput time for admitted patients decreased by 98 minutes per patient, to 458 from 360. The time spent under diversionary status for overcrowding or lack of ICU beds decreased by 6% and 27%, respectively. Limitations of this study include the pre-post design and the implementation at a single institution. Additionally, active-bed management is expensive, and in this case required the hiring of three full-time-equivalent faculty. However, this study successfully demonstrates that a quality improvement partnership between hospitalists and the ED can substantially reduce overcrowding.

Bottom line: Active-bed management by hospitalists improves ED throughput by decreasing the length of time admitted patients spend in the ED and reducing ambulance diversion hours.

Citation: Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.

Literature at a Glance

A guide to this month’s studies.

• Score predicts risk of intracerebral hemorrhage after thrombolysis.
• Trigylcerides and stroke-risk predictors.
• PPI use and risk of community-acquired pneumonia.
• Clopidogrel before coronary intervention might improve outcomes.
• High-dose clopidogrel after coronary intervention is beneficial.
• B-type natriuretic peptide level and sepsis.
• Thrombolytic use in pulmonary embolism.
• Hospitalists and ED patient flow.

Simple Clinical Score Predicts Intracerebral Hemorrhage after Thrombolysis

Clinical question: Is there a simple scoring tool that will predict the risk of intracerebral hemorrhage (ICH) following IV tissue-plasminogen activator (t-PA) in ischemic strokes?

Background: The use of t-PA in acute ischemic stroke (AIS) is about 2% to 4%, due in part to fear of conversion of an ischemic event to an ICH. Several studies using t-PA after AIS have identified risk factors for ICH; however, none has looked at the cumulative risk and prognosis for an individual candidate based on these factors.

Study design: Retrospective, observational cohort study.

Setting: The National Institute of Neurological Disorders and Stroke Trials 1 and 2, and consecutive patients treated at Beth Israel Deaconess Medical Center, Boston.

Synopsis: After an extensive literature review, a five-point scale to determine the risk of hemorrhage after t-PA (HAT) was developed using the top four predictive factors based on odds ratios. These included the National Institutes of Health Stroke Scale (NIHSS), presence and extent of hypodensity on initial CT scan, history of diabetes, and high baseline serum glucose. The predictive value of this scale was tested against two independent cohorts of patients with AIS treated with IV t-PA. The HAT scale was able to reasonably predict both the risk of ICH following t-PA and the functional outcome at 90 days. Higher scores on the scale tended to do worse, especially scores of three or more. Its retrospective nature and small number of patients experiencing ICH limit this study.

Bottom line: The HAT score is a quick bedside tool that can help in the counseling of patients and families in conjunction with the risks and benefits of t-PA after ischemic stroke.

Citation: Lou M, Safdar A, Mehdiratta M, et al. The HAT Score: a simple grading scale for predicting hemorrhage after thrombolysis. Neurology. 2008;71:1417-1423.

Nonfasting Triglycerides Predict Stroke Risk

Clinical question: Is there a correlation between nonfasting triglyceride levels and ischemic stroke?

Background: Most individuals are in a nonfasting state, with the exception of several hours prior to breakfast. Fasting cholesterol levels exclude most remnant lipoproteins, which might play a role in early atherosclerotic disease. Increased levels of triglycerides in a nonfasting state indicate the presence of these remnants.

Study design: Prospective, population-based cohort study.

Setting: The Copenhagen City Heart Study.

Synopsis: The study included 13,956 individuals between the ages of 20 and 93 with a follow-up period of up to 31 years. Cholesterol levels were checked during four evaluation periods: 1976-1978, 1981-1983, 1991-1994, and 2001-2003. Eighty-two percent of the participants had eaten a meal within three hours of the blood draw; the other 18% had eaten more than three hours prior to the draw. The study showed an association between increasing nonfasting triglyceride levels and a step-wise increase in the risk of ischemic stroke. The highest risk came in individuals with nonfasting triglyceride levels > 443mg/dl, which was associated with a three- to fourfold greater risk of ischemic stroke. The study was limited in that it evaluated a homogenous group of individuals, which may not reflect other racial or ethnic populations.

Bottom line: Increasing levels of nonfasting triglycerides are associated with an increased risk of ischemic stroke.

Citation: Freiberg J, Tybjaerg-Hansen A, Jensen JS, Nordestgaard BG. Nonfasting triglycerides and risk of ischemic stroke in the general population. JAMA. 2008;300(18):2142-2152.

Proton-Pump Inhibitor (PPI) Use Increases the Risk of Community-Acquired Pneumonia (CAP)

Clinical question: Is there an association between PPI use and CAP?

Background: CAP is associated with significant morbidity, annually accounting for billions of healthcare dollars. Proton-pump inhibitors (PPI) are a mainstay treatment for gastric acid suppression. Previous studies have suggested using PPIs may increase the risk of developing CAP.

Study design: Nested case control study.

Setting: Outpatient general practices, United Kingdom.

Synopsis: The association between PPI use and CAP was evaluated in a cohort of more than 7 million patients using the UK’s general-practice research database. Eligible participants were divided into two groups: case patients and control patients. Initial results indicated an increased risk of CAP with PPI use. After adjusting for confounding variables, the use of a PPI was strongly associated with CAP development when used within 30 days prior of the diagnosis, and most notably within 48 hours of diagnosis. It also was noted that the risk of developing CAP with longer-term PPI use was much lower. This inverse temporal relationship was noted in two previous studies. The limitations of this study were related to presumed adherence and compliance with PPI therapy. There also was no radiographic data to support the diagnosis of pneumonia in these cases, both of which could bias the results.

Bottom line: There appears to be an increased risk of CAP with PPI use. This risk is most notable within 48 hours. However, long-term, chronic PPI use was not associated with an increased risk of CAP.

Citation: Sarkar M, Hennessy S, Yang YX. Proton-pump inhibitor use and the risk for community-acquired pneumonia. Ann Intern Med. 2008;149:391-398.

Clopidogrel Prior to Percutaneous Intervention (PCI) Might Improve Outcomes in Patients with Acute ST-Elevation Myocardial Infarction (STEMI)

Clinical question: Does pretreatment with clopidogrel prior to PCI in acute STEMI improve outcomes?

Background: Extant guidelines for early utilization of clopidogrel in STEMI patients are based on results of studies of patients with non-ST-elevation acute coronary syndromes or treatment with thrombolytics.

Study design: Systematic review.

Setting: MEDLINE and Cochrane Controlled Trials Register of randomized controlled trials.

Synopsis: The authors selected 38 treatment groups, including 8,429 patients with STEMI who underwent primary PCI. They found a statistically significant difference in initial patency, and further found clopidogrel pretreatment was an independent predictor of early reperfusion and improved clinical outcome. This study suggests a benefit to pretreatment with clopidogrel but likely is not sufficient to establish such pretreatment as the standard of care. The limitations of this study were a retrospective review/meta-analysis, as the ability to limit the influence of confounding variables is reduced.

Bottom line: Pretreatment with clopidogrel in patients with acute STEMI undergoing primary PCI appears beneficial based on the results of this review of available evidence.

Citation: Vlaar PJ, Svilaas T, Damman K, et al. Impact of pretreatment with clopidogrel on initial patency and outcomes in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review. Circulation. 2008;118:1828-1836.

High-Dose Clopidogrel after PCI Is Beneficial

Clinical question: Does high-dose clopidogrel improve patient outcome following PCI?

Background: Studies have shown antiplatelet resistance after PCI is associated with an increased risk of cardiovascular events, including in-stent thrombosis and death. Other studies have shown the benefit of high-dose clopidogrel by the inhibition of platelet aggregation. Limited information is available regarding the applicability to patients after PCI.

Study design: Retrospective study of 2,954 consecutive patients divided into two groups, low-dose and high-dose clopidogrel use.

Setting: Single hospital in France.

Synopsis: The low-dose study group undergoing PCI was pretreated with 300 mg clopidogrel, followed by ASA 75 mg and clopidogrel 75 mg daily for two months. The second group undergoing PCI was pretreated with 600 mg clopidogrel followed by ASA 75 mg and clopidogrel 150 mg for 15 days, then maintained on ASA 75 mg and clopidogrel 75 mg. Patients received follow-up at two months and were evaluated for in-stent thrombosis, myocardial infarction (MI), death, and hemorrhagic complications. The two groups were matched one-to-one using propensity scoring and the nearest-pair-matching method blinded to patient outcome.

The high-dose clopidogrel group showed a decreased incidence of MI, in-stent thrombosis, and death. This benefit confirms the importance of achieving early and adequate antiplatelet therapy. However, the study authors noted a higher percentage of major bleeding and minor bleeding, although the increase was not statistically significant (2.8% vs. 3.5%, P=0.379, and 7.4% vs. 8.2%, P=0.699, respectively).

Bottom line: High-dose clopidogrel before and within the first 15 days after PCI decreases the risk of MI, in-stent thrombosis, and death, with no statistical increase in bleeding complications. Long-range studies beyond the two-month interval might be beneficial.

Citation: Lemesle G, Delhaye C, Sudre A, et al. Impact of high loading and maintenance dose of clopidogrel within the first 15 days after percutaneous coronary intervention on patient outcome. Am Heart J. 2008;10:1-8.

B-Type Natriuretic Peptide (BNP) Identifies Patients Developing Sepsis-Induced Myocardial Depression

Clinical question: Can plasma BNP be used as a marker to identify patients at risk for sepsis-induced depression of myocardial function?

Background: Previous studies have established BNP levels are increased in patients with septic shock but have not examined the relationship between plasma BNP concentration and left ventricular (LV) systolic dysfunction.

Study design: Prospective cohort.

Setting: Academic medical center.

Synopsis: The authors divided 93 prospectively selected ICU patients with severe sepsis into two groups: one with normal left ventricular (LV) function and a group with LV systolic dysfunction. Comparison of the plasma BNP concentrations between these two groups demonstrated a significant positive correlation between the BNP level and the degree of LV systolic dysfunction, suggesting BNP is a reasonable marker for identification of septic patients with sepsis-induced myocardial depression.

Further, the study’s results suggest BNP measurements early in the course of septic shock might be useful prognostic indicators. However, it is unclear to what extent the knowledge gained from such measurements would alter care management, or how BNP compares to echocardiography in terms of diagnostic and prognostic utility. Thus, these results might not be adequate to justify the routine measurement of BNP in patients with severe sepsis.

Bottom line: Elevated BNP in septic patients is associated with the presence or risk of sepsis-induced myocardial depression, and might be a negative prognostic indicator.

Citation: Post F, Weilemann LS, Messow CM, Sinning C, Munzel T. B-type natriuretic peptide as a marker for sepsis-induced myocardial depression in intensive care patients. Crit Care Med. 2008;36:3030–3037.

High Risk of Death with Thrombolytic Use in Low-Risk Pulmonary Embolism (PE)

Clinical question: Is there an advantage to thrombolytic therapy in the treatment of acute PE versus treatment with unfractionated or low-molecular-weight (LMW) heparin?

Background: Given the high mortality linked to PE, consistent indications for thrombolytic therapy in acute PE are needed. An assessment of the prevalence of thrombolytic therapy and mortality, as compared with standard anticoagulation, has been described inconsistently.

Study design: Retrospective cohort study.

Setting: 186 acute-care hospitals in Pennsylvania.

Synopsis: Using a database of ICD-9 codes, 15,116 patients were reviewed. Logistic regression was used to evaluate the association between thrombolytic therapy and 30-day mortality. Poisson regression was used to evaluate the association between thrombolytic therapy and in-hospital mortality. For those receiving thrombolysis and considered unlikely candidates for the therapy based on documentation at presentation (low predicted probability), the in-hospital mortality and overall 30-day mortality rate were higher when compared with those who did not receive thrombolysis. An exception to this was a group of patients with high predicted probability of receiving thrombolysis. In this group, thrombolysis was not associated with increased risk. Limitations to the study include lack of assessment of right ventricular function, changes in condition after presentation, lack of long-term outcomes, and lack of exact cause of death.

Bottom line: Thrombolytic therapy is associated with higher mortality in patients with hemodynamically uncomplicated PE, and therefore not indicated. Thrombolytic therapy in a subgroup of patients with hemodynamic instability or right ventricular dysfunction improves the clinical course and outcome.

Citation: Ibrahim SA, Stone RA, Obrosky S, Geng M, Fine MJ, Aujesky D. Thrombolytic therapy and mortality in patients with acute pulmonary embolism. Arch Intern Med. 2008;168(20):2183-2190.

Hospitalists Improve Patient Flow in the ED

Clinical question: Can active-bed management by hospitalists reduce ED throughput times and diversionary status?

Background: ED overcrowding leads to ambulance diversion, which has been associated with increased mortality. A primary cause of ED crowding is inpatient boarding, which can reduce patient satisfaction and quality of care. Previous studies targeting the ED have had little impact on throughput and ambulance diversion.

Study design: Pre-post case study in a single institution.

Setting: Academic teaching hospital in Baltimore.

Synopsis: ED throughput times and ambulance diversion hours were measured for all adult patients registered in the department from November 2005 to February 2006 (control period) and November 2006 to February 2007 (intervention period). Active-bed management was defined as appointing a hospitalist to assess bed availability in real time and assigning department of medicine admissions to the appropriate clinical setting, as well as the creation of a bed director. Although the ED census was 8.8% higher during the intervention period, throughput time for admitted patients decreased by 98 minutes per patient, to 458 from 360. The time spent under diversionary status for overcrowding or lack of ICU beds decreased by 6% and 27%, respectively. Limitations of this study include the pre-post design and the implementation at a single institution. Additionally, active-bed management is expensive, and in this case required the hiring of three full-time-equivalent faculty. However, this study successfully demonstrates that a quality improvement partnership between hospitalists and the ED can substantially reduce overcrowding.

Bottom line: Active-bed management by hospitalists improves ED throughput by decreasing the length of time admitted patients spend in the ED and reducing ambulance diversion hours.

Citation: Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.

Literature at a Glance

A guide to this month’s studies.

• Score predicts risk of intracerebral hemorrhage after thrombolysis.
• Trigylcerides and stroke-risk predictors.
• PPI use and risk of community-acquired pneumonia.
• Clopidogrel before coronary intervention might improve outcomes.
• High-dose clopidogrel after coronary intervention is beneficial.
• B-type natriuretic peptide level and sepsis.
• Thrombolytic use in pulmonary embolism.
• Hospitalists and ED patient flow.

Simple Clinical Score Predicts Intracerebral Hemorrhage after Thrombolysis

Clinical question: Is there a simple scoring tool that will predict the risk of intracerebral hemorrhage (ICH) following IV tissue-plasminogen activator (t-PA) in ischemic strokes?

Background: The use of t-PA in acute ischemic stroke (AIS) is about 2% to 4%, due in part to fear of conversion of an ischemic event to an ICH. Several studies using t-PA after AIS have identified risk factors for ICH; however, none has looked at the cumulative risk and prognosis for an individual candidate based on these factors.

Study design: Retrospective, observational cohort study.

Setting: The National Institute of Neurological Disorders and Stroke Trials 1 and 2, and consecutive patients treated at Beth Israel Deaconess Medical Center, Boston.

Synopsis: After an extensive literature review, a five-point scale to determine the risk of hemorrhage after t-PA (HAT) was developed using the top four predictive factors based on odds ratios. These included the National Institutes of Health Stroke Scale (NIHSS), presence and extent of hypodensity on initial CT scan, history of diabetes, and high baseline serum glucose. The predictive value of this scale was tested against two independent cohorts of patients with AIS treated with IV t-PA. The HAT scale was able to reasonably predict both the risk of ICH following t-PA and the functional outcome at 90 days. Higher scores on the scale tended to do worse, especially scores of three or more. Its retrospective nature and small number of patients experiencing ICH limit this study.

Bottom line: The HAT score is a quick bedside tool that can help in the counseling of patients and families in conjunction with the risks and benefits of t-PA after ischemic stroke.

Citation: Lou M, Safdar A, Mehdiratta M, et al. The HAT Score: a simple grading scale for predicting hemorrhage after thrombolysis. Neurology. 2008;71:1417-1423.

Nonfasting Triglycerides Predict Stroke Risk

Clinical question: Is there a correlation between nonfasting triglyceride levels and ischemic stroke?

Background: Most individuals are in a nonfasting state, with the exception of several hours prior to breakfast. Fasting cholesterol levels exclude most remnant lipoproteins, which might play a role in early atherosclerotic disease. Increased levels of triglycerides in a nonfasting state indicate the presence of these remnants.

Study design: Prospective, population-based cohort study.

Setting: The Copenhagen City Heart Study.

Synopsis: The study included 13,956 individuals between the ages of 20 and 93 with a follow-up period of up to 31 years. Cholesterol levels were checked during four evaluation periods: 1976-1978, 1981-1983, 1991-1994, and 2001-2003. Eighty-two percent of the participants had eaten a meal within three hours of the blood draw; the other 18% had eaten more than three hours prior to the draw. The study showed an association between increasing nonfasting triglyceride levels and a step-wise increase in the risk of ischemic stroke. The highest risk came in individuals with nonfasting triglyceride levels > 443mg/dl, which was associated with a three- to fourfold greater risk of ischemic stroke. The study was limited in that it evaluated a homogenous group of individuals, which may not reflect other racial or ethnic populations.

Bottom line: Increasing levels of nonfasting triglycerides are associated with an increased risk of ischemic stroke.

Citation: Freiberg J, Tybjaerg-Hansen A, Jensen JS, Nordestgaard BG. Nonfasting triglycerides and risk of ischemic stroke in the general population. JAMA. 2008;300(18):2142-2152.

Proton-Pump Inhibitor (PPI) Use Increases the Risk of Community-Acquired Pneumonia (CAP)

Clinical question: Is there an association between PPI use and CAP?

Background: CAP is associated with significant morbidity, annually accounting for billions of healthcare dollars. Proton-pump inhibitors (PPI) are a mainstay treatment for gastric acid suppression. Previous studies have suggested using PPIs may increase the risk of developing CAP.

Study design: Nested case control study.

Setting: Outpatient general practices, United Kingdom.

Synopsis: The association between PPI use and CAP was evaluated in a cohort of more than 7 million patients using the UK’s general-practice research database. Eligible participants were divided into two groups: case patients and control patients. Initial results indicated an increased risk of CAP with PPI use. After adjusting for confounding variables, the use of a PPI was strongly associated with CAP development when used within 30 days prior of the diagnosis, and most notably within 48 hours of diagnosis. It also was noted that the risk of developing CAP with longer-term PPI use was much lower. This inverse temporal relationship was noted in two previous studies. The limitations of this study were related to presumed adherence and compliance with PPI therapy. There also was no radiographic data to support the diagnosis of pneumonia in these cases, both of which could bias the results.

Bottom line: There appears to be an increased risk of CAP with PPI use. This risk is most notable within 48 hours. However, long-term, chronic PPI use was not associated with an increased risk of CAP.

Citation: Sarkar M, Hennessy S, Yang YX. Proton-pump inhibitor use and the risk for community-acquired pneumonia. Ann Intern Med. 2008;149:391-398.

Clopidogrel Prior to Percutaneous Intervention (PCI) Might Improve Outcomes in Patients with Acute ST-Elevation Myocardial Infarction (STEMI)

Clinical question: Does pretreatment with clopidogrel prior to PCI in acute STEMI improve outcomes?

Background: Extant guidelines for early utilization of clopidogrel in STEMI patients are based on results of studies of patients with non-ST-elevation acute coronary syndromes or treatment with thrombolytics.

Study design: Systematic review.

Setting: MEDLINE and Cochrane Controlled Trials Register of randomized controlled trials.

Synopsis: The authors selected 38 treatment groups, including 8,429 patients with STEMI who underwent primary PCI. They found a statistically significant difference in initial patency, and further found clopidogrel pretreatment was an independent predictor of early reperfusion and improved clinical outcome. This study suggests a benefit to pretreatment with clopidogrel but likely is not sufficient to establish such pretreatment as the standard of care. The limitations of this study were a retrospective review/meta-analysis, as the ability to limit the influence of confounding variables is reduced.

Bottom line: Pretreatment with clopidogrel in patients with acute STEMI undergoing primary PCI appears beneficial based on the results of this review of available evidence.

Citation: Vlaar PJ, Svilaas T, Damman K, et al. Impact of pretreatment with clopidogrel on initial patency and outcomes in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review. Circulation. 2008;118:1828-1836.

High-Dose Clopidogrel after PCI Is Beneficial

Clinical question: Does high-dose clopidogrel improve patient outcome following PCI?

Background: Studies have shown antiplatelet resistance after PCI is associated with an increased risk of cardiovascular events, including in-stent thrombosis and death. Other studies have shown the benefit of high-dose clopidogrel by the inhibition of platelet aggregation. Limited information is available regarding the applicability to patients after PCI.

Study design: Retrospective study of 2,954 consecutive patients divided into two groups, low-dose and high-dose clopidogrel use.

Setting: Single hospital in France.

Synopsis: The low-dose study group undergoing PCI was pretreated with 300 mg clopidogrel, followed by ASA 75 mg and clopidogrel 75 mg daily for two months. The second group undergoing PCI was pretreated with 600 mg clopidogrel followed by ASA 75 mg and clopidogrel 150 mg for 15 days, then maintained on ASA 75 mg and clopidogrel 75 mg. Patients received follow-up at two months and were evaluated for in-stent thrombosis, myocardial infarction (MI), death, and hemorrhagic complications. The two groups were matched one-to-one using propensity scoring and the nearest-pair-matching method blinded to patient outcome.

The high-dose clopidogrel group showed a decreased incidence of MI, in-stent thrombosis, and death. This benefit confirms the importance of achieving early and adequate antiplatelet therapy. However, the study authors noted a higher percentage of major bleeding and minor bleeding, although the increase was not statistically significant (2.8% vs. 3.5%, P=0.379, and 7.4% vs. 8.2%, P=0.699, respectively).

Bottom line: High-dose clopidogrel before and within the first 15 days after PCI decreases the risk of MI, in-stent thrombosis, and death, with no statistical increase in bleeding complications. Long-range studies beyond the two-month interval might be beneficial.

Citation: Lemesle G, Delhaye C, Sudre A, et al. Impact of high loading and maintenance dose of clopidogrel within the first 15 days after percutaneous coronary intervention on patient outcome. Am Heart J. 2008;10:1-8.

B-Type Natriuretic Peptide (BNP) Identifies Patients Developing Sepsis-Induced Myocardial Depression

Clinical question: Can plasma BNP be used as a marker to identify patients at risk for sepsis-induced depression of myocardial function?

Background: Previous studies have established BNP levels are increased in patients with septic shock but have not examined the relationship between plasma BNP concentration and left ventricular (LV) systolic dysfunction.

Study design: Prospective cohort.

Setting: Academic medical center.

Synopsis: The authors divided 93 prospectively selected ICU patients with severe sepsis into two groups: one with normal left ventricular (LV) function and a group with LV systolic dysfunction. Comparison of the plasma BNP concentrations between these two groups demonstrated a significant positive correlation between the BNP level and the degree of LV systolic dysfunction, suggesting BNP is a reasonable marker for identification of septic patients with sepsis-induced myocardial depression.

Further, the study’s results suggest BNP measurements early in the course of septic shock might be useful prognostic indicators. However, it is unclear to what extent the knowledge gained from such measurements would alter care management, or how BNP compares to echocardiography in terms of diagnostic and prognostic utility. Thus, these results might not be adequate to justify the routine measurement of BNP in patients with severe sepsis.

Bottom line: Elevated BNP in septic patients is associated with the presence or risk of sepsis-induced myocardial depression, and might be a negative prognostic indicator.

Citation: Post F, Weilemann LS, Messow CM, Sinning C, Munzel T. B-type natriuretic peptide as a marker for sepsis-induced myocardial depression in intensive care patients. Crit Care Med. 2008;36:3030–3037.

High Risk of Death with Thrombolytic Use in Low-Risk Pulmonary Embolism (PE)

Clinical question: Is there an advantage to thrombolytic therapy in the treatment of acute PE versus treatment with unfractionated or low-molecular-weight (LMW) heparin?

Background: Given the high mortality linked to PE, consistent indications for thrombolytic therapy in acute PE are needed. An assessment of the prevalence of thrombolytic therapy and mortality, as compared with standard anticoagulation, has been described inconsistently.

Study design: Retrospective cohort study.

Setting: 186 acute-care hospitals in Pennsylvania.

Synopsis: Using a database of ICD-9 codes, 15,116 patients were reviewed. Logistic regression was used to evaluate the association between thrombolytic therapy and 30-day mortality. Poisson regression was used to evaluate the association between thrombolytic therapy and in-hospital mortality. For those receiving thrombolysis and considered unlikely candidates for the therapy based on documentation at presentation (low predicted probability), the in-hospital mortality and overall 30-day mortality rate were higher when compared with those who did not receive thrombolysis. An exception to this was a group of patients with high predicted probability of receiving thrombolysis. In this group, thrombolysis was not associated with increased risk. Limitations to the study include lack of assessment of right ventricular function, changes in condition after presentation, lack of long-term outcomes, and lack of exact cause of death.

Bottom line: Thrombolytic therapy is associated with higher mortality in patients with hemodynamically uncomplicated PE, and therefore not indicated. Thrombolytic therapy in a subgroup of patients with hemodynamic instability or right ventricular dysfunction improves the clinical course and outcome.

Citation: Ibrahim SA, Stone RA, Obrosky S, Geng M, Fine MJ, Aujesky D. Thrombolytic therapy and mortality in patients with acute pulmonary embolism. Arch Intern Med. 2008;168(20):2183-2190.

Hospitalists Improve Patient Flow in the ED

Clinical question: Can active-bed management by hospitalists reduce ED throughput times and diversionary status?

Background: ED overcrowding leads to ambulance diversion, which has been associated with increased mortality. A primary cause of ED crowding is inpatient boarding, which can reduce patient satisfaction and quality of care. Previous studies targeting the ED have had little impact on throughput and ambulance diversion.

Study design: Pre-post case study in a single institution.

Setting: Academic teaching hospital in Baltimore.

Synopsis: ED throughput times and ambulance diversion hours were measured for all adult patients registered in the department from November 2005 to February 2006 (control period) and November 2006 to February 2007 (intervention period). Active-bed management was defined as appointing a hospitalist to assess bed availability in real time and assigning department of medicine admissions to the appropriate clinical setting, as well as the creation of a bed director. Although the ED census was 8.8% higher during the intervention period, throughput time for admitted patients decreased by 98 minutes per patient, to 458 from 360. The time spent under diversionary status for overcrowding or lack of ICU beds decreased by 6% and 27%, respectively. Limitations of this study include the pre-post design and the implementation at a single institution. Additionally, active-bed management is expensive, and in this case required the hiring of three full-time-equivalent faculty. However, this study successfully demonstrates that a quality improvement partnership between hospitalists and the ED can substantially reduce overcrowding.

Bottom line: Active-bed management by hospitalists improves ED throughput by decreasing the length of time admitted patients spend in the ED and reducing ambulance diversion hours.

Citation: Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge.

The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.

Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

The study, published in the August 2008 issue of the Journal of General Internal Medicine, garnered praise from Mark Williams, MD, FACP, professor and chief of the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine in Chicago and principal investigator of SHM’s Project BOOST study (see “BOOST Sites Chosen,” August 2008, p. 1), which is examining ways to improve transitions of care.1 “This small but well-done study demonstrates how using interventions similar to components in the Project BOOST toolkit resulted in a significant improvement in outpatient follow-up, and a trend toward a reduction in hospitalizations and emergency room visits,” Dr. Williams says.

The four-part process calls for:

• The patient to receive a comprehensive, “user-friendly” discharge instruction form;
• Electronic transfer of the discharge instruction form to RNs at the patient’s primary-care site;
• A primary-care RN to call the patient by the next business day to monitor his or her condition; and
• The review and modification of the discharge plan by the primary-care provider as needed.

The research team, which included Joel S. Weissman, PhD, of Massachusetts General Hospital, Harvard Medical School, and the Harvard School of Public Health; Peter A. Samuel of Harvard Medical School; and Stephanie Woolhandler, MD, of CHA and Harvard Medical School, thinks the discharge process, a key task for hospitalists, should be treated as vital as the admissions process. “Hospitalists need to improve the level of detail in discharge plans; this form and process supports that,” Dr. Balaban says. By providing this quality information to outpatient providers, collaboration is improved, making hospitalists more effective, he says.

Proof in the Pudding

The process was tested at Somerville Hospital, a 100-bed community hospital and teaching facility affiliated with Harvard Medical School. Approx-imately 25% of Somerville’s patients are non-English-speakers; the process was designed to serve a culturally diverse population.

All patients in the study, conducted between June 2006 and January 2007, had received care from hospitalist-led teams and received outpatient care at CHA facilities. Ninety-six patients were studied; 47 took part in the new discharge process and the rest were discharged according to existing procedures. Outcomes were compared with those of 100 patients who previously had been discharged from the hospital.

The team measured four undesirable outcomes after discharge:

• No outpatient follow-up within 21 days;
• Readmission within 31 days;
• Emergency department visit within 31 days; and
• Failure by the primary-care provider to complete an outpatient workup recommended by hospital doctors.

The study found just 25.5% of the patients who completed the new process had one or more undesirable outcomes, compared with 55.1% of the control group patients and 55% in the historical group. The most significant improvements were in the rates of outpatient follow-up and completed workups (see “Better Process Equals Better Outcomes”).

The process was especially effective among patients discharged on weekends, and had a greater effect on patients who did not speak English, were hospitalized one or two days, and were age 60 and older. The effect of the new process also was evident in outpatient treatment, Dr. Balaban says. At least seven of the 47 patients discharged through the new process had their treatment plan changed by the RNs who made the follow-up phone call. “They weren’t big changes, things like calling in prescriptions and making urgent appointments,” he says, “but they made a difference: for example, providing a pneumonia patient with a thermometer to monitor possible infections, and a scale so that a patient with congestive heart failure could monitor weight gain possibly caused by harmful retention of fluid.”

Dr. Balaban’s team plans to conduct a larger study, though not randomized, at Cambridge Hospital to test the new process on all discharges. “There usually is little collaboration on discharges,” Dr. Balaban says. “This process provides detail, a record of critical information, and creates interchange between care teams. Discharge should be looked at as a continuing, key part of care.” TH

Karla Feuer is a freelance writer based in North Carolina.

Reference

1. Balaban RB, Weissmann JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;8:1228-1233.

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge.

The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.

Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

The study, published in the August 2008 issue of the Journal of General Internal Medicine, garnered praise from Mark Williams, MD, FACP, professor and chief of the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine in Chicago and principal investigator of SHM’s Project BOOST study (see “BOOST Sites Chosen,” August 2008, p. 1), which is examining ways to improve transitions of care.1 “This small but well-done study demonstrates how using interventions similar to components in the Project BOOST toolkit resulted in a significant improvement in outpatient follow-up, and a trend toward a reduction in hospitalizations and emergency room visits,” Dr. Williams says.

The four-part process calls for:

• The patient to receive a comprehensive, “user-friendly” discharge instruction form;
• Electronic transfer of the discharge instruction form to RNs at the patient’s primary-care site;
• A primary-care RN to call the patient by the next business day to monitor his or her condition; and
• The review and modification of the discharge plan by the primary-care provider as needed.

The research team, which included Joel S. Weissman, PhD, of Massachusetts General Hospital, Harvard Medical School, and the Harvard School of Public Health; Peter A. Samuel of Harvard Medical School; and Stephanie Woolhandler, MD, of CHA and Harvard Medical School, thinks the discharge process, a key task for hospitalists, should be treated as vital as the admissions process. “Hospitalists need to improve the level of detail in discharge plans; this form and process supports that,” Dr. Balaban says. By providing this quality information to outpatient providers, collaboration is improved, making hospitalists more effective, he says.

Proof in the Pudding

The process was tested at Somerville Hospital, a 100-bed community hospital and teaching facility affiliated with Harvard Medical School. Approx-imately 25% of Somerville’s patients are non-English-speakers; the process was designed to serve a culturally diverse population.

All patients in the study, conducted between June 2006 and January 2007, had received care from hospitalist-led teams and received outpatient care at CHA facilities. Ninety-six patients were studied; 47 took part in the new discharge process and the rest were discharged according to existing procedures. Outcomes were compared with those of 100 patients who previously had been discharged from the hospital.

The team measured four undesirable outcomes after discharge:

• No outpatient follow-up within 21 days;
• Readmission within 31 days;
• Emergency department visit within 31 days; and
• Failure by the primary-care provider to complete an outpatient workup recommended by hospital doctors.

The study found just 25.5% of the patients who completed the new process had one or more undesirable outcomes, compared with 55.1% of the control group patients and 55% in the historical group. The most significant improvements were in the rates of outpatient follow-up and completed workups (see “Better Process Equals Better Outcomes”).

The process was especially effective among patients discharged on weekends, and had a greater effect on patients who did not speak English, were hospitalized one or two days, and were age 60 and older. The effect of the new process also was evident in outpatient treatment, Dr. Balaban says. At least seven of the 47 patients discharged through the new process had their treatment plan changed by the RNs who made the follow-up phone call. “They weren’t big changes, things like calling in prescriptions and making urgent appointments,” he says, “but they made a difference: for example, providing a pneumonia patient with a thermometer to monitor possible infections, and a scale so that a patient with congestive heart failure could monitor weight gain possibly caused by harmful retention of fluid.”

Dr. Balaban’s team plans to conduct a larger study, though not randomized, at Cambridge Hospital to test the new process on all discharges. “There usually is little collaboration on discharges,” Dr. Balaban says. “This process provides detail, a record of critical information, and creates interchange between care teams. Discharge should be looked at as a continuing, key part of care.” TH

Karla Feuer is a freelance writer based in North Carolina.

Reference

1. Balaban RB, Weissmann JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;8:1228-1233.

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge.

The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.

Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

The study, published in the August 2008 issue of the Journal of General Internal Medicine, garnered praise from Mark Williams, MD, FACP, professor and chief of the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine in Chicago and principal investigator of SHM’s Project BOOST study (see “BOOST Sites Chosen,” August 2008, p. 1), which is examining ways to improve transitions of care.1 “This small but well-done study demonstrates how using interventions similar to components in the Project BOOST toolkit resulted in a significant improvement in outpatient follow-up, and a trend toward a reduction in hospitalizations and emergency room visits,” Dr. Williams says.

The four-part process calls for:

• The patient to receive a comprehensive, “user-friendly” discharge instruction form;
• Electronic transfer of the discharge instruction form to RNs at the patient’s primary-care site;
• A primary-care RN to call the patient by the next business day to monitor his or her condition; and
• The review and modification of the discharge plan by the primary-care provider as needed.

The research team, which included Joel S. Weissman, PhD, of Massachusetts General Hospital, Harvard Medical School, and the Harvard School of Public Health; Peter A. Samuel of Harvard Medical School; and Stephanie Woolhandler, MD, of CHA and Harvard Medical School, thinks the discharge process, a key task for hospitalists, should be treated as vital as the admissions process. “Hospitalists need to improve the level of detail in discharge plans; this form and process supports that,” Dr. Balaban says. By providing this quality information to outpatient providers, collaboration is improved, making hospitalists more effective, he says.

Proof in the Pudding

The process was tested at Somerville Hospital, a 100-bed community hospital and teaching facility affiliated with Harvard Medical School. Approx-imately 25% of Somerville’s patients are non-English-speakers; the process was designed to serve a culturally diverse population.

All patients in the study, conducted between June 2006 and January 2007, had received care from hospitalist-led teams and received outpatient care at CHA facilities. Ninety-six patients were studied; 47 took part in the new discharge process and the rest were discharged according to existing procedures. Outcomes were compared with those of 100 patients who previously had been discharged from the hospital.

The team measured four undesirable outcomes after discharge:

• No outpatient follow-up within 21 days;
• Readmission within 31 days;
• Emergency department visit within 31 days; and
• Failure by the primary-care provider to complete an outpatient workup recommended by hospital doctors.

The study found just 25.5% of the patients who completed the new process had one or more undesirable outcomes, compared with 55.1% of the control group patients and 55% in the historical group. The most significant improvements were in the rates of outpatient follow-up and completed workups (see “Better Process Equals Better Outcomes”).

The process was especially effective among patients discharged on weekends, and had a greater effect on patients who did not speak English, were hospitalized one or two days, and were age 60 and older. The effect of the new process also was evident in outpatient treatment, Dr. Balaban says. At least seven of the 47 patients discharged through the new process had their treatment plan changed by the RNs who made the follow-up phone call. “They weren’t big changes, things like calling in prescriptions and making urgent appointments,” he says, “but they made a difference: for example, providing a pneumonia patient with a thermometer to monitor possible infections, and a scale so that a patient with congestive heart failure could monitor weight gain possibly caused by harmful retention of fluid.”

Dr. Balaban’s team plans to conduct a larger study, though not randomized, at Cambridge Hospital to test the new process on all discharges. “There usually is little collaboration on discharges,” Dr. Balaban says. “This process provides detail, a record of critical information, and creates interchange between care teams. Discharge should be looked at as a continuing, key part of care.” TH

Karla Feuer is a freelance writer based in North Carolina.

Reference

1. Balaban RB, Weissmann JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;8:1228-1233.

Protection of the Medicare program has reached new heights in recent years. One of the most important ways hospitalist groups can protect their Medicare funding is the discovery and recovery of improper contractor payments of Medicare claims.

The Centers for Medicare and Medicaid Services (CMS) reviews various types of contractors—Medicare administrative contractors (MACs),  carriers, durable medical equipment regional carriers (DMERCs), fiscal intermediaries (FIs), and quality improvement organizations (QIOs)—through its protection efforts as part of the Comprehensive Error Rate Testing (CERT) program and Hospital Payment Monitoring Program (HPMP). The CERT program’s contractors review physician (i.e., professional) claims processed by MACs and carriers.

The primary goal of a contractor is to “pay it right”—that is, pay the correct amount to the right provider for covered and correctly coded services.1 During the 12-month reporting period ending Sept. 30, 2007, the CERT program sampled 129,875 claims from carriers, DMERCs, FIs, and MACs.

The CERT contractor randomly and electronically selects about 172 claims each month from each type of claims-processing contractor. Since some of these contractors were transitioning to MACs, the target Part B (i.e., professional) sample size for the May 2008 report was approximately 2,000 reviewable claims per MAC cluster. However, this might have varied if a MAC was not processing claims during the entire sampling period.

click table for large version

click table for large version

Document Requests

Physicians need to be mindful of CERT requests for documentation. When possible, every attempt is made to benefit the physician. Initial CERT requests are attempted by way of a letter. If the physician does not respond within 30 days, the CERT contractor attempts one to three more contacts with correspondence and phone calls. If documentation is received after 75 days, it is considered “late.” It then will be reviewed, unless the reporting period has expired.

However, this should not be considered a prudent approach, and timely responses are ideal. If the physician offers no response, and documentation is not received, it is counted as a “no documentation” error.

Physicians often worry about accusations of fraud. The purpose of the CERT program is not to assume or accuse physicians of fraud, although it may serve as a deterrent. It does not, and cannot, label a claim fraudulent.

One scenario of potential fraud the CERT program is able to identify occurs when a CERT documentation contractor is unable to locate a provider or supplier when requesting medical record documentation.2

Outcomes

Individual contractors are notified of improper payments. These include overpayments and underpayments. Unfortunately, contractors do not have to resolve CERT issues involving underpayments, although they are encouraged to do so by CMS.

The CERT program identified overpayments totaling $875,005 during the 12-month reporting period, but collected only $650,418 in overpayments after consideration of appeals that overturned a CERT decision or the provider discontinued business operations. (See Table 1, p. 18, for error rates and Table 2, p. 18, for highest rates of improper payment)

To improve billing compliance and prevent repetitive errors, contractors must implement provider education regarding erroneously paid claims. A contractor may determine the best education method to distribute information about Medicare rules and effectively answer coverage and coding questions.

Some contractors have designed Web-based training modules, Web pages with frequently-asked-questions sections, or local coverage analyses to address contractor-specific errors. Detailed CERT contractor information can be found at www.cms.hhs.gov/ mcd/indexes.asp?from2=indexes.asp&

Due to its successful outcomes, future CMS goals include the continuation of the CERT program. MACs will look more closely at service types based on identified error rates.

Apart from CERT requests, prepayment contractor reviews already exist for most of the services included in Table 2 (p. 18). Timely response is crucial to justify and receive appropriate reimbursement. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Improper Medicare fee-for-service payments report: May 2008. CMS Web site. Available at: www.cms.hhs.gov/apps/er_report/preview_er_report.asp?from=public&which=long&reportID=9. Accessed Dec. 20, 2008.

2. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association; 2008.

Protection of the Medicare program has reached new heights in recent years. One of the most important ways hospitalist groups can protect their Medicare funding is the discovery and recovery of improper contractor payments of Medicare claims.

The Centers for Medicare and Medicaid Services (CMS) reviews various types of contractors—Medicare administrative contractors (MACs),  carriers, durable medical equipment regional carriers (DMERCs), fiscal intermediaries (FIs), and quality improvement organizations (QIOs)—through its protection efforts as part of the Comprehensive Error Rate Testing (CERT) program and Hospital Payment Monitoring Program (HPMP). The CERT program’s contractors review physician (i.e., professional) claims processed by MACs and carriers.

The primary goal of a contractor is to “pay it right”—that is, pay the correct amount to the right provider for covered and correctly coded services.1 During the 12-month reporting period ending Sept. 30, 2007, the CERT program sampled 129,875 claims from carriers, DMERCs, FIs, and MACs.

The CERT contractor randomly and electronically selects about 172 claims each month from each type of claims-processing contractor. Since some of these contractors were transitioning to MACs, the target Part B (i.e., professional) sample size for the May 2008 report was approximately 2,000 reviewable claims per MAC cluster. However, this might have varied if a MAC was not processing claims during the entire sampling period.

click table for large version

click table for large version

Document Requests

Physicians need to be mindful of CERT requests for documentation. When possible, every attempt is made to benefit the physician. Initial CERT requests are attempted by way of a letter. If the physician does not respond within 30 days, the CERT contractor attempts one to three more contacts with correspondence and phone calls. If documentation is received after 75 days, it is considered “late.” It then will be reviewed, unless the reporting period has expired.

However, this should not be considered a prudent approach, and timely responses are ideal. If the physician offers no response, and documentation is not received, it is counted as a “no documentation” error.

Physicians often worry about accusations of fraud. The purpose of the CERT program is not to assume or accuse physicians of fraud, although it may serve as a deterrent. It does not, and cannot, label a claim fraudulent.

One scenario of potential fraud the CERT program is able to identify occurs when a CERT documentation contractor is unable to locate a provider or supplier when requesting medical record documentation.2

Outcomes

Individual contractors are notified of improper payments. These include overpayments and underpayments. Unfortunately, contractors do not have to resolve CERT issues involving underpayments, although they are encouraged to do so by CMS.

The CERT program identified overpayments totaling $875,005 during the 12-month reporting period, but collected only $650,418 in overpayments after consideration of appeals that overturned a CERT decision or the provider discontinued business operations. (See Table 1, p. 18, for error rates and Table 2, p. 18, for highest rates of improper payment)

To improve billing compliance and prevent repetitive errors, contractors must implement provider education regarding erroneously paid claims. A contractor may determine the best education method to distribute information about Medicare rules and effectively answer coverage and coding questions.

Some contractors have designed Web-based training modules, Web pages with frequently-asked-questions sections, or local coverage analyses to address contractor-specific errors. Detailed CERT contractor information can be found at www.cms.hhs.gov/ mcd/indexes.asp?from2=indexes.asp&

Due to its successful outcomes, future CMS goals include the continuation of the CERT program. MACs will look more closely at service types based on identified error rates.

Apart from CERT requests, prepayment contractor reviews already exist for most of the services included in Table 2 (p. 18). Timely response is crucial to justify and receive appropriate reimbursement. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Improper Medicare fee-for-service payments report: May 2008. CMS Web site. Available at: www.cms.hhs.gov/apps/er_report/preview_er_report.asp?from=public&which=long&reportID=9. Accessed Dec. 20, 2008.

2. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association; 2008.

Protection of the Medicare program has reached new heights in recent years. One of the most important ways hospitalist groups can protect their Medicare funding is the discovery and recovery of improper contractor payments of Medicare claims.

The Centers for Medicare and Medicaid Services (CMS) reviews various types of contractors—Medicare administrative contractors (MACs),  carriers, durable medical equipment regional carriers (DMERCs), fiscal intermediaries (FIs), and quality improvement organizations (QIOs)—through its protection efforts as part of the Comprehensive Error Rate Testing (CERT) program and Hospital Payment Monitoring Program (HPMP). The CERT program’s contractors review physician (i.e., professional) claims processed by MACs and carriers.

The primary goal of a contractor is to “pay it right”—that is, pay the correct amount to the right provider for covered and correctly coded services.1 During the 12-month reporting period ending Sept. 30, 2007, the CERT program sampled 129,875 claims from carriers, DMERCs, FIs, and MACs.

The CERT contractor randomly and electronically selects about 172 claims each month from each type of claims-processing contractor. Since some of these contractors were transitioning to MACs, the target Part B (i.e., professional) sample size for the May 2008 report was approximately 2,000 reviewable claims per MAC cluster. However, this might have varied if a MAC was not processing claims during the entire sampling period.

click table for large version

click table for large version

Document Requests

Physicians need to be mindful of CERT requests for documentation. When possible, every attempt is made to benefit the physician. Initial CERT requests are attempted by way of a letter. If the physician does not respond within 30 days, the CERT contractor attempts one to three more contacts with correspondence and phone calls. If documentation is received after 75 days, it is considered “late.” It then will be reviewed, unless the reporting period has expired.

However, this should not be considered a prudent approach, and timely responses are ideal. If the physician offers no response, and documentation is not received, it is counted as a “no documentation” error.

Physicians often worry about accusations of fraud. The purpose of the CERT program is not to assume or accuse physicians of fraud, although it may serve as a deterrent. It does not, and cannot, label a claim fraudulent.

One scenario of potential fraud the CERT program is able to identify occurs when a CERT documentation contractor is unable to locate a provider or supplier when requesting medical record documentation.2

Outcomes

Individual contractors are notified of improper payments. These include overpayments and underpayments. Unfortunately, contractors do not have to resolve CERT issues involving underpayments, although they are encouraged to do so by CMS.

The CERT program identified overpayments totaling $875,005 during the 12-month reporting period, but collected only $650,418 in overpayments after consideration of appeals that overturned a CERT decision or the provider discontinued business operations. (See Table 1, p. 18, for error rates and Table 2, p. 18, for highest rates of improper payment)

To improve billing compliance and prevent repetitive errors, contractors must implement provider education regarding erroneously paid claims. A contractor may determine the best education method to distribute information about Medicare rules and effectively answer coverage and coding questions.

Some contractors have designed Web-based training modules, Web pages with frequently-asked-questions sections, or local coverage analyses to address contractor-specific errors. Detailed CERT contractor information can be found at www.cms.hhs.gov/ mcd/indexes.asp?from2=indexes.asp&

Due to its successful outcomes, future CMS goals include the continuation of the CERT program. MACs will look more closely at service types based on identified error rates.

Apart from CERT requests, prepayment contractor reviews already exist for most of the services included in Table 2 (p. 18). Timely response is crucial to justify and receive appropriate reimbursement. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Improper Medicare fee-for-service payments report: May 2008. CMS Web site. Available at: www.cms.hhs.gov/apps/er_report/preview_er_report.asp?from=public&which=long&reportID=9. Accessed Dec. 20, 2008.

2. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association; 2008.

Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville, Tenn., was working in the emergency department when a woman arrived with an asthma exacerbation. The woman, who spoke only Spanish, had been hospitalized just five days earlier for asthma, and hospital staff had given her discharge instructions through her husband. Speaking to the patient in Spanish, Dr. Kripalani soon learned something had been lost in translation: The patient had not taken any of the prescribed prednisone tablets, and instead was taking a burst of montelukast. She also was taking a long-acting bronchodilator every two hours instead of every 12, and she was incorrectly using her rescue inhaler.

As the principal investigator of a trial aiming to reduce post-discharge adverse events and emergency room visits, Dr. Kripalani knows well the issues that contributed to the patient’s re-hospitalization.1 Through research, he and his colleagues hope to prevent future cases.

“It’s very rewarding to identify problems in the care of hospitalized patients and then develop and evaluate interventions to solve those problems,” says Dr. Kripalani, a 2001 graduate of the Emory Mentored Clinical Research Scholars Program who also leads Vanderbilt University’s hospital medicine fellowship. “Sharing those solutions with colleagues so they can be applied to patient care at my institution and others brings the research full circle.”

As the field of hospital medicine grows, the number of hospitalists moving into research careers is expanding, says Peter Kaboli, MD, MS, associate professor in the Department of Internal Medicine at the University of Iowa and a 2001 graduate of the Veterans Administration Quality Scholars Fellowship program. Research training programs, or fellowships, put hospitalists on the path to new skills and position them for careers in academic medicine and other leadership positions, Dr. Kaboli says. Training programs also put fellows in contact with mentors who provide valuable guidance.

Although there are dozens of general internal medicine (GIM) fellowships available to hospitalists, few programs are specifically designed to train hospitalists in research. “Hospital medicine is still a relatively new field,” Dr. Kaboli explains. “The field still does not have many research training options that are separate from general internal medicine.”

Still, hospitalists have advanced training choices, and, depending on their interests, can pursue field-specific programs or follow a general internal medicine path.

HOSPITAL RESEARCH: WHERE THE HEART IS

Are you considering a research training program? Dr. Brotman recommends physicians consider the following before starting their search.

• If you want to work as a hospitalist in an academic center or you want to be a clinical leader, and you want to participate in research but you don’t anticipate committing the majority of your time to research, then many of the programs listed on SHM’s Web site (www.hospitalmedicine.org) could be useful.
• If you want to spend the bulk of your time performing research, the best programs will be focused on research and allow you to devote at least 50% of your time to research training.

Here are a couple of questions to ask yourself as you narrow your fellowship search:

Q: Will this fellowship lead to an advanced degree?

A: The statistical and methodological training provided by a master’s or PhD degree curriculum will provide the fellow with many of the tools needed to successfully compete for research funding as a faculty member in an academic center.

Q: What kind of research is expected?

A: Most programs encourage fellows to do some research, but if it is a formal expectation rather than an opportunity, it is likely that there will be a greater faculty and program commitment to research. This ensures the fellow leaves the program having completed a research program and, ideally, publishing on it.—GG

Career Investment

Many hospitalists receive basic research training from GIM fellowships. Once they have a research foundation, they can take their experience in another direction.

“Some physicians use their clinical interest—hospital medicine—as the platform for their research,” Dr. Kaboli says, using his own resume as an example. “It’s a nice synergy—doing research in a clinical area of interest.”

Physicians interested in fellowships often start looking for opportunities before they complete their residency, or immediately after. The transition makes sense for some; they move from one academic setting to another. Others, however, consider fellowship programs after they have spent some time in practice and get what Dr. Kaboli calls “boots-on-the-ground experience.”

“I think this is an area where there is potential for growth,” Dr. Kaboli says of physicians returning to fellowship programs after years spent in practice. “It’s the equivalent of a businessperson going back to school to get an MBA. They say, ‘Now I understand what this job really means, and I want to do more.’ ”

The caveat is a pay cut. Physicians in fellowship programs generally are paid a stipend of about $50,000 a year, Kaboli says. By comparison, the average hospitalist makes about $193,000 per year, according to SHM’s 2007-2008 Bi-Annual Survey on the State of Hospital Medicine. For two years, fellows devote their lives to training, coursework, and research, and spend only about 25% of their time treating patients, he says.

Road to Research

Hospitalists can choose from a range of general internal medicine fellowships at universities, clinics, and medical centers across the country. Each program offers something different; the fit depends on the candidates’ interests, says Geri Barnes, SHM senior director of education and meetings. For instance, training programs offer advanced study in the areas of biostatistics, epidemiology, and research methodology, to name a few. GIM fellowships (see “To Be or Not to Be a Fellow,” May 2006, p. 26) encourage scholars to develop relationships with mentors to guide them through research projects, she explains. A program’s duration can span one to three years. Some programs give fellows the opportunity to earn an advanced degree in quality improvement, clinical research, public policy, health studies, public health, or clinical epidemiology.

A handful of institutions, including Johns Hopkins Hospital in Baltimore, offer GIM fellowships with a hospital medicine emphasis. The National Institutes of Health (NIH) funds the Johns Hopkins program with training grants, says Daniel J. Brotman, MD, director of the hospitalist program there. GIM leadership is taking a “big tent” approach, promoting the development of hospital medicine tracks within the full program, which is good for the fellowship and for the hospitalist program, Dr. Brotman says.

“Some of the challenges for hospitalists are that they are generally young and don’t have the skills to succeed in academic medicine,” Dr. Brotman says, “and the number of mentors in hospitalist medicine is few and far between. [The fellowship] allows scholars to tap into experienced research mentors who may not be hospitalists themselves but are interested in investigating research questions and promoting academic careers in hospitalist medicine.”

The GIM program at Johns Hopkins draws physicians trained in internal medicine as well as general medicine/pediatrics. Candidates are required to have completed an internal medicine or medicine/pediatrics residency and must provide strong letters of recommendation. Scholars receive training in statistical methods while obtaining a master’s degree in public health or health science at the Johns Hopkins Bloomberg School of Public Health. Fellows commit 80% of their time to research and research training, and 20% of their time to clinical duties; they are expected to form relationships with faculty, which ultimately leads to careers in academia or public health, Dr. Brotman explains.

Minimize Burnout

Physician burnout—so common in the current healthcare system—is an excellent reason to consider a research career. Five years ago, David Meltzer, MD, PhD, an associate professor in the Department of Medicine at the University of Chicago, wanted to increase the number of research-trained hospitalists, so he moved to create a hospitalist training program. Around the same time, the hospital approached Dr. Meltzer and others, asking them to expand the number of clinical physician positions.

“We were afraid the new physicians would burn out rather quickly if their jobs included only clinical work,” Dr. Meltzer says. “We designed positions that had less clinical work but more time for physicians to develop research skills to support sustainable academic careers.”

Hospital leaders agreed, and the university’s Hospitalist Scholars Training Program was born. The two-year curriculum trains hospitalists for a career in academic research, and combines inpatient clinical work, coursework, and mentored training related to an academic project. Scholars typically leave the program with a master’s degree in public policy or health studies.

“Most of our graduates are working in academic research,” Dr. Meltzer says. “The program has been a great source of new faculty for us.”

Short-term programs are available in select topics. For example, the University of Chicago offers a summer program in outcomes research training for hospitalists interested in careers in health research, Dr. Meltzer says. SHM and the Agency for Healthcare Research and Quality have provided funding to expand the program to include as many as six hospitalists from around the country.

Pioneer Program

Applicants from any medical or surgical specialty are eligible to apply for the Robert Wood Johnson (RWJ) Clinical Scholars Program, the nation’s oldest research training program for physicians in health services, research, and leadership.

“The mandate of Robert Wood Johnson is ‘health and healthcare for all Americans,’ ” says Desmond Runyan, MD, DrPH, national program director of the RWJ Clinical Scholars Program. “We give physicians the skills they need to be leaders, and then we push them out the door so they can go out and shape the future of healthcare in this country.”

Applicants must be U.S. citizens and, with the exception of surgeons, must complete their residency training before entering the clinical scholars program. The two-year program offers a master’s degree in graduate-level study and research, and scholars may be considered for a third year of support. Scholars have their choice of four training sites: the University of California at Los Angeles; Yale University in New Haven, Conn.; the University of Pennsylvania in Philadelphia; or the University of Michigan in Ann Arbor.

Programs vary, but each university has a curriculum to teach the basics of healthcare research. It also provides protected time for research; about 20% of time is spent on clinical activities, according to the program’s Web site. Graduates receive leadership, health services, and community-based research training.

The RWJ Foundation spends about $9 million per year on the program, which covers research support, salaries for scholars and program administrators, travel, and other expenses. About half of the program’s graduates go into academic positions; the other half go into public health or other leadership positions. One recent graduate opted for a position in quality control; three other graduates serve as staff in the U.S. House of Representatives and the U.S. Senate, he says. Other graduates work with foundations, state and federal health agencies, or with companies working in the healthcare industry.

“This program looks for people who don’t march to a standard drummer,” Dr. Runyon says. “We are looking for risk-takers who want to make a difference.”

VA Training

The Veterans Administration National Quality Scholars Fellowship Program (VAQS) welcomes physicians from all medical specialties, including pathology, OB/GYN, surgery, and dermatology. This year, the program will begin recruiting nurses.

The program is offered at six academic-affiliated VA medical centers: Iowa City, Iowa; Nashville, Tenn.; Birmingham, Ala.; Cleveland; San Francisco; and White River Junction, Vt. The Iowa City and Nashville programs have a track designed specifically for hospitalists. These tracks focus on clinical research and quality improvement work in the inpatient setting, and provide fellows with training for advancement in academic and private-sector hospitalist careers, says Dr. Kaboli, the Iowa City VAQS Fellowship director.

To qualify, fellowship applicants must have completed an Accreditation Council for Graduate Medical Education residency or fellowship (see “A Pregnant Pause: The necessary evolution of residency training,” January 2007, p. 35), be board-eligible or board-certified, and have an active, unrestricted U.S. license to practice. International graduates must meet visa and Educational Commission for Foreign Medical Graduates requirements.

The two-year VAQS focuses on quality improvement in healthcare, Dr. Kaboli says. The program offers master’s-level training in epidemiology and biostatistics, and trains fellows to design and conduct research and improvement projects. Fellows publish the results of their research in peer-reviewed journals. They also learn how to write grants to gain funding for future projects.

Mentoring is an important element of the VAQS program, Dr. Kaboli says, adding that the value a trainee receives from any fellowship depends on the level of mentoring available through the program. Fellows work with senior faculty members who provide guidance on all aspects of research, Dr. Kaboli says. This includes study design, research methodology, data collection and analyses, and writing.

New experiences and the opportunity to take part in research are among the benefits of completing the VAQS program, Dr. Kaboli says. Some physicians also find a great deal of career satisfaction through research.

“I love seeing patients,” Dr. Kaboli says, “but I also like the challenge of doing research to find new ways to improve patient care.” TH

Gina Gotsill is a freelance medical writer based in California.

Reference

1. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowship: works in progress. Am J Med. 2006;119;72.e1-72.e7.

Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville, Tenn., was working in the emergency department when a woman arrived with an asthma exacerbation. The woman, who spoke only Spanish, had been hospitalized just five days earlier for asthma, and hospital staff had given her discharge instructions through her husband. Speaking to the patient in Spanish, Dr. Kripalani soon learned something had been lost in translation: The patient had not taken any of the prescribed prednisone tablets, and instead was taking a burst of montelukast. She also was taking a long-acting bronchodilator every two hours instead of every 12, and she was incorrectly using her rescue inhaler.

As the principal investigator of a trial aiming to reduce post-discharge adverse events and emergency room visits, Dr. Kripalani knows well the issues that contributed to the patient’s re-hospitalization.1 Through research, he and his colleagues hope to prevent future cases.

“It’s very rewarding to identify problems in the care of hospitalized patients and then develop and evaluate interventions to solve those problems,” says Dr. Kripalani, a 2001 graduate of the Emory Mentored Clinical Research Scholars Program who also leads Vanderbilt University’s hospital medicine fellowship. “Sharing those solutions with colleagues so they can be applied to patient care at my institution and others brings the research full circle.”

As the field of hospital medicine grows, the number of hospitalists moving into research careers is expanding, says Peter Kaboli, MD, MS, associate professor in the Department of Internal Medicine at the University of Iowa and a 2001 graduate of the Veterans Administration Quality Scholars Fellowship program. Research training programs, or fellowships, put hospitalists on the path to new skills and position them for careers in academic medicine and other leadership positions, Dr. Kaboli says. Training programs also put fellows in contact with mentors who provide valuable guidance.

Although there are dozens of general internal medicine (GIM) fellowships available to hospitalists, few programs are specifically designed to train hospitalists in research. “Hospital medicine is still a relatively new field,” Dr. Kaboli explains. “The field still does not have many research training options that are separate from general internal medicine.”

Still, hospitalists have advanced training choices, and, depending on their interests, can pursue field-specific programs or follow a general internal medicine path.

HOSPITAL RESEARCH: WHERE THE HEART IS

Are you considering a research training program? Dr. Brotman recommends physicians consider the following before starting their search.

• If you want to work as a hospitalist in an academic center or you want to be a clinical leader, and you want to participate in research but you don’t anticipate committing the majority of your time to research, then many of the programs listed on SHM’s Web site (www.hospitalmedicine.org) could be useful.
• If you want to spend the bulk of your time performing research, the best programs will be focused on research and allow you to devote at least 50% of your time to research training.

Here are a couple of questions to ask yourself as you narrow your fellowship search:

Q: Will this fellowship lead to an advanced degree?

A: The statistical and methodological training provided by a master’s or PhD degree curriculum will provide the fellow with many of the tools needed to successfully compete for research funding as a faculty member in an academic center.

Q: What kind of research is expected?

A: Most programs encourage fellows to do some research, but if it is a formal expectation rather than an opportunity, it is likely that there will be a greater faculty and program commitment to research. This ensures the fellow leaves the program having completed a research program and, ideally, publishing on it.—GG

Career Investment

Many hospitalists receive basic research training from GIM fellowships. Once they have a research foundation, they can take their experience in another direction.

“Some physicians use their clinical interest—hospital medicine—as the platform for their research,” Dr. Kaboli says, using his own resume as an example. “It’s a nice synergy—doing research in a clinical area of interest.”

Physicians interested in fellowships often start looking for opportunities before they complete their residency, or immediately after. The transition makes sense for some; they move from one academic setting to another. Others, however, consider fellowship programs after they have spent some time in practice and get what Dr. Kaboli calls “boots-on-the-ground experience.”

“I think this is an area where there is potential for growth,” Dr. Kaboli says of physicians returning to fellowship programs after years spent in practice. “It’s the equivalent of a businessperson going back to school to get an MBA. They say, ‘Now I understand what this job really means, and I want to do more.’ ”

The caveat is a pay cut. Physicians in fellowship programs generally are paid a stipend of about $50,000 a year, Kaboli says. By comparison, the average hospitalist makes about $193,000 per year, according to SHM’s 2007-2008 Bi-Annual Survey on the State of Hospital Medicine. For two years, fellows devote their lives to training, coursework, and research, and spend only about 25% of their time treating patients, he says.

Road to Research

Hospitalists can choose from a range of general internal medicine fellowships at universities, clinics, and medical centers across the country. Each program offers something different; the fit depends on the candidates’ interests, says Geri Barnes, SHM senior director of education and meetings. For instance, training programs offer advanced study in the areas of biostatistics, epidemiology, and research methodology, to name a few. GIM fellowships (see “To Be or Not to Be a Fellow,” May 2006, p. 26) encourage scholars to develop relationships with mentors to guide them through research projects, she explains. A program’s duration can span one to three years. Some programs give fellows the opportunity to earn an advanced degree in quality improvement, clinical research, public policy, health studies, public health, or clinical epidemiology.

A handful of institutions, including Johns Hopkins Hospital in Baltimore, offer GIM fellowships with a hospital medicine emphasis. The National Institutes of Health (NIH) funds the Johns Hopkins program with training grants, says Daniel J. Brotman, MD, director of the hospitalist program there. GIM leadership is taking a “big tent” approach, promoting the development of hospital medicine tracks within the full program, which is good for the fellowship and for the hospitalist program, Dr. Brotman says.

“Some of the challenges for hospitalists are that they are generally young and don’t have the skills to succeed in academic medicine,” Dr. Brotman says, “and the number of mentors in hospitalist medicine is few and far between. [The fellowship] allows scholars to tap into experienced research mentors who may not be hospitalists themselves but are interested in investigating research questions and promoting academic careers in hospitalist medicine.”

The GIM program at Johns Hopkins draws physicians trained in internal medicine as well as general medicine/pediatrics. Candidates are required to have completed an internal medicine or medicine/pediatrics residency and must provide strong letters of recommendation. Scholars receive training in statistical methods while obtaining a master’s degree in public health or health science at the Johns Hopkins Bloomberg School of Public Health. Fellows commit 80% of their time to research and research training, and 20% of their time to clinical duties; they are expected to form relationships with faculty, which ultimately leads to careers in academia or public health, Dr. Brotman explains.

Minimize Burnout

Physician burnout—so common in the current healthcare system—is an excellent reason to consider a research career. Five years ago, David Meltzer, MD, PhD, an associate professor in the Department of Medicine at the University of Chicago, wanted to increase the number of research-trained hospitalists, so he moved to create a hospitalist training program. Around the same time, the hospital approached Dr. Meltzer and others, asking them to expand the number of clinical physician positions.

“We were afraid the new physicians would burn out rather quickly if their jobs included only clinical work,” Dr. Meltzer says. “We designed positions that had less clinical work but more time for physicians to develop research skills to support sustainable academic careers.”

Hospital leaders agreed, and the university’s Hospitalist Scholars Training Program was born. The two-year curriculum trains hospitalists for a career in academic research, and combines inpatient clinical work, coursework, and mentored training related to an academic project. Scholars typically leave the program with a master’s degree in public policy or health studies.

“Most of our graduates are working in academic research,” Dr. Meltzer says. “The program has been a great source of new faculty for us.”

Short-term programs are available in select topics. For example, the University of Chicago offers a summer program in outcomes research training for hospitalists interested in careers in health research, Dr. Meltzer says. SHM and the Agency for Healthcare Research and Quality have provided funding to expand the program to include as many as six hospitalists from around the country.

Pioneer Program

Applicants from any medical or surgical specialty are eligible to apply for the Robert Wood Johnson (RWJ) Clinical Scholars Program, the nation’s oldest research training program for physicians in health services, research, and leadership.

“The mandate of Robert Wood Johnson is ‘health and healthcare for all Americans,’ ” says Desmond Runyan, MD, DrPH, national program director of the RWJ Clinical Scholars Program. “We give physicians the skills they need to be leaders, and then we push them out the door so they can go out and shape the future of healthcare in this country.”

Applicants must be U.S. citizens and, with the exception of surgeons, must complete their residency training before entering the clinical scholars program. The two-year program offers a master’s degree in graduate-level study and research, and scholars may be considered for a third year of support. Scholars have their choice of four training sites: the University of California at Los Angeles; Yale University in New Haven, Conn.; the University of Pennsylvania in Philadelphia; or the University of Michigan in Ann Arbor.

Programs vary, but each university has a curriculum to teach the basics of healthcare research. It also provides protected time for research; about 20% of time is spent on clinical activities, according to the program’s Web site. Graduates receive leadership, health services, and community-based research training.

The RWJ Foundation spends about $9 million per year on the program, which covers research support, salaries for scholars and program administrators, travel, and other expenses. About half of the program’s graduates go into academic positions; the other half go into public health or other leadership positions. One recent graduate opted for a position in quality control; three other graduates serve as staff in the U.S. House of Representatives and the U.S. Senate, he says. Other graduates work with foundations, state and federal health agencies, or with companies working in the healthcare industry.

“This program looks for people who don’t march to a standard drummer,” Dr. Runyon says. “We are looking for risk-takers who want to make a difference.”

VA Training

The Veterans Administration National Quality Scholars Fellowship Program (VAQS) welcomes physicians from all medical specialties, including pathology, OB/GYN, surgery, and dermatology. This year, the program will begin recruiting nurses.

The program is offered at six academic-affiliated VA medical centers: Iowa City, Iowa; Nashville, Tenn.; Birmingham, Ala.; Cleveland; San Francisco; and White River Junction, Vt. The Iowa City and Nashville programs have a track designed specifically for hospitalists. These tracks focus on clinical research and quality improvement work in the inpatient setting, and provide fellows with training for advancement in academic and private-sector hospitalist careers, says Dr. Kaboli, the Iowa City VAQS Fellowship director.

To qualify, fellowship applicants must have completed an Accreditation Council for Graduate Medical Education residency or fellowship (see “A Pregnant Pause: The necessary evolution of residency training,” January 2007, p. 35), be board-eligible or board-certified, and have an active, unrestricted U.S. license to practice. International graduates must meet visa and Educational Commission for Foreign Medical Graduates requirements.

The two-year VAQS focuses on quality improvement in healthcare, Dr. Kaboli says. The program offers master’s-level training in epidemiology and biostatistics, and trains fellows to design and conduct research and improvement projects. Fellows publish the results of their research in peer-reviewed journals. They also learn how to write grants to gain funding for future projects.

Mentoring is an important element of the VAQS program, Dr. Kaboli says, adding that the value a trainee receives from any fellowship depends on the level of mentoring available through the program. Fellows work with senior faculty members who provide guidance on all aspects of research, Dr. Kaboli says. This includes study design, research methodology, data collection and analyses, and writing.

New experiences and the opportunity to take part in research are among the benefits of completing the VAQS program, Dr. Kaboli says. Some physicians also find a great deal of career satisfaction through research.

“I love seeing patients,” Dr. Kaboli says, “but I also like the challenge of doing research to find new ways to improve patient care.” TH

Gina Gotsill is a freelance medical writer based in California.

Reference

1. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowship: works in progress. Am J Med. 2006;119;72.e1-72.e7.

Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville, Tenn., was working in the emergency department when a woman arrived with an asthma exacerbation. The woman, who spoke only Spanish, had been hospitalized just five days earlier for asthma, and hospital staff had given her discharge instructions through her husband. Speaking to the patient in Spanish, Dr. Kripalani soon learned something had been lost in translation: The patient had not taken any of the prescribed prednisone tablets, and instead was taking a burst of montelukast. She also was taking a long-acting bronchodilator every two hours instead of every 12, and she was incorrectly using her rescue inhaler.

As the principal investigator of a trial aiming to reduce post-discharge adverse events and emergency room visits, Dr. Kripalani knows well the issues that contributed to the patient’s re-hospitalization.1 Through research, he and his colleagues hope to prevent future cases.

“It’s very rewarding to identify problems in the care of hospitalized patients and then develop and evaluate interventions to solve those problems,” says Dr. Kripalani, a 2001 graduate of the Emory Mentored Clinical Research Scholars Program who also leads Vanderbilt University’s hospital medicine fellowship. “Sharing those solutions with colleagues so they can be applied to patient care at my institution and others brings the research full circle.”

As the field of hospital medicine grows, the number of hospitalists moving into research careers is expanding, says Peter Kaboli, MD, MS, associate professor in the Department of Internal Medicine at the University of Iowa and a 2001 graduate of the Veterans Administration Quality Scholars Fellowship program. Research training programs, or fellowships, put hospitalists on the path to new skills and position them for careers in academic medicine and other leadership positions, Dr. Kaboli says. Training programs also put fellows in contact with mentors who provide valuable guidance.

Although there are dozens of general internal medicine (GIM) fellowships available to hospitalists, few programs are specifically designed to train hospitalists in research. “Hospital medicine is still a relatively new field,” Dr. Kaboli explains. “The field still does not have many research training options that are separate from general internal medicine.”

Still, hospitalists have advanced training choices, and, depending on their interests, can pursue field-specific programs or follow a general internal medicine path.

HOSPITAL RESEARCH: WHERE THE HEART IS

Are you considering a research training program? Dr. Brotman recommends physicians consider the following before starting their search.

• If you want to work as a hospitalist in an academic center or you want to be a clinical leader, and you want to participate in research but you don’t anticipate committing the majority of your time to research, then many of the programs listed on SHM’s Web site (www.hospitalmedicine.org) could be useful.
• If you want to spend the bulk of your time performing research, the best programs will be focused on research and allow you to devote at least 50% of your time to research training.

Here are a couple of questions to ask yourself as you narrow your fellowship search:

Q: Will this fellowship lead to an advanced degree?

A: The statistical and methodological training provided by a master’s or PhD degree curriculum will provide the fellow with many of the tools needed to successfully compete for research funding as a faculty member in an academic center.

Q: What kind of research is expected?

A: Most programs encourage fellows to do some research, but if it is a formal expectation rather than an opportunity, it is likely that there will be a greater faculty and program commitment to research. This ensures the fellow leaves the program having completed a research program and, ideally, publishing on it.—GG

Career Investment

Many hospitalists receive basic research training from GIM fellowships. Once they have a research foundation, they can take their experience in another direction.

“Some physicians use their clinical interest—hospital medicine—as the platform for their research,” Dr. Kaboli says, using his own resume as an example. “It’s a nice synergy—doing research in a clinical area of interest.”

Physicians interested in fellowships often start looking for opportunities before they complete their residency, or immediately after. The transition makes sense for some; they move from one academic setting to another. Others, however, consider fellowship programs after they have spent some time in practice and get what Dr. Kaboli calls “boots-on-the-ground experience.”

“I think this is an area where there is potential for growth,” Dr. Kaboli says of physicians returning to fellowship programs after years spent in practice. “It’s the equivalent of a businessperson going back to school to get an MBA. They say, ‘Now I understand what this job really means, and I want to do more.’ ”

The caveat is a pay cut. Physicians in fellowship programs generally are paid a stipend of about $50,000 a year, Kaboli says. By comparison, the average hospitalist makes about $193,000 per year, according to SHM’s 2007-2008 Bi-Annual Survey on the State of Hospital Medicine. For two years, fellows devote their lives to training, coursework, and research, and spend only about 25% of their time treating patients, he says.

Road to Research

Hospitalists can choose from a range of general internal medicine fellowships at universities, clinics, and medical centers across the country. Each program offers something different; the fit depends on the candidates’ interests, says Geri Barnes, SHM senior director of education and meetings. For instance, training programs offer advanced study in the areas of biostatistics, epidemiology, and research methodology, to name a few. GIM fellowships (see “To Be or Not to Be a Fellow,” May 2006, p. 26) encourage scholars to develop relationships with mentors to guide them through research projects, she explains. A program’s duration can span one to three years. Some programs give fellows the opportunity to earn an advanced degree in quality improvement, clinical research, public policy, health studies, public health, or clinical epidemiology.

A handful of institutions, including Johns Hopkins Hospital in Baltimore, offer GIM fellowships with a hospital medicine emphasis. The National Institutes of Health (NIH) funds the Johns Hopkins program with training grants, says Daniel J. Brotman, MD, director of the hospitalist program there. GIM leadership is taking a “big tent” approach, promoting the development of hospital medicine tracks within the full program, which is good for the fellowship and for the hospitalist program, Dr. Brotman says.

“Some of the challenges for hospitalists are that they are generally young and don’t have the skills to succeed in academic medicine,” Dr. Brotman says, “and the number of mentors in hospitalist medicine is few and far between. [The fellowship] allows scholars to tap into experienced research mentors who may not be hospitalists themselves but are interested in investigating research questions and promoting academic careers in hospitalist medicine.”

The GIM program at Johns Hopkins draws physicians trained in internal medicine as well as general medicine/pediatrics. Candidates are required to have completed an internal medicine or medicine/pediatrics residency and must provide strong letters of recommendation. Scholars receive training in statistical methods while obtaining a master’s degree in public health or health science at the Johns Hopkins Bloomberg School of Public Health. Fellows commit 80% of their time to research and research training, and 20% of their time to clinical duties; they are expected to form relationships with faculty, which ultimately leads to careers in academia or public health, Dr. Brotman explains.

Minimize Burnout

Physician burnout—so common in the current healthcare system—is an excellent reason to consider a research career. Five years ago, David Meltzer, MD, PhD, an associate professor in the Department of Medicine at the University of Chicago, wanted to increase the number of research-trained hospitalists, so he moved to create a hospitalist training program. Around the same time, the hospital approached Dr. Meltzer and others, asking them to expand the number of clinical physician positions.

“We were afraid the new physicians would burn out rather quickly if their jobs included only clinical work,” Dr. Meltzer says. “We designed positions that had less clinical work but more time for physicians to develop research skills to support sustainable academic careers.”

Hospital leaders agreed, and the university’s Hospitalist Scholars Training Program was born. The two-year curriculum trains hospitalists for a career in academic research, and combines inpatient clinical work, coursework, and mentored training related to an academic project. Scholars typically leave the program with a master’s degree in public policy or health studies.

“Most of our graduates are working in academic research,” Dr. Meltzer says. “The program has been a great source of new faculty for us.”

Short-term programs are available in select topics. For example, the University of Chicago offers a summer program in outcomes research training for hospitalists interested in careers in health research, Dr. Meltzer says. SHM and the Agency for Healthcare Research and Quality have provided funding to expand the program to include as many as six hospitalists from around the country.

Pioneer Program

Applicants from any medical or surgical specialty are eligible to apply for the Robert Wood Johnson (RWJ) Clinical Scholars Program, the nation’s oldest research training program for physicians in health services, research, and leadership.

“The mandate of Robert Wood Johnson is ‘health and healthcare for all Americans,’ ” says Desmond Runyan, MD, DrPH, national program director of the RWJ Clinical Scholars Program. “We give physicians the skills they need to be leaders, and then we push them out the door so they can go out and shape the future of healthcare in this country.”

Applicants must be U.S. citizens and, with the exception of surgeons, must complete their residency training before entering the clinical scholars program. The two-year program offers a master’s degree in graduate-level study and research, and scholars may be considered for a third year of support. Scholars have their choice of four training sites: the University of California at Los Angeles; Yale University in New Haven, Conn.; the University of Pennsylvania in Philadelphia; or the University of Michigan in Ann Arbor.

Programs vary, but each university has a curriculum to teach the basics of healthcare research. It also provides protected time for research; about 20% of time is spent on clinical activities, according to the program’s Web site. Graduates receive leadership, health services, and community-based research training.

The RWJ Foundation spends about $9 million per year on the program, which covers research support, salaries for scholars and program administrators, travel, and other expenses. About half of the program’s graduates go into academic positions; the other half go into public health or other leadership positions. One recent graduate opted for a position in quality control; three other graduates serve as staff in the U.S. House of Representatives and the U.S. Senate, he says. Other graduates work with foundations, state and federal health agencies, or with companies working in the healthcare industry.

“This program looks for people who don’t march to a standard drummer,” Dr. Runyon says. “We are looking for risk-takers who want to make a difference.”

VA Training

The Veterans Administration National Quality Scholars Fellowship Program (VAQS) welcomes physicians from all medical specialties, including pathology, OB/GYN, surgery, and dermatology. This year, the program will begin recruiting nurses.

The program is offered at six academic-affiliated VA medical centers: Iowa City, Iowa; Nashville, Tenn.; Birmingham, Ala.; Cleveland; San Francisco; and White River Junction, Vt. The Iowa City and Nashville programs have a track designed specifically for hospitalists. These tracks focus on clinical research and quality improvement work in the inpatient setting, and provide fellows with training for advancement in academic and private-sector hospitalist careers, says Dr. Kaboli, the Iowa City VAQS Fellowship director.

To qualify, fellowship applicants must have completed an Accreditation Council for Graduate Medical Education residency or fellowship (see “A Pregnant Pause: The necessary evolution of residency training,” January 2007, p. 35), be board-eligible or board-certified, and have an active, unrestricted U.S. license to practice. International graduates must meet visa and Educational Commission for Foreign Medical Graduates requirements.

The two-year VAQS focuses on quality improvement in healthcare, Dr. Kaboli says. The program offers master’s-level training in epidemiology and biostatistics, and trains fellows to design and conduct research and improvement projects. Fellows publish the results of their research in peer-reviewed journals. They also learn how to write grants to gain funding for future projects.

Mentoring is an important element of the VAQS program, Dr. Kaboli says, adding that the value a trainee receives from any fellowship depends on the level of mentoring available through the program. Fellows work with senior faculty members who provide guidance on all aspects of research, Dr. Kaboli says. This includes study design, research methodology, data collection and analyses, and writing.

New experiences and the opportunity to take part in research are among the benefits of completing the VAQS program, Dr. Kaboli says. Some physicians also find a great deal of career satisfaction through research.

“I love seeing patients,” Dr. Kaboli says, “but I also like the challenge of doing research to find new ways to improve patient care.” TH

Gina Gotsill is a freelance medical writer based in California.

Reference

1. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowship: works in progress. Am J Med. 2006;119;72.e1-72.e7.

The Value of Medicare’s Nursing Home Ratings

Is it true that the government has gone public with ratings of nursing homes? If so, where can I find this information? Is this information useful?

H. Sawyer, Richmond, Va.

Dr. Hospitalist responds: Many healthcare providers are familiar with Medicare’s goal to improve the quality of inpatient care. Medicare reports this data at www.hospitalcompare.hhs.gov. The program has its critics, many of whom question whether checking off a list really represents an improved quality of care.

Analogous to its Web site with information about hospital care, Medicare recently unveiled a site with information about the quality of care that our nation’s nursing homes are delivering to Medicare beneficiaries. You can find this information at www.medicare.gov/nhcompare. Medi-care ranks nursing homes on a system that awards ratings from one to five stars, with five stars being the best. Medicare explains it created this rating system to “help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions.” Medicare utilized information from three sources of data to create this overall rating:

• Staffing;
• Quality measures; and
• Health inspections.

The site provides an individual rating for each piece of data and combines the info to determine a composite rating.

Pros and Cons

Medicare acknowledges the rating system has strengths and weaknesses. The staffing information is adjusted for acuity of illness in a given facility’s resident population. That said, the data is self-reported and gathered annually, so it reflects data from just two weeks out of the year. Medicare notes each facility is judged on 10 quality measures, but again, the data is self-reported, is not adjusted for severity, and represents just a few of the many aspects of care that may be important to residents and their families.

Medicare also notes the health inspections are comprehensive and require onsite visits by trained inspectors. Comparisons are best made between facilities in the same state.

Nursing Home Checklist

Aside from facility ratings, Medicare also provides the public with a “nursing home checklist” and encourages the public to take a printed copy of the checklist, along with other information provided on its Web site, when they visit a nursing home. Medicare encourages the public to “talk with the nursing home staff about the information.”

I found no surprising information on this checklist. It encourages the public to think about basic information, such as:

• Is the home Medicare- and Medicaid-certified?
• Is the facility close to family and friends, clean, free from unpleasant odors, and comfortable for its residents?
• Is there a physician present every day and available when necessary?
• Are licensed nurses available 24 hours a day; is an RN available eight hours per day, seven days per week.

The site says individuals should think about resident rooms and the areas outside the resident rooms. It also encourages the public to think about the food and activities available to residents.

Much like the program for evaluating hospital care, I believe Medicare has taken a reasonable first step in providing information to the public to evaluate the care being provided in our nation’s nursing homes. But you will not find information regarding nursing homes that do not accept Medicare. And this information is only about nursing homes, and does not include other types of residential facilities. TH

The Value of Medicare’s Nursing Home Ratings

Is it true that the government has gone public with ratings of nursing homes? If so, where can I find this information? Is this information useful?

H. Sawyer, Richmond, Va.

Dr. Hospitalist responds: Many healthcare providers are familiar with Medicare’s goal to improve the quality of inpatient care. Medicare reports this data at www.hospitalcompare.hhs.gov. The program has its critics, many of whom question whether checking off a list really represents an improved quality of care.

Analogous to its Web site with information about hospital care, Medicare recently unveiled a site with information about the quality of care that our nation’s nursing homes are delivering to Medicare beneficiaries. You can find this information at www.medicare.gov/nhcompare. Medi-care ranks nursing homes on a system that awards ratings from one to five stars, with five stars being the best. Medicare explains it created this rating system to “help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions.” Medicare utilized information from three sources of data to create this overall rating:

• Staffing;
• Quality measures; and
• Health inspections.

The site provides an individual rating for each piece of data and combines the info to determine a composite rating.

Pros and Cons

Medicare acknowledges the rating system has strengths and weaknesses. The staffing information is adjusted for acuity of illness in a given facility’s resident population. That said, the data is self-reported and gathered annually, so it reflects data from just two weeks out of the year. Medicare notes each facility is judged on 10 quality measures, but again, the data is self-reported, is not adjusted for severity, and represents just a few of the many aspects of care that may be important to residents and their families.

Medicare also notes the health inspections are comprehensive and require onsite visits by trained inspectors. Comparisons are best made between facilities in the same state.

Nursing Home Checklist

Aside from facility ratings, Medicare also provides the public with a “nursing home checklist” and encourages the public to take a printed copy of the checklist, along with other information provided on its Web site, when they visit a nursing home. Medicare encourages the public to “talk with the nursing home staff about the information.”

I found no surprising information on this checklist. It encourages the public to think about basic information, such as:

• Is the home Medicare- and Medicaid-certified?
• Is the facility close to family and friends, clean, free from unpleasant odors, and comfortable for its residents?
• Is there a physician present every day and available when necessary?
• Are licensed nurses available 24 hours a day; is an RN available eight hours per day, seven days per week.

The site says individuals should think about resident rooms and the areas outside the resident rooms. It also encourages the public to think about the food and activities available to residents.

Much like the program for evaluating hospital care, I believe Medicare has taken a reasonable first step in providing information to the public to evaluate the care being provided in our nation’s nursing homes. But you will not find information regarding nursing homes that do not accept Medicare. And this information is only about nursing homes, and does not include other types of residential facilities. TH

The Value of Medicare’s Nursing Home Ratings

Is it true that the government has gone public with ratings of nursing homes? If so, where can I find this information? Is this information useful?

H. Sawyer, Richmond, Va.

Dr. Hospitalist responds: Many healthcare providers are familiar with Medicare’s goal to improve the quality of inpatient care. Medicare reports this data at www.hospitalcompare.hhs.gov. The program has its critics, many of whom question whether checking off a list really represents an improved quality of care.

Analogous to its Web site with information about hospital care, Medicare recently unveiled a site with information about the quality of care that our nation’s nursing homes are delivering to Medicare beneficiaries. You can find this information at www.medicare.gov/nhcompare. Medi-care ranks nursing homes on a system that awards ratings from one to five stars, with five stars being the best. Medicare explains it created this rating system to “help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions.” Medicare utilized information from three sources of data to create this overall rating:

• Staffing;
• Quality measures; and
• Health inspections.

The site provides an individual rating for each piece of data and combines the info to determine a composite rating.

Pros and Cons

Medicare acknowledges the rating system has strengths and weaknesses. The staffing information is adjusted for acuity of illness in a given facility’s resident population. That said, the data is self-reported and gathered annually, so it reflects data from just two weeks out of the year. Medicare notes each facility is judged on 10 quality measures, but again, the data is self-reported, is not adjusted for severity, and represents just a few of the many aspects of care that may be important to residents and their families.

Medicare also notes the health inspections are comprehensive and require onsite visits by trained inspectors. Comparisons are best made between facilities in the same state.

Nursing Home Checklist

Aside from facility ratings, Medicare also provides the public with a “nursing home checklist” and encourages the public to take a printed copy of the checklist, along with other information provided on its Web site, when they visit a nursing home. Medicare encourages the public to “talk with the nursing home staff about the information.”

I found no surprising information on this checklist. It encourages the public to think about basic information, such as:

• Is the home Medicare- and Medicaid-certified?
• Is the facility close to family and friends, clean, free from unpleasant odors, and comfortable for its residents?
• Is there a physician present every day and available when necessary?
• Are licensed nurses available 24 hours a day; is an RN available eight hours per day, seven days per week.

The site says individuals should think about resident rooms and the areas outside the resident rooms. It also encourages the public to think about the food and activities available to residents.

Much like the program for evaluating hospital care, I believe Medicare has taken a reasonable first step in providing information to the public to evaluate the care being provided in our nation’s nursing homes. But you will not find information regarding nursing homes that do not accept Medicare. And this information is only about nursing homes, and does not include other types of residential facilities. TH

I always wear a sport coat and tie when I’m speaking, but I thought I knew the orthopedic psyche well enough to know they would be very casually dressed for their conference on a warm Saturday this past fall. I was stunned to see about 40 of the 60 orthopods in attendance wearing jackets and ties—a very dapper bunch. While I misjudged their fashion sense, I’m still confident I’ll fit in wearing a bow tie (borrowed, since I don’t own one) to a neurology conference or a Mickey Mouse tie to a pediatric conference.

I had been invited to speak at the Washington State Orthopedic Association last fall. (Maybe they spell it “orthopædics,” but that seems a little pretentious to me.) They wanted to hear about the latest trends in how orthopods and hospitalists collaborate in the care of patients, and how this interaction might evolve.

Attending or Consultants?

I told them that, in my experience, determining the best doctor to serve as attending for certain types of patients generates a wide range of sometimes passionately held opinions among hospitalists. In my consulting work with practices around the country, I’ve come across some hospitalists who are insistent that they should never serve as attending for patients whose primary reason for admission is:

• Hip fracture due to osteoporosis and fall from ground level;
• Nonoperative low-speed or low-impact trauma, such as pelvic fracture; and
• Limb infection with potential for compartment syndrome.

Interestingly, I’ve found that hospitalists almost universally admit patients with osteoporotic vertebral compression fractures, even if they strongly believe that they shouldn’t admit patients with pelvic fractures.

My own experience leads me to believe that hospitalists in most settings should plan to serve as attending for all of these patient types, if they aren’t already. For example, a hip fracture is essentially a marker for a sick and frail person with complex medical needs. While it is the marquee event of the hospital stay, surgical repair of the fracture is just one of many important things that need to happen before discharge. Most of these patients need attention for medical comorbidities—such as a urinary infection or decompensated heart failure—which often are the proximate cause of the fracture. The patient might need a discussion of medical directives, which usually is an area in which orthopods usually don’t excel (and I’m being kind to the orthopods).

Let me be clear: Reasonable people can conclude hospitalists should not serve as attending for the diagnoses listed above. SHM does not have a position on this, and I’m not speaking for all hospitalists. But don’t you think hospitalists opposed to admitting these types of patients will find themselves in a small and shrinking minority? It seems to me that the pressure to serve as attending for these patients is similar to surviving a riptide: You shouldn’t try to swim directly against the riptide toward shore, and instead should swim across it or even go with the flow.

Popular Term, No Universal Definition

I went on to talk with the orthopods about the concept of partnering with hospitalists to co-manage patients. Orthopods and hospital executives usually are enthusiastic supporters of the co-management idea, and hospitalists usually are supportive, though sometimes with a little less excitement than the others. In public, all three parties usually express confidence that co-management will be good for patient outcomes and have other benefits, such as improved efficiency. But in private, orthopods sometimes let on that their support of the idea is largely based on their belief that it relieves them of tedious paperwork and late-night phone calls.

A hospital CEO might not know the details of the co-management model, so the CEO’s public support of it often boils down to an analysis along the lines of “Isn’t co-management just a euphemism for hospitalists doing more of the scut work to keep the hospital’s money-making specialists—like orthopods—happy?” Even hospitalists themselves sometimes express public support for the idea, but privately are thinking, “These guys want me to do what?”

My view is that co-management is a broad term and can mean very different things from one institution to the next. The term “co-management” has a connotation of something new and progressive, and might help steer conversations about who does what in a more positive direction than the old vocabulary of who is dumping on whom—you know, the traditional role for the doctors in each specialty.

A terrific entry in “Debates in Hospital Medicine” that runs periodically in the Journal of Hospital Medicine offers two points of view. In the September/October 2008 issue of JHM, Christopher Whinney, MD, and Frank Michota, MD, of Cleveland Clinic took the stance in favor of co-management, and Eric Siegal, MD, SHM’s Public Policy Committee chair (and formerly in private and corporate hospitalist practice), raised concerns about co-management.1 The articles review what little—and in my view inconclusive—research exists on this topic but provide some thoughtful advice and opinions.

Issues to Address

As I have written in the past, I’m convinced hospitalists’ scope of practice will broaden and grow to include patients we don’t commonly admit today.2 But we will need to think carefully about how to mitigate the potential problems created by changes in how doctors divide responsibility for who does what. In the case of hospitalists serving as admitters and attending for hip fracture patients, I have concerns, such as:

• Will there be delays in going to the operating room or confusion regarding which orthopedist is responsible for the patient?
• Will the orthopedist be less available to talk with the patient and family post-op?
• How long before the orthopedist stops making post-op visits?
• Who decides about transfusion and manages post-op and discharge pain control, wound care, and rehab?
• Who gets the nighttime call regarding a laxative or sleeping pill?
• Who handles discharge paperwork?

Your list of concerns probably differs from mine, but you should take the time to write down the issues that concern you any time duties and responsibilities shift from one specialty to another. Keep that list handy the next time you talk with another specialty about co-management or other new ways of dividing the work to ensure good outcomes for patients, doctors (including hospitalists), and the healthcare system as a whole. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospital practice management consulting firm. He is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official SHM position.

References

1. Whinney C, Michota F, and Siegal EM. Surgical comanagement: a natural evolution of hospitalist practice. Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5); 394-402.

2. Nelson J. Hip fractures to head bleeds: The hospitalist’s ever-changing scope of practice. The Hospitalist. 2006; 10(9);77.

I always wear a sport coat and tie when I’m speaking, but I thought I knew the orthopedic psyche well enough to know they would be very casually dressed for their conference on a warm Saturday this past fall. I was stunned to see about 40 of the 60 orthopods in attendance wearing jackets and ties—a very dapper bunch. While I misjudged their fashion sense, I’m still confident I’ll fit in wearing a bow tie (borrowed, since I don’t own one) to a neurology conference or a Mickey Mouse tie to a pediatric conference.

I had been invited to speak at the Washington State Orthopedic Association last fall. (Maybe they spell it “orthopædics,” but that seems a little pretentious to me.) They wanted to hear about the latest trends in how orthopods and hospitalists collaborate in the care of patients, and how this interaction might evolve.

Attending or Consultants?

I told them that, in my experience, determining the best doctor to serve as attending for certain types of patients generates a wide range of sometimes passionately held opinions among hospitalists. In my consulting work with practices around the country, I’ve come across some hospitalists who are insistent that they should never serve as attending for patients whose primary reason for admission is:

• Hip fracture due to osteoporosis and fall from ground level;
• Nonoperative low-speed or low-impact trauma, such as pelvic fracture; and
• Limb infection with potential for compartment syndrome.

Interestingly, I’ve found that hospitalists almost universally admit patients with osteoporotic vertebral compression fractures, even if they strongly believe that they shouldn’t admit patients with pelvic fractures.

My own experience leads me to believe that hospitalists in most settings should plan to serve as attending for all of these patient types, if they aren’t already. For example, a hip fracture is essentially a marker for a sick and frail person with complex medical needs. While it is the marquee event of the hospital stay, surgical repair of the fracture is just one of many important things that need to happen before discharge. Most of these patients need attention for medical comorbidities—such as a urinary infection or decompensated heart failure—which often are the proximate cause of the fracture. The patient might need a discussion of medical directives, which usually is an area in which orthopods usually don’t excel (and I’m being kind to the orthopods).

Let me be clear: Reasonable people can conclude hospitalists should not serve as attending for the diagnoses listed above. SHM does not have a position on this, and I’m not speaking for all hospitalists. But don’t you think hospitalists opposed to admitting these types of patients will find themselves in a small and shrinking minority? It seems to me that the pressure to serve as attending for these patients is similar to surviving a riptide: You shouldn’t try to swim directly against the riptide toward shore, and instead should swim across it or even go with the flow.

Popular Term, No Universal Definition

I went on to talk with the orthopods about the concept of partnering with hospitalists to co-manage patients. Orthopods and hospital executives usually are enthusiastic supporters of the co-management idea, and hospitalists usually are supportive, though sometimes with a little less excitement than the others. In public, all three parties usually express confidence that co-management will be good for patient outcomes and have other benefits, such as improved efficiency. But in private, orthopods sometimes let on that their support of the idea is largely based on their belief that it relieves them of tedious paperwork and late-night phone calls.

A hospital CEO might not know the details of the co-management model, so the CEO’s public support of it often boils down to an analysis along the lines of “Isn’t co-management just a euphemism for hospitalists doing more of the scut work to keep the hospital’s money-making specialists—like orthopods—happy?” Even hospitalists themselves sometimes express public support for the idea, but privately are thinking, “These guys want me to do what?”

My view is that co-management is a broad term and can mean very different things from one institution to the next. The term “co-management” has a connotation of something new and progressive, and might help steer conversations about who does what in a more positive direction than the old vocabulary of who is dumping on whom—you know, the traditional role for the doctors in each specialty.

A terrific entry in “Debates in Hospital Medicine” that runs periodically in the Journal of Hospital Medicine offers two points of view. In the September/October 2008 issue of JHM, Christopher Whinney, MD, and Frank Michota, MD, of Cleveland Clinic took the stance in favor of co-management, and Eric Siegal, MD, SHM’s Public Policy Committee chair (and formerly in private and corporate hospitalist practice), raised concerns about co-management.1 The articles review what little—and in my view inconclusive—research exists on this topic but provide some thoughtful advice and opinions.

Issues to Address

As I have written in the past, I’m convinced hospitalists’ scope of practice will broaden and grow to include patients we don’t commonly admit today.2 But we will need to think carefully about how to mitigate the potential problems created by changes in how doctors divide responsibility for who does what. In the case of hospitalists serving as admitters and attending for hip fracture patients, I have concerns, such as:

• Will there be delays in going to the operating room or confusion regarding which orthopedist is responsible for the patient?
• Will the orthopedist be less available to talk with the patient and family post-op?
• How long before the orthopedist stops making post-op visits?
• Who decides about transfusion and manages post-op and discharge pain control, wound care, and rehab?
• Who gets the nighttime call regarding a laxative or sleeping pill?
• Who handles discharge paperwork?

Your list of concerns probably differs from mine, but you should take the time to write down the issues that concern you any time duties and responsibilities shift from one specialty to another. Keep that list handy the next time you talk with another specialty about co-management or other new ways of dividing the work to ensure good outcomes for patients, doctors (including hospitalists), and the healthcare system as a whole. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospital practice management consulting firm. He is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official SHM position.

References

1. Whinney C, Michota F, and Siegal EM. Surgical comanagement: a natural evolution of hospitalist practice. Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5); 394-402.

2. Nelson J. Hip fractures to head bleeds: The hospitalist’s ever-changing scope of practice. The Hospitalist. 2006; 10(9);77.

I always wear a sport coat and tie when I’m speaking, but I thought I knew the orthopedic psyche well enough to know they would be very casually dressed for their conference on a warm Saturday this past fall. I was stunned to see about 40 of the 60 orthopods in attendance wearing jackets and ties—a very dapper bunch. While I misjudged their fashion sense, I’m still confident I’ll fit in wearing a bow tie (borrowed, since I don’t own one) to a neurology conference or a Mickey Mouse tie to a pediatric conference.

I had been invited to speak at the Washington State Orthopedic Association last fall. (Maybe they spell it “orthopædics,” but that seems a little pretentious to me.) They wanted to hear about the latest trends in how orthopods and hospitalists collaborate in the care of patients, and how this interaction might evolve.

Attending or Consultants?

I told them that, in my experience, determining the best doctor to serve as attending for certain types of patients generates a wide range of sometimes passionately held opinions among hospitalists. In my consulting work with practices around the country, I’ve come across some hospitalists who are insistent that they should never serve as attending for patients whose primary reason for admission is:

• Hip fracture due to osteoporosis and fall from ground level;
• Nonoperative low-speed or low-impact trauma, such as pelvic fracture; and
• Limb infection with potential for compartment syndrome.

Interestingly, I’ve found that hospitalists almost universally admit patients with osteoporotic vertebral compression fractures, even if they strongly believe that they shouldn’t admit patients with pelvic fractures.

My own experience leads me to believe that hospitalists in most settings should plan to serve as attending for all of these patient types, if they aren’t already. For example, a hip fracture is essentially a marker for a sick and frail person with complex medical needs. While it is the marquee event of the hospital stay, surgical repair of the fracture is just one of many important things that need to happen before discharge. Most of these patients need attention for medical comorbidities—such as a urinary infection or decompensated heart failure—which often are the proximate cause of the fracture. The patient might need a discussion of medical directives, which usually is an area in which orthopods usually don’t excel (and I’m being kind to the orthopods).

Let me be clear: Reasonable people can conclude hospitalists should not serve as attending for the diagnoses listed above. SHM does not have a position on this, and I’m not speaking for all hospitalists. But don’t you think hospitalists opposed to admitting these types of patients will find themselves in a small and shrinking minority? It seems to me that the pressure to serve as attending for these patients is similar to surviving a riptide: You shouldn’t try to swim directly against the riptide toward shore, and instead should swim across it or even go with the flow.

Popular Term, No Universal Definition

I went on to talk with the orthopods about the concept of partnering with hospitalists to co-manage patients. Orthopods and hospital executives usually are enthusiastic supporters of the co-management idea, and hospitalists usually are supportive, though sometimes with a little less excitement than the others. In public, all three parties usually express confidence that co-management will be good for patient outcomes and have other benefits, such as improved efficiency. But in private, orthopods sometimes let on that their support of the idea is largely based on their belief that it relieves them of tedious paperwork and late-night phone calls.

A hospital CEO might not know the details of the co-management model, so the CEO’s public support of it often boils down to an analysis along the lines of “Isn’t co-management just a euphemism for hospitalists doing more of the scut work to keep the hospital’s money-making specialists—like orthopods—happy?” Even hospitalists themselves sometimes express public support for the idea, but privately are thinking, “These guys want me to do what?”

My view is that co-management is a broad term and can mean very different things from one institution to the next. The term “co-management” has a connotation of something new and progressive, and might help steer conversations about who does what in a more positive direction than the old vocabulary of who is dumping on whom—you know, the traditional role for the doctors in each specialty.

A terrific entry in “Debates in Hospital Medicine” that runs periodically in the Journal of Hospital Medicine offers two points of view. In the September/October 2008 issue of JHM, Christopher Whinney, MD, and Frank Michota, MD, of Cleveland Clinic took the stance in favor of co-management, and Eric Siegal, MD, SHM’s Public Policy Committee chair (and formerly in private and corporate hospitalist practice), raised concerns about co-management.1 The articles review what little—and in my view inconclusive—research exists on this topic but provide some thoughtful advice and opinions.

Issues to Address

As I have written in the past, I’m convinced hospitalists’ scope of practice will broaden and grow to include patients we don’t commonly admit today.2 But we will need to think carefully about how to mitigate the potential problems created by changes in how doctors divide responsibility for who does what. In the case of hospitalists serving as admitters and attending for hip fracture patients, I have concerns, such as:

• Will there be delays in going to the operating room or confusion regarding which orthopedist is responsible for the patient?
• Will the orthopedist be less available to talk with the patient and family post-op?
• How long before the orthopedist stops making post-op visits?
• Who decides about transfusion and manages post-op and discharge pain control, wound care, and rehab?
• Who gets the nighttime call regarding a laxative or sleeping pill?
• Who handles discharge paperwork?

Your list of concerns probably differs from mine, but you should take the time to write down the issues that concern you any time duties and responsibilities shift from one specialty to another. Keep that list handy the next time you talk with another specialty about co-management or other new ways of dividing the work to ensure good outcomes for patients, doctors (including hospitalists), and the healthcare system as a whole. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospital practice management consulting firm. He is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official SHM position.

References

1. Whinney C, Michota F, and Siegal EM. Surgical comanagement: a natural evolution of hospitalist practice. Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5); 394-402.

2. Nelson J. Hip fractures to head bleeds: The hospitalist’s ever-changing scope of practice. The Hospitalist. 2006; 10(9);77.

Round One

“Plane down, mass casualties possible; initiate disaster plan.”

The page interrupted my evening out with friends a few Saturday nights ago. Looking up from my dinner, I noticed the restaurant television had cut away to a news story at Denver International Airport. Continental Flight 1404, en route to Houston, had crashed during takeoff, belly-flopping to a fiery rest a few hundred yards off the runway. The airport is about 10 miles from the nearest hospital—mine.

The situation ended considerably better than originally expected. Thirty-eight people were treated at several Denver hospitals, 11 of them at my hospital, with most patients discharged from the emergency department. No one died. The case remains under review, and little is known about the cause of the crash.

Round Two

“Give me a call. I need to talk to you urgently.”

That page arrived the following Monday morning. It was from a co-worker. There had been an unexpected bad outcome in a young male patient. The hospital’s quality and risk management group had found out about the case and called for a peer review. My colleague was scared; would he be publicly criticized? Punished? Fired?

The patient had been admitted with a chronic disease flare-up. He was on the mend after receiving an increased dose of medication. The night before he was scheduled to be discharged, he developed a new symptom, was evaluated by the cross-cover team, and a plan was set in motion. However, a critical lab result, which became available overnight, mistakenly was not called to the provider and went unnoticed by the primary team that triaged the patient to the end of the team’s rounds. By then, he was in extremis.

Getty Images

Planes and Patients

The proximity of these two events provoked comparisons.

By now, comparing healthcare to the aviation industry has become cliché. Both industries demand highly trained and skilled conductors; errors in both industries can result in death; both depend on technology; and both have turned to systems engineering to improve efficiencies and reduce mistakes. This is where the two industries diverge, and I think we get it wrong in medicine.

In aviation, there are very proscriptive algorithms that must be followed, and much of a pilot’s work is under constant scrutiny by air traffic controllers and data recorders. A deviation in protocol rarely goes unnoticed. Errors are systematically compiled, scrutinized, and compartmentalized, with the aim of further refining systems to reduce the likelihood of future errors. Although blame is often prescribed, it is in the context of improving the system. Thus, the aviation industry is awash with data to inform and fuel its systems engineering.

Meanwhile, in medicine our indelible sense of autonomy breeds variability, which is not only tolerated, but often goes unnoticed. Further, we employ a model of error analysis that focuses on affixing blame, as if somehow culpability will prevent future errors. Someone made an error, a bad outcome ensued, and the culprit must be identified and punished. This results in reprimand, remediation, or banishment from the medical staff. At times, this is an appropriate response, as some errors are so egregious or indicative of a chronic problem. More often, the punitive process misses the mark because it focuses on blame instead of prevention of the next error. Unlike the aviation industry, this leaves medicine bereft of data for improving our care systems.

“Blame and Punish” Doesn’t Work

There are two problems with the “blame and punish” approach. First, it is predicated on the belief that providers make errors because they are poorly trained, inept, or just plain careless. Sometimes this is the case.

However, the vast majority of peer reviews that I’ve participated in involved an error performed by extremely well trained, highly skilled clinicians with the highest level of integrity and vigilance. The real problem lies in the human condition.

Humans make mistakes. Always have, always will.

In college, I worked summers in a factory that applied coating to paper. This combined colossal machines spinning at breakneck speeds, huge rolls of paper, and hands—a recipe for handless employees. But accidents rarely happened. Over time, the mill engineers had designed systems so foolproof that the workers couldn’t chop their hands off, even if they wanted to. This level of safety was achieved, in principle, by learning how errors were made so that future errors could be prevented. It was not achieved by blaming handless employees. This paper-plant process recognizes the fallible nature of human beings; it’s the same recognition we need in medicine.

Whether we commit a systems error (e.g., the lab test results arrived after the patient was discharged), a cognitive error (e.g., I continue to believe this pulmonary embolism is pneumonia because my night-coverage partner signed it out as pneumonia), or simply a human error (e.g., the lab forgot to call a critical result to the ordering physician), we work in systems that often result in errors. And the only meaningful hope we have to reduce errors depends on our ability to identify them and build systems so safe that we couldn’t hurt a patient, even if we tried.

This leads to the second problem with the blame-and-punish mentality: It breeds concealment of errors, as providers become reticent to expose mistakes for fear of retribution. Thus, an important pipeline of information about system deficiencies dries up, and we are left to suffer the same cycle of errors.

Budging the quality and patient-safety needle will require a culture that freely and openly admits mistakes in order to analyze and prevent future mistakes. This is inherently difficult for most of us to do, and next to impossible when we fear reprimand. Then again, if we endeavor to fundamentally enhance the safety of hospital care, we must allow providers to openly discuss errors without fear of rebuke. Accomplishing this will require understanding, leadership and action—and it starts with each of us.

Anything short of this will just result in more bad pages. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of Hospital Medicine and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Round One

“Plane down, mass casualties possible; initiate disaster plan.”

The page interrupted my evening out with friends a few Saturday nights ago. Looking up from my dinner, I noticed the restaurant television had cut away to a news story at Denver International Airport. Continental Flight 1404, en route to Houston, had crashed during takeoff, belly-flopping to a fiery rest a few hundred yards off the runway. The airport is about 10 miles from the nearest hospital—mine.

The situation ended considerably better than originally expected. Thirty-eight people were treated at several Denver hospitals, 11 of them at my hospital, with most patients discharged from the emergency department. No one died. The case remains under review, and little is known about the cause of the crash.

Round Two

“Give me a call. I need to talk to you urgently.”

That page arrived the following Monday morning. It was from a co-worker. There had been an unexpected bad outcome in a young male patient. The hospital’s quality and risk management group had found out about the case and called for a peer review. My colleague was scared; would he be publicly criticized? Punished? Fired?

The patient had been admitted with a chronic disease flare-up. He was on the mend after receiving an increased dose of medication. The night before he was scheduled to be discharged, he developed a new symptom, was evaluated by the cross-cover team, and a plan was set in motion. However, a critical lab result, which became available overnight, mistakenly was not called to the provider and went unnoticed by the primary team that triaged the patient to the end of the team’s rounds. By then, he was in extremis.

Getty Images

Planes and Patients

The proximity of these two events provoked comparisons.

By now, comparing healthcare to the aviation industry has become cliché. Both industries demand highly trained and skilled conductors; errors in both industries can result in death; both depend on technology; and both have turned to systems engineering to improve efficiencies and reduce mistakes. This is where the two industries diverge, and I think we get it wrong in medicine.

In aviation, there are very proscriptive algorithms that must be followed, and much of a pilot’s work is under constant scrutiny by air traffic controllers and data recorders. A deviation in protocol rarely goes unnoticed. Errors are systematically compiled, scrutinized, and compartmentalized, with the aim of further refining systems to reduce the likelihood of future errors. Although blame is often prescribed, it is in the context of improving the system. Thus, the aviation industry is awash with data to inform and fuel its systems engineering.

Meanwhile, in medicine our indelible sense of autonomy breeds variability, which is not only tolerated, but often goes unnoticed. Further, we employ a model of error analysis that focuses on affixing blame, as if somehow culpability will prevent future errors. Someone made an error, a bad outcome ensued, and the culprit must be identified and punished. This results in reprimand, remediation, or banishment from the medical staff. At times, this is an appropriate response, as some errors are so egregious or indicative of a chronic problem. More often, the punitive process misses the mark because it focuses on blame instead of prevention of the next error. Unlike the aviation industry, this leaves medicine bereft of data for improving our care systems.

“Blame and Punish” Doesn’t Work

There are two problems with the “blame and punish” approach. First, it is predicated on the belief that providers make errors because they are poorly trained, inept, or just plain careless. Sometimes this is the case.

However, the vast majority of peer reviews that I’ve participated in involved an error performed by extremely well trained, highly skilled clinicians with the highest level of integrity and vigilance. The real problem lies in the human condition.

Humans make mistakes. Always have, always will.

In college, I worked summers in a factory that applied coating to paper. This combined colossal machines spinning at breakneck speeds, huge rolls of paper, and hands—a recipe for handless employees. But accidents rarely happened. Over time, the mill engineers had designed systems so foolproof that the workers couldn’t chop their hands off, even if they wanted to. This level of safety was achieved, in principle, by learning how errors were made so that future errors could be prevented. It was not achieved by blaming handless employees. This paper-plant process recognizes the fallible nature of human beings; it’s the same recognition we need in medicine.

Whether we commit a systems error (e.g., the lab test results arrived after the patient was discharged), a cognitive error (e.g., I continue to believe this pulmonary embolism is pneumonia because my night-coverage partner signed it out as pneumonia), or simply a human error (e.g., the lab forgot to call a critical result to the ordering physician), we work in systems that often result in errors. And the only meaningful hope we have to reduce errors depends on our ability to identify them and build systems so safe that we couldn’t hurt a patient, even if we tried.

This leads to the second problem with the blame-and-punish mentality: It breeds concealment of errors, as providers become reticent to expose mistakes for fear of retribution. Thus, an important pipeline of information about system deficiencies dries up, and we are left to suffer the same cycle of errors.

Budging the quality and patient-safety needle will require a culture that freely and openly admits mistakes in order to analyze and prevent future mistakes. This is inherently difficult for most of us to do, and next to impossible when we fear reprimand. Then again, if we endeavor to fundamentally enhance the safety of hospital care, we must allow providers to openly discuss errors without fear of rebuke. Accomplishing this will require understanding, leadership and action—and it starts with each of us.

Anything short of this will just result in more bad pages. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of Hospital Medicine and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Round One

“Plane down, mass casualties possible; initiate disaster plan.”

The page interrupted my evening out with friends a few Saturday nights ago. Looking up from my dinner, I noticed the restaurant television had cut away to a news story at Denver International Airport. Continental Flight 1404, en route to Houston, had crashed during takeoff, belly-flopping to a fiery rest a few hundred yards off the runway. The airport is about 10 miles from the nearest hospital—mine.

The situation ended considerably better than originally expected. Thirty-eight people were treated at several Denver hospitals, 11 of them at my hospital, with most patients discharged from the emergency department. No one died. The case remains under review, and little is known about the cause of the crash.

Round Two

“Give me a call. I need to talk to you urgently.”

That page arrived the following Monday morning. It was from a co-worker. There had been an unexpected bad outcome in a young male patient. The hospital’s quality and risk management group had found out about the case and called for a peer review. My colleague was scared; would he be publicly criticized? Punished? Fired?

The patient had been admitted with a chronic disease flare-up. He was on the mend after receiving an increased dose of medication. The night before he was scheduled to be discharged, he developed a new symptom, was evaluated by the cross-cover team, and a plan was set in motion. However, a critical lab result, which became available overnight, mistakenly was not called to the provider and went unnoticed by the primary team that triaged the patient to the end of the team’s rounds. By then, he was in extremis.

Getty Images

Planes and Patients

The proximity of these two events provoked comparisons.

By now, comparing healthcare to the aviation industry has become cliché. Both industries demand highly trained and skilled conductors; errors in both industries can result in death; both depend on technology; and both have turned to systems engineering to improve efficiencies and reduce mistakes. This is where the two industries diverge, and I think we get it wrong in medicine.

In aviation, there are very proscriptive algorithms that must be followed, and much of a pilot’s work is under constant scrutiny by air traffic controllers and data recorders. A deviation in protocol rarely goes unnoticed. Errors are systematically compiled, scrutinized, and compartmentalized, with the aim of further refining systems to reduce the likelihood of future errors. Although blame is often prescribed, it is in the context of improving the system. Thus, the aviation industry is awash with data to inform and fuel its systems engineering.

Meanwhile, in medicine our indelible sense of autonomy breeds variability, which is not only tolerated, but often goes unnoticed. Further, we employ a model of error analysis that focuses on affixing blame, as if somehow culpability will prevent future errors. Someone made an error, a bad outcome ensued, and the culprit must be identified and punished. This results in reprimand, remediation, or banishment from the medical staff. At times, this is an appropriate response, as some errors are so egregious or indicative of a chronic problem. More often, the punitive process misses the mark because it focuses on blame instead of prevention of the next error. Unlike the aviation industry, this leaves medicine bereft of data for improving our care systems.

“Blame and Punish” Doesn’t Work

There are two problems with the “blame and punish” approach. First, it is predicated on the belief that providers make errors because they are poorly trained, inept, or just plain careless. Sometimes this is the case.

However, the vast majority of peer reviews that I’ve participated in involved an error performed by extremely well trained, highly skilled clinicians with the highest level of integrity and vigilance. The real problem lies in the human condition.

Humans make mistakes. Always have, always will.

In college, I worked summers in a factory that applied coating to paper. This combined colossal machines spinning at breakneck speeds, huge rolls of paper, and hands—a recipe for handless employees. But accidents rarely happened. Over time, the mill engineers had designed systems so foolproof that the workers couldn’t chop their hands off, even if they wanted to. This level of safety was achieved, in principle, by learning how errors were made so that future errors could be prevented. It was not achieved by blaming handless employees. This paper-plant process recognizes the fallible nature of human beings; it’s the same recognition we need in medicine.

Whether we commit a systems error (e.g., the lab test results arrived after the patient was discharged), a cognitive error (e.g., I continue to believe this pulmonary embolism is pneumonia because my night-coverage partner signed it out as pneumonia), or simply a human error (e.g., the lab forgot to call a critical result to the ordering physician), we work in systems that often result in errors. And the only meaningful hope we have to reduce errors depends on our ability to identify them and build systems so safe that we couldn’t hurt a patient, even if we tried.

This leads to the second problem with the blame-and-punish mentality: It breeds concealment of errors, as providers become reticent to expose mistakes for fear of retribution. Thus, an important pipeline of information about system deficiencies dries up, and we are left to suffer the same cycle of errors.

Budging the quality and patient-safety needle will require a culture that freely and openly admits mistakes in order to analyze and prevent future mistakes. This is inherently difficult for most of us to do, and next to impossible when we fear reprimand. Then again, if we endeavor to fundamentally enhance the safety of hospital care, we must allow providers to openly discuss errors without fear of rebuke. Accomplishing this will require understanding, leadership and action—and it starts with each of us.

Anything short of this will just result in more bad pages. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of Hospital Medicine and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Hospitals as major employers and community resources can do nothing but reflect the realities of our country’s recession, now in its second year. For hospitalists who are integral to a hospital’s performance and are, at the same time, dependent on the institution’s financial success, there is the shared concern often seen by passengers in a two-person airplane buffeted by storms and fierce winds.

Hospitals are hit by a variety of forces during recessions, including tightening credit, increased borrowing costs, reduced returns from investments, decreased philanthropic donations, and the unkindest cut of all: more patients with less ability to pay.

American hospitals, which employ more than 5 million people, have witnessed all these forces magnify the long-standing issue of under-reimbursements from Medicare and Medicaid, which generally don’t even cover the rising costs of labor and technology. In New Jersey, 47% of hospitals were in the red in 2007, and five of the state’s 79 acute-care hospitals closed in 2008.

According to recent data, more than 65% of surveyed hospitals saw decreases in elective procedures and an increase in nonpaying patients. The hit to hospitals’ investments has mirrored the 401(k) crisis. More than 550 hospitals watched their recent investment declines combine for a total loss of $832 million in the third quarter of 2008, compared with a $396 million aggregate gain in the same time period in 2007. All this bad news led Moody’s to change its 12- to 18-month outlook for both profit and nonprofit hospitals from stable to negative due to increasing bad debt, credit tightening, and loss of investments.

Hospitals are keenly affected by local employment, too. When local businesses have layoffs, former employees often lose their insurance coverage. When companies cut back on expenses to hold on to their workers, often that translates into no health insurance or very high deductibles. When patients lose their jobs or their insurance, they stop getting preventive care; they stop buying prescriptions. The end result is increased ED visits and admissions for decompensated heart failure, flu that turns into pneumonia, or out-of-control diabetes.

More admissions might mean more business for hospitals and hospitalists, but it certainly does not mean more money. It likely means more no-pays and increasing bad debt. It means turning a precarious, marginally balanced bottom line into losses and layoffs.

As if that weren’t bad enough, 44 of our 50 states are operating in the red and looking at trimming big-ticket items to stem the losses. For most states, the budget items under scrutiny include education, prisons, and healthcare. Medicaid payments—already inadequate—are shrinking further at a time when more people need a safety net.

Prove Thy Worth

These are tough times to be running a hospital, but aren’t hospitalists, so dependent on the viability of their hospitals, also on a slippery slope—and running downhill? Actually, these tough times might make hospitalists—and our value—all the more important to their hospitals, helping administrators weather the storm and be resources for their healthcare communities.

Hospitalists can deliver just what we need today—efficient and effective care with appropriate use of resources, better hospital throughput, attention to safety, and measurable efforts to improve performance.

In addition, as primary-care physicians (PCPs), surgeons, and subspecialists retrench to stay away from no-pays so they can find a better payor mix in order to survive, patients keep coming to hospitals, and hospitalists are positioned to pick up the slack and jump right in. Obviously, there is the chance PCPs and others in difficult times might actually come back to inpatient care as office and procedure revenues dwindle, but this is less likely to affect hospitalists when we seem to always have far more work than we have staff or time to manage.

Change Agents

Times of crisis create opportunities for real change. President Obama and many key legislators and thought leaders have signaled a genuine desire to change a system that rewards performance (value-based purchasing) and bundles hospital and physician payments, which will be tied to key outcomes and performance. SHM has been able to show Washington decision-makers that hospitalists can reduce preventable deep vein thrombosis (DVT) in hospitalized patients from 50 per year to three per year. We have shown that hospitalists, using SHM’s BOOST protocols, can improve the discharge process, identify high-risk patients, and reduce ED visits and readmissions. This is just the type of system improvement that leads to better care at a lower cost—the Holy Grail in hard times.

Couple all this with the Institute of Medicine’s call to further reduce residency hours, which only leads to a greater need for hospitalists in teaching institutions, and there is an increasing demand for hospitalists seemingly everywhere. And even in a recession, high demand with a small supply leads to the need to nurture and reward hospitalists, especially those who are experienced and can deliver efficient and effective inpatient care.

At a national level, we will see experimentation with demonstration projects to look at rewarding performance and bundling payments for inpatient care. Similarly, hospitalists should be emboldened to use the current crisis to experiment locally by using teams of hospitalists, nurses, pharmacists, and case managers to revise the way care is delivered. There are opportunities to responsibly involve nurse practitioners and physician assistants as integral parts of your hospitalist team.

While the rest of medicine might be forced to look out for themselves in tough times, hospitalists, by their very positioning, must focus on the survival and improvement of the system, of their hospital, and of the healthcare community. In hospital medicine, we recognize that the days of “Lone Ranger” physicians carving out their own destinies are long gone. In many ways, physicians are intricately intertwined. And that forces us to survive or fail together. That will be hospitalists’ salvation in these hard times: knowing there are better times ahead for us, our hospitals, and our patients. TH

Larry Wellikson is CEO of SHM.

Hospitals as major employers and community resources can do nothing but reflect the realities of our country’s recession, now in its second year. For hospitalists who are integral to a hospital’s performance and are, at the same time, dependent on the institution’s financial success, there is the shared concern often seen by passengers in a two-person airplane buffeted by storms and fierce winds.

Hospitals are hit by a variety of forces during recessions, including tightening credit, increased borrowing costs, reduced returns from investments, decreased philanthropic donations, and the unkindest cut of all: more patients with less ability to pay.

American hospitals, which employ more than 5 million people, have witnessed all these forces magnify the long-standing issue of under-reimbursements from Medicare and Medicaid, which generally don’t even cover the rising costs of labor and technology. In New Jersey, 47% of hospitals were in the red in 2007, and five of the state’s 79 acute-care hospitals closed in 2008.

According to recent data, more than 65% of surveyed hospitals saw decreases in elective procedures and an increase in nonpaying patients. The hit to hospitals’ investments has mirrored the 401(k) crisis. More than 550 hospitals watched their recent investment declines combine for a total loss of $832 million in the third quarter of 2008, compared with a $396 million aggregate gain in the same time period in 2007. All this bad news led Moody’s to change its 12- to 18-month outlook for both profit and nonprofit hospitals from stable to negative due to increasing bad debt, credit tightening, and loss of investments.

Hospitals are keenly affected by local employment, too. When local businesses have layoffs, former employees often lose their insurance coverage. When companies cut back on expenses to hold on to their workers, often that translates into no health insurance or very high deductibles. When patients lose their jobs or their insurance, they stop getting preventive care; they stop buying prescriptions. The end result is increased ED visits and admissions for decompensated heart failure, flu that turns into pneumonia, or out-of-control diabetes.

More admissions might mean more business for hospitals and hospitalists, but it certainly does not mean more money. It likely means more no-pays and increasing bad debt. It means turning a precarious, marginally balanced bottom line into losses and layoffs.

As if that weren’t bad enough, 44 of our 50 states are operating in the red and looking at trimming big-ticket items to stem the losses. For most states, the budget items under scrutiny include education, prisons, and healthcare. Medicaid payments—already inadequate—are shrinking further at a time when more people need a safety net.

Prove Thy Worth

These are tough times to be running a hospital, but aren’t hospitalists, so dependent on the viability of their hospitals, also on a slippery slope—and running downhill? Actually, these tough times might make hospitalists—and our value—all the more important to their hospitals, helping administrators weather the storm and be resources for their healthcare communities.

Hospitalists can deliver just what we need today—efficient and effective care with appropriate use of resources, better hospital throughput, attention to safety, and measurable efforts to improve performance.

In addition, as primary-care physicians (PCPs), surgeons, and subspecialists retrench to stay away from no-pays so they can find a better payor mix in order to survive, patients keep coming to hospitals, and hospitalists are positioned to pick up the slack and jump right in. Obviously, there is the chance PCPs and others in difficult times might actually come back to inpatient care as office and procedure revenues dwindle, but this is less likely to affect hospitalists when we seem to always have far more work than we have staff or time to manage.

Change Agents

Times of crisis create opportunities for real change. President Obama and many key legislators and thought leaders have signaled a genuine desire to change a system that rewards performance (value-based purchasing) and bundles hospital and physician payments, which will be tied to key outcomes and performance. SHM has been able to show Washington decision-makers that hospitalists can reduce preventable deep vein thrombosis (DVT) in hospitalized patients from 50 per year to three per year. We have shown that hospitalists, using SHM’s BOOST protocols, can improve the discharge process, identify high-risk patients, and reduce ED visits and readmissions. This is just the type of system improvement that leads to better care at a lower cost—the Holy Grail in hard times.

Couple all this with the Institute of Medicine’s call to further reduce residency hours, which only leads to a greater need for hospitalists in teaching institutions, and there is an increasing demand for hospitalists seemingly everywhere. And even in a recession, high demand with a small supply leads to the need to nurture and reward hospitalists, especially those who are experienced and can deliver efficient and effective inpatient care.

At a national level, we will see experimentation with demonstration projects to look at rewarding performance and bundling payments for inpatient care. Similarly, hospitalists should be emboldened to use the current crisis to experiment locally by using teams of hospitalists, nurses, pharmacists, and case managers to revise the way care is delivered. There are opportunities to responsibly involve nurse practitioners and physician assistants as integral parts of your hospitalist team.

While the rest of medicine might be forced to look out for themselves in tough times, hospitalists, by their very positioning, must focus on the survival and improvement of the system, of their hospital, and of the healthcare community. In hospital medicine, we recognize that the days of “Lone Ranger” physicians carving out their own destinies are long gone. In many ways, physicians are intricately intertwined. And that forces us to survive or fail together. That will be hospitalists’ salvation in these hard times: knowing there are better times ahead for us, our hospitals, and our patients. TH

Larry Wellikson is CEO of SHM.

Hospitals as major employers and community resources can do nothing but reflect the realities of our country’s recession, now in its second year. For hospitalists who are integral to a hospital’s performance and are, at the same time, dependent on the institution’s financial success, there is the shared concern often seen by passengers in a two-person airplane buffeted by storms and fierce winds.

Hospitals are hit by a variety of forces during recessions, including tightening credit, increased borrowing costs, reduced returns from investments, decreased philanthropic donations, and the unkindest cut of all: more patients with less ability to pay.

American hospitals, which employ more than 5 million people, have witnessed all these forces magnify the long-standing issue of under-reimbursements from Medicare and Medicaid, which generally don’t even cover the rising costs of labor and technology. In New Jersey, 47% of hospitals were in the red in 2007, and five of the state’s 79 acute-care hospitals closed in 2008.

According to recent data, more than 65% of surveyed hospitals saw decreases in elective procedures and an increase in nonpaying patients. The hit to hospitals’ investments has mirrored the 401(k) crisis. More than 550 hospitals watched their recent investment declines combine for a total loss of $832 million in the third quarter of 2008, compared with a $396 million aggregate gain in the same time period in 2007. All this bad news led Moody’s to change its 12- to 18-month outlook for both profit and nonprofit hospitals from stable to negative due to increasing bad debt, credit tightening, and loss of investments.

Hospitals are keenly affected by local employment, too. When local businesses have layoffs, former employees often lose their insurance coverage. When companies cut back on expenses to hold on to their workers, often that translates into no health insurance or very high deductibles. When patients lose their jobs or their insurance, they stop getting preventive care; they stop buying prescriptions. The end result is increased ED visits and admissions for decompensated heart failure, flu that turns into pneumonia, or out-of-control diabetes.

More admissions might mean more business for hospitals and hospitalists, but it certainly does not mean more money. It likely means more no-pays and increasing bad debt. It means turning a precarious, marginally balanced bottom line into losses and layoffs.

As if that weren’t bad enough, 44 of our 50 states are operating in the red and looking at trimming big-ticket items to stem the losses. For most states, the budget items under scrutiny include education, prisons, and healthcare. Medicaid payments—already inadequate—are shrinking further at a time when more people need a safety net.

Prove Thy Worth

These are tough times to be running a hospital, but aren’t hospitalists, so dependent on the viability of their hospitals, also on a slippery slope—and running downhill? Actually, these tough times might make hospitalists—and our value—all the more important to their hospitals, helping administrators weather the storm and be resources for their healthcare communities.

Hospitalists can deliver just what we need today—efficient and effective care with appropriate use of resources, better hospital throughput, attention to safety, and measurable efforts to improve performance.

In addition, as primary-care physicians (PCPs), surgeons, and subspecialists retrench to stay away from no-pays so they can find a better payor mix in order to survive, patients keep coming to hospitals, and hospitalists are positioned to pick up the slack and jump right in. Obviously, there is the chance PCPs and others in difficult times might actually come back to inpatient care as office and procedure revenues dwindle, but this is less likely to affect hospitalists when we seem to always have far more work than we have staff or time to manage.

Change Agents

Times of crisis create opportunities for real change. President Obama and many key legislators and thought leaders have signaled a genuine desire to change a system that rewards performance (value-based purchasing) and bundles hospital and physician payments, which will be tied to key outcomes and performance. SHM has been able to show Washington decision-makers that hospitalists can reduce preventable deep vein thrombosis (DVT) in hospitalized patients from 50 per year to three per year. We have shown that hospitalists, using SHM’s BOOST protocols, can improve the discharge process, identify high-risk patients, and reduce ED visits and readmissions. This is just the type of system improvement that leads to better care at a lower cost—the Holy Grail in hard times.

Couple all this with the Institute of Medicine’s call to further reduce residency hours, which only leads to a greater need for hospitalists in teaching institutions, and there is an increasing demand for hospitalists seemingly everywhere. And even in a recession, high demand with a small supply leads to the need to nurture and reward hospitalists, especially those who are experienced and can deliver efficient and effective inpatient care.

At a national level, we will see experimentation with demonstration projects to look at rewarding performance and bundling payments for inpatient care. Similarly, hospitalists should be emboldened to use the current crisis to experiment locally by using teams of hospitalists, nurses, pharmacists, and case managers to revise the way care is delivered. There are opportunities to responsibly involve nurse practitioners and physician assistants as integral parts of your hospitalist team.

While the rest of medicine might be forced to look out for themselves in tough times, hospitalists, by their very positioning, must focus on the survival and improvement of the system, of their hospital, and of the healthcare community. In hospital medicine, we recognize that the days of “Lone Ranger” physicians carving out their own destinies are long gone. In many ways, physicians are intricately intertwined. And that forces us to survive or fail together. That will be hospitalists’ salvation in these hard times: knowing there are better times ahead for us, our hospitals, and our patients. TH

Larry Wellikson is CEO of SHM.

Dedication to hard work, a passion for improving health outcomes and medical curricula, a background in business administration, and a knack for team-building have catapulted Alpesh Amin, MD, MBA, FACP, to the forefront of change at the University of California at Irvine Health Affairs, comprised of the UC Irvine Medical Center and School of Medicine. Those skill sets and determination have landed Dr. Amin an HM first: appointment as interim chair of an academic Department of Medicine.

Dr. Amin’s new role—he supervises 11 divisions and more than 200 faculty—means he’s responsible for the department’s budget and administration. He also is charged with advancing the department’s clinical, teaching, and research missions, demonstrating that it’s possible for hospitalists to rise through the department ranks through an HM track. And that, says Scott Flanders, SHM’s president-elect and associate professor of medicine and director of the HM program at the University of Michigan Health System in Ann Arbor, “bodes well for the future of academic hospitalists at many institutions across the country.”

Traditionally, lofty hospital appointments have gone to academics with a background in biomedical and basic science research. But as academic and teaching hospitals focus more and more on quality issues and improved performance, hospitalists are positioned to advance into department leadership positions.

Dr. Amin’s appointment could signal the first of many opportunities for academic hospitalists, according to Joseph Ming-Wah Li, MD, assistant professor of medicine at Harvard Medical School and director of the HM program at Beth Israel Deaconess Medical Center in Boston. Dr. Li, who served with Dr. Amin on SHM’s Board of Directors, was not surprised when Alpesh was named the first hospitalist to chair a department of medicine. “He is a very gregarious person, he’s bright, and he’s logical in his thinking,” Dr. Li says.

Career Foundation

Dr. Amin credits his family with instilling in him strong values and dedication to his work. Born in Baroda, India, he emigrated to the U.S. before his first birthday; he graduated from Northgate High School in Walnut Creek, Calif., in 1985, and from UC San Diego with a degree in bioengineering in 1989. He obtained his MD in 1994 from Northwestern University’s Feinberg School of Medicine in Chicago.

During his internship and residency at UC Irvine, Dr. Amin pondered the possibilities of a subspecialty within internal medicine. He opted to follow his interests in medical education and healthcare outcomes and research. The HM field intrigued him, he says, “because there was an opportunity to improve on systems and patient-care delivery.” Numerous mentors along the way encouraged his interests in curriculum development and design, quality improvement, and developing delivery models for patient care.

Trendsetter

As a medical resident, Dr. Amin demonstrated a desire to become a leader and change agent. “He was truly an outstanding resident, and then he joined the faculty and did spectacularly in organizing the hospitalist program, which has become very successful,” recalls Nosratola D. Vaziri, MD, chief of the division of nephrology and hypertension at UC Irvine’s School of Medicine. Dr. Amin founded the UC Irvine hospitalist program in 1998. At the same time, he acquired his MBA in healthcare administration, thus rounding out an already impressive skill set. “The MBA has been a valuable tool,” says Dr. Amin, “because I learned—among other skills—leadership, strategic planning, developing business plans, and improving on operations.”

He has applied those techniques throughout his career, serving in various leadership roles at his institution, including medicine clerkship director, associate program director for the internal medicine residency program, vice chair for clinical affairs and quality assurance, and chief of the division of general internal medicine.

Are Hospitalists the Logical Choice to Chair Departments of Medicine?

Yes, says Joseph Ming-Wah Li, an SHM board member who heads the hospital medicine group at Beth Israel Deaconess in Boston. “The department chair of medicine of yesterday is very different from today—and that’s due to the changes in academic medical centers. It’s not enough anymore to just be a skilled teacher, or a bright clinician or be able to publish. You actually have to be a very skilled administrator and be able to see the bigger picture. That’s where people like [Dr. Amin] are so valuable. They understand what’s happening in terms of the hospital’s workflow, and he’s had to develop and hone those skills during his years as a hospitalist.”

Perhaps, says Matthew Brenner, MD, professor of medicine and chief of pulmonary and critical-care medicine at UC Irvine, but it’s not just hospitalist training that will project someone into a department chair post. What’s required is specific expertise in the business of healthcare. “It’s hard to be chair of medicine today without knowing how to run a business,” he says.

 

Yes, says SHM President-elect Scott Flanders, MD, associate professor of medicine and director of the hospital medicine program at the University of Michigan in Ann Arbor. “Many in the hospitalist community, including those at academic medical centers, are required to focus on business and leadership skills. We’re constantly having to juggle clinical tasks and administrative roles, both at a departmental level as well as the institutional level. Those skills are essential for department chairs. As a field, hospital medicine prepares people very well for future leadership roles beyond just the local hospitalist community.”

Yes, says Jeffrey Wiese, MD, FACP, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans and an SHM board member. “There is now an acceptance toward a mentality and culture that is empowered to fix the problems. And that’s our task, as hospitalists—to work as part of the patient-care team.” He also believes the research agenda may also benefit with a hospitalist-trained chair: “The more you can evoke collaboration between all subspecialties of medicine, the better off you will be in terms of fostering meaningful and fruitful research.”

Yes, says Eric Howell, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, where he is also division director of collaborative inpatient medicine service; he is also chair of SHM’s Leadership Committee. “My belief is that hospitalists will be natural leaders of hospitals in the private sector, and also of departments and divisions in some academic environments. All hospitalists are trained to manage teams, so it’s not such a big leap for a hospitalist, as it might be for another specialist who may not be quite so used to managing teams.”

By developing and nurturing the UC Irvine hospitalist program, Dr. Amin has exhibited a deep commitment to the core missions of hospital medicine. “Our multidisciplinary program has nine different specialties managed under one program,” he notes. He has structured the program in such a way that members hold dual appointments in the HM program and their individual departments or divisions, thus creating a bridge between the HM program and other departments.

“We have an integrated group that is working together for the focus of advancement in the hospital setting, in terms of clinical care, teaching, team-building, quality and systems improvement. As a result, we’ve had great outcomes in terms of length of stay, quality, and core measures,” Dr. Amin says. “I’ve been fortunate to work with a team of hospitalist faculty who are spectacular and collectively deserve kudos for the success of our group.”

Dr. Amin has shared his passion for quality improvement and curriculum development with all of hospital medicine. As chair of SHM’s education committee, he pushed for the first education summit in 2001, securing support to form a core-curriculum task force. Four years later, Dr. Amin and a small group of industry leaders published “Core Competencies in Hospital Medicine” in the Journal of Hospital Medicine (www.hospitalmedicine.org/corecomp).

“Dr. Amin has really set the trend [for improved hospital performance], not only here for the hospitalist program, but nationwide,” says David N. Bailey, MD, dean and vice chancellor for UC Irvine Health Affairs.

Bucking Tradition

Hospitalists have been advancing into leadership positions in the private sector for many years. It’s been a slower ascent in the academic medical center setting.

“Until recently, it would not have been possible to ascend to the level of chair at most academic centers unless your background was in biomedical and basic science research,” says Robert Wachter, MD, professor and chief of the division of HM at the University of California San Francisco, a former SHM president and author of the blog Wachter’s World (www.wachtersworld .com). “Quality, patient safety, and systems improvement were not considered to be legitimate enough academic work to garner the necessary credibility. I think that’s changing.”

Jeffrey Wiese, MD, FACP, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans and an SHM board member, believes Dr. Amin’s interim appointment “speaks in broad strokes to the new skill set—that is, financial and organizational abilities—that are increasingly becoming valued by academic medicine.” Agendas of patient safety, quality, and delivery of efficient, cost-effective, and safe healthcare are gaining parity, Dr. Wiese says, with academic research agendas. “For one to supercede the other is not a good thing, but for the two to be in balance, I think, is a very good thing,” he says.

“Renaissance Physician”

Dr. Bailey appointed Dr. Amin to what he describes as a “long-term” interim post last June. To make his decision, Dr. Bailey consulted with 11 division chiefs, and Dr. Amin emerged as the leading candidate. “Alpesh does it all, from clinical research to leading a department to running an outstanding hospitalist service,” Dr. Bailey says. “He’s really a renaissance physician.”

The promotion coincides with another of Dr. Amin’s recent accomplishments: He received the Laureate Award for the California Southern Region 2 of the American College of Physicians.

Ever energetic, Dr. Amin is not resting on his laurels. “I’m looking forward to helping the department continue to be a flagship within the UC Irvine School of Medicine,” he says. “This is a challenging and positive opportunity to balance systems-based practice, the business of medicine, and the science of medicine.”

Dr. Amin thinks his appointment signifies the new opportunities open to the growing number of U.S. hospitalists—now more than 28,000 strong and growing every day. “This [appointment] shows that hospitalists can move in the direction of being both academic leaders and healthcare administrative leaders.” TH

Gretchen Henkel is a freelance medical writer based in California.

Dedication to hard work, a passion for improving health outcomes and medical curricula, a background in business administration, and a knack for team-building have catapulted Alpesh Amin, MD, MBA, FACP, to the forefront of change at the University of California at Irvine Health Affairs, comprised of the UC Irvine Medical Center and School of Medicine. Those skill sets and determination have landed Dr. Amin an HM first: appointment as interim chair of an academic Department of Medicine.

Dr. Amin’s new role—he supervises 11 divisions and more than 200 faculty—means he’s responsible for the department’s budget and administration. He also is charged with advancing the department’s clinical, teaching, and research missions, demonstrating that it’s possible for hospitalists to rise through the department ranks through an HM track. And that, says Scott Flanders, SHM’s president-elect and associate professor of medicine and director of the HM program at the University of Michigan Health System in Ann Arbor, “bodes well for the future of academic hospitalists at many institutions across the country.”

Traditionally, lofty hospital appointments have gone to academics with a background in biomedical and basic science research. But as academic and teaching hospitals focus more and more on quality issues and improved performance, hospitalists are positioned to advance into department leadership positions.

Dr. Amin’s appointment could signal the first of many opportunities for academic hospitalists, according to Joseph Ming-Wah Li, MD, assistant professor of medicine at Harvard Medical School and director of the HM program at Beth Israel Deaconess Medical Center in Boston. Dr. Li, who served with Dr. Amin on SHM’s Board of Directors, was not surprised when Alpesh was named the first hospitalist to chair a department of medicine. “He is a very gregarious person, he’s bright, and he’s logical in his thinking,” Dr. Li says.

Career Foundation

Dr. Amin credits his family with instilling in him strong values and dedication to his work. Born in Baroda, India, he emigrated to the U.S. before his first birthday; he graduated from Northgate High School in Walnut Creek, Calif., in 1985, and from UC San Diego with a degree in bioengineering in 1989. He obtained his MD in 1994 from Northwestern University’s Feinberg School of Medicine in Chicago.

During his internship and residency at UC Irvine, Dr. Amin pondered the possibilities of a subspecialty within internal medicine. He opted to follow his interests in medical education and healthcare outcomes and research. The HM field intrigued him, he says, “because there was an opportunity to improve on systems and patient-care delivery.” Numerous mentors along the way encouraged his interests in curriculum development and design, quality improvement, and developing delivery models for patient care.

Trendsetter

As a medical resident, Dr. Amin demonstrated a desire to become a leader and change agent. “He was truly an outstanding resident, and then he joined the faculty and did spectacularly in organizing the hospitalist program, which has become very successful,” recalls Nosratola D. Vaziri, MD, chief of the division of nephrology and hypertension at UC Irvine’s School of Medicine. Dr. Amin founded the UC Irvine hospitalist program in 1998. At the same time, he acquired his MBA in healthcare administration, thus rounding out an already impressive skill set. “The MBA has been a valuable tool,” says Dr. Amin, “because I learned—among other skills—leadership, strategic planning, developing business plans, and improving on operations.”

He has applied those techniques throughout his career, serving in various leadership roles at his institution, including medicine clerkship director, associate program director for the internal medicine residency program, vice chair for clinical affairs and quality assurance, and chief of the division of general internal medicine.

Are Hospitalists the Logical Choice to Chair Departments of Medicine?

Yes, says Joseph Ming-Wah Li, an SHM board member who heads the hospital medicine group at Beth Israel Deaconess in Boston. “The department chair of medicine of yesterday is very different from today—and that’s due to the changes in academic medical centers. It’s not enough anymore to just be a skilled teacher, or a bright clinician or be able to publish. You actually have to be a very skilled administrator and be able to see the bigger picture. That’s where people like [Dr. Amin] are so valuable. They understand what’s happening in terms of the hospital’s workflow, and he’s had to develop and hone those skills during his years as a hospitalist.”

Perhaps, says Matthew Brenner, MD, professor of medicine and chief of pulmonary and critical-care medicine at UC Irvine, but it’s not just hospitalist training that will project someone into a department chair post. What’s required is specific expertise in the business of healthcare. “It’s hard to be chair of medicine today without knowing how to run a business,” he says.

 

Yes, says SHM President-elect Scott Flanders, MD, associate professor of medicine and director of the hospital medicine program at the University of Michigan in Ann Arbor. “Many in the hospitalist community, including those at academic medical centers, are required to focus on business and leadership skills. We’re constantly having to juggle clinical tasks and administrative roles, both at a departmental level as well as the institutional level. Those skills are essential for department chairs. As a field, hospital medicine prepares people very well for future leadership roles beyond just the local hospitalist community.”

Yes, says Jeffrey Wiese, MD, FACP, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans and an SHM board member. “There is now an acceptance toward a mentality and culture that is empowered to fix the problems. And that’s our task, as hospitalists—to work as part of the patient-care team.” He also believes the research agenda may also benefit with a hospitalist-trained chair: “The more you can evoke collaboration between all subspecialties of medicine, the better off you will be in terms of fostering meaningful and fruitful research.”

Yes, says Eric Howell, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, where he is also division director of collaborative inpatient medicine service; he is also chair of SHM’s Leadership Committee. “My belief is that hospitalists will be natural leaders of hospitals in the private sector, and also of departments and divisions in some academic environments. All hospitalists are trained to manage teams, so it’s not such a big leap for a hospitalist, as it might be for another specialist who may not be quite so used to managing teams.”

By developing and nurturing the UC Irvine hospitalist program, Dr. Amin has exhibited a deep commitment to the core missions of hospital medicine. “Our multidisciplinary program has nine different specialties managed under one program,” he notes. He has structured the program in such a way that members hold dual appointments in the HM program and their individual departments or divisions, thus creating a bridge between the HM program and other departments.

“We have an integrated group that is working together for the focus of advancement in the hospital setting, in terms of clinical care, teaching, team-building, quality and systems improvement. As a result, we’ve had great outcomes in terms of length of stay, quality, and core measures,” Dr. Amin says. “I’ve been fortunate to work with a team of hospitalist faculty who are spectacular and collectively deserve kudos for the success of our group.”

Dr. Amin has shared his passion for quality improvement and curriculum development with all of hospital medicine. As chair of SHM’s education committee, he pushed for the first education summit in 2001, securing support to form a core-curriculum task force. Four years later, Dr. Amin and a small group of industry leaders published “Core Competencies in Hospital Medicine” in the Journal of Hospital Medicine (www.hospitalmedicine.org/corecomp).

“Dr. Amin has really set the trend [for improved hospital performance], not only here for the hospitalist program, but nationwide,” says David N. Bailey, MD, dean and vice chancellor for UC Irvine Health Affairs.

Bucking Tradition

Hospitalists have been advancing into leadership positions in the private sector for many years. It’s been a slower ascent in the academic medical center setting.

“Until recently, it would not have been possible to ascend to the level of chair at most academic centers unless your background was in biomedical and basic science research,” says Robert Wachter, MD, professor and chief of the division of HM at the University of California San Francisco, a former SHM president and author of the blog Wachter’s World (www.wachtersworld .com). “Quality, patient safety, and systems improvement were not considered to be legitimate enough academic work to garner the necessary credibility. I think that’s changing.”

Jeffrey Wiese, MD, FACP, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans and an SHM board member, believes Dr. Amin’s interim appointment “speaks in broad strokes to the new skill set—that is, financial and organizational abilities—that are increasingly becoming valued by academic medicine.” Agendas of patient safety, quality, and delivery of efficient, cost-effective, and safe healthcare are gaining parity, Dr. Wiese says, with academic research agendas. “For one to supercede the other is not a good thing, but for the two to be in balance, I think, is a very good thing,” he says.

“Renaissance Physician”

Dr. Bailey appointed Dr. Amin to what he describes as a “long-term” interim post last June. To make his decision, Dr. Bailey consulted with 11 division chiefs, and Dr. Amin emerged as the leading candidate. “Alpesh does it all, from clinical research to leading a department to running an outstanding hospitalist service,” Dr. Bailey says. “He’s really a renaissance physician.”

The promotion coincides with another of Dr. Amin’s recent accomplishments: He received the Laureate Award for the California Southern Region 2 of the American College of Physicians.

Ever energetic, Dr. Amin is not resting on his laurels. “I’m looking forward to helping the department continue to be a flagship within the UC Irvine School of Medicine,” he says. “This is a challenging and positive opportunity to balance systems-based practice, the business of medicine, and the science of medicine.”

Dr. Amin thinks his appointment signifies the new opportunities open to the growing number of U.S. hospitalists—now more than 28,000 strong and growing every day. “This [appointment] shows that hospitalists can move in the direction of being both academic leaders and healthcare administrative leaders.” TH

Gretchen Henkel is a freelance medical writer based in California.

Dedication to hard work, a passion for improving health outcomes and medical curricula, a background in business administration, and a knack for team-building have catapulted Alpesh Amin, MD, MBA, FACP, to the forefront of change at the University of California at Irvine Health Affairs, comprised of the UC Irvine Medical Center and School of Medicine. Those skill sets and determination have landed Dr. Amin an HM first: appointment as interim chair of an academic Department of Medicine.

Dr. Amin’s new role—he supervises 11 divisions and more than 200 faculty—means he’s responsible for the department’s budget and administration. He also is charged with advancing the department’s clinical, teaching, and research missions, demonstrating that it’s possible for hospitalists to rise through the department ranks through an HM track. And that, says Scott Flanders, SHM’s president-elect and associate professor of medicine and director of the HM program at the University of Michigan Health System in Ann Arbor, “bodes well for the future of academic hospitalists at many institutions across the country.”

Traditionally, lofty hospital appointments have gone to academics with a background in biomedical and basic science research. But as academic and teaching hospitals focus more and more on quality issues and improved performance, hospitalists are positioned to advance into department leadership positions.

Dr. Amin’s appointment could signal the first of many opportunities for academic hospitalists, according to Joseph Ming-Wah Li, MD, assistant professor of medicine at Harvard Medical School and director of the HM program at Beth Israel Deaconess Medical Center in Boston. Dr. Li, who served with Dr. Amin on SHM’s Board of Directors, was not surprised when Alpesh was named the first hospitalist to chair a department of medicine. “He is a very gregarious person, he’s bright, and he’s logical in his thinking,” Dr. Li says.

Career Foundation

Dr. Amin credits his family with instilling in him strong values and dedication to his work. Born in Baroda, India, he emigrated to the U.S. before his first birthday; he graduated from Northgate High School in Walnut Creek, Calif., in 1985, and from UC San Diego with a degree in bioengineering in 1989. He obtained his MD in 1994 from Northwestern University’s Feinberg School of Medicine in Chicago.

During his internship and residency at UC Irvine, Dr. Amin pondered the possibilities of a subspecialty within internal medicine. He opted to follow his interests in medical education and healthcare outcomes and research. The HM field intrigued him, he says, “because there was an opportunity to improve on systems and patient-care delivery.” Numerous mentors along the way encouraged his interests in curriculum development and design, quality improvement, and developing delivery models for patient care.

Trendsetter

As a medical resident, Dr. Amin demonstrated a desire to become a leader and change agent. “He was truly an outstanding resident, and then he joined the faculty and did spectacularly in organizing the hospitalist program, which has become very successful,” recalls Nosratola D. Vaziri, MD, chief of the division of nephrology and hypertension at UC Irvine’s School of Medicine. Dr. Amin founded the UC Irvine hospitalist program in 1998. At the same time, he acquired his MBA in healthcare administration, thus rounding out an already impressive skill set. “The MBA has been a valuable tool,” says Dr. Amin, “because I learned—among other skills—leadership, strategic planning, developing business plans, and improving on operations.”

He has applied those techniques throughout his career, serving in various leadership roles at his institution, including medicine clerkship director, associate program director for the internal medicine residency program, vice chair for clinical affairs and quality assurance, and chief of the division of general internal medicine.

Are Hospitalists the Logical Choice to Chair Departments of Medicine?

Yes, says Joseph Ming-Wah Li, an SHM board member who heads the hospital medicine group at Beth Israel Deaconess in Boston. “The department chair of medicine of yesterday is very different from today—and that’s due to the changes in academic medical centers. It’s not enough anymore to just be a skilled teacher, or a bright clinician or be able to publish. You actually have to be a very skilled administrator and be able to see the bigger picture. That’s where people like [Dr. Amin] are so valuable. They understand what’s happening in terms of the hospital’s workflow, and he’s had to develop and hone those skills during his years as a hospitalist.”

Perhaps, says Matthew Brenner, MD, professor of medicine and chief of pulmonary and critical-care medicine at UC Irvine, but it’s not just hospitalist training that will project someone into a department chair post. What’s required is specific expertise in the business of healthcare. “It’s hard to be chair of medicine today without knowing how to run a business,” he says.

 

Yes, says SHM President-elect Scott Flanders, MD, associate professor of medicine and director of the hospital medicine program at the University of Michigan in Ann Arbor. “Many in the hospitalist community, including those at academic medical centers, are required to focus on business and leadership skills. We’re constantly having to juggle clinical tasks and administrative roles, both at a departmental level as well as the institutional level. Those skills are essential for department chairs. As a field, hospital medicine prepares people very well for future leadership roles beyond just the local hospitalist community.”

Yes, says Jeffrey Wiese, MD, FACP, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans and an SHM board member. “There is now an acceptance toward a mentality and culture that is empowered to fix the problems. And that’s our task, as hospitalists—to work as part of the patient-care team.” He also believes the research agenda may also benefit with a hospitalist-trained chair: “The more you can evoke collaboration between all subspecialties of medicine, the better off you will be in terms of fostering meaningful and fruitful research.”

Yes, says Eric Howell, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, where he is also division director of collaborative inpatient medicine service; he is also chair of SHM’s Leadership Committee. “My belief is that hospitalists will be natural leaders of hospitals in the private sector, and also of departments and divisions in some academic environments. All hospitalists are trained to manage teams, so it’s not such a big leap for a hospitalist, as it might be for another specialist who may not be quite so used to managing teams.”

By developing and nurturing the UC Irvine hospitalist program, Dr. Amin has exhibited a deep commitment to the core missions of hospital medicine. “Our multidisciplinary program has nine different specialties managed under one program,” he notes. He has structured the program in such a way that members hold dual appointments in the HM program and their individual departments or divisions, thus creating a bridge between the HM program and other departments.

“We have an integrated group that is working together for the focus of advancement in the hospital setting, in terms of clinical care, teaching, team-building, quality and systems improvement. As a result, we’ve had great outcomes in terms of length of stay, quality, and core measures,” Dr. Amin says. “I’ve been fortunate to work with a team of hospitalist faculty who are spectacular and collectively deserve kudos for the success of our group.”

Dr. Amin has shared his passion for quality improvement and curriculum development with all of hospital medicine. As chair of SHM’s education committee, he pushed for the first education summit in 2001, securing support to form a core-curriculum task force. Four years later, Dr. Amin and a small group of industry leaders published “Core Competencies in Hospital Medicine” in the Journal of Hospital Medicine (www.hospitalmedicine.org/corecomp).

“Dr. Amin has really set the trend [for improved hospital performance], not only here for the hospitalist program, but nationwide,” says David N. Bailey, MD, dean and vice chancellor for UC Irvine Health Affairs.

Bucking Tradition

Hospitalists have been advancing into leadership positions in the private sector for many years. It’s been a slower ascent in the academic medical center setting.

“Until recently, it would not have been possible to ascend to the level of chair at most academic centers unless your background was in biomedical and basic science research,” says Robert Wachter, MD, professor and chief of the division of HM at the University of California San Francisco, a former SHM president and author of the blog Wachter’s World (www.wachtersworld .com). “Quality, patient safety, and systems improvement were not considered to be legitimate enough academic work to garner the necessary credibility. I think that’s changing.”

Jeffrey Wiese, MD, FACP, professor of medicine and associate dean for graduate medical education at Tulane University Health Sciences Center in New Orleans and an SHM board member, believes Dr. Amin’s interim appointment “speaks in broad strokes to the new skill set—that is, financial and organizational abilities—that are increasingly becoming valued by academic medicine.” Agendas of patient safety, quality, and delivery of efficient, cost-effective, and safe healthcare are gaining parity, Dr. Wiese says, with academic research agendas. “For one to supercede the other is not a good thing, but for the two to be in balance, I think, is a very good thing,” he says.

“Renaissance Physician”

Dr. Bailey appointed Dr. Amin to what he describes as a “long-term” interim post last June. To make his decision, Dr. Bailey consulted with 11 division chiefs, and Dr. Amin emerged as the leading candidate. “Alpesh does it all, from clinical research to leading a department to running an outstanding hospitalist service,” Dr. Bailey says. “He’s really a renaissance physician.”

The promotion coincides with another of Dr. Amin’s recent accomplishments: He received the Laureate Award for the California Southern Region 2 of the American College of Physicians.

Ever energetic, Dr. Amin is not resting on his laurels. “I’m looking forward to helping the department continue to be a flagship within the UC Irvine School of Medicine,” he says. “This is a challenging and positive opportunity to balance systems-based practice, the business of medicine, and the science of medicine.”

Dr. Amin thinks his appointment signifies the new opportunities open to the growing number of U.S. hospitalists—now more than 28,000 strong and growing every day. “This [appointment] shows that hospitalists can move in the direction of being both academic leaders and healthcare administrative leaders.” TH

Gretchen Henkel is a freelance medical writer based in California.

Case

An 84-year-old woman presents with watery diarrhea. She recently received a fluoroquinolone antibiotic during a hospitalization for pneumonia. Her temperature is 101 degrees, her heart rate is 110 beats per minute, and her respiratory rate is 22 breaths per minute. Her abdominal exam is significant for mild distention, hyperactive bowel sounds, and diffuse, mild tenderness without rebound or guarding. Her white blood cell count is 18,200 cells/mm3. You suspect C. difficile infection. Should you treat empirically with antibiotics and, if so, which antibiotic should you prescribe?

Overview

C. difficile is an anaerobic gram-positive bacillus that produces spores and toxins. In 1978, C. difficile was identified as the causative agent for antibiotic-associated diarrhea.1 The portal of entry is via the fecal-oral route.

Some patients carry C. difficile in their intestinal flora and show no signs of infection. Patients who develop symptoms commonly present with profuse, watery diarrhea. Nausea, vomiting, and abdominal pain also can be seen. Severe cases of C. difficile-associated diarrhea (CDAD) can present with significant abdominal pain and multisystem organ failure, with toxic megacolon resulting from toxin production and ileus.2 In severe cases due to ileus, diarrhea may be absent. Risk of mortality in severe cases is high, with some reviews citing death rates of 57% in patients requiring total colectomy.3 Risk factors for developing CDAD include the prior or current use of antibiotics, advanced age, hospitalization, and prior gastrointestinal surgery or procedures.4

The initial CDAD treatment involves removal of the agent that incited the infection. In most cases, this means discontinuation of an antimicrobial agent. Removal of the inciting agent allows restoration of the normal bowel flora. In mild CDAD cases, this may be sufficient therapy. However, most CDAD cases require treatment. Although many antimicrobial and probiotic agents have been used in CDAD treatment, metronidazole and vancomycin are the most commonly prescribed agents. There is an ongoing debate as to which should be considered the first-line agent.

Review of the Data

Metronidazole and vancomycin have the longest histories of use and are the most studied agents in CDAD. Metronidazole is prescribed 250 mg four times daily (or 500 mg twice daily) for 14 days. It is reasonably tolerated, although it can cause a metallic taste in the mouth. Vancomycin is given 125 mg four times daily (or 500 mg three times daily) for 10 to 14 days. Unlike metronidazole, which can be given by mouth or intravenously, only oral vancomycin is effective in CDAD.

Historically, metronidazole has been prescribed more frequently as the first-line agent in CDAD. Proponents of the drug tout its low cost and the importance of minimizing the development of vancomycin-resistant enteric pathogens. There are two small, prospective, randomized studies comparing the efficacy of the agents against one another in the treatment of C. difficile infection, with similar efficacy demonstrated in both studies. In the early 1980s, Teasley and colleagues randomized 94 patients with C. difficile infection to either metronidazole or vancomycin.5 All the patients receiving vancomycin resolved their disease; 95% of patients receiving metronidazole were cured. The differences were not statistically significant.

In the mid-1990s, Wenisch and colleagues randomized patients with C. difficile infection to receive vancomycin, metronidazole, fusidic acid, or teicoplanin therapy.6 Ninety-four percent of patients in both the vancomycin and metronidazole groups were cured.

However, since 2000, investigators have reported higher failure rates with metronidazole therapy in C. difficile infections. For example, in 2005, Pepin and colleagues reviewed cases of C. difficile infections at a hospital in Quebec.7 They determined the number of patients with C. difficile infection initially treated with metronidazole who required additional therapy had markedly increased. Between 1991 and 2002, 9.6% of patients who initially were treated with metronidazole required a switch to vancomycin (or the addition of vancomycin) because of a disappointing response. This figure doubled to 25.7% in 2003-2004. The 60-day probability of recurrence also increased in the 2003-2004 test group (47.2%), compared with the 1991-2002 group (20.8%). Both results were statistically significant. Such data contributed to the debate regarding whether metronidazole or vancomycin is the superior agent in the treatment of C. difficile infections.

In 2007, Zar and colleagues studied the efficacy of metronidazole and vancomycin in the treatment of CDAD patients, but the study stratified patients according to disease severity.8 This allowed the authors to investigate whether one agent was superior in treating mild or severe CDAD. They determined disease severity by assigning points to individual patient characteristics. Patients with two or more points were deemed to have “severe” CDAD.

The investigators assigned one point for each of the following patient characteristics: temperature >38.3 degrees Celsius, age >60 years, albumin level <2.5 mg/dL, and white blood cell count >15,000 cells/mm3 within 48 hours of enrolling in the study. Any patient with endoscopic evidence of pseudomembrane formation or admission to the intensive-care unit (ICU) for CDAD treatment was considered to have severe disease.

Medical-on-Line/Alamy

This was a prospective, randomized controlled trial of 150 patients. Patients were randomly prescribed 500 mg metronidazole by mouth three times daily or 125 mg of vancomycin by mouth four times daily. Patients with mild CDAD had similar cure rates: 90% metronidazole versus 98% vancomycin (P=0.36). However, patients with severe CDAD fared statistically better when treated with oral vancomycin. Ninety-seven percent of severe CDAD patients treated with oral vancomycin had a clinical cure, while only 76% of those treated with metronidazole were cured (P=0.02). Recurrence of the disease was similar in each treatment group.

Based on this study, metronidazole and vancomycin appear equally effective in the treatment of mild CDAD, but vancomycin is the superior agent in the treatment of patients with severe CDAD.

Back to the Case

Our patient had several risk factors predisposing her to developing CDAD. She was of advanced age and took a fluoroquinolone antibiotic during a recent hospitalization. She also presented with signs consistent with a severe case of CDAD. She had a fever, a white blood cell count >15,000 cells/mm3, and was older than 60. Thus, she should be treated with supportive care, placed on contact precautions, and administered oral vancomycin 125 mg by mouth every six hours for 10 days as empiric therapy for CDAD. Stool cultures should be sent to confirm the presence of the C. difficile toxin.

click for larger table

Bottom Line

The appropriate antibiotic choice to treat CDAD in any patient depends upon the clinical severity of the disease. Treat patients with mild CDAD with metronidazole; prescribe oral vancomycin for patients with severe CDAD. TH

Dr. Mattison, instructor of medicine at Harvard Medical School, is a hospitalist and co-director of the Inpatient Geriatrics Unit at Beth Israel Deaconess Medical Center (BIDMC) in Boston. Dr. Li, assistant professor of medicine at Harvard Medical School, is director of hospital medicine and associate chief of BIDMC’s Division of General Medicine and Primary Care.

References

1.Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB. Role of C. difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology. 1978;75(5):778-782.

2.Poutanen SM, Simor AE. C. difficile-associated diarrhea in adults. CMAJ. 2004;171(1):51-58.

3.Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant C. difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235(3):363-372.

4.Bartlett JG. Narrative review: the new epidemic of C. difficile-associated enteric disease. Ann Intern Med. 2006;145(10):758-764.

5.Teasley DG, Gerding DN, Olson MM, et al. Prospective randomized trial of metronidazole versus vancomycin for C. difficile-associated diarrhea and colitis. Lancet. 1983;2:1043-1046.

6.Wenisch C, Parschalk B, Hasenhündl M, Hirschl AM, Graninger W. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of C. difficile-associated diarrhea. Clin Infect Dis. 1996;22:813-818.

7.Pepin J, Alary M, Valiquette L, et al. Increasing risk of relapse after treatment of C. difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597.

8.Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of C. difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45(3):302-307.

Case

An 84-year-old woman presents with watery diarrhea. She recently received a fluoroquinolone antibiotic during a hospitalization for pneumonia. Her temperature is 101 degrees, her heart rate is 110 beats per minute, and her respiratory rate is 22 breaths per minute. Her abdominal exam is significant for mild distention, hyperactive bowel sounds, and diffuse, mild tenderness without rebound or guarding. Her white blood cell count is 18,200 cells/mm3. You suspect C. difficile infection. Should you treat empirically with antibiotics and, if so, which antibiotic should you prescribe?

Overview

C. difficile is an anaerobic gram-positive bacillus that produces spores and toxins. In 1978, C. difficile was identified as the causative agent for antibiotic-associated diarrhea.1 The portal of entry is via the fecal-oral route.

Some patients carry C. difficile in their intestinal flora and show no signs of infection. Patients who develop symptoms commonly present with profuse, watery diarrhea. Nausea, vomiting, and abdominal pain also can be seen. Severe cases of C. difficile-associated diarrhea (CDAD) can present with significant abdominal pain and multisystem organ failure, with toxic megacolon resulting from toxin production and ileus.2 In severe cases due to ileus, diarrhea may be absent. Risk of mortality in severe cases is high, with some reviews citing death rates of 57% in patients requiring total colectomy.3 Risk factors for developing CDAD include the prior or current use of antibiotics, advanced age, hospitalization, and prior gastrointestinal surgery or procedures.4

The initial CDAD treatment involves removal of the agent that incited the infection. In most cases, this means discontinuation of an antimicrobial agent. Removal of the inciting agent allows restoration of the normal bowel flora. In mild CDAD cases, this may be sufficient therapy. However, most CDAD cases require treatment. Although many antimicrobial and probiotic agents have been used in CDAD treatment, metronidazole and vancomycin are the most commonly prescribed agents. There is an ongoing debate as to which should be considered the first-line agent.

Review of the Data

Metronidazole and vancomycin have the longest histories of use and are the most studied agents in CDAD. Metronidazole is prescribed 250 mg four times daily (or 500 mg twice daily) for 14 days. It is reasonably tolerated, although it can cause a metallic taste in the mouth. Vancomycin is given 125 mg four times daily (or 500 mg three times daily) for 10 to 14 days. Unlike metronidazole, which can be given by mouth or intravenously, only oral vancomycin is effective in CDAD.

Historically, metronidazole has been prescribed more frequently as the first-line agent in CDAD. Proponents of the drug tout its low cost and the importance of minimizing the development of vancomycin-resistant enteric pathogens. There are two small, prospective, randomized studies comparing the efficacy of the agents against one another in the treatment of C. difficile infection, with similar efficacy demonstrated in both studies. In the early 1980s, Teasley and colleagues randomized 94 patients with C. difficile infection to either metronidazole or vancomycin.5 All the patients receiving vancomycin resolved their disease; 95% of patients receiving metronidazole were cured. The differences were not statistically significant.

In the mid-1990s, Wenisch and colleagues randomized patients with C. difficile infection to receive vancomycin, metronidazole, fusidic acid, or teicoplanin therapy.6 Ninety-four percent of patients in both the vancomycin and metronidazole groups were cured.

However, since 2000, investigators have reported higher failure rates with metronidazole therapy in C. difficile infections. For example, in 2005, Pepin and colleagues reviewed cases of C. difficile infections at a hospital in Quebec.7 They determined the number of patients with C. difficile infection initially treated with metronidazole who required additional therapy had markedly increased. Between 1991 and 2002, 9.6% of patients who initially were treated with metronidazole required a switch to vancomycin (or the addition of vancomycin) because of a disappointing response. This figure doubled to 25.7% in 2003-2004. The 60-day probability of recurrence also increased in the 2003-2004 test group (47.2%), compared with the 1991-2002 group (20.8%). Both results were statistically significant. Such data contributed to the debate regarding whether metronidazole or vancomycin is the superior agent in the treatment of C. difficile infections.

In 2007, Zar and colleagues studied the efficacy of metronidazole and vancomycin in the treatment of CDAD patients, but the study stratified patients according to disease severity.8 This allowed the authors to investigate whether one agent was superior in treating mild or severe CDAD. They determined disease severity by assigning points to individual patient characteristics. Patients with two or more points were deemed to have “severe” CDAD.

The investigators assigned one point for each of the following patient characteristics: temperature >38.3 degrees Celsius, age >60 years, albumin level <2.5 mg/dL, and white blood cell count >15,000 cells/mm3 within 48 hours of enrolling in the study. Any patient with endoscopic evidence of pseudomembrane formation or admission to the intensive-care unit (ICU) for CDAD treatment was considered to have severe disease.

Medical-on-Line/Alamy

This was a prospective, randomized controlled trial of 150 patients. Patients were randomly prescribed 500 mg metronidazole by mouth three times daily or 125 mg of vancomycin by mouth four times daily. Patients with mild CDAD had similar cure rates: 90% metronidazole versus 98% vancomycin (P=0.36). However, patients with severe CDAD fared statistically better when treated with oral vancomycin. Ninety-seven percent of severe CDAD patients treated with oral vancomycin had a clinical cure, while only 76% of those treated with metronidazole were cured (P=0.02). Recurrence of the disease was similar in each treatment group.

Based on this study, metronidazole and vancomycin appear equally effective in the treatment of mild CDAD, but vancomycin is the superior agent in the treatment of patients with severe CDAD.

Back to the Case

Our patient had several risk factors predisposing her to developing CDAD. She was of advanced age and took a fluoroquinolone antibiotic during a recent hospitalization. She also presented with signs consistent with a severe case of CDAD. She had a fever, a white blood cell count >15,000 cells/mm3, and was older than 60. Thus, she should be treated with supportive care, placed on contact precautions, and administered oral vancomycin 125 mg by mouth every six hours for 10 days as empiric therapy for CDAD. Stool cultures should be sent to confirm the presence of the C. difficile toxin.

click for larger table

Bottom Line

The appropriate antibiotic choice to treat CDAD in any patient depends upon the clinical severity of the disease. Treat patients with mild CDAD with metronidazole; prescribe oral vancomycin for patients with severe CDAD. TH

Dr. Mattison, instructor of medicine at Harvard Medical School, is a hospitalist and co-director of the Inpatient Geriatrics Unit at Beth Israel Deaconess Medical Center (BIDMC) in Boston. Dr. Li, assistant professor of medicine at Harvard Medical School, is director of hospital medicine and associate chief of BIDMC’s Division of General Medicine and Primary Care.

References

1.Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB. Role of C. difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology. 1978;75(5):778-782.

2.Poutanen SM, Simor AE. C. difficile-associated diarrhea in adults. CMAJ. 2004;171(1):51-58.

3.Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant C. difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235(3):363-372.

4.Bartlett JG. Narrative review: the new epidemic of C. difficile-associated enteric disease. Ann Intern Med. 2006;145(10):758-764.

5.Teasley DG, Gerding DN, Olson MM, et al. Prospective randomized trial of metronidazole versus vancomycin for C. difficile-associated diarrhea and colitis. Lancet. 1983;2:1043-1046.

6.Wenisch C, Parschalk B, Hasenhündl M, Hirschl AM, Graninger W. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of C. difficile-associated diarrhea. Clin Infect Dis. 1996;22:813-818.

7.Pepin J, Alary M, Valiquette L, et al. Increasing risk of relapse after treatment of C. difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597.

8.Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of C. difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45(3):302-307.

Case

An 84-year-old woman presents with watery diarrhea. She recently received a fluoroquinolone antibiotic during a hospitalization for pneumonia. Her temperature is 101 degrees, her heart rate is 110 beats per minute, and her respiratory rate is 22 breaths per minute. Her abdominal exam is significant for mild distention, hyperactive bowel sounds, and diffuse, mild tenderness without rebound or guarding. Her white blood cell count is 18,200 cells/mm3. You suspect C. difficile infection. Should you treat empirically with antibiotics and, if so, which antibiotic should you prescribe?

Overview

C. difficile is an anaerobic gram-positive bacillus that produces spores and toxins. In 1978, C. difficile was identified as the causative agent for antibiotic-associated diarrhea.1 The portal of entry is via the fecal-oral route.

Some patients carry C. difficile in their intestinal flora and show no signs of infection. Patients who develop symptoms commonly present with profuse, watery diarrhea. Nausea, vomiting, and abdominal pain also can be seen. Severe cases of C. difficile-associated diarrhea (CDAD) can present with significant abdominal pain and multisystem organ failure, with toxic megacolon resulting from toxin production and ileus.2 In severe cases due to ileus, diarrhea may be absent. Risk of mortality in severe cases is high, with some reviews citing death rates of 57% in patients requiring total colectomy.3 Risk factors for developing CDAD include the prior or current use of antibiotics, advanced age, hospitalization, and prior gastrointestinal surgery or procedures.4

The initial CDAD treatment involves removal of the agent that incited the infection. In most cases, this means discontinuation of an antimicrobial agent. Removal of the inciting agent allows restoration of the normal bowel flora. In mild CDAD cases, this may be sufficient therapy. However, most CDAD cases require treatment. Although many antimicrobial and probiotic agents have been used in CDAD treatment, metronidazole and vancomycin are the most commonly prescribed agents. There is an ongoing debate as to which should be considered the first-line agent.

Review of the Data

Metronidazole and vancomycin have the longest histories of use and are the most studied agents in CDAD. Metronidazole is prescribed 250 mg four times daily (or 500 mg twice daily) for 14 days. It is reasonably tolerated, although it can cause a metallic taste in the mouth. Vancomycin is given 125 mg four times daily (or 500 mg three times daily) for 10 to 14 days. Unlike metronidazole, which can be given by mouth or intravenously, only oral vancomycin is effective in CDAD.

Historically, metronidazole has been prescribed more frequently as the first-line agent in CDAD. Proponents of the drug tout its low cost and the importance of minimizing the development of vancomycin-resistant enteric pathogens. There are two small, prospective, randomized studies comparing the efficacy of the agents against one another in the treatment of C. difficile infection, with similar efficacy demonstrated in both studies. In the early 1980s, Teasley and colleagues randomized 94 patients with C. difficile infection to either metronidazole or vancomycin.5 All the patients receiving vancomycin resolved their disease; 95% of patients receiving metronidazole were cured. The differences were not statistically significant.

In the mid-1990s, Wenisch and colleagues randomized patients with C. difficile infection to receive vancomycin, metronidazole, fusidic acid, or teicoplanin therapy.6 Ninety-four percent of patients in both the vancomycin and metronidazole groups were cured.

However, since 2000, investigators have reported higher failure rates with metronidazole therapy in C. difficile infections. For example, in 2005, Pepin and colleagues reviewed cases of C. difficile infections at a hospital in Quebec.7 They determined the number of patients with C. difficile infection initially treated with metronidazole who required additional therapy had markedly increased. Between 1991 and 2002, 9.6% of patients who initially were treated with metronidazole required a switch to vancomycin (or the addition of vancomycin) because of a disappointing response. This figure doubled to 25.7% in 2003-2004. The 60-day probability of recurrence also increased in the 2003-2004 test group (47.2%), compared with the 1991-2002 group (20.8%). Both results were statistically significant. Such data contributed to the debate regarding whether metronidazole or vancomycin is the superior agent in the treatment of C. difficile infections.

In 2007, Zar and colleagues studied the efficacy of metronidazole and vancomycin in the treatment of CDAD patients, but the study stratified patients according to disease severity.8 This allowed the authors to investigate whether one agent was superior in treating mild or severe CDAD. They determined disease severity by assigning points to individual patient characteristics. Patients with two or more points were deemed to have “severe” CDAD.

The investigators assigned one point for each of the following patient characteristics: temperature >38.3 degrees Celsius, age >60 years, albumin level <2.5 mg/dL, and white blood cell count >15,000 cells/mm3 within 48 hours of enrolling in the study. Any patient with endoscopic evidence of pseudomembrane formation or admission to the intensive-care unit (ICU) for CDAD treatment was considered to have severe disease.

Medical-on-Line/Alamy

This was a prospective, randomized controlled trial of 150 patients. Patients were randomly prescribed 500 mg metronidazole by mouth three times daily or 125 mg of vancomycin by mouth four times daily. Patients with mild CDAD had similar cure rates: 90% metronidazole versus 98% vancomycin (P=0.36). However, patients with severe CDAD fared statistically better when treated with oral vancomycin. Ninety-seven percent of severe CDAD patients treated with oral vancomycin had a clinical cure, while only 76% of those treated with metronidazole were cured (P=0.02). Recurrence of the disease was similar in each treatment group.

Based on this study, metronidazole and vancomycin appear equally effective in the treatment of mild CDAD, but vancomycin is the superior agent in the treatment of patients with severe CDAD.

Back to the Case

Our patient had several risk factors predisposing her to developing CDAD. She was of advanced age and took a fluoroquinolone antibiotic during a recent hospitalization. She also presented with signs consistent with a severe case of CDAD. She had a fever, a white blood cell count >15,000 cells/mm3, and was older than 60. Thus, she should be treated with supportive care, placed on contact precautions, and administered oral vancomycin 125 mg by mouth every six hours for 10 days as empiric therapy for CDAD. Stool cultures should be sent to confirm the presence of the C. difficile toxin.

click for larger table

Bottom Line

The appropriate antibiotic choice to treat CDAD in any patient depends upon the clinical severity of the disease. Treat patients with mild CDAD with metronidazole; prescribe oral vancomycin for patients with severe CDAD. TH

Dr. Mattison, instructor of medicine at Harvard Medical School, is a hospitalist and co-director of the Inpatient Geriatrics Unit at Beth Israel Deaconess Medical Center (BIDMC) in Boston. Dr. Li, assistant professor of medicine at Harvard Medical School, is director of hospital medicine and associate chief of BIDMC’s Division of General Medicine and Primary Care.

References

1.Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB. Role of C. difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology. 1978;75(5):778-782.

2.Poutanen SM, Simor AE. C. difficile-associated diarrhea in adults. CMAJ. 2004;171(1):51-58.

3.Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant C. difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235(3):363-372.

4.Bartlett JG. Narrative review: the new epidemic of C. difficile-associated enteric disease. Ann Intern Med. 2006;145(10):758-764.

5.Teasley DG, Gerding DN, Olson MM, et al. Prospective randomized trial of metronidazole versus vancomycin for C. difficile-associated diarrhea and colitis. Lancet. 1983;2:1043-1046.

6.Wenisch C, Parschalk B, Hasenhündl M, Hirschl AM, Graninger W. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of C. difficile-associated diarrhea. Clin Infect Dis. 1996;22:813-818.

7.Pepin J, Alary M, Valiquette L, et al. Increasing risk of relapse after treatment of C. difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597.

8.Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of C. difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45(3):302-307.