Midlevel providers (physician assistants and nurse practitioners) have long been employed by academic medical centers, predominantly on surgical services, or on medical subspecialty services, where they have typically had a limited scope of practice, focused in a narrowly defined area or set of procedures.17 In contrast, there are relatively few reports of experiences deploying midlevel providers to replace house staff on inpatient general medicine services in academic centers,810 and few studies of the effect of midlevel providers on quality and efficiency of care in the academic setting. Despite this, reductions in house officer duty hours as mandated by the Accreditation Council on Graduate Medical Education (ACGME)11 have resulted in academic centers increasingly using midlevel providers to decrease house staff workload on inpatient services.12, 13 In general, midlevel practitioners on general medicine services have been deployed to: (1) care for a population of patients separate from and in parallel with house staff; this population may be narrowly defined (eg, patients with chest pain) or not; (2) assist with the management of patients cared for by house staff by performing certain tasks (eg, scheduling appointments, discharging patients). Even as midlevel providers become more prevalent on academic general medicine services, the best model of care incorporating them into clinical care remains unclear, and few studies have rigorously examined the care provided on services that use them.

We developed an inpatient general medicine service within a large academic medical center staffed by physician assistants and hospitalists to help our residency program meet ACGME duty hour requirements. We hypothesized that by creating a service that is geographically localized and supervised by full‐time hospitalists, by instituting multidisciplinary rounds, and by investing in the professional development of highly‐skilled physician assistants, we could provide care for medically complex, acutely ill general medicine inpatients with similar quality and efficiency as compared to house staff teams. We report our experience during the first year of implementing the service, and compare quality and efficiency of care on this service with that of our traditional house staff services. We also evaluate the effects of this service on patient satisfaction and self‐reported house staff workload.

PATIENTS AND METHODS

RESULTS

Patient Satisfaction

Patients were similarly satisfied with their care on the PACE service and on the house staff services. In specific areas and globally, percentages of patients satisfied with their physicians and with the discharge process were not different, as measured by the Press‐Ganey survey (Press‐Ganey Associates, South Bend, IN; Figures 1 and 2). The survey distinguishes between attendings and residents, but not physician assistants; therefore, Figure 1 only includes responses to the attending questions. Given the sampling procedure of the Press‐Ganey survey, exact response rates cannot be calculated, but Press‐Ganey reports a response rate of about 40% for the English survey and about 20% for the Spanish survey.

Figure 1

Figure 2

DISCUSSION

As academic centers struggle with developing a workforce to provide patient care no longer provided by residents, questions about the ideal structure of nonhouse staff inpatient services abound. Although solutions to this problem will be determined to some extent by local factors such as institutional culture and resources, some lessons learned in developing such services will be more widely applicable. We found that by implementing a geographically localized, physician assistant‐staffed hospitalist service, we were able to provide care of similar quality and efficiency to that of traditional house staff services, despite inexperienced hospitalists staffing the service and a medical residency program commonly recognized as one of the best in the country. Adjusted total costs were slightly lower on the PACE service, but this difference was small and of borderline statistical significance. Likewise, no significant differences were seen in any of several quality measures or in patient satisfaction.

Our findings add to the available evidence supporting the use of physician assistants on academic general medicine services, and are germane to academic centers facing reductions in house staff availability and seeking alternative models of care for inpatients. Several specific characteristics of the PACE service and the implications of these should be considered:

• 1

  The service accepted all patients, regardless of diagnosis, acuity, or complexity of illness. This was unlike many previously described nonhouse staff services which were more limited in scope, and allowed more flexibility with patient flow. However, in the end, patients on the PACE service did have a modestly lower case mix index and Charlson score, suggesting that, despite a lack of triage guidelines, there was some bias in the triage of admissions, possibly due to a perception that physician assistants should take care of lower complexity patients. If it is desirable to have a similar distribution of higher complexity patients across house staff and nonhouse staff services, extra efforts may be necessary to overcome this perception.

• 2

  The service was geographically regionalized. Geographic regionalization offered many important advantages, especially with regards to communication among staff, nursing, and consultants, and allowed for multidisciplinary rounds. However, it is possible that the modest, but not statistically significant, trend toward an increased LOS seen on the PACE service might be a reflection of geographic admitting (less incentive to discharge since discharging a patient means taking a new admission).

• 3

  The education and professional development of the physician assistants was a priority. Physician assistants had considerable autonomy and responsibility, and rather than being assigned only lower level administrative tasks, performed all aspects of patient care. They also received regular teaching from the hospitalists, attended house staff teaching conferences, and developed nonclinical roles in education and quality improvement. The higher standards expected of the physician assistants were quite possibly a factor in the quality of care delivered, and almost certainly contributed to physician assistant satisfaction and retention.

Our findings contrast with those of Myers et al.,9 who found that a nonteaching service staffed by hospitalists and nurse practitioners had a significantly lower median LOS and hospital charges compared to similar patients on resident‐based services. However, unlike ours, their service cared for a select patient population, and only accepted patients with chest pain at low risk for acute coronary syndrome. Van Rhee et al.10 found that physician assistants on a general medicine service used fewer resources for patients with pneumonia, stroke, and congestive heart failure than resident physicians, and did not exceed the resources used by residents in other diagnoses. The authors did not find a difference in LOS, but did find a significantly higher mortality among patients with pneumonia cared for by physician assistants.

Several limitations should be noted. First, the study was a retrospective analysis of administrative data rather than a randomized trial, and although we employed a standard approach to adjust for a wide range of patient characteristics including severity of illness, there may have been undetected differences in the patient populations studied that may have confounded our results. Second, resident moonlighters admitted patients to the PACE service and, at other times, to the house staff services, and this may have diluted any differences between the groups. However, when we limited our analysis to the subgroup of patients admitted during the day, similar results were obtained, with the exception that the PACE service had a lower rate of 14‐day readmissions, an unexpected finding deserving of further study. Third, the study was conducted in a single academic institution and our findings may not be generalizable to others with different needs and resources; indeed, the costs associated with implementing such a service may be prohibitive for some institutions. Fourth, because of simultaneous changes that were taking place in our residency program, we are unable to accurately assess the impact of the PACE service on resident duty hours. However, resident duty hours did not increase over this time period on the general medicine service, and implementation of the service allowed for redistribution of house staff to other services and positions. Fifth, patient satisfaction data were obtained from responses to the mailed Press‐Ganey survey, to which there is a relatively low response rate. Also, we did not survey providers regarding their satisfaction with the service during the study period. Sixth, the study had limited power to detect clinically important differences in mortality and ICU transfers. Finally, this study is unable to compare this particular model of incorporating midlevel providers into general medical services with other models, only with traditional house staff services.

Future research should focus on determining the most effective and efficient ways to incorporate midlevel providers on academic general medicine services. One important question from the standpoint of house staff training is whether such services should be separate but equal, or should house staff gain experience during residency working with midlevel providers, since they are likely to encounter them in the future whether they stay in academics or not. Different models of care will likely have large implications for the quality and efficiency of patient care, house staff education and satisfaction, and physician assistant job satisfaction and turnover.

In summary, our study demonstrates that a geographically regionalized, multidisciplinary service staffed by hospitalists and physician assistants can be a safe alternative to house staff‐based services for the care of general medicine inpatients in an academic medical center.

Midlevel providers (physician assistants and nurse practitioners) have long been employed by academic medical centers, predominantly on surgical services, or on medical subspecialty services, where they have typically had a limited scope of practice, focused in a narrowly defined area or set of procedures.17 In contrast, there are relatively few reports of experiences deploying midlevel providers to replace house staff on inpatient general medicine services in academic centers,810 and few studies of the effect of midlevel providers on quality and efficiency of care in the academic setting. Despite this, reductions in house officer duty hours as mandated by the Accreditation Council on Graduate Medical Education (ACGME)11 have resulted in academic centers increasingly using midlevel providers to decrease house staff workload on inpatient services.12, 13 In general, midlevel practitioners on general medicine services have been deployed to: (1) care for a population of patients separate from and in parallel with house staff; this population may be narrowly defined (eg, patients with chest pain) or not; (2) assist with the management of patients cared for by house staff by performing certain tasks (eg, scheduling appointments, discharging patients). Even as midlevel providers become more prevalent on academic general medicine services, the best model of care incorporating them into clinical care remains unclear, and few studies have rigorously examined the care provided on services that use them.

We developed an inpatient general medicine service within a large academic medical center staffed by physician assistants and hospitalists to help our residency program meet ACGME duty hour requirements. We hypothesized that by creating a service that is geographically localized and supervised by full‐time hospitalists, by instituting multidisciplinary rounds, and by investing in the professional development of highly‐skilled physician assistants, we could provide care for medically complex, acutely ill general medicine inpatients with similar quality and efficiency as compared to house staff teams. We report our experience during the first year of implementing the service, and compare quality and efficiency of care on this service with that of our traditional house staff services. We also evaluate the effects of this service on patient satisfaction and self‐reported house staff workload.

PATIENTS AND METHODS

RESULTS

Patient Satisfaction

Patients were similarly satisfied with their care on the PACE service and on the house staff services. In specific areas and globally, percentages of patients satisfied with their physicians and with the discharge process were not different, as measured by the Press‐Ganey survey (Press‐Ganey Associates, South Bend, IN; Figures 1 and 2). The survey distinguishes between attendings and residents, but not physician assistants; therefore, Figure 1 only includes responses to the attending questions. Given the sampling procedure of the Press‐Ganey survey, exact response rates cannot be calculated, but Press‐Ganey reports a response rate of about 40% for the English survey and about 20% for the Spanish survey.

Figure 1

Figure 2

DISCUSSION

As academic centers struggle with developing a workforce to provide patient care no longer provided by residents, questions about the ideal structure of nonhouse staff inpatient services abound. Although solutions to this problem will be determined to some extent by local factors such as institutional culture and resources, some lessons learned in developing such services will be more widely applicable. We found that by implementing a geographically localized, physician assistant‐staffed hospitalist service, we were able to provide care of similar quality and efficiency to that of traditional house staff services, despite inexperienced hospitalists staffing the service and a medical residency program commonly recognized as one of the best in the country. Adjusted total costs were slightly lower on the PACE service, but this difference was small and of borderline statistical significance. Likewise, no significant differences were seen in any of several quality measures or in patient satisfaction.

Our findings add to the available evidence supporting the use of physician assistants on academic general medicine services, and are germane to academic centers facing reductions in house staff availability and seeking alternative models of care for inpatients. Several specific characteristics of the PACE service and the implications of these should be considered:

• 1

  The service accepted all patients, regardless of diagnosis, acuity, or complexity of illness. This was unlike many previously described nonhouse staff services which were more limited in scope, and allowed more flexibility with patient flow. However, in the end, patients on the PACE service did have a modestly lower case mix index and Charlson score, suggesting that, despite a lack of triage guidelines, there was some bias in the triage of admissions, possibly due to a perception that physician assistants should take care of lower complexity patients. If it is desirable to have a similar distribution of higher complexity patients across house staff and nonhouse staff services, extra efforts may be necessary to overcome this perception.

• 2

  The service was geographically regionalized. Geographic regionalization offered many important advantages, especially with regards to communication among staff, nursing, and consultants, and allowed for multidisciplinary rounds. However, it is possible that the modest, but not statistically significant, trend toward an increased LOS seen on the PACE service might be a reflection of geographic admitting (less incentive to discharge since discharging a patient means taking a new admission).

• 3

  The education and professional development of the physician assistants was a priority. Physician assistants had considerable autonomy and responsibility, and rather than being assigned only lower level administrative tasks, performed all aspects of patient care. They also received regular teaching from the hospitalists, attended house staff teaching conferences, and developed nonclinical roles in education and quality improvement. The higher standards expected of the physician assistants were quite possibly a factor in the quality of care delivered, and almost certainly contributed to physician assistant satisfaction and retention.

Our findings contrast with those of Myers et al.,9 who found that a nonteaching service staffed by hospitalists and nurse practitioners had a significantly lower median LOS and hospital charges compared to similar patients on resident‐based services. However, unlike ours, their service cared for a select patient population, and only accepted patients with chest pain at low risk for acute coronary syndrome. Van Rhee et al.10 found that physician assistants on a general medicine service used fewer resources for patients with pneumonia, stroke, and congestive heart failure than resident physicians, and did not exceed the resources used by residents in other diagnoses. The authors did not find a difference in LOS, but did find a significantly higher mortality among patients with pneumonia cared for by physician assistants.

Several limitations should be noted. First, the study was a retrospective analysis of administrative data rather than a randomized trial, and although we employed a standard approach to adjust for a wide range of patient characteristics including severity of illness, there may have been undetected differences in the patient populations studied that may have confounded our results. Second, resident moonlighters admitted patients to the PACE service and, at other times, to the house staff services, and this may have diluted any differences between the groups. However, when we limited our analysis to the subgroup of patients admitted during the day, similar results were obtained, with the exception that the PACE service had a lower rate of 14‐day readmissions, an unexpected finding deserving of further study. Third, the study was conducted in a single academic institution and our findings may not be generalizable to others with different needs and resources; indeed, the costs associated with implementing such a service may be prohibitive for some institutions. Fourth, because of simultaneous changes that were taking place in our residency program, we are unable to accurately assess the impact of the PACE service on resident duty hours. However, resident duty hours did not increase over this time period on the general medicine service, and implementation of the service allowed for redistribution of house staff to other services and positions. Fifth, patient satisfaction data were obtained from responses to the mailed Press‐Ganey survey, to which there is a relatively low response rate. Also, we did not survey providers regarding their satisfaction with the service during the study period. Sixth, the study had limited power to detect clinically important differences in mortality and ICU transfers. Finally, this study is unable to compare this particular model of incorporating midlevel providers into general medical services with other models, only with traditional house staff services.

Future research should focus on determining the most effective and efficient ways to incorporate midlevel providers on academic general medicine services. One important question from the standpoint of house staff training is whether such services should be separate but equal, or should house staff gain experience during residency working with midlevel providers, since they are likely to encounter them in the future whether they stay in academics or not. Different models of care will likely have large implications for the quality and efficiency of patient care, house staff education and satisfaction, and physician assistant job satisfaction and turnover.

In summary, our study demonstrates that a geographically regionalized, multidisciplinary service staffed by hospitalists and physician assistants can be a safe alternative to house staff‐based services for the care of general medicine inpatients in an academic medical center.

Midlevel providers (physician assistants and nurse practitioners) have long been employed by academic medical centers, predominantly on surgical services, or on medical subspecialty services, where they have typically had a limited scope of practice, focused in a narrowly defined area or set of procedures.17 In contrast, there are relatively few reports of experiences deploying midlevel providers to replace house staff on inpatient general medicine services in academic centers,810 and few studies of the effect of midlevel providers on quality and efficiency of care in the academic setting. Despite this, reductions in house officer duty hours as mandated by the Accreditation Council on Graduate Medical Education (ACGME)11 have resulted in academic centers increasingly using midlevel providers to decrease house staff workload on inpatient services.12, 13 In general, midlevel practitioners on general medicine services have been deployed to: (1) care for a population of patients separate from and in parallel with house staff; this population may be narrowly defined (eg, patients with chest pain) or not; (2) assist with the management of patients cared for by house staff by performing certain tasks (eg, scheduling appointments, discharging patients). Even as midlevel providers become more prevalent on academic general medicine services, the best model of care incorporating them into clinical care remains unclear, and few studies have rigorously examined the care provided on services that use them.

We developed an inpatient general medicine service within a large academic medical center staffed by physician assistants and hospitalists to help our residency program meet ACGME duty hour requirements. We hypothesized that by creating a service that is geographically localized and supervised by full‐time hospitalists, by instituting multidisciplinary rounds, and by investing in the professional development of highly‐skilled physician assistants, we could provide care for medically complex, acutely ill general medicine inpatients with similar quality and efficiency as compared to house staff teams. We report our experience during the first year of implementing the service, and compare quality and efficiency of care on this service with that of our traditional house staff services. We also evaluate the effects of this service on patient satisfaction and self‐reported house staff workload.

PATIENTS AND METHODS

RESULTS

Patient Satisfaction

Patients were similarly satisfied with their care on the PACE service and on the house staff services. In specific areas and globally, percentages of patients satisfied with their physicians and with the discharge process were not different, as measured by the Press‐Ganey survey (Press‐Ganey Associates, South Bend, IN; Figures 1 and 2). The survey distinguishes between attendings and residents, but not physician assistants; therefore, Figure 1 only includes responses to the attending questions. Given the sampling procedure of the Press‐Ganey survey, exact response rates cannot be calculated, but Press‐Ganey reports a response rate of about 40% for the English survey and about 20% for the Spanish survey.

Figure 1

Figure 2

DISCUSSION

As academic centers struggle with developing a workforce to provide patient care no longer provided by residents, questions about the ideal structure of nonhouse staff inpatient services abound. Although solutions to this problem will be determined to some extent by local factors such as institutional culture and resources, some lessons learned in developing such services will be more widely applicable. We found that by implementing a geographically localized, physician assistant‐staffed hospitalist service, we were able to provide care of similar quality and efficiency to that of traditional house staff services, despite inexperienced hospitalists staffing the service and a medical residency program commonly recognized as one of the best in the country. Adjusted total costs were slightly lower on the PACE service, but this difference was small and of borderline statistical significance. Likewise, no significant differences were seen in any of several quality measures or in patient satisfaction.

Our findings add to the available evidence supporting the use of physician assistants on academic general medicine services, and are germane to academic centers facing reductions in house staff availability and seeking alternative models of care for inpatients. Several specific characteristics of the PACE service and the implications of these should be considered:

• 1

  The service accepted all patients, regardless of diagnosis, acuity, or complexity of illness. This was unlike many previously described nonhouse staff services which were more limited in scope, and allowed more flexibility with patient flow. However, in the end, patients on the PACE service did have a modestly lower case mix index and Charlson score, suggesting that, despite a lack of triage guidelines, there was some bias in the triage of admissions, possibly due to a perception that physician assistants should take care of lower complexity patients. If it is desirable to have a similar distribution of higher complexity patients across house staff and nonhouse staff services, extra efforts may be necessary to overcome this perception.

• 2

  The service was geographically regionalized. Geographic regionalization offered many important advantages, especially with regards to communication among staff, nursing, and consultants, and allowed for multidisciplinary rounds. However, it is possible that the modest, but not statistically significant, trend toward an increased LOS seen on the PACE service might be a reflection of geographic admitting (less incentive to discharge since discharging a patient means taking a new admission).

• 3

  The education and professional development of the physician assistants was a priority. Physician assistants had considerable autonomy and responsibility, and rather than being assigned only lower level administrative tasks, performed all aspects of patient care. They also received regular teaching from the hospitalists, attended house staff teaching conferences, and developed nonclinical roles in education and quality improvement. The higher standards expected of the physician assistants were quite possibly a factor in the quality of care delivered, and almost certainly contributed to physician assistant satisfaction and retention.

Our findings contrast with those of Myers et al.,9 who found that a nonteaching service staffed by hospitalists and nurse practitioners had a significantly lower median LOS and hospital charges compared to similar patients on resident‐based services. However, unlike ours, their service cared for a select patient population, and only accepted patients with chest pain at low risk for acute coronary syndrome. Van Rhee et al.10 found that physician assistants on a general medicine service used fewer resources for patients with pneumonia, stroke, and congestive heart failure than resident physicians, and did not exceed the resources used by residents in other diagnoses. The authors did not find a difference in LOS, but did find a significantly higher mortality among patients with pneumonia cared for by physician assistants.

Several limitations should be noted. First, the study was a retrospective analysis of administrative data rather than a randomized trial, and although we employed a standard approach to adjust for a wide range of patient characteristics including severity of illness, there may have been undetected differences in the patient populations studied that may have confounded our results. Second, resident moonlighters admitted patients to the PACE service and, at other times, to the house staff services, and this may have diluted any differences between the groups. However, when we limited our analysis to the subgroup of patients admitted during the day, similar results were obtained, with the exception that the PACE service had a lower rate of 14‐day readmissions, an unexpected finding deserving of further study. Third, the study was conducted in a single academic institution and our findings may not be generalizable to others with different needs and resources; indeed, the costs associated with implementing such a service may be prohibitive for some institutions. Fourth, because of simultaneous changes that were taking place in our residency program, we are unable to accurately assess the impact of the PACE service on resident duty hours. However, resident duty hours did not increase over this time period on the general medicine service, and implementation of the service allowed for redistribution of house staff to other services and positions. Fifth, patient satisfaction data were obtained from responses to the mailed Press‐Ganey survey, to which there is a relatively low response rate. Also, we did not survey providers regarding their satisfaction with the service during the study period. Sixth, the study had limited power to detect clinically important differences in mortality and ICU transfers. Finally, this study is unable to compare this particular model of incorporating midlevel providers into general medical services with other models, only with traditional house staff services.

Future research should focus on determining the most effective and efficient ways to incorporate midlevel providers on academic general medicine services. One important question from the standpoint of house staff training is whether such services should be separate but equal, or should house staff gain experience during residency working with midlevel providers, since they are likely to encounter them in the future whether they stay in academics or not. Different models of care will likely have large implications for the quality and efficiency of patient care, house staff education and satisfaction, and physician assistant job satisfaction and turnover.

In summary, our study demonstrates that a geographically regionalized, multidisciplinary service staffed by hospitalists and physician assistants can be a safe alternative to house staff‐based services for the care of general medicine inpatients in an academic medical center.

A30‐year‐old woman was referred for evaluation of chest pain, palpitations, and exercise intolerance. She had been previously healthy, active, and physically fit. Five months prior to our evaluation, she had an elective C5C6 cervical spine discectomy with interbody allograft fusion for a chronic neck injury that occurred 11 years ago during gymnastics. Two weeks after spine surgery, the patient developed numbness and tingling of her left thumb and palm that occurred with exertion or exposure to cold and subsided with rest. These episodes increased in frequency and intensity and after 1 week became associated with sharp, occasionally stabbing chest pain that radiated to the left arm. On one occasion, the patient had an episode of exertional chest pain with prolonged left arm cyanosis. Emergent left upper extremity angiography revealed normal great vessel anatomy with spasm of the radial artery and collateral ulnar flow. The patient was diagnosed with Raynaud's phenomenon and was started on nifedipine. A subsequent rheumatologic evaluation was unrevealing, and the patient was empirically switched to amlodipine with no improvement in symptoms.

This otherwise very healthy 30‐year‐old developed a multitude of symptoms. The patient's chest pain is atypical and in a young woman is unlikely to signify atherosclerotic coronary disease, but it should not be entirely disregarded. Vasospasm triggered by exposure to cold does raise suspicion for Raynaud's phenomenon, which is not uncommon in this demographic. However, this presentation is quite unusual because the vasospasm was limited to one vascular distribution of one extremity. Associated coronary vasospasm could explain the other symptoms, although coronary spasm is generally not associated with Raynaud's phenomenon. Vasculitis may also affect the pulmonary vasculature, leading to pulmonary hypertension and exercise intolerance. The temporal association with her spine surgery is intriguing but of unclear significance.

The patient continued to have frequent exertional episodes of sharp precordial chest pain radiating to her left arm that were accompanied by dyspnea and left upper extremity symptoms despite amlodipine therapy. These now occurred with limited activity when she walked 1 to 2 blocks uphill. Over the previous 2 months, she had also noticed palpitations occurring reliably with exercise that were relieved with 15 to 20 min of rest. With prolonged episodes, she reported dizziness, nausea, and blurry vision that improved with lying down. She twice had syncope with these symptoms. She noted lower extremity edema while taking calcium channel blockers, but this had resolved after discontinuation of the drugs.

The patient's past medical history included several high‐school orthopedic injuries. She had 2 kidney stones at ages 18 and 23 and had an appendectomy at age 28. Her only medication was an oral contraceptive, and she had discontinued the amlodipine. She denied the use of tobacco, alcohol, herbal medications, or illicit substances. There was no family history of sudden death or heart disease.

Palpitations in a 30‐year‐old woman may signify a cardiac arrhythmia. Paroxysmal supraventricular arrhythmias, such as atrioventricular nodal reentrant tachycardia, atrial tachycardia, and atrial fibrillation, are well described in the young. Ventricular tachycardia (VT) is another possible cause and could be idiopathic or related to occult structural heart disease. Young patients typically tolerate lone arrhythmias quite well, and her failure to do so raises suspicion for concomitant structural heart disease. Her palpitations may be from appropriate sinus tachycardia, which could be compensatory because of inadequate cardiac output reserve, which in turn could be caused by valvular disease, congenital heart disease, or ventricular dysfunction. The exertional chest pain is worrisome for ischemia. Pulmonary hypertension, severe ventricular hypertrophy, or congenital anomalies of the coronary circulation could lead to subendocardial myocardial ischemia with exertion, resulting in angina, dyspnea, and arrhythmias. However, the patient also experiences exertional palpitations without chest pain, which may signify an exertional tachyarrhythmia possibly mediated by catecholamines. Based solely on the history, the differential diagnosis remains broad.

On physical examination, the patient was a fit, thin, healthy woman. Her blood pressure was 120/70 mm Hg supine in both arms and 115/75 mm Hg standing; her pulse was 85 supine and 110 standing, Oxygen saturation was 100% on room air. A cardiac exam revealed a normal jugular venous pressure, normal point of maximal impulse, regular rhythm with occasional ectopy, normal S1, and physiologically split S2 without extra heart sounds or murmurs. The right ventricular impulse was faintly palpable at the left sternal border. Head, neck, chest, abdominal, musculoskeletal, neurologic, extremity, and peripheral pulse examinations were normal.

Laboratory data showed a normal complete blood count and normal chemistries. Serum tests for hepatitis C antibody, cardiolipin antibody, rheumatoid factor, cryoglobulins, and anti‐nuclear antibody were negative. The erythrocyte sedimentation rate and thyroid stimulating hormone levels were within normal limits. An electrocardiogram (ECG) demonstrated a normal sinus rhythm with frequent premature ventricular complexes (PVCs) and normal axis and intervals. (Figure 1). The PR segment was normal and without preexcitation. A prior ECG from 3 months ago was similar with ventricular trigeminy.

Figure 1

Her unremarkable cardiac examination does not favor structural or valvular heart disease, and there are no obvious stigmata of vasculitis. She did become mildly tachycardic upon standing, and this raises the possibility of orthostatic tachycardia. A comprehensive rheumatologic panel revealed no evidence of autoimmune disease or vasculitis, and the clinical constellation is not consistent with primary or secondary Raynaud's disease. The ECG demonstrates frequent monomorphic PVCs complexes with a left bundle branch block pattern and an inferior axis. This pattern suggests that the PVCs arise from the right ventricular outflow tract. Idiopathic right ventricular outflow tract VT and arrhythmogenic right ventricular dysplasia must be considered as a cause of exertional or catecholamine‐mediated tachycardia. The normal ECG argues against arrhythmogenic right ventricular dysplasia, in which patients typically have incomplete or complete right bundle branch block, right precordial T wave abnormalities, and occasionally epsilon waves. Her QT interval is normal, but excluding long‐QT syndrome with a single ECG has poor sensitivity. The next critical step is to document her cardiac rhythm during symptoms and to exclude malignant arrhythmias.

An event recorder and exercise echocardiogram were ordered. While the patient was wearing her event recorder, she had 4 episodes of exertional syncope while hiking and successfully triggered event recording before losing consciousness. She had chest pain and left arm pain after regaining consciousness. The patient came to the emergency room for evaluation. Her blood pressure was 116/80 mm Hg supine and 112/70 mm Hg seated. Her heart rate increased from 82 supine to 132 seated. The physical examination was unremarkable. ECG showed sinus rhythm with frequent PVCs. Troponin‐I measurements 10 hours apart were 0.7 and 0.3 g/L (normal 1.1), with normal creatinine kinase and creatinine kinase MB fractions. Interrogation of the event recorder revealed multiple episodes of a narrow complex tachycardia with rates up to 180 bpm that correlated with symptoms (Figure 2). There were no episodes of wide complex tachycardia.

Figure 2

The patient was not hypotensive in the emergency room, but she had evidence of a marked orthostatic tachycardia. The minimal but significant troponin elevations are also troubling. Although her clinical picture is not consistent with an acute coronary syndrome, I am concerned about other mechanisms of myocardial ischemia or injury, such as a coronary anomaly or subendocardial ischemia from globally reduced myocardial perfusion. The presence of event recorder data from her syncopal events was fortuitous and revealed a supraventricular tachycardia. The arrhythmia was gradual in onset and resolution and had no triggers, such as premature atrial or ventricular complexes, which could suggest reentrant arrhythmias. The P wave morphology was also unchanged, and this argues against an atrial tachycardia. These findings are consistent with sinus tachycardia, which was notably out of proportion to her workload. This arrhythmia may be the primary cause of syncope, such as in inappropriate sinus tachycardia, or it may be a compensatory mechanism. Tachycardia from coronary vasospasm is often preceded by ST segment changes, which are not seen here. Although the event recorder had no episodes of VT, the patient's persistent frequent PVCs are still of concern. I would obtain an echocardiogram to exclude structural heart disease and an exercise test to exclude exertional VT. Finally, coronary angiography may be helpful in excluding congenital anomalies.

The patient was admitted for evaluation. An exercise treadmill test was performed, and the patient exercised 20 min on the standard Bruce protocol with a peak heart rate of 180 bpm. The test was notable for a premature rise in heart rate (in stage 1) without a rise in blood pressure. There were no symptoms or ST/T wave changes. Transthoracic echocardiogram showed normal left ventricular size and function with normal anatomy, valves, and hemodynamics. Coronary angiography showed a right dominant system with normal anatomy and no atherosclerotic disease.

Ventricular arrhythmias could not be elicited with exercise. Her high exercise tolerance virtually excluded hemodynamically significant structural or valvular disease, and this was confirmed by the echocardiogram. Coronary angiography excluded coronary anomalies and myocardial bridging. The most intriguing finding is the rise in the patient's heart rate out of proportion to the workload. This, along with her orthostatic tachycardia, raises the issue of inappropriate sinus tachycardia or postural orthostatic tachycardia syndrome (POTS). Carotid hypersensitivity is also a possibility. The patient was hiking when she fainted, and even light pressure on the patient's neck with head turning or from a camera strap, for example, could produce syncope. Although carotid hypersensitivity usually results in sinus bradycardia and AV block, it may be followed by reflex tachycardia, which was seen in this patient's event recordings. I would perform a tilt‐table test with carotid massage to make the diagnosis.

Tilt‐table testing was performed (Figure 3). Her supine blood pressure was 128/68 mm Hg, and her heart rate was 72 bpm with no change during the 10‐min supine period. Upon elevation to a 70‐degree tilt, the patient had an immediate increase in her heart rate to 160 bpm with a blood pressure nadir of 109/58 mm Hg and symptoms of palpitations, dizziness, dyspnea, chest pain, blurry vision, and nausea. Her peak heart rate was 172 bpm, and her peak blood pressure was 122/72 mm Hg. Vital signs did not change in response to carotid sinus massage in the supine or upright positions.

Figure 3

The tilt‐table test has 3 notable findings. First, her heart rate increased rapidly with tilt and decreased rapidly in supine recovery. Second, her usual symptoms started immediately after tilt and quickly resolved in recovery when vital signs returned to baseline. Finally, there was only a modest drop in blood pressure. These findings are classic for POTS. POTS is defined as symptomatic orthostasis with a heart rate increase of 30 bpm or a heart rate of 120 bpm. The physiologic lesions found in the syndrome are heterogeneous, but they all lead to a failure of orthostatic compensation. In POTS, the tachycardia is a reflex secondary to hypotension (baroreceptor reflex) or reduced preload (cardiac mechanoreceptors), in contrast to inappropriate sinus tachycardia. Interestingly, blood pressure is usually preserved until the final moments preceding syncope, when venous return further declines, tachycardia decreases the diastolic filling time and stroke volume, and mean arterial pressure sharply falls.

The patient was started on labetalol (200 mg 3 times daily), and her symptoms worsened. She also developed nausea and constipation. Midodrine and pindolol were also tried without success. She was then switched to fludrocortisone, salt supplementation, and leg support stockings with dramatic improvement.

COMMENTARY

In 1871, DeCosta1 published a report on the irritable heart, noting an affliction of extreme fatigue and exercise intolerance that occurred suddenly and without obvious cause. Subsequently, the terms vasoregulatory asthenia and neurocirculatory asthenia were used to link cardiovascular symptoms to impaired regulation of peripheral blood flow.2, 3 The term POTS was first used in 1982 to describe a single patient with postural tachycardia without hypotension and palpitations, weakness, abdominal pain, and presyncope.4

POTS is one of several disorders of autonomic control associated with orthostatic intolerance. The criteria for diagnosis are listed in Table 1. POTS typically occurs in women between the ages of 15 and 50 but tends to present during adolescence or young adulthood. The physiology has only recently been elucidated. When a person stands, 500 cc of the total blood volume is displaced to the dependent extremities and inferior mesenteric vessels.5 Normally, orthostatic stabilization occurs in less than 1 minute via 3 mechanisms: baroreceptor input, sympathetic reflex tachycardia and vasoconstriction, and enhanced venous return via the pumping action of skeletal muscles and venoconstriction. In POTS, there is a failure of at least one of these mechanisms, leading to decreased venous return, a 40% reduction in stroke volume, and cerebral hypoperfusion.6

POTS is divided into 2 major subtypes on the basis of pathophysiology.5, 7 The partial dysautonomic form is the most common and the type that this patient most likely had. In this form, the development of an acquired peripheral autonomic neuropathy results in a failure of sympathetic venoconstriction, which leads to excessive venous pooling in the lower extremities and splanchnic circulation.8, 9 Failure to mobilize this venous reservoir upon standing leads to excessive orthostatic tachycardia secondary to a marked reduction in stroke volume. Peripheral arterial vasoconstriction is generally preserved, which is why midodrine, an arterial vasoconstrictor, did not improve symptoms. The labetalol may have further exacerbated peripheral pooling because of its alpha‐adrenergic blocking properties. Because total plasma volume is decreased and plasma renin activity is inappropriately low,10 volume expanders, including salt, low‐dose steroids, and fluids, can attenuate symptoms.11 The extrinsic venous compression from leg and abdominal support stockings may also dramatically reduce venous pooling.

In the less common hyperadrenergic form of POTS, patients may have orthostatic hypertension, tremulousness, cold, sweaty extremities, and anxiety due to an exaggerated response to beta‐adrenergic stimulation.7 The excessive sympathetic activity, which is poorly modulated by baroreflex activity, may be due to impaired mechanisms of norepinephrine reuptake by sympathetic ganglia.12 Consequently, serum norepinephrine levels are markedly elevated (>600 pg/mL).5

In adults, the presence of a POTS trigger is common and is usually an antecedent viral illness. Antibodies to the ganglionic acetylcholine receptor have been found in a subset of POTS patients,13 and this may suggest an idiopathic or postinflammatory autoimmune mechanism.14 This patient's presentation is unique because her symptoms developed after C5C6 spine surgery. The cervical spinal cord and sympathetic ganglia are dense with nerves involved in autonomic cardiovascular control, and damage to these fibers could explain the patient's physiology and symptoms. Among these, the descending vasomotor pathways traverse through the C5C8 area to innervate the splanchnic and leg venous circulation, receiving input from the heart along the way.15 The pattern of numbness and tingling fits the C5/C6 dermatomal distribution, as does the innervation of the radial artery. The frequent PVCs with a left bundle branch block pattern and inferior axis appear to arise from the right ventricular outflow tract and may be associated with regional sympathetic denervation, which has been described in idiopathic ventricular arrhythmias.16 POTS has been anecdotally reported after neck injury from motor vehicle accidents (whiplash), which is also thought to be related to cervical sympathetic nerve damage (B.P. Grubb, personal communication, 2005). Most cases of triggered POTS improve spontaneously after months to years, but this patient's prognosis remains uncertain because of the presumed mechanical disruption of the autonomic nerve fibers at the time of surgery.

This case demonstrates the complexities of arriving at a unifying diagnosis in the setting of a constellation of nonspecific symptoms and findings, some of which even suggest life‐threatening conditions. Because young women are primarily affected, symptoms of POTS can be mistakenly attributed to anxiety or other nonphysiological factors. A systematic approach excluded life‐threatening causes, including primary ventricular arrhythmias, coronary vasospasm, and coronary anomalies. The investigations narrowed the differential diagnosis, and the tilt‐table test confirmed POTS. Because the cardiac and circulatory dysautonomias encompass an array of distinct physiologic processes, understanding the patient's mechanism is critical to her management. The only effective therapies were those that counteracted venous pooling and improved venous return.

A30‐year‐old woman was referred for evaluation of chest pain, palpitations, and exercise intolerance. She had been previously healthy, active, and physically fit. Five months prior to our evaluation, she had an elective C5C6 cervical spine discectomy with interbody allograft fusion for a chronic neck injury that occurred 11 years ago during gymnastics. Two weeks after spine surgery, the patient developed numbness and tingling of her left thumb and palm that occurred with exertion or exposure to cold and subsided with rest. These episodes increased in frequency and intensity and after 1 week became associated with sharp, occasionally stabbing chest pain that radiated to the left arm. On one occasion, the patient had an episode of exertional chest pain with prolonged left arm cyanosis. Emergent left upper extremity angiography revealed normal great vessel anatomy with spasm of the radial artery and collateral ulnar flow. The patient was diagnosed with Raynaud's phenomenon and was started on nifedipine. A subsequent rheumatologic evaluation was unrevealing, and the patient was empirically switched to amlodipine with no improvement in symptoms.

This otherwise very healthy 30‐year‐old developed a multitude of symptoms. The patient's chest pain is atypical and in a young woman is unlikely to signify atherosclerotic coronary disease, but it should not be entirely disregarded. Vasospasm triggered by exposure to cold does raise suspicion for Raynaud's phenomenon, which is not uncommon in this demographic. However, this presentation is quite unusual because the vasospasm was limited to one vascular distribution of one extremity. Associated coronary vasospasm could explain the other symptoms, although coronary spasm is generally not associated with Raynaud's phenomenon. Vasculitis may also affect the pulmonary vasculature, leading to pulmonary hypertension and exercise intolerance. The temporal association with her spine surgery is intriguing but of unclear significance.

The patient continued to have frequent exertional episodes of sharp precordial chest pain radiating to her left arm that were accompanied by dyspnea and left upper extremity symptoms despite amlodipine therapy. These now occurred with limited activity when she walked 1 to 2 blocks uphill. Over the previous 2 months, she had also noticed palpitations occurring reliably with exercise that were relieved with 15 to 20 min of rest. With prolonged episodes, she reported dizziness, nausea, and blurry vision that improved with lying down. She twice had syncope with these symptoms. She noted lower extremity edema while taking calcium channel blockers, but this had resolved after discontinuation of the drugs.

The patient's past medical history included several high‐school orthopedic injuries. She had 2 kidney stones at ages 18 and 23 and had an appendectomy at age 28. Her only medication was an oral contraceptive, and she had discontinued the amlodipine. She denied the use of tobacco, alcohol, herbal medications, or illicit substances. There was no family history of sudden death or heart disease.

Palpitations in a 30‐year‐old woman may signify a cardiac arrhythmia. Paroxysmal supraventricular arrhythmias, such as atrioventricular nodal reentrant tachycardia, atrial tachycardia, and atrial fibrillation, are well described in the young. Ventricular tachycardia (VT) is another possible cause and could be idiopathic or related to occult structural heart disease. Young patients typically tolerate lone arrhythmias quite well, and her failure to do so raises suspicion for concomitant structural heart disease. Her palpitations may be from appropriate sinus tachycardia, which could be compensatory because of inadequate cardiac output reserve, which in turn could be caused by valvular disease, congenital heart disease, or ventricular dysfunction. The exertional chest pain is worrisome for ischemia. Pulmonary hypertension, severe ventricular hypertrophy, or congenital anomalies of the coronary circulation could lead to subendocardial myocardial ischemia with exertion, resulting in angina, dyspnea, and arrhythmias. However, the patient also experiences exertional palpitations without chest pain, which may signify an exertional tachyarrhythmia possibly mediated by catecholamines. Based solely on the history, the differential diagnosis remains broad.

On physical examination, the patient was a fit, thin, healthy woman. Her blood pressure was 120/70 mm Hg supine in both arms and 115/75 mm Hg standing; her pulse was 85 supine and 110 standing, Oxygen saturation was 100% on room air. A cardiac exam revealed a normal jugular venous pressure, normal point of maximal impulse, regular rhythm with occasional ectopy, normal S1, and physiologically split S2 without extra heart sounds or murmurs. The right ventricular impulse was faintly palpable at the left sternal border. Head, neck, chest, abdominal, musculoskeletal, neurologic, extremity, and peripheral pulse examinations were normal.

Laboratory data showed a normal complete blood count and normal chemistries. Serum tests for hepatitis C antibody, cardiolipin antibody, rheumatoid factor, cryoglobulins, and anti‐nuclear antibody were negative. The erythrocyte sedimentation rate and thyroid stimulating hormone levels were within normal limits. An electrocardiogram (ECG) demonstrated a normal sinus rhythm with frequent premature ventricular complexes (PVCs) and normal axis and intervals. (Figure 1). The PR segment was normal and without preexcitation. A prior ECG from 3 months ago was similar with ventricular trigeminy.

Figure 1

Her unremarkable cardiac examination does not favor structural or valvular heart disease, and there are no obvious stigmata of vasculitis. She did become mildly tachycardic upon standing, and this raises the possibility of orthostatic tachycardia. A comprehensive rheumatologic panel revealed no evidence of autoimmune disease or vasculitis, and the clinical constellation is not consistent with primary or secondary Raynaud's disease. The ECG demonstrates frequent monomorphic PVCs complexes with a left bundle branch block pattern and an inferior axis. This pattern suggests that the PVCs arise from the right ventricular outflow tract. Idiopathic right ventricular outflow tract VT and arrhythmogenic right ventricular dysplasia must be considered as a cause of exertional or catecholamine‐mediated tachycardia. The normal ECG argues against arrhythmogenic right ventricular dysplasia, in which patients typically have incomplete or complete right bundle branch block, right precordial T wave abnormalities, and occasionally epsilon waves. Her QT interval is normal, but excluding long‐QT syndrome with a single ECG has poor sensitivity. The next critical step is to document her cardiac rhythm during symptoms and to exclude malignant arrhythmias.

An event recorder and exercise echocardiogram were ordered. While the patient was wearing her event recorder, she had 4 episodes of exertional syncope while hiking and successfully triggered event recording before losing consciousness. She had chest pain and left arm pain after regaining consciousness. The patient came to the emergency room for evaluation. Her blood pressure was 116/80 mm Hg supine and 112/70 mm Hg seated. Her heart rate increased from 82 supine to 132 seated. The physical examination was unremarkable. ECG showed sinus rhythm with frequent PVCs. Troponin‐I measurements 10 hours apart were 0.7 and 0.3 g/L (normal 1.1), with normal creatinine kinase and creatinine kinase MB fractions. Interrogation of the event recorder revealed multiple episodes of a narrow complex tachycardia with rates up to 180 bpm that correlated with symptoms (Figure 2). There were no episodes of wide complex tachycardia.

Figure 2

The patient was not hypotensive in the emergency room, but she had evidence of a marked orthostatic tachycardia. The minimal but significant troponin elevations are also troubling. Although her clinical picture is not consistent with an acute coronary syndrome, I am concerned about other mechanisms of myocardial ischemia or injury, such as a coronary anomaly or subendocardial ischemia from globally reduced myocardial perfusion. The presence of event recorder data from her syncopal events was fortuitous and revealed a supraventricular tachycardia. The arrhythmia was gradual in onset and resolution and had no triggers, such as premature atrial or ventricular complexes, which could suggest reentrant arrhythmias. The P wave morphology was also unchanged, and this argues against an atrial tachycardia. These findings are consistent with sinus tachycardia, which was notably out of proportion to her workload. This arrhythmia may be the primary cause of syncope, such as in inappropriate sinus tachycardia, or it may be a compensatory mechanism. Tachycardia from coronary vasospasm is often preceded by ST segment changes, which are not seen here. Although the event recorder had no episodes of VT, the patient's persistent frequent PVCs are still of concern. I would obtain an echocardiogram to exclude structural heart disease and an exercise test to exclude exertional VT. Finally, coronary angiography may be helpful in excluding congenital anomalies.

The patient was admitted for evaluation. An exercise treadmill test was performed, and the patient exercised 20 min on the standard Bruce protocol with a peak heart rate of 180 bpm. The test was notable for a premature rise in heart rate (in stage 1) without a rise in blood pressure. There were no symptoms or ST/T wave changes. Transthoracic echocardiogram showed normal left ventricular size and function with normal anatomy, valves, and hemodynamics. Coronary angiography showed a right dominant system with normal anatomy and no atherosclerotic disease.

Ventricular arrhythmias could not be elicited with exercise. Her high exercise tolerance virtually excluded hemodynamically significant structural or valvular disease, and this was confirmed by the echocardiogram. Coronary angiography excluded coronary anomalies and myocardial bridging. The most intriguing finding is the rise in the patient's heart rate out of proportion to the workload. This, along with her orthostatic tachycardia, raises the issue of inappropriate sinus tachycardia or postural orthostatic tachycardia syndrome (POTS). Carotid hypersensitivity is also a possibility. The patient was hiking when she fainted, and even light pressure on the patient's neck with head turning or from a camera strap, for example, could produce syncope. Although carotid hypersensitivity usually results in sinus bradycardia and AV block, it may be followed by reflex tachycardia, which was seen in this patient's event recordings. I would perform a tilt‐table test with carotid massage to make the diagnosis.

Tilt‐table testing was performed (Figure 3). Her supine blood pressure was 128/68 mm Hg, and her heart rate was 72 bpm with no change during the 10‐min supine period. Upon elevation to a 70‐degree tilt, the patient had an immediate increase in her heart rate to 160 bpm with a blood pressure nadir of 109/58 mm Hg and symptoms of palpitations, dizziness, dyspnea, chest pain, blurry vision, and nausea. Her peak heart rate was 172 bpm, and her peak blood pressure was 122/72 mm Hg. Vital signs did not change in response to carotid sinus massage in the supine or upright positions.

Figure 3

The tilt‐table test has 3 notable findings. First, her heart rate increased rapidly with tilt and decreased rapidly in supine recovery. Second, her usual symptoms started immediately after tilt and quickly resolved in recovery when vital signs returned to baseline. Finally, there was only a modest drop in blood pressure. These findings are classic for POTS. POTS is defined as symptomatic orthostasis with a heart rate increase of 30 bpm or a heart rate of 120 bpm. The physiologic lesions found in the syndrome are heterogeneous, but they all lead to a failure of orthostatic compensation. In POTS, the tachycardia is a reflex secondary to hypotension (baroreceptor reflex) or reduced preload (cardiac mechanoreceptors), in contrast to inappropriate sinus tachycardia. Interestingly, blood pressure is usually preserved until the final moments preceding syncope, when venous return further declines, tachycardia decreases the diastolic filling time and stroke volume, and mean arterial pressure sharply falls.

The patient was started on labetalol (200 mg 3 times daily), and her symptoms worsened. She also developed nausea and constipation. Midodrine and pindolol were also tried without success. She was then switched to fludrocortisone, salt supplementation, and leg support stockings with dramatic improvement.

COMMENTARY

In 1871, DeCosta1 published a report on the irritable heart, noting an affliction of extreme fatigue and exercise intolerance that occurred suddenly and without obvious cause. Subsequently, the terms vasoregulatory asthenia and neurocirculatory asthenia were used to link cardiovascular symptoms to impaired regulation of peripheral blood flow.2, 3 The term POTS was first used in 1982 to describe a single patient with postural tachycardia without hypotension and palpitations, weakness, abdominal pain, and presyncope.4

POTS is one of several disorders of autonomic control associated with orthostatic intolerance. The criteria for diagnosis are listed in Table 1. POTS typically occurs in women between the ages of 15 and 50 but tends to present during adolescence or young adulthood. The physiology has only recently been elucidated. When a person stands, 500 cc of the total blood volume is displaced to the dependent extremities and inferior mesenteric vessels.5 Normally, orthostatic stabilization occurs in less than 1 minute via 3 mechanisms: baroreceptor input, sympathetic reflex tachycardia and vasoconstriction, and enhanced venous return via the pumping action of skeletal muscles and venoconstriction. In POTS, there is a failure of at least one of these mechanisms, leading to decreased venous return, a 40% reduction in stroke volume, and cerebral hypoperfusion.6

POTS is divided into 2 major subtypes on the basis of pathophysiology.5, 7 The partial dysautonomic form is the most common and the type that this patient most likely had. In this form, the development of an acquired peripheral autonomic neuropathy results in a failure of sympathetic venoconstriction, which leads to excessive venous pooling in the lower extremities and splanchnic circulation.8, 9 Failure to mobilize this venous reservoir upon standing leads to excessive orthostatic tachycardia secondary to a marked reduction in stroke volume. Peripheral arterial vasoconstriction is generally preserved, which is why midodrine, an arterial vasoconstrictor, did not improve symptoms. The labetalol may have further exacerbated peripheral pooling because of its alpha‐adrenergic blocking properties. Because total plasma volume is decreased and plasma renin activity is inappropriately low,10 volume expanders, including salt, low‐dose steroids, and fluids, can attenuate symptoms.11 The extrinsic venous compression from leg and abdominal support stockings may also dramatically reduce venous pooling.

In the less common hyperadrenergic form of POTS, patients may have orthostatic hypertension, tremulousness, cold, sweaty extremities, and anxiety due to an exaggerated response to beta‐adrenergic stimulation.7 The excessive sympathetic activity, which is poorly modulated by baroreflex activity, may be due to impaired mechanisms of norepinephrine reuptake by sympathetic ganglia.12 Consequently, serum norepinephrine levels are markedly elevated (>600 pg/mL).5

In adults, the presence of a POTS trigger is common and is usually an antecedent viral illness. Antibodies to the ganglionic acetylcholine receptor have been found in a subset of POTS patients,13 and this may suggest an idiopathic or postinflammatory autoimmune mechanism.14 This patient's presentation is unique because her symptoms developed after C5C6 spine surgery. The cervical spinal cord and sympathetic ganglia are dense with nerves involved in autonomic cardiovascular control, and damage to these fibers could explain the patient's physiology and symptoms. Among these, the descending vasomotor pathways traverse through the C5C8 area to innervate the splanchnic and leg venous circulation, receiving input from the heart along the way.15 The pattern of numbness and tingling fits the C5/C6 dermatomal distribution, as does the innervation of the radial artery. The frequent PVCs with a left bundle branch block pattern and inferior axis appear to arise from the right ventricular outflow tract and may be associated with regional sympathetic denervation, which has been described in idiopathic ventricular arrhythmias.16 POTS has been anecdotally reported after neck injury from motor vehicle accidents (whiplash), which is also thought to be related to cervical sympathetic nerve damage (B.P. Grubb, personal communication, 2005). Most cases of triggered POTS improve spontaneously after months to years, but this patient's prognosis remains uncertain because of the presumed mechanical disruption of the autonomic nerve fibers at the time of surgery.

This case demonstrates the complexities of arriving at a unifying diagnosis in the setting of a constellation of nonspecific symptoms and findings, some of which even suggest life‐threatening conditions. Because young women are primarily affected, symptoms of POTS can be mistakenly attributed to anxiety or other nonphysiological factors. A systematic approach excluded life‐threatening causes, including primary ventricular arrhythmias, coronary vasospasm, and coronary anomalies. The investigations narrowed the differential diagnosis, and the tilt‐table test confirmed POTS. Because the cardiac and circulatory dysautonomias encompass an array of distinct physiologic processes, understanding the patient's mechanism is critical to her management. The only effective therapies were those that counteracted venous pooling and improved venous return.

A30‐year‐old woman was referred for evaluation of chest pain, palpitations, and exercise intolerance. She had been previously healthy, active, and physically fit. Five months prior to our evaluation, she had an elective C5C6 cervical spine discectomy with interbody allograft fusion for a chronic neck injury that occurred 11 years ago during gymnastics. Two weeks after spine surgery, the patient developed numbness and tingling of her left thumb and palm that occurred with exertion or exposure to cold and subsided with rest. These episodes increased in frequency and intensity and after 1 week became associated with sharp, occasionally stabbing chest pain that radiated to the left arm. On one occasion, the patient had an episode of exertional chest pain with prolonged left arm cyanosis. Emergent left upper extremity angiography revealed normal great vessel anatomy with spasm of the radial artery and collateral ulnar flow. The patient was diagnosed with Raynaud's phenomenon and was started on nifedipine. A subsequent rheumatologic evaluation was unrevealing, and the patient was empirically switched to amlodipine with no improvement in symptoms.

This otherwise very healthy 30‐year‐old developed a multitude of symptoms. The patient's chest pain is atypical and in a young woman is unlikely to signify atherosclerotic coronary disease, but it should not be entirely disregarded. Vasospasm triggered by exposure to cold does raise suspicion for Raynaud's phenomenon, which is not uncommon in this demographic. However, this presentation is quite unusual because the vasospasm was limited to one vascular distribution of one extremity. Associated coronary vasospasm could explain the other symptoms, although coronary spasm is generally not associated with Raynaud's phenomenon. Vasculitis may also affect the pulmonary vasculature, leading to pulmonary hypertension and exercise intolerance. The temporal association with her spine surgery is intriguing but of unclear significance.

The patient continued to have frequent exertional episodes of sharp precordial chest pain radiating to her left arm that were accompanied by dyspnea and left upper extremity symptoms despite amlodipine therapy. These now occurred with limited activity when she walked 1 to 2 blocks uphill. Over the previous 2 months, she had also noticed palpitations occurring reliably with exercise that were relieved with 15 to 20 min of rest. With prolonged episodes, she reported dizziness, nausea, and blurry vision that improved with lying down. She twice had syncope with these symptoms. She noted lower extremity edema while taking calcium channel blockers, but this had resolved after discontinuation of the drugs.

The patient's past medical history included several high‐school orthopedic injuries. She had 2 kidney stones at ages 18 and 23 and had an appendectomy at age 28. Her only medication was an oral contraceptive, and she had discontinued the amlodipine. She denied the use of tobacco, alcohol, herbal medications, or illicit substances. There was no family history of sudden death or heart disease.

Palpitations in a 30‐year‐old woman may signify a cardiac arrhythmia. Paroxysmal supraventricular arrhythmias, such as atrioventricular nodal reentrant tachycardia, atrial tachycardia, and atrial fibrillation, are well described in the young. Ventricular tachycardia (VT) is another possible cause and could be idiopathic or related to occult structural heart disease. Young patients typically tolerate lone arrhythmias quite well, and her failure to do so raises suspicion for concomitant structural heart disease. Her palpitations may be from appropriate sinus tachycardia, which could be compensatory because of inadequate cardiac output reserve, which in turn could be caused by valvular disease, congenital heart disease, or ventricular dysfunction. The exertional chest pain is worrisome for ischemia. Pulmonary hypertension, severe ventricular hypertrophy, or congenital anomalies of the coronary circulation could lead to subendocardial myocardial ischemia with exertion, resulting in angina, dyspnea, and arrhythmias. However, the patient also experiences exertional palpitations without chest pain, which may signify an exertional tachyarrhythmia possibly mediated by catecholamines. Based solely on the history, the differential diagnosis remains broad.

On physical examination, the patient was a fit, thin, healthy woman. Her blood pressure was 120/70 mm Hg supine in both arms and 115/75 mm Hg standing; her pulse was 85 supine and 110 standing, Oxygen saturation was 100% on room air. A cardiac exam revealed a normal jugular venous pressure, normal point of maximal impulse, regular rhythm with occasional ectopy, normal S1, and physiologically split S2 without extra heart sounds or murmurs. The right ventricular impulse was faintly palpable at the left sternal border. Head, neck, chest, abdominal, musculoskeletal, neurologic, extremity, and peripheral pulse examinations were normal.

Laboratory data showed a normal complete blood count and normal chemistries. Serum tests for hepatitis C antibody, cardiolipin antibody, rheumatoid factor, cryoglobulins, and anti‐nuclear antibody were negative. The erythrocyte sedimentation rate and thyroid stimulating hormone levels were within normal limits. An electrocardiogram (ECG) demonstrated a normal sinus rhythm with frequent premature ventricular complexes (PVCs) and normal axis and intervals. (Figure 1). The PR segment was normal and without preexcitation. A prior ECG from 3 months ago was similar with ventricular trigeminy.

Figure 1

Her unremarkable cardiac examination does not favor structural or valvular heart disease, and there are no obvious stigmata of vasculitis. She did become mildly tachycardic upon standing, and this raises the possibility of orthostatic tachycardia. A comprehensive rheumatologic panel revealed no evidence of autoimmune disease or vasculitis, and the clinical constellation is not consistent with primary or secondary Raynaud's disease. The ECG demonstrates frequent monomorphic PVCs complexes with a left bundle branch block pattern and an inferior axis. This pattern suggests that the PVCs arise from the right ventricular outflow tract. Idiopathic right ventricular outflow tract VT and arrhythmogenic right ventricular dysplasia must be considered as a cause of exertional or catecholamine‐mediated tachycardia. The normal ECG argues against arrhythmogenic right ventricular dysplasia, in which patients typically have incomplete or complete right bundle branch block, right precordial T wave abnormalities, and occasionally epsilon waves. Her QT interval is normal, but excluding long‐QT syndrome with a single ECG has poor sensitivity. The next critical step is to document her cardiac rhythm during symptoms and to exclude malignant arrhythmias.

An event recorder and exercise echocardiogram were ordered. While the patient was wearing her event recorder, she had 4 episodes of exertional syncope while hiking and successfully triggered event recording before losing consciousness. She had chest pain and left arm pain after regaining consciousness. The patient came to the emergency room for evaluation. Her blood pressure was 116/80 mm Hg supine and 112/70 mm Hg seated. Her heart rate increased from 82 supine to 132 seated. The physical examination was unremarkable. ECG showed sinus rhythm with frequent PVCs. Troponin‐I measurements 10 hours apart were 0.7 and 0.3 g/L (normal 1.1), with normal creatinine kinase and creatinine kinase MB fractions. Interrogation of the event recorder revealed multiple episodes of a narrow complex tachycardia with rates up to 180 bpm that correlated with symptoms (Figure 2). There were no episodes of wide complex tachycardia.

Figure 2

The patient was not hypotensive in the emergency room, but she had evidence of a marked orthostatic tachycardia. The minimal but significant troponin elevations are also troubling. Although her clinical picture is not consistent with an acute coronary syndrome, I am concerned about other mechanisms of myocardial ischemia or injury, such as a coronary anomaly or subendocardial ischemia from globally reduced myocardial perfusion. The presence of event recorder data from her syncopal events was fortuitous and revealed a supraventricular tachycardia. The arrhythmia was gradual in onset and resolution and had no triggers, such as premature atrial or ventricular complexes, which could suggest reentrant arrhythmias. The P wave morphology was also unchanged, and this argues against an atrial tachycardia. These findings are consistent with sinus tachycardia, which was notably out of proportion to her workload. This arrhythmia may be the primary cause of syncope, such as in inappropriate sinus tachycardia, or it may be a compensatory mechanism. Tachycardia from coronary vasospasm is often preceded by ST segment changes, which are not seen here. Although the event recorder had no episodes of VT, the patient's persistent frequent PVCs are still of concern. I would obtain an echocardiogram to exclude structural heart disease and an exercise test to exclude exertional VT. Finally, coronary angiography may be helpful in excluding congenital anomalies.

The patient was admitted for evaluation. An exercise treadmill test was performed, and the patient exercised 20 min on the standard Bruce protocol with a peak heart rate of 180 bpm. The test was notable for a premature rise in heart rate (in stage 1) without a rise in blood pressure. There were no symptoms or ST/T wave changes. Transthoracic echocardiogram showed normal left ventricular size and function with normal anatomy, valves, and hemodynamics. Coronary angiography showed a right dominant system with normal anatomy and no atherosclerotic disease.

Ventricular arrhythmias could not be elicited with exercise. Her high exercise tolerance virtually excluded hemodynamically significant structural or valvular disease, and this was confirmed by the echocardiogram. Coronary angiography excluded coronary anomalies and myocardial bridging. The most intriguing finding is the rise in the patient's heart rate out of proportion to the workload. This, along with her orthostatic tachycardia, raises the issue of inappropriate sinus tachycardia or postural orthostatic tachycardia syndrome (POTS). Carotid hypersensitivity is also a possibility. The patient was hiking when she fainted, and even light pressure on the patient's neck with head turning or from a camera strap, for example, could produce syncope. Although carotid hypersensitivity usually results in sinus bradycardia and AV block, it may be followed by reflex tachycardia, which was seen in this patient's event recordings. I would perform a tilt‐table test with carotid massage to make the diagnosis.

Tilt‐table testing was performed (Figure 3). Her supine blood pressure was 128/68 mm Hg, and her heart rate was 72 bpm with no change during the 10‐min supine period. Upon elevation to a 70‐degree tilt, the patient had an immediate increase in her heart rate to 160 bpm with a blood pressure nadir of 109/58 mm Hg and symptoms of palpitations, dizziness, dyspnea, chest pain, blurry vision, and nausea. Her peak heart rate was 172 bpm, and her peak blood pressure was 122/72 mm Hg. Vital signs did not change in response to carotid sinus massage in the supine or upright positions.

Figure 3

The tilt‐table test has 3 notable findings. First, her heart rate increased rapidly with tilt and decreased rapidly in supine recovery. Second, her usual symptoms started immediately after tilt and quickly resolved in recovery when vital signs returned to baseline. Finally, there was only a modest drop in blood pressure. These findings are classic for POTS. POTS is defined as symptomatic orthostasis with a heart rate increase of 30 bpm or a heart rate of 120 bpm. The physiologic lesions found in the syndrome are heterogeneous, but they all lead to a failure of orthostatic compensation. In POTS, the tachycardia is a reflex secondary to hypotension (baroreceptor reflex) or reduced preload (cardiac mechanoreceptors), in contrast to inappropriate sinus tachycardia. Interestingly, blood pressure is usually preserved until the final moments preceding syncope, when venous return further declines, tachycardia decreases the diastolic filling time and stroke volume, and mean arterial pressure sharply falls.

The patient was started on labetalol (200 mg 3 times daily), and her symptoms worsened. She also developed nausea and constipation. Midodrine and pindolol were also tried without success. She was then switched to fludrocortisone, salt supplementation, and leg support stockings with dramatic improvement.

COMMENTARY

In 1871, DeCosta1 published a report on the irritable heart, noting an affliction of extreme fatigue and exercise intolerance that occurred suddenly and without obvious cause. Subsequently, the terms vasoregulatory asthenia and neurocirculatory asthenia were used to link cardiovascular symptoms to impaired regulation of peripheral blood flow.2, 3 The term POTS was first used in 1982 to describe a single patient with postural tachycardia without hypotension and palpitations, weakness, abdominal pain, and presyncope.4

POTS is one of several disorders of autonomic control associated with orthostatic intolerance. The criteria for diagnosis are listed in Table 1. POTS typically occurs in women between the ages of 15 and 50 but tends to present during adolescence or young adulthood. The physiology has only recently been elucidated. When a person stands, 500 cc of the total blood volume is displaced to the dependent extremities and inferior mesenteric vessels.5 Normally, orthostatic stabilization occurs in less than 1 minute via 3 mechanisms: baroreceptor input, sympathetic reflex tachycardia and vasoconstriction, and enhanced venous return via the pumping action of skeletal muscles and venoconstriction. In POTS, there is a failure of at least one of these mechanisms, leading to decreased venous return, a 40% reduction in stroke volume, and cerebral hypoperfusion.6

POTS is divided into 2 major subtypes on the basis of pathophysiology.5, 7 The partial dysautonomic form is the most common and the type that this patient most likely had. In this form, the development of an acquired peripheral autonomic neuropathy results in a failure of sympathetic venoconstriction, which leads to excessive venous pooling in the lower extremities and splanchnic circulation.8, 9 Failure to mobilize this venous reservoir upon standing leads to excessive orthostatic tachycardia secondary to a marked reduction in stroke volume. Peripheral arterial vasoconstriction is generally preserved, which is why midodrine, an arterial vasoconstrictor, did not improve symptoms. The labetalol may have further exacerbated peripheral pooling because of its alpha‐adrenergic blocking properties. Because total plasma volume is decreased and plasma renin activity is inappropriately low,10 volume expanders, including salt, low‐dose steroids, and fluids, can attenuate symptoms.11 The extrinsic venous compression from leg and abdominal support stockings may also dramatically reduce venous pooling.

In the less common hyperadrenergic form of POTS, patients may have orthostatic hypertension, tremulousness, cold, sweaty extremities, and anxiety due to an exaggerated response to beta‐adrenergic stimulation.7 The excessive sympathetic activity, which is poorly modulated by baroreflex activity, may be due to impaired mechanisms of norepinephrine reuptake by sympathetic ganglia.12 Consequently, serum norepinephrine levels are markedly elevated (>600 pg/mL).5

In adults, the presence of a POTS trigger is common and is usually an antecedent viral illness. Antibodies to the ganglionic acetylcholine receptor have been found in a subset of POTS patients,13 and this may suggest an idiopathic or postinflammatory autoimmune mechanism.14 This patient's presentation is unique because her symptoms developed after C5C6 spine surgery. The cervical spinal cord and sympathetic ganglia are dense with nerves involved in autonomic cardiovascular control, and damage to these fibers could explain the patient's physiology and symptoms. Among these, the descending vasomotor pathways traverse through the C5C8 area to innervate the splanchnic and leg venous circulation, receiving input from the heart along the way.15 The pattern of numbness and tingling fits the C5/C6 dermatomal distribution, as does the innervation of the radial artery. The frequent PVCs with a left bundle branch block pattern and inferior axis appear to arise from the right ventricular outflow tract and may be associated with regional sympathetic denervation, which has been described in idiopathic ventricular arrhythmias.16 POTS has been anecdotally reported after neck injury from motor vehicle accidents (whiplash), which is also thought to be related to cervical sympathetic nerve damage (B.P. Grubb, personal communication, 2005). Most cases of triggered POTS improve spontaneously after months to years, but this patient's prognosis remains uncertain because of the presumed mechanical disruption of the autonomic nerve fibers at the time of surgery.

This case demonstrates the complexities of arriving at a unifying diagnosis in the setting of a constellation of nonspecific symptoms and findings, some of which even suggest life‐threatening conditions. Because young women are primarily affected, symptoms of POTS can be mistakenly attributed to anxiety or other nonphysiological factors. A systematic approach excluded life‐threatening causes, including primary ventricular arrhythmias, coronary vasospasm, and coronary anomalies. The investigations narrowed the differential diagnosis, and the tilt‐table test confirmed POTS. Because the cardiac and circulatory dysautonomias encompass an array of distinct physiologic processes, understanding the patient's mechanism is critical to her management. The only effective therapies were those that counteracted venous pooling and improved venous return.

Population‐based surveys of the adult US population estimate a prevalence of smoking of 25% and a prevalence of hazardous alcohol or illegal drug use of 23% and 8% respectively,1 with frequent concurrent use of these substances.2 The mortality associated with smoking and substance use is extremely high with tobacco first, alcohol third, and illicit drug use ninth as the leading causes of death in the US.3 Worldwide, the burden of disease from tobacco, alcohol, and illicit drugs accounts for almost 10% of all disability‐adjusted life years.4 Despite the availability of effective treatments,57 many patients do not receive professional intervention and few are offered comprehensive programs that address all of their harmful substance use.

Interventions have been successfully implemented for hospitalized smokers. Earlier work by Emmons8 and Orleans9 suggests that many smokers seek assistance to quit smoking during hospitalization. Over the past 15 years, hospital‐based smoking cessation interventions have been successfully implemented.10 Although mute on hospital‐based settings, the United States Preventive Service Task Force recommends screening and counseling interventions to reduce alcohol misuse among adults seen in primary care settings (B recommendation).6 Referral to specialized care is the accepted standard for most patients with substance dependence disorders7 regardless of the medical setting in which the diagnosis is made. Hospitalization provides a unique opportunity to initiate change in harmful substance use and smoking;11 however, interventions rarely are coordinated.

A high prevalence of smoking among substance users has been reported from population‐based surveys1215 and among patients in substance use treatment facilities.1618 Rates of concurrent smoking and substance use range from 35%44% in population‐based studies and may reach 80% in populations seeking substance use treatment.19 A recent hospital‐based study found at‐risk alcohol users were 3 times more likely to smoke.20 There are limited data describing concurrent smoking and substance use in the hospital population,15 and no reports describing the association between patients' willingness to quit smoking and readiness to change substance use behavior.

To better inform hospital‐based smoking and substance use intervention strategies, the epidemiology of smoking and substance use in the hospital population needs to be better described. Furthermore, there may be opportunities for synergy between these programs. In this study, we screened inpatients from multiple services at 2 hospitals for tobacco, alcohol, and illicit substance use. We report the prevalence and co‐occurrence of these behaviors and willingness to quit smoking among patients with and without at‐risk substance use.

METHODS

Data for this study were obtained for a 5‐year Substance Abuse and Mental Health Services Administration (SAMHSA) grant to the Illinois Office of the Governor. The grant was awarded to implement screening, brief intervention, brief treatment, and referral to treatment programs for patients of the Cook County Bureau of Health Services who had alcohol or other drug use disorders. We analyzed data collected from nonIntensive Care Unit patients who had been hospitalized on the internal medicine, family practice, HIV, or surgery services at John H. Stroger Jr Hospital of Cook County (formerly Cook County Hospital, a 464‐bed public, tertiary‐care hospital) or Provident Hospital of Cook County (a 100‐bed public community hospital), in Chicago, Illinois. Because internal medicine and family practice patients were similar in demographic characteristics and interview responses, we considered these as a single service. There is an HIV service at Stroger Hospital; all HIV‐infected patients are admitted or transferred to this service. For each patient, we used data collected from their initial hospitalization during a 9‐month study period (April 1, 2006 through December 31, 2006). Using hospital admission data, we estimated that 65% of patients were interviewed by a counselor; only 5% of patients could not be interviewed due to patient refusal or mental status changes.

Patients were screened for alcohol use, drug use, and smoking history by bedside interview. We defined at‐risk substance use as any illicit drug use within the previous 3 months or alcohol use that exceeded the National Institute for Alcohol Abuse and Alcoholism (NIAAA) guidelines for low‐risk drinking (no more than 5 drinks per day or 14 drinks per week for men up to age 65; no more than 3 drinks per day or 7 drinks per week for men over 65 and women). Based on their responses to questions about smoking history, patients were categorized into the following 4 groups: current smokers (ie, smoked within the previous 7 days), recent quitters (ie, quit within 8 days and 6 months), ex‐smokers (quit more than 6 months ago), or never smokers. Current smokers were also asked about their heaviness of smoking and willingness to quit. All smokers received a counseling session during hospitalization. All smokers who indicated a desire to quit were encouraged to call the Illinois Quitline after hospital discharge. Individuals who smoked between 10‐14 cigarettes per day and smoked their first cigarette within 30 minutes of waking or who smoked 15 or more cigarettes per day were classified as moderate or heavy smokers; all other smokers were classified as light smokers. We established these cut‐points by modifying the Public Health Service guideline and Heaviness of Smoking Index.5, 21, 22 The heaviness of smoking classification was used to guide recommendations to the primary service regarding the appropriateness of nicotine patch therapy during and after hospitalization. For moderate to heavy smokers who were willing to quit, the recommendation was to continue nicotine replacement after hospitalization.5

Patients were considered low health risk if their alcohol use did not exceed NIAAA guidelines and they reported no recent drug use. For all patients who reported alcohol use that exceeded the NIAAA guidelines or recent drug use, we administered the Texas Christian University Drug Screen II (TCU)23 to further characterize the severity of their use. Patients who had a TCU score of 3 were considered at‐risk substance users with substance dependence disorder; patients with scores of 2 or less were considered at‐risk substance users without dependence. Among all at‐risk substance users, we used a 10‐point visual analog scale to assess their readiness to change substance use. After evaluating the distribution and clustering of scores, we prespecified that a score 8 was indicative of a patient being ready to change their substance use behavior. This ruler has been successfully implemented as part of the Brief Negotiated Interview and Active Referral to Treatment Institute toolbox.24

RESULTS

Willingness to Quit

Most patients (61%) who smoked were willing to immediately quit smoking. After adjusting for other demographic confounders, non‐Hispanic Blacks and the elderly (age > 65) were more willing to quit (P < 0.05, data not shown). The substance use risk categories of low risk, at‐risk, and dependence were not associated with willingness to quit tobacco (Fig. 1, left panel).

Figure 1

Regardless of substance use category, most patients were ready to change their substance use behavior (Fig. 1). Those patients who were ready to change their substance use behavior, regardless of whether they were substance‐dependent, were significantly more likely to report a willingness to quit smoking than those who were not ready to change (Fig. 1, right panel). In fact, at‐risk substance users without dependence who were ready to change their substance use were more willing to quit smoking than patients without at‐risk substance use (72% versus 64%; P < 0.05).

DISCUSSION

Among hospital patients, we found a 46% absolute increase in the prevalence of smoking among those who used illicit substances or alcohol above NIAAA guidelines compared to those who did not report such use. The prevalence of smoking increased across the spectrum of substance use, being highest for patients who met criteria for dependence. Also, patients who were substance dependent were more likely to be moderate to heavy smokers, suggesting an association between alcohol or other drug dependence disorders and nicotine dependence. Regardless of their patterns of substance use, most patients expressed a desire to immediately quit smoking and there was a strong association between willingness to quit smoking and readiness to reduce substance use.

In our hospital population, the prevalence of smoking among patients who use illicit drugs or at‐risk quantities of alcohol far exceeds estimates obtained from population‐based surveys. In addition to the relatively high prevalence of smoking, focusing attention on hospital patients who use substances is important for several other reasons. Individuals who use substances are less likely to receive health care from a primary care physician.28 Also, most patients who have substance use disorders do not enter treatment programs,1 even after hospitalization.29 Further, hospitals provide a setting that facilitates change; patients are temporarily required to stop smoking, and often they are available for relatively long counseling sessions. Finally, for patients without substance use disorders, hospital‐based smoking cessation intervention programs have been proven to be successful in several randomized controlled trials.10, 30

Because alcohol and drug use are so common among hospitalized smokers, it is unfortunate that there is little evidence from clinical trials to inform intervention strategies for patients with concurrent use. The clinical trials that form the evidence base for intervention among hospitalized smokers10 either have explicitly excluded patients who reported substance use,10, 15, 3133 did not assess baseline substance use,34, 35 or were underpowered to perform subgroup analyses on this population.36 Awaiting better evidence, we have chosen to routinely screen hospital patients for tobacco, alcohol, and drug use. For treatment strategies, we extrapolate the findings from successful interventions in the ambulatory setting37 or among hospital patients who do not use substances to our population. We offer smoking cessation interventions to patients regardless of other substance use.

Understanding the similarities and differences between smokers who use substances and those who do not is important in implementing successful strategies for smoking cessation. Rather than a step‐wise increase in heaviness of smoking across substance use categories (ie, no‐risk or low‐risk use, at‐risk use without dependence, and substance dependence), we found an increased heaviness of smoking only among substance‐dependent smokers; there was no difference in heaviness of smoking between those with at‐risk use without dependence and those with no‐risk or low‐risk use. Because interventions for patients who have nicotine dependence are more likely to succeed when pharmacotherapy is offered as an adjunct to behavior therapy,38 smokers who also are substance‐dependent likely will benefit from the addition of pharmacotherapy. One similarity is that all patients, regardless of substance use category, were willing to quit smoking. In fact, hospitalized smokers who were ready to change at‐risk substance use were more willing to quit smoking than patients who had no‐risk or low‐risk substance use. Previous investigators have found that smokers who use substances have fewer quit attempts,39 higher nicotine dependence,37, 39 and lower enrollment in smoking cessation interventions.38

Our study only includes data from patients at 2 public hospitals; therefore, our findings may not generalize to populations of higher socioeconomic status. Also, our smoking screening tool had relatively low sensitivity for categorizing current smokers as moderate to heavy smokers; therefore, we may have underestimated the number of moderate to heavy smokers.5, 22 Further, given our cross‐sectional study design, we were unable to evaluate whether patients who have at‐risk substance use remain willing to quit smoking after hospital discharge or to the effectiveness of our smoking cessation program. Finally, socially desirable responses may have caused patients to overstate their willingness to quit tobacco and readiness to change substance use. Additional research is needed to determine whether post‐hospitalization quit rates are similar between smokers with and without at‐risk substance use, and the optimal timing for smoking cessation interventions in relation to substance dependence treatment.40

Hospital patients who have substance use disorders are also highly likely to smoke, and these patients express a willingness to quit smoking. Given the frequency of concurrent smoking and other substance misuse and patients' desire to change both behaviors, there is a role for coordination of substance use and smoking cessation intervention programs.

Population‐based surveys of the adult US population estimate a prevalence of smoking of 25% and a prevalence of hazardous alcohol or illegal drug use of 23% and 8% respectively,1 with frequent concurrent use of these substances.2 The mortality associated with smoking and substance use is extremely high with tobacco first, alcohol third, and illicit drug use ninth as the leading causes of death in the US.3 Worldwide, the burden of disease from tobacco, alcohol, and illicit drugs accounts for almost 10% of all disability‐adjusted life years.4 Despite the availability of effective treatments,57 many patients do not receive professional intervention and few are offered comprehensive programs that address all of their harmful substance use.

Interventions have been successfully implemented for hospitalized smokers. Earlier work by Emmons8 and Orleans9 suggests that many smokers seek assistance to quit smoking during hospitalization. Over the past 15 years, hospital‐based smoking cessation interventions have been successfully implemented.10 Although mute on hospital‐based settings, the United States Preventive Service Task Force recommends screening and counseling interventions to reduce alcohol misuse among adults seen in primary care settings (B recommendation).6 Referral to specialized care is the accepted standard for most patients with substance dependence disorders7 regardless of the medical setting in which the diagnosis is made. Hospitalization provides a unique opportunity to initiate change in harmful substance use and smoking;11 however, interventions rarely are coordinated.

A high prevalence of smoking among substance users has been reported from population‐based surveys1215 and among patients in substance use treatment facilities.1618 Rates of concurrent smoking and substance use range from 35%44% in population‐based studies and may reach 80% in populations seeking substance use treatment.19 A recent hospital‐based study found at‐risk alcohol users were 3 times more likely to smoke.20 There are limited data describing concurrent smoking and substance use in the hospital population,15 and no reports describing the association between patients' willingness to quit smoking and readiness to change substance use behavior.

To better inform hospital‐based smoking and substance use intervention strategies, the epidemiology of smoking and substance use in the hospital population needs to be better described. Furthermore, there may be opportunities for synergy between these programs. In this study, we screened inpatients from multiple services at 2 hospitals for tobacco, alcohol, and illicit substance use. We report the prevalence and co‐occurrence of these behaviors and willingness to quit smoking among patients with and without at‐risk substance use.

METHODS

Data for this study were obtained for a 5‐year Substance Abuse and Mental Health Services Administration (SAMHSA) grant to the Illinois Office of the Governor. The grant was awarded to implement screening, brief intervention, brief treatment, and referral to treatment programs for patients of the Cook County Bureau of Health Services who had alcohol or other drug use disorders. We analyzed data collected from nonIntensive Care Unit patients who had been hospitalized on the internal medicine, family practice, HIV, or surgery services at John H. Stroger Jr Hospital of Cook County (formerly Cook County Hospital, a 464‐bed public, tertiary‐care hospital) or Provident Hospital of Cook County (a 100‐bed public community hospital), in Chicago, Illinois. Because internal medicine and family practice patients were similar in demographic characteristics and interview responses, we considered these as a single service. There is an HIV service at Stroger Hospital; all HIV‐infected patients are admitted or transferred to this service. For each patient, we used data collected from their initial hospitalization during a 9‐month study period (April 1, 2006 through December 31, 2006). Using hospital admission data, we estimated that 65% of patients were interviewed by a counselor; only 5% of patients could not be interviewed due to patient refusal or mental status changes.

Patients were screened for alcohol use, drug use, and smoking history by bedside interview. We defined at‐risk substance use as any illicit drug use within the previous 3 months or alcohol use that exceeded the National Institute for Alcohol Abuse and Alcoholism (NIAAA) guidelines for low‐risk drinking (no more than 5 drinks per day or 14 drinks per week for men up to age 65; no more than 3 drinks per day or 7 drinks per week for men over 65 and women). Based on their responses to questions about smoking history, patients were categorized into the following 4 groups: current smokers (ie, smoked within the previous 7 days), recent quitters (ie, quit within 8 days and 6 months), ex‐smokers (quit more than 6 months ago), or never smokers. Current smokers were also asked about their heaviness of smoking and willingness to quit. All smokers received a counseling session during hospitalization. All smokers who indicated a desire to quit were encouraged to call the Illinois Quitline after hospital discharge. Individuals who smoked between 10‐14 cigarettes per day and smoked their first cigarette within 30 minutes of waking or who smoked 15 or more cigarettes per day were classified as moderate or heavy smokers; all other smokers were classified as light smokers. We established these cut‐points by modifying the Public Health Service guideline and Heaviness of Smoking Index.5, 21, 22 The heaviness of smoking classification was used to guide recommendations to the primary service regarding the appropriateness of nicotine patch therapy during and after hospitalization. For moderate to heavy smokers who were willing to quit, the recommendation was to continue nicotine replacement after hospitalization.5

Patients were considered low health risk if their alcohol use did not exceed NIAAA guidelines and they reported no recent drug use. For all patients who reported alcohol use that exceeded the NIAAA guidelines or recent drug use, we administered the Texas Christian University Drug Screen II (TCU)23 to further characterize the severity of their use. Patients who had a TCU score of 3 were considered at‐risk substance users with substance dependence disorder; patients with scores of 2 or less were considered at‐risk substance users without dependence. Among all at‐risk substance users, we used a 10‐point visual analog scale to assess their readiness to change substance use. After evaluating the distribution and clustering of scores, we prespecified that a score 8 was indicative of a patient being ready to change their substance use behavior. This ruler has been successfully implemented as part of the Brief Negotiated Interview and Active Referral to Treatment Institute toolbox.24

RESULTS

Willingness to Quit

Most patients (61%) who smoked were willing to immediately quit smoking. After adjusting for other demographic confounders, non‐Hispanic Blacks and the elderly (age > 65) were more willing to quit (P < 0.05, data not shown). The substance use risk categories of low risk, at‐risk, and dependence were not associated with willingness to quit tobacco (Fig. 1, left panel).

Figure 1

Regardless of substance use category, most patients were ready to change their substance use behavior (Fig. 1). Those patients who were ready to change their substance use behavior, regardless of whether they were substance‐dependent, were significantly more likely to report a willingness to quit smoking than those who were not ready to change (Fig. 1, right panel). In fact, at‐risk substance users without dependence who were ready to change their substance use were more willing to quit smoking than patients without at‐risk substance use (72% versus 64%; P < 0.05).

DISCUSSION

Among hospital patients, we found a 46% absolute increase in the prevalence of smoking among those who used illicit substances or alcohol above NIAAA guidelines compared to those who did not report such use. The prevalence of smoking increased across the spectrum of substance use, being highest for patients who met criteria for dependence. Also, patients who were substance dependent were more likely to be moderate to heavy smokers, suggesting an association between alcohol or other drug dependence disorders and nicotine dependence. Regardless of their patterns of substance use, most patients expressed a desire to immediately quit smoking and there was a strong association between willingness to quit smoking and readiness to reduce substance use.

In our hospital population, the prevalence of smoking among patients who use illicit drugs or at‐risk quantities of alcohol far exceeds estimates obtained from population‐based surveys. In addition to the relatively high prevalence of smoking, focusing attention on hospital patients who use substances is important for several other reasons. Individuals who use substances are less likely to receive health care from a primary care physician.28 Also, most patients who have substance use disorders do not enter treatment programs,1 even after hospitalization.29 Further, hospitals provide a setting that facilitates change; patients are temporarily required to stop smoking, and often they are available for relatively long counseling sessions. Finally, for patients without substance use disorders, hospital‐based smoking cessation intervention programs have been proven to be successful in several randomized controlled trials.10, 30

Because alcohol and drug use are so common among hospitalized smokers, it is unfortunate that there is little evidence from clinical trials to inform intervention strategies for patients with concurrent use. The clinical trials that form the evidence base for intervention among hospitalized smokers10 either have explicitly excluded patients who reported substance use,10, 15, 3133 did not assess baseline substance use,34, 35 or were underpowered to perform subgroup analyses on this population.36 Awaiting better evidence, we have chosen to routinely screen hospital patients for tobacco, alcohol, and drug use. For treatment strategies, we extrapolate the findings from successful interventions in the ambulatory setting37 or among hospital patients who do not use substances to our population. We offer smoking cessation interventions to patients regardless of other substance use.

Understanding the similarities and differences between smokers who use substances and those who do not is important in implementing successful strategies for smoking cessation. Rather than a step‐wise increase in heaviness of smoking across substance use categories (ie, no‐risk or low‐risk use, at‐risk use without dependence, and substance dependence), we found an increased heaviness of smoking only among substance‐dependent smokers; there was no difference in heaviness of smoking between those with at‐risk use without dependence and those with no‐risk or low‐risk use. Because interventions for patients who have nicotine dependence are more likely to succeed when pharmacotherapy is offered as an adjunct to behavior therapy,38 smokers who also are substance‐dependent likely will benefit from the addition of pharmacotherapy. One similarity is that all patients, regardless of substance use category, were willing to quit smoking. In fact, hospitalized smokers who were ready to change at‐risk substance use were more willing to quit smoking than patients who had no‐risk or low‐risk substance use. Previous investigators have found that smokers who use substances have fewer quit attempts,39 higher nicotine dependence,37, 39 and lower enrollment in smoking cessation interventions.38

Our study only includes data from patients at 2 public hospitals; therefore, our findings may not generalize to populations of higher socioeconomic status. Also, our smoking screening tool had relatively low sensitivity for categorizing current smokers as moderate to heavy smokers; therefore, we may have underestimated the number of moderate to heavy smokers.5, 22 Further, given our cross‐sectional study design, we were unable to evaluate whether patients who have at‐risk substance use remain willing to quit smoking after hospital discharge or to the effectiveness of our smoking cessation program. Finally, socially desirable responses may have caused patients to overstate their willingness to quit tobacco and readiness to change substance use. Additional research is needed to determine whether post‐hospitalization quit rates are similar between smokers with and without at‐risk substance use, and the optimal timing for smoking cessation interventions in relation to substance dependence treatment.40

Hospital patients who have substance use disorders are also highly likely to smoke, and these patients express a willingness to quit smoking. Given the frequency of concurrent smoking and other substance misuse and patients' desire to change both behaviors, there is a role for coordination of substance use and smoking cessation intervention programs.

Population‐based surveys of the adult US population estimate a prevalence of smoking of 25% and a prevalence of hazardous alcohol or illegal drug use of 23% and 8% respectively,1 with frequent concurrent use of these substances.2 The mortality associated with smoking and substance use is extremely high with tobacco first, alcohol third, and illicit drug use ninth as the leading causes of death in the US.3 Worldwide, the burden of disease from tobacco, alcohol, and illicit drugs accounts for almost 10% of all disability‐adjusted life years.4 Despite the availability of effective treatments,57 many patients do not receive professional intervention and few are offered comprehensive programs that address all of their harmful substance use.

Interventions have been successfully implemented for hospitalized smokers. Earlier work by Emmons8 and Orleans9 suggests that many smokers seek assistance to quit smoking during hospitalization. Over the past 15 years, hospital‐based smoking cessation interventions have been successfully implemented.10 Although mute on hospital‐based settings, the United States Preventive Service Task Force recommends screening and counseling interventions to reduce alcohol misuse among adults seen in primary care settings (B recommendation).6 Referral to specialized care is the accepted standard for most patients with substance dependence disorders7 regardless of the medical setting in which the diagnosis is made. Hospitalization provides a unique opportunity to initiate change in harmful substance use and smoking;11 however, interventions rarely are coordinated.

A high prevalence of smoking among substance users has been reported from population‐based surveys1215 and among patients in substance use treatment facilities.1618 Rates of concurrent smoking and substance use range from 35%44% in population‐based studies and may reach 80% in populations seeking substance use treatment.19 A recent hospital‐based study found at‐risk alcohol users were 3 times more likely to smoke.20 There are limited data describing concurrent smoking and substance use in the hospital population,15 and no reports describing the association between patients' willingness to quit smoking and readiness to change substance use behavior.

To better inform hospital‐based smoking and substance use intervention strategies, the epidemiology of smoking and substance use in the hospital population needs to be better described. Furthermore, there may be opportunities for synergy between these programs. In this study, we screened inpatients from multiple services at 2 hospitals for tobacco, alcohol, and illicit substance use. We report the prevalence and co‐occurrence of these behaviors and willingness to quit smoking among patients with and without at‐risk substance use.

METHODS

Data for this study were obtained for a 5‐year Substance Abuse and Mental Health Services Administration (SAMHSA) grant to the Illinois Office of the Governor. The grant was awarded to implement screening, brief intervention, brief treatment, and referral to treatment programs for patients of the Cook County Bureau of Health Services who had alcohol or other drug use disorders. We analyzed data collected from nonIntensive Care Unit patients who had been hospitalized on the internal medicine, family practice, HIV, or surgery services at John H. Stroger Jr Hospital of Cook County (formerly Cook County Hospital, a 464‐bed public, tertiary‐care hospital) or Provident Hospital of Cook County (a 100‐bed public community hospital), in Chicago, Illinois. Because internal medicine and family practice patients were similar in demographic characteristics and interview responses, we considered these as a single service. There is an HIV service at Stroger Hospital; all HIV‐infected patients are admitted or transferred to this service. For each patient, we used data collected from their initial hospitalization during a 9‐month study period (April 1, 2006 through December 31, 2006). Using hospital admission data, we estimated that 65% of patients were interviewed by a counselor; only 5% of patients could not be interviewed due to patient refusal or mental status changes.

Patients were screened for alcohol use, drug use, and smoking history by bedside interview. We defined at‐risk substance use as any illicit drug use within the previous 3 months or alcohol use that exceeded the National Institute for Alcohol Abuse and Alcoholism (NIAAA) guidelines for low‐risk drinking (no more than 5 drinks per day or 14 drinks per week for men up to age 65; no more than 3 drinks per day or 7 drinks per week for men over 65 and women). Based on their responses to questions about smoking history, patients were categorized into the following 4 groups: current smokers (ie, smoked within the previous 7 days), recent quitters (ie, quit within 8 days and 6 months), ex‐smokers (quit more than 6 months ago), or never smokers. Current smokers were also asked about their heaviness of smoking and willingness to quit. All smokers received a counseling session during hospitalization. All smokers who indicated a desire to quit were encouraged to call the Illinois Quitline after hospital discharge. Individuals who smoked between 10‐14 cigarettes per day and smoked their first cigarette within 30 minutes of waking or who smoked 15 or more cigarettes per day were classified as moderate or heavy smokers; all other smokers were classified as light smokers. We established these cut‐points by modifying the Public Health Service guideline and Heaviness of Smoking Index.5, 21, 22 The heaviness of smoking classification was used to guide recommendations to the primary service regarding the appropriateness of nicotine patch therapy during and after hospitalization. For moderate to heavy smokers who were willing to quit, the recommendation was to continue nicotine replacement after hospitalization.5

Patients were considered low health risk if their alcohol use did not exceed NIAAA guidelines and they reported no recent drug use. For all patients who reported alcohol use that exceeded the NIAAA guidelines or recent drug use, we administered the Texas Christian University Drug Screen II (TCU)23 to further characterize the severity of their use. Patients who had a TCU score of 3 were considered at‐risk substance users with substance dependence disorder; patients with scores of 2 or less were considered at‐risk substance users without dependence. Among all at‐risk substance users, we used a 10‐point visual analog scale to assess their readiness to change substance use. After evaluating the distribution and clustering of scores, we prespecified that a score 8 was indicative of a patient being ready to change their substance use behavior. This ruler has been successfully implemented as part of the Brief Negotiated Interview and Active Referral to Treatment Institute toolbox.24

RESULTS

Willingness to Quit

Most patients (61%) who smoked were willing to immediately quit smoking. After adjusting for other demographic confounders, non‐Hispanic Blacks and the elderly (age > 65) were more willing to quit (P < 0.05, data not shown). The substance use risk categories of low risk, at‐risk, and dependence were not associated with willingness to quit tobacco (Fig. 1, left panel).

Figure 1

Regardless of substance use category, most patients were ready to change their substance use behavior (Fig. 1). Those patients who were ready to change their substance use behavior, regardless of whether they were substance‐dependent, were significantly more likely to report a willingness to quit smoking than those who were not ready to change (Fig. 1, right panel). In fact, at‐risk substance users without dependence who were ready to change their substance use were more willing to quit smoking than patients without at‐risk substance use (72% versus 64%; P < 0.05).

DISCUSSION

Among hospital patients, we found a 46% absolute increase in the prevalence of smoking among those who used illicit substances or alcohol above NIAAA guidelines compared to those who did not report such use. The prevalence of smoking increased across the spectrum of substance use, being highest for patients who met criteria for dependence. Also, patients who were substance dependent were more likely to be moderate to heavy smokers, suggesting an association between alcohol or other drug dependence disorders and nicotine dependence. Regardless of their patterns of substance use, most patients expressed a desire to immediately quit smoking and there was a strong association between willingness to quit smoking and readiness to reduce substance use.

In our hospital population, the prevalence of smoking among patients who use illicit drugs or at‐risk quantities of alcohol far exceeds estimates obtained from population‐based surveys. In addition to the relatively high prevalence of smoking, focusing attention on hospital patients who use substances is important for several other reasons. Individuals who use substances are less likely to receive health care from a primary care physician.28 Also, most patients who have substance use disorders do not enter treatment programs,1 even after hospitalization.29 Further, hospitals provide a setting that facilitates change; patients are temporarily required to stop smoking, and often they are available for relatively long counseling sessions. Finally, for patients without substance use disorders, hospital‐based smoking cessation intervention programs have been proven to be successful in several randomized controlled trials.10, 30

Because alcohol and drug use are so common among hospitalized smokers, it is unfortunate that there is little evidence from clinical trials to inform intervention strategies for patients with concurrent use. The clinical trials that form the evidence base for intervention among hospitalized smokers10 either have explicitly excluded patients who reported substance use,10, 15, 3133 did not assess baseline substance use,34, 35 or were underpowered to perform subgroup analyses on this population.36 Awaiting better evidence, we have chosen to routinely screen hospital patients for tobacco, alcohol, and drug use. For treatment strategies, we extrapolate the findings from successful interventions in the ambulatory setting37 or among hospital patients who do not use substances to our population. We offer smoking cessation interventions to patients regardless of other substance use.

Understanding the similarities and differences between smokers who use substances and those who do not is important in implementing successful strategies for smoking cessation. Rather than a step‐wise increase in heaviness of smoking across substance use categories (ie, no‐risk or low‐risk use, at‐risk use without dependence, and substance dependence), we found an increased heaviness of smoking only among substance‐dependent smokers; there was no difference in heaviness of smoking between those with at‐risk use without dependence and those with no‐risk or low‐risk use. Because interventions for patients who have nicotine dependence are more likely to succeed when pharmacotherapy is offered as an adjunct to behavior therapy,38 smokers who also are substance‐dependent likely will benefit from the addition of pharmacotherapy. One similarity is that all patients, regardless of substance use category, were willing to quit smoking. In fact, hospitalized smokers who were ready to change at‐risk substance use were more willing to quit smoking than patients who had no‐risk or low‐risk substance use. Previous investigators have found that smokers who use substances have fewer quit attempts,39 higher nicotine dependence,37, 39 and lower enrollment in smoking cessation interventions.38

Our study only includes data from patients at 2 public hospitals; therefore, our findings may not generalize to populations of higher socioeconomic status. Also, our smoking screening tool had relatively low sensitivity for categorizing current smokers as moderate to heavy smokers; therefore, we may have underestimated the number of moderate to heavy smokers.5, 22 Further, given our cross‐sectional study design, we were unable to evaluate whether patients who have at‐risk substance use remain willing to quit smoking after hospital discharge or to the effectiveness of our smoking cessation program. Finally, socially desirable responses may have caused patients to overstate their willingness to quit tobacco and readiness to change substance use. Additional research is needed to determine whether post‐hospitalization quit rates are similar between smokers with and without at‐risk substance use, and the optimal timing for smoking cessation interventions in relation to substance dependence treatment.40

Hospital patients who have substance use disorders are also highly likely to smoke, and these patients express a willingness to quit smoking. Given the frequency of concurrent smoking and other substance misuse and patients' desire to change both behaviors, there is a role for coordination of substance use and smoking cessation intervention programs.

A crucial arena of innovative educational programs for the care of the elderly must include the hospital setting, a place of great cost, morbidity, and mortality for a population currently occupying approximately half of US hospital beds.1 With a marked acceleration in the number of persons living to an advanced age, there is a clear imperative to address the health‐care needs of the elderly, particularly the complex and frail.24 An educational grounding that steps beyond the traditional organ‐based models of disease to a much broader patient‐centered framework of care is necessary to aid physicians in advanced clinical decision‐making in the care of older patients. Organizing the medical care of the older patient within existing systems of care and a team care management network must also be improved.

Curricular materials and methods are widely available for teaching geriatric medicine,57 but most are geared toward outpatient care and management, with few addressing the care of the hospitalized, older medical patient.810 There is even less published on curricular materials, methods, and tools for such teaching outside of specialized hospital‐based geriatric units by nongeriatrics‐trained faculty.1113 Furthermore, the evaluation of geriatrics educational programs in the hospital setting has not been done with the ultimate assessment, the linking of educational programs to demonstrated changes in clinical practice and patient care outcomes.

To address these needs, we designed and implemented the Curriculum for the Hospitalized Aging Medical Patient (CHAMP) Faculty Development Program (FDP). CHAMP was funded by a grant from the Donald W. Reynolds Foundation Aging and Quality of Life Program with a matching commitment from the University of Chicago Department of Medicine. At the core of CHAMP are principles of care for the older patient in the hospital setting, with an emphasis on identifying and providing care for the complex and frail elderly with nongeriatrician inpatient medicine faculty as the primary teachers of these materials. The overall educational goals of the CHAMP FDP are the following: (1) to train hospitalists and general internists to recognize opportunities to teach geriatric medicine topics specific to the care of the hospitalized older patient; (2) to create teaching materials, tools, and methods that can be used in the busy medical inpatient setting at the bedside; (3) to create materials and tools that facilitate teaching the Accreditation Council for Graduate Medical Education (ACGME) core competencies14 during ward rounds; and (4) to increase the frequency and effectiveness with which this geriatrics content is taught in the hospital setting. This article describes the development and refinement of the CHAMP FDP and evaluation results to date.

METHODS

The CHAMP FDP was developed by a core group of geriatricians, hospitalists, general medicine faculty, and PhD educators from the Office of the Dean at the University of Chicago Pritzker School of Medicine. The core group piloted the FDP for themselves in spring 2004, and the FDP was offered to target learners annually from 2004 to 2006.

RESULTS

We pilot‐tested the format, materials, methods, and evaluation components of the CHAMP FDP with the CHAMP core faculty in the spring of 2004. The revised CHAMP FDP was given in the fall of 2004 to the first group of 8 faculty learners. Similar annual CHAMP FDPs have occurred since 2004, with a total of 29 Faculty Scholars by 2006. This includes approximately half of the University of Chicago general medicine faculty and the majority of the hospitalist faculty. Geriatrics fellows, a medicine chief resident, and other internal medicine subspecialists have also taken the CHAMP FDP. The average evaluations of all CHAMP sessions by all participants are shown in Table 3.

Faculty Scholars rated the FDP highly regarding preparation for teaching and incorporation of the material into their teaching and practice. Likewise, qualitative comments by the Faculty Scholars were strongly supportive of CHAMP:

• Significantly more aware and confident in teaching around typical geriatric issues present in our patients.

• Provided concrete, structured ideas about curriculum, learning goals, content materials and how to implement them.

• The online teaching resources were something I used on an almost daily basis.

• Wish we had this for outpatient.

CHAMP had a favorable impact on the Faculty Scholars across the domains of knowledge, attitudes, and perceived behavior change (Table 4). Significant differences on paired‐sample t tests found significant improvement on all but one measure (importance of teaching). After the CHAMP program, Faculty Scholars were more knowledgeable about geriatrics content (P = 0.023), had more positive attitudes to older patients (P = 0.049), and had greater confidence in their ability to care for older patients (P < 0.001) and teach geriatric medicine skills (P < 0.001) and Teaching on Today's Wards content (P < 0.001). There was a significant increase in the perceived importance of practicing the learned skills (P = 0.008) and Teaching on Today's Wards (P = 0.001). The increased importance of teaching geriatrics skills was marginally significant (P = 0.064).

DISCUSSION

Central to CHAMP's design are (1) the creation of teaching materials and teaching resources that specifically address the challenges of teaching the care of the hospitalized older patient in busy hospital settings, (2) the provision of methods to reinforce the newly learned geriatrics teaching skills, and (3) a multidimensional evaluation scheme. The enthusiastic response to the CHAMP FDP and the evaluation results to date support the relevance and importance of CHAMP's focus, materials, and educational methods. The ideal outcome for our CHAMP FDP graduates is more informed, confident, and frequent teaching of geriatrics topics keyed to quality improvement and systems of care through a more streamlined but personalized bedside teaching process.13, 46 The CHAMP Faculty Scholar graduates' self‐report surveys of their performance and teaching of CHAMP course geriatrics skills did reveal a significant shift in clinical behavior, teaching, and confidence. Although the strongest indicator of perceived behavior change was in the enhanced self‐confidence in practicing and teaching, the significant changes in knowledge and attitude reinforce our observations of a shift in the mindset about teaching and caring for hospitalized elderly patients. This provides strong evidence for the efficacy of the CHAMP course in positively influencing participants.

Our biggest challenge with the CHAMP FDP was providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes. After pilot testing, we added multiple types of support and follow‐up to the FDP: observed structured teaching exercises to practice CHAMP geriatrics content and teaching skills; modification of Teaching on Today's Wards through the addition of practice‐oriented exercises, games, and tutorials; frequent contact with our Faculty Scholar graduates post‐CHAMP FDP through CTC contracts; annual Faculty Scholars reunions; and continued access for the scholars to CHAMP materials on our Web site. Maintaining face‐to‐face contact between CHAMP core faculty and Faculty Scholars once the latter have finished the FDP has been challenging, largely because of clinical and teaching obligations over geographically separate sites. To overcome this, we are working to integrate CHAMP core faculty into hospitalist and general medicine section lecture series, increasing the frequency of CHAMP reunions, renewing CTC contracts with the Faculty Scholar graduates annually, and considering the concept of CHAMP core faculty guests attending during Faculty Scholars inpatient ward rounds.47

The CHAMP FDP and our evaluations to date have several limitations. First, FDP Scholars were volunteer participants who may have been more motivated to improve their geriatric care and teaching than nonparticipants. However, FDP Scholars had only moderate levels of geriatrics knowledge, attitudes, and confidence in their teaching on baseline testing and showed marked improvements in these domains after the FDP. In addition, Scholars' FDP participation was made possible by a reduction of other clinical obligations through direct reimbursement to their sections with CHAMP funds. Other incentives for CHAMP participation could include its focus on generalizable bedside teaching skills and provision of specific techniques for teaching the ACGME core competencies and quality improvement while using geriatrics content. Although the CHAMP FDP in its 48‐hour format is not sustainable or generalizable, the FDP modules and CHAMP materials were specifically designed to be usable in small pieces that could be incorporated into existing teaching structures, grand rounds, section meetings, teacher conferences, and continuing medical education workshops. CHAMP core group members have already presented and taught CHAMP components in many venues (see Dissemination on the CHAMP Web site). The excitement generated by CHAMP at national and specialty meetings, including multiple requests for materials, speaks to widespread interest in our CHAMP model. We are pursuing the creation of a mini‐CHAMP, an abbreviated FDP with an online component. These activities as well as feedback from users of CHAMP materials from the CHAMP Web site and the Portal of Geriatric Online Education will provide important opportunities for examining the use and acceptance of CHAMP outside our institution.

Another limitation of the CHAMP FDP is reliance on FDP Scholar self‐assessment in several of the evaluation components. Some studies have shown poor concordance between physicians' self‐assessment and external assessment over a range of domains.48 However, others have noted that despite these limitations, self‐assessment remains an essential tool for enabling physicians to discover the motivational discomfort of a performance gap, which may lead to changing concepts and mental models or changing work‐flow processes.49 Teaching on Today's Wards sessions in CHAMP emphasize self‐audit processes (such as process mapping and census audits) that can augment self‐assessment. We used such self‐audit processes in 1 small pilot study to date, providing summative and qualitative feedback to a group of FDP Scholars on their use of census audits.

However, the evaluation of the CHAMP FDP is enhanced by a yearly survey of all medical residents and medical students and by the linking of the teaching reported by residents and medical students to specific attendings. We have begun the analysis of resident perceptions of being taught CHAMP geriatrics topics by CHAMP faculty versus non‐CHAMP faculty. In addition, we are gathering data on patient‐level process of care and outcomes tied to the CHAMP FDP course session objectives by linking to the ongoing University of Chicago Hospitalist Project, a large clinical research project that enrolls general medicine inpatients in a study examining the quality of care and resource allocation for these patients.50 Because the ultimate goal of CHAMP is to improve the quality of care and outcomes for elderly hospitalized patients, the University of Chicago Hospitalist Project infrastructure was modified by the incorporation of the Vulnerable Elder Survey‐1351 and a process‐of‐care chart audit specifically based on the Assessing Care of the Vulnerable Elders Hospital Quality Indicators.52 Preliminary work included testing and validating these measures.53 Further evaluation of these clinical outcomes and CHAMP's efficacy and durability at the University of Chicago is ongoing and will be presented in future reports.

CONCLUSIONS

Through a collaboration of geriatricians, hospitalists, and general internists, the CHAMP FDP provides educational materials and methods keyed to bedside teaching in the fast‐paced world of the hospital. CHAMP improves faculty knowledge and attitudes and the frequency of teaching geriatrics topics and skills necessary to deliver quality care to the elderly hospitalized medical patient. Although the CHAMP FDP was developed and refined for use at a specific institution, the multitiered CHAMP FDP materials and methods have the potential for widespread use by multiple types of inpatient attendings for teaching the care of the older hospitalized medicine patient. Hospitalists in particular will require this expertise as both clinicians and teachers as their role, leadership, and influence continue to expand nationally.

A crucial arena of innovative educational programs for the care of the elderly must include the hospital setting, a place of great cost, morbidity, and mortality for a population currently occupying approximately half of US hospital beds.1 With a marked acceleration in the number of persons living to an advanced age, there is a clear imperative to address the health‐care needs of the elderly, particularly the complex and frail.24 An educational grounding that steps beyond the traditional organ‐based models of disease to a much broader patient‐centered framework of care is necessary to aid physicians in advanced clinical decision‐making in the care of older patients. Organizing the medical care of the older patient within existing systems of care and a team care management network must also be improved.

Curricular materials and methods are widely available for teaching geriatric medicine,57 but most are geared toward outpatient care and management, with few addressing the care of the hospitalized, older medical patient.810 There is even less published on curricular materials, methods, and tools for such teaching outside of specialized hospital‐based geriatric units by nongeriatrics‐trained faculty.1113 Furthermore, the evaluation of geriatrics educational programs in the hospital setting has not been done with the ultimate assessment, the linking of educational programs to demonstrated changes in clinical practice and patient care outcomes.

To address these needs, we designed and implemented the Curriculum for the Hospitalized Aging Medical Patient (CHAMP) Faculty Development Program (FDP). CHAMP was funded by a grant from the Donald W. Reynolds Foundation Aging and Quality of Life Program with a matching commitment from the University of Chicago Department of Medicine. At the core of CHAMP are principles of care for the older patient in the hospital setting, with an emphasis on identifying and providing care for the complex and frail elderly with nongeriatrician inpatient medicine faculty as the primary teachers of these materials. The overall educational goals of the CHAMP FDP are the following: (1) to train hospitalists and general internists to recognize opportunities to teach geriatric medicine topics specific to the care of the hospitalized older patient; (2) to create teaching materials, tools, and methods that can be used in the busy medical inpatient setting at the bedside; (3) to create materials and tools that facilitate teaching the Accreditation Council for Graduate Medical Education (ACGME) core competencies14 during ward rounds; and (4) to increase the frequency and effectiveness with which this geriatrics content is taught in the hospital setting. This article describes the development and refinement of the CHAMP FDP and evaluation results to date.

METHODS

The CHAMP FDP was developed by a core group of geriatricians, hospitalists, general medicine faculty, and PhD educators from the Office of the Dean at the University of Chicago Pritzker School of Medicine. The core group piloted the FDP for themselves in spring 2004, and the FDP was offered to target learners annually from 2004 to 2006.

RESULTS

We pilot‐tested the format, materials, methods, and evaluation components of the CHAMP FDP with the CHAMP core faculty in the spring of 2004. The revised CHAMP FDP was given in the fall of 2004 to the first group of 8 faculty learners. Similar annual CHAMP FDPs have occurred since 2004, with a total of 29 Faculty Scholars by 2006. This includes approximately half of the University of Chicago general medicine faculty and the majority of the hospitalist faculty. Geriatrics fellows, a medicine chief resident, and other internal medicine subspecialists have also taken the CHAMP FDP. The average evaluations of all CHAMP sessions by all participants are shown in Table 3.

Faculty Scholars rated the FDP highly regarding preparation for teaching and incorporation of the material into their teaching and practice. Likewise, qualitative comments by the Faculty Scholars were strongly supportive of CHAMP:

• Significantly more aware and confident in teaching around typical geriatric issues present in our patients.

• Provided concrete, structured ideas about curriculum, learning goals, content materials and how to implement them.

• The online teaching resources were something I used on an almost daily basis.

• Wish we had this for outpatient.

CHAMP had a favorable impact on the Faculty Scholars across the domains of knowledge, attitudes, and perceived behavior change (Table 4). Significant differences on paired‐sample t tests found significant improvement on all but one measure (importance of teaching). After the CHAMP program, Faculty Scholars were more knowledgeable about geriatrics content (P = 0.023), had more positive attitudes to older patients (P = 0.049), and had greater confidence in their ability to care for older patients (P < 0.001) and teach geriatric medicine skills (P < 0.001) and Teaching on Today's Wards content (P < 0.001). There was a significant increase in the perceived importance of practicing the learned skills (P = 0.008) and Teaching on Today's Wards (P = 0.001). The increased importance of teaching geriatrics skills was marginally significant (P = 0.064).

DISCUSSION

Central to CHAMP's design are (1) the creation of teaching materials and teaching resources that specifically address the challenges of teaching the care of the hospitalized older patient in busy hospital settings, (2) the provision of methods to reinforce the newly learned geriatrics teaching skills, and (3) a multidimensional evaluation scheme. The enthusiastic response to the CHAMP FDP and the evaluation results to date support the relevance and importance of CHAMP's focus, materials, and educational methods. The ideal outcome for our CHAMP FDP graduates is more informed, confident, and frequent teaching of geriatrics topics keyed to quality improvement and systems of care through a more streamlined but personalized bedside teaching process.13, 46 The CHAMP Faculty Scholar graduates' self‐report surveys of their performance and teaching of CHAMP course geriatrics skills did reveal a significant shift in clinical behavior, teaching, and confidence. Although the strongest indicator of perceived behavior change was in the enhanced self‐confidence in practicing and teaching, the significant changes in knowledge and attitude reinforce our observations of a shift in the mindset about teaching and caring for hospitalized elderly patients. This provides strong evidence for the efficacy of the CHAMP course in positively influencing participants.

Our biggest challenge with the CHAMP FDP was providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes. After pilot testing, we added multiple types of support and follow‐up to the FDP: observed structured teaching exercises to practice CHAMP geriatrics content and teaching skills; modification of Teaching on Today's Wards through the addition of practice‐oriented exercises, games, and tutorials; frequent contact with our Faculty Scholar graduates post‐CHAMP FDP through CTC contracts; annual Faculty Scholars reunions; and continued access for the scholars to CHAMP materials on our Web site. Maintaining face‐to‐face contact between CHAMP core faculty and Faculty Scholars once the latter have finished the FDP has been challenging, largely because of clinical and teaching obligations over geographically separate sites. To overcome this, we are working to integrate CHAMP core faculty into hospitalist and general medicine section lecture series, increasing the frequency of CHAMP reunions, renewing CTC contracts with the Faculty Scholar graduates annually, and considering the concept of CHAMP core faculty guests attending during Faculty Scholars inpatient ward rounds.47

The CHAMP FDP and our evaluations to date have several limitations. First, FDP Scholars were volunteer participants who may have been more motivated to improve their geriatric care and teaching than nonparticipants. However, FDP Scholars had only moderate levels of geriatrics knowledge, attitudes, and confidence in their teaching on baseline testing and showed marked improvements in these domains after the FDP. In addition, Scholars' FDP participation was made possible by a reduction of other clinical obligations through direct reimbursement to their sections with CHAMP funds. Other incentives for CHAMP participation could include its focus on generalizable bedside teaching skills and provision of specific techniques for teaching the ACGME core competencies and quality improvement while using geriatrics content. Although the CHAMP FDP in its 48‐hour format is not sustainable or generalizable, the FDP modules and CHAMP materials were specifically designed to be usable in small pieces that could be incorporated into existing teaching structures, grand rounds, section meetings, teacher conferences, and continuing medical education workshops. CHAMP core group members have already presented and taught CHAMP components in many venues (see Dissemination on the CHAMP Web site). The excitement generated by CHAMP at national and specialty meetings, including multiple requests for materials, speaks to widespread interest in our CHAMP model. We are pursuing the creation of a mini‐CHAMP, an abbreviated FDP with an online component. These activities as well as feedback from users of CHAMP materials from the CHAMP Web site and the Portal of Geriatric Online Education will provide important opportunities for examining the use and acceptance of CHAMP outside our institution.

Another limitation of the CHAMP FDP is reliance on FDP Scholar self‐assessment in several of the evaluation components. Some studies have shown poor concordance between physicians' self‐assessment and external assessment over a range of domains.48 However, others have noted that despite these limitations, self‐assessment remains an essential tool for enabling physicians to discover the motivational discomfort of a performance gap, which may lead to changing concepts and mental models or changing work‐flow processes.49 Teaching on Today's Wards sessions in CHAMP emphasize self‐audit processes (such as process mapping and census audits) that can augment self‐assessment. We used such self‐audit processes in 1 small pilot study to date, providing summative and qualitative feedback to a group of FDP Scholars on their use of census audits.

However, the evaluation of the CHAMP FDP is enhanced by a yearly survey of all medical residents and medical students and by the linking of the teaching reported by residents and medical students to specific attendings. We have begun the analysis of resident perceptions of being taught CHAMP geriatrics topics by CHAMP faculty versus non‐CHAMP faculty. In addition, we are gathering data on patient‐level process of care and outcomes tied to the CHAMP FDP course session objectives by linking to the ongoing University of Chicago Hospitalist Project, a large clinical research project that enrolls general medicine inpatients in a study examining the quality of care and resource allocation for these patients.50 Because the ultimate goal of CHAMP is to improve the quality of care and outcomes for elderly hospitalized patients, the University of Chicago Hospitalist Project infrastructure was modified by the incorporation of the Vulnerable Elder Survey‐1351 and a process‐of‐care chart audit specifically based on the Assessing Care of the Vulnerable Elders Hospital Quality Indicators.52 Preliminary work included testing and validating these measures.53 Further evaluation of these clinical outcomes and CHAMP's efficacy and durability at the University of Chicago is ongoing and will be presented in future reports.

CONCLUSIONS

Through a collaboration of geriatricians, hospitalists, and general internists, the CHAMP FDP provides educational materials and methods keyed to bedside teaching in the fast‐paced world of the hospital. CHAMP improves faculty knowledge and attitudes and the frequency of teaching geriatrics topics and skills necessary to deliver quality care to the elderly hospitalized medical patient. Although the CHAMP FDP was developed and refined for use at a specific institution, the multitiered CHAMP FDP materials and methods have the potential for widespread use by multiple types of inpatient attendings for teaching the care of the older hospitalized medicine patient. Hospitalists in particular will require this expertise as both clinicians and teachers as their role, leadership, and influence continue to expand nationally.

A crucial arena of innovative educational programs for the care of the elderly must include the hospital setting, a place of great cost, morbidity, and mortality for a population currently occupying approximately half of US hospital beds.1 With a marked acceleration in the number of persons living to an advanced age, there is a clear imperative to address the health‐care needs of the elderly, particularly the complex and frail.24 An educational grounding that steps beyond the traditional organ‐based models of disease to a much broader patient‐centered framework of care is necessary to aid physicians in advanced clinical decision‐making in the care of older patients. Organizing the medical care of the older patient within existing systems of care and a team care management network must also be improved.

Curricular materials and methods are widely available for teaching geriatric medicine,57 but most are geared toward outpatient care and management, with few addressing the care of the hospitalized, older medical patient.810 There is even less published on curricular materials, methods, and tools for such teaching outside of specialized hospital‐based geriatric units by nongeriatrics‐trained faculty.1113 Furthermore, the evaluation of geriatrics educational programs in the hospital setting has not been done with the ultimate assessment, the linking of educational programs to demonstrated changes in clinical practice and patient care outcomes.

To address these needs, we designed and implemented the Curriculum for the Hospitalized Aging Medical Patient (CHAMP) Faculty Development Program (FDP). CHAMP was funded by a grant from the Donald W. Reynolds Foundation Aging and Quality of Life Program with a matching commitment from the University of Chicago Department of Medicine. At the core of CHAMP are principles of care for the older patient in the hospital setting, with an emphasis on identifying and providing care for the complex and frail elderly with nongeriatrician inpatient medicine faculty as the primary teachers of these materials. The overall educational goals of the CHAMP FDP are the following: (1) to train hospitalists and general internists to recognize opportunities to teach geriatric medicine topics specific to the care of the hospitalized older patient; (2) to create teaching materials, tools, and methods that can be used in the busy medical inpatient setting at the bedside; (3) to create materials and tools that facilitate teaching the Accreditation Council for Graduate Medical Education (ACGME) core competencies14 during ward rounds; and (4) to increase the frequency and effectiveness with which this geriatrics content is taught in the hospital setting. This article describes the development and refinement of the CHAMP FDP and evaluation results to date.

METHODS

The CHAMP FDP was developed by a core group of geriatricians, hospitalists, general medicine faculty, and PhD educators from the Office of the Dean at the University of Chicago Pritzker School of Medicine. The core group piloted the FDP for themselves in spring 2004, and the FDP was offered to target learners annually from 2004 to 2006.

RESULTS

We pilot‐tested the format, materials, methods, and evaluation components of the CHAMP FDP with the CHAMP core faculty in the spring of 2004. The revised CHAMP FDP was given in the fall of 2004 to the first group of 8 faculty learners. Similar annual CHAMP FDPs have occurred since 2004, with a total of 29 Faculty Scholars by 2006. This includes approximately half of the University of Chicago general medicine faculty and the majority of the hospitalist faculty. Geriatrics fellows, a medicine chief resident, and other internal medicine subspecialists have also taken the CHAMP FDP. The average evaluations of all CHAMP sessions by all participants are shown in Table 3.

Faculty Scholars rated the FDP highly regarding preparation for teaching and incorporation of the material into their teaching and practice. Likewise, qualitative comments by the Faculty Scholars were strongly supportive of CHAMP:

• Significantly more aware and confident in teaching around typical geriatric issues present in our patients.

• Provided concrete, structured ideas about curriculum, learning goals, content materials and how to implement them.

• The online teaching resources were something I used on an almost daily basis.

• Wish we had this for outpatient.

CHAMP had a favorable impact on the Faculty Scholars across the domains of knowledge, attitudes, and perceived behavior change (Table 4). Significant differences on paired‐sample t tests found significant improvement on all but one measure (importance of teaching). After the CHAMP program, Faculty Scholars were more knowledgeable about geriatrics content (P = 0.023), had more positive attitudes to older patients (P = 0.049), and had greater confidence in their ability to care for older patients (P < 0.001) and teach geriatric medicine skills (P < 0.001) and Teaching on Today's Wards content (P < 0.001). There was a significant increase in the perceived importance of practicing the learned skills (P = 0.008) and Teaching on Today's Wards (P = 0.001). The increased importance of teaching geriatrics skills was marginally significant (P = 0.064).