How many times have you been asked a medical question outside the hospital? Undoubtedly, it happens too many times to count.

An acquaintance asks about a strange pain; you look at a rash on your neighbor’s son; you guide a nurse when she can’t reach a patient’s physician; a colleague asks for a curbside consult; or you provide medical advice over the phone to another provider while on-call at the hospital. When do any of the people in these situations become your patient?

Unfortunately, there is no easy answer. Legally, the question of whether a physician-patient relationship is created is determined on a case-by-case basis. As a general rule, if a physician undertakes to treat or provide medical care, a physician-patient relationship exists and the physician contracts to exercise reasonable skill in providing the care.

Implied Relationships

Absent an express agreement to enter a physician-patient relationship, the law may imply a relationship based on conduct that demonstrates consent to a relationship. A patient demonstrates consent by seeking medical services. Consent may also be implied when, for example, a patient needs emergency care, services are provided at the request of a treating physician, or treatment is mandated by a court.

Physicians consent to a relationship by diagnosing, treating, or otherwise providing care. A physician can also consent simply because of a working arrangement with a hospital or other entity—such as an agreement to accept assignment of patients.

In determining whether a physician-patient relationship has been created, consider the absence or existence of affirmative acts by a physician. For example, when a physician receives a call from a patient’s treating physician and the two physicians discuss the patient, the conversation might not create a physician-patient relationship if the consulting physician does not expressly provide an opinion. This is because there is no affirmative action upon which a court can imply a duty. Likewise, an on-call doctor does not create a physician-patient relationship simply by being on-call when she does not see, treat, or participate in the care of a patient.

Conversely, acts sufficient to create a physician-patient relationship exist when an on-call or consulting physician offers advice, provides treatment, or discharges a patient. Notably, an implied duty can be inferred even if the physician has not had direct contact with a patient if the court determines the physician’s conduct has interfered with a patient’s interests—thereby entitling the patient to legal protection.

Duties of Physicians

Even absent a physician-patient relationship, the law can impose general duties on physicians. Physicians have a duty to use reasonable care in regard to affirmative conduct when it is foreseeable that another might be injured.

For example, the Colorado Supreme Court found that an anesthesiologist owed a general duty to hospital patients who were not his patients when the physician’s failure to properly dispose of medication exposed patients to a foreseeable risk of harm.

The court has also found that a physician retained by defendants in a personal injury lawsuit owed a duty of reasonable care when subjecting the plaintiff to medical examinations. Similarly, the court concluded that an independent medical examiner could be liable for any injury the examiner causes during an examination, even though the examiner does not owe a duty to accurately diagnose the patient.

Is That Your Patient?

Ultimately, a physician-patient relationship and its corresponding duties arise when reasonable people would recognize a duty and agree that it exists. You must analyze your conduct and interactions, including your:

• Communication with patients or nonpatients (including e-mail or conversations in passing);
• On-call status;
• Agreements with facilities, a service, or other providers to accept patients;
• Degree of responsibility for a given patient’s care;
• Charges or fee discussion;
• Affirmative acts of care or treatment as distinguished from examination solely for the benefit of a third party;
• Initiation of contact with the patient or patient’s family;
• Referral from another physician or non-physician; and
• Consultations with other physicians, either formal or informal and whether different areas of expertise are involved or specific care or advise is given.

Ultimate determination of whether a physician-patient relationship exists is fact-specific—and no single fact is definitive. The above factors may guide you in assessing the nature of your interactions with patients and your attendant responsibilities. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

How many times have you been asked a medical question outside the hospital? Undoubtedly, it happens too many times to count.

An acquaintance asks about a strange pain; you look at a rash on your neighbor’s son; you guide a nurse when she can’t reach a patient’s physician; a colleague asks for a curbside consult; or you provide medical advice over the phone to another provider while on-call at the hospital. When do any of the people in these situations become your patient?

Unfortunately, there is no easy answer. Legally, the question of whether a physician-patient relationship is created is determined on a case-by-case basis. As a general rule, if a physician undertakes to treat or provide medical care, a physician-patient relationship exists and the physician contracts to exercise reasonable skill in providing the care.

Implied Relationships

Absent an express agreement to enter a physician-patient relationship, the law may imply a relationship based on conduct that demonstrates consent to a relationship. A patient demonstrates consent by seeking medical services. Consent may also be implied when, for example, a patient needs emergency care, services are provided at the request of a treating physician, or treatment is mandated by a court.

Physicians consent to a relationship by diagnosing, treating, or otherwise providing care. A physician can also consent simply because of a working arrangement with a hospital or other entity—such as an agreement to accept assignment of patients.

In determining whether a physician-patient relationship has been created, consider the absence or existence of affirmative acts by a physician. For example, when a physician receives a call from a patient’s treating physician and the two physicians discuss the patient, the conversation might not create a physician-patient relationship if the consulting physician does not expressly provide an opinion. This is because there is no affirmative action upon which a court can imply a duty. Likewise, an on-call doctor does not create a physician-patient relationship simply by being on-call when she does not see, treat, or participate in the care of a patient.

Conversely, acts sufficient to create a physician-patient relationship exist when an on-call or consulting physician offers advice, provides treatment, or discharges a patient. Notably, an implied duty can be inferred even if the physician has not had direct contact with a patient if the court determines the physician’s conduct has interfered with a patient’s interests—thereby entitling the patient to legal protection.

Duties of Physicians

Even absent a physician-patient relationship, the law can impose general duties on physicians. Physicians have a duty to use reasonable care in regard to affirmative conduct when it is foreseeable that another might be injured.

For example, the Colorado Supreme Court found that an anesthesiologist owed a general duty to hospital patients who were not his patients when the physician’s failure to properly dispose of medication exposed patients to a foreseeable risk of harm.

The court has also found that a physician retained by defendants in a personal injury lawsuit owed a duty of reasonable care when subjecting the plaintiff to medical examinations. Similarly, the court concluded that an independent medical examiner could be liable for any injury the examiner causes during an examination, even though the examiner does not owe a duty to accurately diagnose the patient.

Is That Your Patient?

Ultimately, a physician-patient relationship and its corresponding duties arise when reasonable people would recognize a duty and agree that it exists. You must analyze your conduct and interactions, including your:

• Communication with patients or nonpatients (including e-mail or conversations in passing);
• On-call status;
• Agreements with facilities, a service, or other providers to accept patients;
• Degree of responsibility for a given patient’s care;
• Charges or fee discussion;
• Affirmative acts of care or treatment as distinguished from examination solely for the benefit of a third party;
• Initiation of contact with the patient or patient’s family;
• Referral from another physician or non-physician; and
• Consultations with other physicians, either formal or informal and whether different areas of expertise are involved or specific care or advise is given.

Ultimate determination of whether a physician-patient relationship exists is fact-specific—and no single fact is definitive. The above factors may guide you in assessing the nature of your interactions with patients and your attendant responsibilities. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

How many times have you been asked a medical question outside the hospital? Undoubtedly, it happens too many times to count.

An acquaintance asks about a strange pain; you look at a rash on your neighbor’s son; you guide a nurse when she can’t reach a patient’s physician; a colleague asks for a curbside consult; or you provide medical advice over the phone to another provider while on-call at the hospital. When do any of the people in these situations become your patient?

Unfortunately, there is no easy answer. Legally, the question of whether a physician-patient relationship is created is determined on a case-by-case basis. As a general rule, if a physician undertakes to treat or provide medical care, a physician-patient relationship exists and the physician contracts to exercise reasonable skill in providing the care.

Implied Relationships

Absent an express agreement to enter a physician-patient relationship, the law may imply a relationship based on conduct that demonstrates consent to a relationship. A patient demonstrates consent by seeking medical services. Consent may also be implied when, for example, a patient needs emergency care, services are provided at the request of a treating physician, or treatment is mandated by a court.

Physicians consent to a relationship by diagnosing, treating, or otherwise providing care. A physician can also consent simply because of a working arrangement with a hospital or other entity—such as an agreement to accept assignment of patients.

In determining whether a physician-patient relationship has been created, consider the absence or existence of affirmative acts by a physician. For example, when a physician receives a call from a patient’s treating physician and the two physicians discuss the patient, the conversation might not create a physician-patient relationship if the consulting physician does not expressly provide an opinion. This is because there is no affirmative action upon which a court can imply a duty. Likewise, an on-call doctor does not create a physician-patient relationship simply by being on-call when she does not see, treat, or participate in the care of a patient.

Conversely, acts sufficient to create a physician-patient relationship exist when an on-call or consulting physician offers advice, provides treatment, or discharges a patient. Notably, an implied duty can be inferred even if the physician has not had direct contact with a patient if the court determines the physician’s conduct has interfered with a patient’s interests—thereby entitling the patient to legal protection.

Duties of Physicians

Even absent a physician-patient relationship, the law can impose general duties on physicians. Physicians have a duty to use reasonable care in regard to affirmative conduct when it is foreseeable that another might be injured.

For example, the Colorado Supreme Court found that an anesthesiologist owed a general duty to hospital patients who were not his patients when the physician’s failure to properly dispose of medication exposed patients to a foreseeable risk of harm.

The court has also found that a physician retained by defendants in a personal injury lawsuit owed a duty of reasonable care when subjecting the plaintiff to medical examinations. Similarly, the court concluded that an independent medical examiner could be liable for any injury the examiner causes during an examination, even though the examiner does not owe a duty to accurately diagnose the patient.

Is That Your Patient?

Ultimately, a physician-patient relationship and its corresponding duties arise when reasonable people would recognize a duty and agree that it exists. You must analyze your conduct and interactions, including your:

• Communication with patients or nonpatients (including e-mail or conversations in passing);
• On-call status;
• Agreements with facilities, a service, or other providers to accept patients;
• Degree of responsibility for a given patient’s care;
• Charges or fee discussion;
• Affirmative acts of care or treatment as distinguished from examination solely for the benefit of a third party;
• Initiation of contact with the patient or patient’s family;
• Referral from another physician or non-physician; and
• Consultations with other physicians, either formal or informal and whether different areas of expertise are involved or specific care or advise is given.

Ultimate determination of whether a physician-patient relationship exists is fact-specific—and no single fact is definitive. The above factors may guide you in assessing the nature of your interactions with patients and your attendant responsibilities. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.

Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA).

1995, 1997 Guidelines

Two sets of documentation guidelines are in place, referred to as the 1995 and 1997 guidelines. Increased criticism of the ambiguity in the 1995 guidelines from auditors and providers inspired development of the 1997 guidelines.

While the 1997 guidelines were intended to create a more objective and unified approach to documentation, the level of specificity required brought criticism and frustration. But while the physician community balked, most auditors praised these efforts.

To satisfy all parties and allow physicians to document as they prefer, both sets of guidelines remain. Physicians can document according to either style, and auditors are obligated to review provider records against both sets of guidelines, selecting the final visit level with the set that best supports provider documentation.

click for large version

Elements of History

Chief complaint (CC): The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).

History of present illness (HPI): This is a description of the present illness as it developed. It is typically formatted and documented with reference to location, quality, severity, timing, context, modifying factors, and associated signs/symptoms as related to the chief complaint. The HPI may be classified as brief (a comment on fewer than HPI elements) or extended (a comment on more than four HPI elements). Sample documentation of an extended HPI is: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”

The 1997 guidelines offer an alternate format for documenting the HPI. In contrast to the standard method above, the physician may list and status the patient’s chronic or inactive conditions. An extended HPI consists of the status of at least three chronic or inactive conditions (e.g., “Diabetes controlled by oral medication; extrinsic asthma without acute exacerbation in past six months; hypertension stable with pressures ranging from 130-140/80-90”). Failing to document the status negates the opportunity for the physician to receive HPI credit. Instead, he will receive credit for a past medical history.

The HPI should never be documented by ancillary staff (e.g., registered nurse, medical assistant, students). HPI might be documented by residents (e.g., residents, fellows, interns) or nonphysician providers (nurse practitioners and physician assistants) when utilizing the Teaching Physician Rules or Split-Shared Billing Rules, respectively (teaching Physician Rules and Split-Shared Billing Rules will be addressed in an upcoming issue).

Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:

• Constitutional;
• Eyes; ears, nose, mouth, throat;
• Cardiovascular;
• Respiratory;
• Gastrointestinal;
• Genitourinary;
• Musculoskeletal;
• Integumentary (including skin and/or breast);
• Neurological;
• Psychiatric;
• Endocrine;
• Hematologic/lymphatic; and
• Allergic/immunologic.

The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).

Documentation of a complete ROS (more than 10 systems) can occur in two ways:

• The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or
• The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.

Information involving the ROS can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented ROS in his progress note. Re-documentation of the ROS is not necessary unless a revision is required.

Past, family, and social history (PFSH): Documentation of PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH can be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). Documentation that exemplifies a complete PFSH is: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

As with ROS, the PFSH can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented PFSH in his progress note. Re-documentation of the PFSH is not necessary unless a revision is required. It is important to note that while documentation of the PFSH is required when billing higher level consultations (99254-99255) or initial inpatient care (99221-99223), it is not required when reporting subsequent hospital care services (99231-99233).

click for large version

Levels of History

There are four levels of history, determined by the number of elements documented in the progress note (see Table 1, p. 21). The physician must meet all the requirements in a specific level of history before assigning it.

If all of the required elements in a given history level are not documented, the level assigned is that of the least documented element. For example, physician documentation may include four HPI elements and a complete PFSH, yet only eight ROS. The physician can only receive credit for a detailed history. If the physician submitted a claim for 99222 (initial hospital care requiring a comprehensive history, a comprehensive exam, and moderate-complexity decision making), documentation would not support the reported service due to the underdocumented ROS. Deficiencies in the ROS and family history are the most common physician documentation errors involving the history component.

A specific level of history is associated with each type of physician encounter, and must be documented accordingly (see Table 2, right). The most common visit categories provided by hospitalists that include documentation requirements for history are initial inpatient consultations, initial hospital care, subsequent hospital care, and initial observation care. Other visit categories, such as critical care and discharge day management, have neither associated levels of history nor documentation requirements for historical elements. TH

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

Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.

Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA).

1995, 1997 Guidelines

Two sets of documentation guidelines are in place, referred to as the 1995 and 1997 guidelines. Increased criticism of the ambiguity in the 1995 guidelines from auditors and providers inspired development of the 1997 guidelines.

While the 1997 guidelines were intended to create a more objective and unified approach to documentation, the level of specificity required brought criticism and frustration. But while the physician community balked, most auditors praised these efforts.

To satisfy all parties and allow physicians to document as they prefer, both sets of guidelines remain. Physicians can document according to either style, and auditors are obligated to review provider records against both sets of guidelines, selecting the final visit level with the set that best supports provider documentation.

click for large version

Elements of History

Chief complaint (CC): The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).

History of present illness (HPI): This is a description of the present illness as it developed. It is typically formatted and documented with reference to location, quality, severity, timing, context, modifying factors, and associated signs/symptoms as related to the chief complaint. The HPI may be classified as brief (a comment on fewer than HPI elements) or extended (a comment on more than four HPI elements). Sample documentation of an extended HPI is: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”

The 1997 guidelines offer an alternate format for documenting the HPI. In contrast to the standard method above, the physician may list and status the patient’s chronic or inactive conditions. An extended HPI consists of the status of at least three chronic or inactive conditions (e.g., “Diabetes controlled by oral medication; extrinsic asthma without acute exacerbation in past six months; hypertension stable with pressures ranging from 130-140/80-90”). Failing to document the status negates the opportunity for the physician to receive HPI credit. Instead, he will receive credit for a past medical history.

The HPI should never be documented by ancillary staff (e.g., registered nurse, medical assistant, students). HPI might be documented by residents (e.g., residents, fellows, interns) or nonphysician providers (nurse practitioners and physician assistants) when utilizing the Teaching Physician Rules or Split-Shared Billing Rules, respectively (teaching Physician Rules and Split-Shared Billing Rules will be addressed in an upcoming issue).

Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:

• Constitutional;
• Eyes; ears, nose, mouth, throat;
• Cardiovascular;
• Respiratory;
• Gastrointestinal;
• Genitourinary;
• Musculoskeletal;
• Integumentary (including skin and/or breast);
• Neurological;
• Psychiatric;
• Endocrine;
• Hematologic/lymphatic; and
• Allergic/immunologic.

The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).

Documentation of a complete ROS (more than 10 systems) can occur in two ways:

• The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or
• The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.

Information involving the ROS can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented ROS in his progress note. Re-documentation of the ROS is not necessary unless a revision is required.

Past, family, and social history (PFSH): Documentation of PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH can be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). Documentation that exemplifies a complete PFSH is: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

As with ROS, the PFSH can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented PFSH in his progress note. Re-documentation of the PFSH is not necessary unless a revision is required. It is important to note that while documentation of the PFSH is required when billing higher level consultations (99254-99255) or initial inpatient care (99221-99223), it is not required when reporting subsequent hospital care services (99231-99233).

click for large version

Levels of History

There are four levels of history, determined by the number of elements documented in the progress note (see Table 1, p. 21). The physician must meet all the requirements in a specific level of history before assigning it.

If all of the required elements in a given history level are not documented, the level assigned is that of the least documented element. For example, physician documentation may include four HPI elements and a complete PFSH, yet only eight ROS. The physician can only receive credit for a detailed history. If the physician submitted a claim for 99222 (initial hospital care requiring a comprehensive history, a comprehensive exam, and moderate-complexity decision making), documentation would not support the reported service due to the underdocumented ROS. Deficiencies in the ROS and family history are the most common physician documentation errors involving the history component.

A specific level of history is associated with each type of physician encounter, and must be documented accordingly (see Table 2, right). The most common visit categories provided by hospitalists that include documentation requirements for history are initial inpatient consultations, initial hospital care, subsequent hospital care, and initial observation care. Other visit categories, such as critical care and discharge day management, have neither associated levels of history nor documentation requirements for historical elements. TH

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

Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.

Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA).

1995, 1997 Guidelines

Two sets of documentation guidelines are in place, referred to as the 1995 and 1997 guidelines. Increased criticism of the ambiguity in the 1995 guidelines from auditors and providers inspired development of the 1997 guidelines.

While the 1997 guidelines were intended to create a more objective and unified approach to documentation, the level of specificity required brought criticism and frustration. But while the physician community balked, most auditors praised these efforts.

To satisfy all parties and allow physicians to document as they prefer, both sets of guidelines remain. Physicians can document according to either style, and auditors are obligated to review provider records against both sets of guidelines, selecting the final visit level with the set that best supports provider documentation.

click for large version

Elements of History

Chief complaint (CC): The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).

History of present illness (HPI): This is a description of the present illness as it developed. It is typically formatted and documented with reference to location, quality, severity, timing, context, modifying factors, and associated signs/symptoms as related to the chief complaint. The HPI may be classified as brief (a comment on fewer than HPI elements) or extended (a comment on more than four HPI elements). Sample documentation of an extended HPI is: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”

The 1997 guidelines offer an alternate format for documenting the HPI. In contrast to the standard method above, the physician may list and status the patient’s chronic or inactive conditions. An extended HPI consists of the status of at least three chronic or inactive conditions (e.g., “Diabetes controlled by oral medication; extrinsic asthma without acute exacerbation in past six months; hypertension stable with pressures ranging from 130-140/80-90”). Failing to document the status negates the opportunity for the physician to receive HPI credit. Instead, he will receive credit for a past medical history.

The HPI should never be documented by ancillary staff (e.g., registered nurse, medical assistant, students). HPI might be documented by residents (e.g., residents, fellows, interns) or nonphysician providers (nurse practitioners and physician assistants) when utilizing the Teaching Physician Rules or Split-Shared Billing Rules, respectively (teaching Physician Rules and Split-Shared Billing Rules will be addressed in an upcoming issue).

Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:

• Constitutional;
• Eyes; ears, nose, mouth, throat;
• Cardiovascular;
• Respiratory;
• Gastrointestinal;
• Genitourinary;
• Musculoskeletal;
• Integumentary (including skin and/or breast);
• Neurological;
• Psychiatric;
• Endocrine;
• Hematologic/lymphatic; and
• Allergic/immunologic.

The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).

Documentation of a complete ROS (more than 10 systems) can occur in two ways:

• The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or
• The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.

Information involving the ROS can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented ROS in his progress note. Re-documentation of the ROS is not necessary unless a revision is required.

Past, family, and social history (PFSH): Documentation of PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH can be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). Documentation that exemplifies a complete PFSH is: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

As with ROS, the PFSH can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented PFSH in his progress note. Re-documentation of the PFSH is not necessary unless a revision is required. It is important to note that while documentation of the PFSH is required when billing higher level consultations (99254-99255) or initial inpatient care (99221-99223), it is not required when reporting subsequent hospital care services (99231-99233).

click for large version

Levels of History

There are four levels of history, determined by the number of elements documented in the progress note (see Table 1, p. 21). The physician must meet all the requirements in a specific level of history before assigning it.

If all of the required elements in a given history level are not documented, the level assigned is that of the least documented element. For example, physician documentation may include four HPI elements and a complete PFSH, yet only eight ROS. The physician can only receive credit for a detailed history. If the physician submitted a claim for 99222 (initial hospital care requiring a comprehensive history, a comprehensive exam, and moderate-complexity decision making), documentation would not support the reported service due to the underdocumented ROS. Deficiencies in the ROS and family history are the most common physician documentation errors involving the history component.

A specific level of history is associated with each type of physician encounter, and must be documented accordingly (see Table 2, right). The most common visit categories provided by hospitalists that include documentation requirements for history are initial inpatient consultations, initial hospital care, subsequent hospital care, and initial observation care. Other visit categories, such as critical care and discharge day management, have neither associated levels of history nor documentation requirements for historical elements. TH

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

The current pay-for-reporting program from the Centers for Medicare and Medicaid (CMS) seems tailor-made for hospitalists. Here’s a look at the voluntary Physician Quality Reporting Initiative (PQRI) program, and why and how hospitalists are—and are not—participating.

CMS has revised the reporting program that began as a six-month trial in 2007. The current PQRI runs the full calendar year for 2008 and includes 119 quality measures—11 of which hospitalists can report on. Detailed specifications for the measures are available on the CMS Web site at www.cms.hhs.gov.

The earnings in this pay-for-reporting program remain the same as 2007: Physicians who successfully report on measures can earn a bonus payment equal to 1.5% of their total Medicare-allowed charges. Some hospitalists have collected their bonus for participating in the 2007 trial; it’s likely more will participate this year.

CMS has yet to release data on participation in the 2007 PQRI trial or this year’s initiative. However, SHM has urged hospitalists to participate, and many are. During a national, SHM-sponsored conference call with CMS in summer 2007, approximately 20% of the 160 hospitalists participating in the call responded to a follow-up survey. Almost half of all respondents indicated they planned to participate in PQRI reporting.

“That percentage comes from a select group of hospitalists who were highly interested in the PQRI,” points out Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

Unlike many specialists, hospitalists are finding reporting to be a straightforward process. “For hospitalists, PQRI reporting on specific measures harmonizes nicely with workflow,” says Dr. Torcson. “Most applicable measures take place during admission or discharge. Documentation and reporting for PQRI can take place during these times.”

Report on Reporting

At St. Tammany, Dr. Torcson’s eight-hospitalist team is participating in PQRI. Although you need only to report on three measures to qualify for a bonus payment from the program, “we’re actually reporting on the full list of [hospitalist-applicable] measures,” Dr. Torcson says. It’s up to each St. Tammany hospitalist to remember to report on the 11 measures.

“Support for [reporting] really comes down to physician memory,” says Dr. Torcson. “Long term, this is going to have to be part of an electronic system, with decision support and billing capability from an electronic health record.”

In spite of the added step of PQRI reporting, Dr. Torcson says, “we’ve had an enthusiastic response from our hospitalists.” The payoff for the hospital medicine program and the hospital is yet to be seen. “You hope that PQRI performance reporting will result in improved quality of care,” henotes.

But many physicians—including hospitalists—are not participating in PQRI.

“It comes down to different practice models,” explains Dr. Torcson. “But for many physicians, a major reason not to participate is that they’re taking a wait-­and-see approach. They’re waiting to see if this is just the latest flavor of the month, and think it’s not worth investing time and effort until it proves otherwise.”

Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego (UCSD) School of Medicine, Division of Hospital Medicine, is a member of SHM’s Public Policy Committee and says he was disappointed his group is unable to participate in PQRI.

“I work for UCSD, where our hospitalist group is one of many, many subspecialty groups that work out of our hospital,” he explains “We do a lot of QI work, and we were certainly interested in participating in PQRI.” However, the hospital uses an electronic billing system incompatible with reporting on the measures. The software could be upgraded for about $15,000, says Dr. Seymann, but hospital administration sees no return on the investment.

“The cost wouldn’t match the increase in revenues because besides hospital medicine, there aren’t a lot of other subspecialties that would be interested in participating,” explains Dr. Seymann. “As much as I wanted our group to participate, I can’t fully fault UCSD on this decision on business grounds. They want to see some stability in [the decision to continue PQRI] before they invest.”

In the meantime, the orthopedics group at UCSD has invested in reporting. They are tracking PQRI measures on paper and reporting to CMS, and they’ll ultimately be able to show the administration whether the bonus per physician might add up to the cost of the necessary billing-system upgrade.

Beyond 2008

Everyone involved—not just UCSD—is asking: Is PQRI here to stay? That decision rests with federal lawmakers. At the end of this year, Congress must vote on whether to extend the program—and no one can guarantee whether that will happen.

“The chairs of the Senate Finance Committee have been tremendously supportive of the PQRI,” says Dr. Torcson. “There is a lot of political will behind this right now. [PQRI supporters in Congress] want better quality in healthcare for better pay.”

This year’s election will have a major impact on this decision: “A change in administration will definitely factor in,” warns Dr. Torcson. “The 2008 Medicare Physician Payment Update seemed to divide along party lines. Republicans were somewhat supportive, and Democrats didn’t seem to support it. It’s not quite that simple, but that was a general pattern.”

The best advice for physicians invested or interested in investing in PQRI is to keep an eye on the November election results and the Senate Finance Committee to find out what 2009 and beyond will look like for PQRI or other CMS pay-for-reporting initiatives.

Too Late to Participate?

Although the PQRI began Jan. 1, there is no enrollment process; physicians can start reporting any time during the year. However, participants reporting on three measures report in at least 80% of the instances in which those measures are reportable—that means all year—in order to qualify for a bonus. If you begin reporting this far into the year, you’re not likely to reach that threshold and earn your bonus.

“Starting late in the year could affect reaching that threshold, but it’s never too late to start the practice and process of reporting,” says Dr. Torcson. “You can still make that commitment to performance reporting. Even if you don’t get the 1.5% bonus, you get the benefit of getting started in the important practice of performance reporting.”

Read more about the PQRI on SHM’s Web site (www.hospitalmedicine.org). TH

Jane Jerrard has written for The Hospitalist since 2005.

The current pay-for-reporting program from the Centers for Medicare and Medicaid (CMS) seems tailor-made for hospitalists. Here’s a look at the voluntary Physician Quality Reporting Initiative (PQRI) program, and why and how hospitalists are—and are not—participating.

CMS has revised the reporting program that began as a six-month trial in 2007. The current PQRI runs the full calendar year for 2008 and includes 119 quality measures—11 of which hospitalists can report on. Detailed specifications for the measures are available on the CMS Web site at www.cms.hhs.gov.

The earnings in this pay-for-reporting program remain the same as 2007: Physicians who successfully report on measures can earn a bonus payment equal to 1.5% of their total Medicare-allowed charges. Some hospitalists have collected their bonus for participating in the 2007 trial; it’s likely more will participate this year.

CMS has yet to release data on participation in the 2007 PQRI trial or this year’s initiative. However, SHM has urged hospitalists to participate, and many are. During a national, SHM-sponsored conference call with CMS in summer 2007, approximately 20% of the 160 hospitalists participating in the call responded to a follow-up survey. Almost half of all respondents indicated they planned to participate in PQRI reporting.

“That percentage comes from a select group of hospitalists who were highly interested in the PQRI,” points out Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

Unlike many specialists, hospitalists are finding reporting to be a straightforward process. “For hospitalists, PQRI reporting on specific measures harmonizes nicely with workflow,” says Dr. Torcson. “Most applicable measures take place during admission or discharge. Documentation and reporting for PQRI can take place during these times.”

Report on Reporting

At St. Tammany, Dr. Torcson’s eight-hospitalist team is participating in PQRI. Although you need only to report on three measures to qualify for a bonus payment from the program, “we’re actually reporting on the full list of [hospitalist-applicable] measures,” Dr. Torcson says. It’s up to each St. Tammany hospitalist to remember to report on the 11 measures.

“Support for [reporting] really comes down to physician memory,” says Dr. Torcson. “Long term, this is going to have to be part of an electronic system, with decision support and billing capability from an electronic health record.”

In spite of the added step of PQRI reporting, Dr. Torcson says, “we’ve had an enthusiastic response from our hospitalists.” The payoff for the hospital medicine program and the hospital is yet to be seen. “You hope that PQRI performance reporting will result in improved quality of care,” henotes.

But many physicians—including hospitalists—are not participating in PQRI.

“It comes down to different practice models,” explains Dr. Torcson. “But for many physicians, a major reason not to participate is that they’re taking a wait-­and-see approach. They’re waiting to see if this is just the latest flavor of the month, and think it’s not worth investing time and effort until it proves otherwise.”

Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego (UCSD) School of Medicine, Division of Hospital Medicine, is a member of SHM’s Public Policy Committee and says he was disappointed his group is unable to participate in PQRI.

“I work for UCSD, where our hospitalist group is one of many, many subspecialty groups that work out of our hospital,” he explains “We do a lot of QI work, and we were certainly interested in participating in PQRI.” However, the hospital uses an electronic billing system incompatible with reporting on the measures. The software could be upgraded for about $15,000, says Dr. Seymann, but hospital administration sees no return on the investment.

“The cost wouldn’t match the increase in revenues because besides hospital medicine, there aren’t a lot of other subspecialties that would be interested in participating,” explains Dr. Seymann. “As much as I wanted our group to participate, I can’t fully fault UCSD on this decision on business grounds. They want to see some stability in [the decision to continue PQRI] before they invest.”

In the meantime, the orthopedics group at UCSD has invested in reporting. They are tracking PQRI measures on paper and reporting to CMS, and they’ll ultimately be able to show the administration whether the bonus per physician might add up to the cost of the necessary billing-system upgrade.

Beyond 2008

Everyone involved—not just UCSD—is asking: Is PQRI here to stay? That decision rests with federal lawmakers. At the end of this year, Congress must vote on whether to extend the program—and no one can guarantee whether that will happen.

“The chairs of the Senate Finance Committee have been tremendously supportive of the PQRI,” says Dr. Torcson. “There is a lot of political will behind this right now. [PQRI supporters in Congress] want better quality in healthcare for better pay.”

This year’s election will have a major impact on this decision: “A change in administration will definitely factor in,” warns Dr. Torcson. “The 2008 Medicare Physician Payment Update seemed to divide along party lines. Republicans were somewhat supportive, and Democrats didn’t seem to support it. It’s not quite that simple, but that was a general pattern.”

The best advice for physicians invested or interested in investing in PQRI is to keep an eye on the November election results and the Senate Finance Committee to find out what 2009 and beyond will look like for PQRI or other CMS pay-for-reporting initiatives.

Too Late to Participate?

Although the PQRI began Jan. 1, there is no enrollment process; physicians can start reporting any time during the year. However, participants reporting on three measures report in at least 80% of the instances in which those measures are reportable—that means all year—in order to qualify for a bonus. If you begin reporting this far into the year, you’re not likely to reach that threshold and earn your bonus.

“Starting late in the year could affect reaching that threshold, but it’s never too late to start the practice and process of reporting,” says Dr. Torcson. “You can still make that commitment to performance reporting. Even if you don’t get the 1.5% bonus, you get the benefit of getting started in the important practice of performance reporting.”

Read more about the PQRI on SHM’s Web site (www.hospitalmedicine.org). TH

Jane Jerrard has written for The Hospitalist since 2005.

The current pay-for-reporting program from the Centers for Medicare and Medicaid (CMS) seems tailor-made for hospitalists. Here’s a look at the voluntary Physician Quality Reporting Initiative (PQRI) program, and why and how hospitalists are—and are not—participating.

CMS has revised the reporting program that began as a six-month trial in 2007. The current PQRI runs the full calendar year for 2008 and includes 119 quality measures—11 of which hospitalists can report on. Detailed specifications for the measures are available on the CMS Web site at www.cms.hhs.gov.

The earnings in this pay-for-reporting program remain the same as 2007: Physicians who successfully report on measures can earn a bonus payment equal to 1.5% of their total Medicare-allowed charges. Some hospitalists have collected their bonus for participating in the 2007 trial; it’s likely more will participate this year.

CMS has yet to release data on participation in the 2007 PQRI trial or this year’s initiative. However, SHM has urged hospitalists to participate, and many are. During a national, SHM-sponsored conference call with CMS in summer 2007, approximately 20% of the 160 hospitalists participating in the call responded to a follow-up survey. Almost half of all respondents indicated they planned to participate in PQRI reporting.

“That percentage comes from a select group of hospitalists who were highly interested in the PQRI,” points out Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

Unlike many specialists, hospitalists are finding reporting to be a straightforward process. “For hospitalists, PQRI reporting on specific measures harmonizes nicely with workflow,” says Dr. Torcson. “Most applicable measures take place during admission or discharge. Documentation and reporting for PQRI can take place during these times.”

Report on Reporting

At St. Tammany, Dr. Torcson’s eight-hospitalist team is participating in PQRI. Although you need only to report on three measures to qualify for a bonus payment from the program, “we’re actually reporting on the full list of [hospitalist-applicable] measures,” Dr. Torcson says. It’s up to each St. Tammany hospitalist to remember to report on the 11 measures.

“Support for [reporting] really comes down to physician memory,” says Dr. Torcson. “Long term, this is going to have to be part of an electronic system, with decision support and billing capability from an electronic health record.”

In spite of the added step of PQRI reporting, Dr. Torcson says, “we’ve had an enthusiastic response from our hospitalists.” The payoff for the hospital medicine program and the hospital is yet to be seen. “You hope that PQRI performance reporting will result in improved quality of care,” henotes.

But many physicians—including hospitalists—are not participating in PQRI.

“It comes down to different practice models,” explains Dr. Torcson. “But for many physicians, a major reason not to participate is that they’re taking a wait-­and-see approach. They’re waiting to see if this is just the latest flavor of the month, and think it’s not worth investing time and effort until it proves otherwise.”

Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego (UCSD) School of Medicine, Division of Hospital Medicine, is a member of SHM’s Public Policy Committee and says he was disappointed his group is unable to participate in PQRI.

“I work for UCSD, where our hospitalist group is one of many, many subspecialty groups that work out of our hospital,” he explains “We do a lot of QI work, and we were certainly interested in participating in PQRI.” However, the hospital uses an electronic billing system incompatible with reporting on the measures. The software could be upgraded for about $15,000, says Dr. Seymann, but hospital administration sees no return on the investment.

“The cost wouldn’t match the increase in revenues because besides hospital medicine, there aren’t a lot of other subspecialties that would be interested in participating,” explains Dr. Seymann. “As much as I wanted our group to participate, I can’t fully fault UCSD on this decision on business grounds. They want to see some stability in [the decision to continue PQRI] before they invest.”

In the meantime, the orthopedics group at UCSD has invested in reporting. They are tracking PQRI measures on paper and reporting to CMS, and they’ll ultimately be able to show the administration whether the bonus per physician might add up to the cost of the necessary billing-system upgrade.

Beyond 2008

Everyone involved—not just UCSD—is asking: Is PQRI here to stay? That decision rests with federal lawmakers. At the end of this year, Congress must vote on whether to extend the program—and no one can guarantee whether that will happen.

“The chairs of the Senate Finance Committee have been tremendously supportive of the PQRI,” says Dr. Torcson. “There is a lot of political will behind this right now. [PQRI supporters in Congress] want better quality in healthcare for better pay.”

This year’s election will have a major impact on this decision: “A change in administration will definitely factor in,” warns Dr. Torcson. “The 2008 Medicare Physician Payment Update seemed to divide along party lines. Republicans were somewhat supportive, and Democrats didn’t seem to support it. It’s not quite that simple, but that was a general pattern.”

The best advice for physicians invested or interested in investing in PQRI is to keep an eye on the November election results and the Senate Finance Committee to find out what 2009 and beyond will look like for PQRI or other CMS pay-for-reporting initiatives.

Too Late to Participate?

Although the PQRI began Jan. 1, there is no enrollment process; physicians can start reporting any time during the year. However, participants reporting on three measures report in at least 80% of the instances in which those measures are reportable—that means all year—in order to qualify for a bonus. If you begin reporting this far into the year, you’re not likely to reach that threshold and earn your bonus.

“Starting late in the year could affect reaching that threshold, but it’s never too late to start the practice and process of reporting,” says Dr. Torcson. “You can still make that commitment to performance reporting. Even if you don’t get the 1.5% bonus, you get the benefit of getting started in the important practice of performance reporting.”

Read more about the PQRI on SHM’s Web site (www.hospitalmedicine.org). TH

Jane Jerrard has written for The Hospitalist since 2005.

By putting a little time and effort into your presentation skills, you can become more persuasive and effective in your day-to-day job—and even advance your career and reputation.

For hospitalists, with their often-heavy committee load and frequent formal or informal teaching conversations, addressing groups is part of the job.

“At the end of the day, hospitalists are advocates—whether for quality improvement or patient-care issues,” says Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate director of student programs, internal medicine. “And most of their advocacy efforts [are] going to be person-to-person, verbal discussions, where their passion and conviction can come through.”

Even if you’re never asked to present at a national meeting, you are likely to address a lot of committees, teams, and task forces in your career.

“It’s important to realize that people’s time is valuable in committee meetings,” stresses Dr. Wiese. “You have to be able to speak clearly, concisely, and to the point to make your case effectively.”

Learn by Listening

If you haven’t had much experience addressing groups or you feel your presentation skills are lacking, there are simple steps to become comfortable—even accomplished—at speaking.

“Most effective speakers are partly born but mostly made,” says Robert Wachter, MD, co-founder of SHM, frequent keynote speaker and professor and associate chairman of the Department of Medicine at the University of California, San Francisco.

Becoming an effective speaker may require formal training, perhaps from a course or a book. But one step every aspiring speaker can easily take is to listen to other speakers—a lot of them.

While working on his own presentation skills, Dr. Wachter says: “I learned to be a shameless mimic and thief. Even now, when I hear a good lecture, I always ask myself what that person did really well, and can I do that, too. And when I hear a crummy speaker, I wonder what I would tell them to them improve.”

Dr. Wiese does the same thing. “My strategy is to learn from every talk I sit in on,” he says. “Watch how the speaker is performing—not just at medical meetings, but also on TV. In this election year there are a lot of opportunities to listen to speeches. Note good speakers’ cadence, pitch and tone, and borrow from them.”

Simple Secrets

Effective speaking is built on some basic tenets. “There are fundamental skills that most speakers don’t use—you’d be surprised how basic these skills are,” says Dr. Wiese. These basics include:

Practice makes perfect: No matter how confident you are of your material, practice. Whether you’ll teach, speak to a quality-improvement committee or address a national group, make an outline and run through your speech. “There’s no talk I give without at least sitting down an hour beforehand to think through what I’m going to say,” says Dr. Wiese.

Give it all you’ve got: “When you’re asked to address a group, you have to convince yourself that this is the most important talk you’ve ever given,” stresses Dr. Wiese. “Your belief in this will give you the passion and commitment to your topic that comes out in how you speak.”

Start strong: Getting your audience’s interest and attention immediately is crucial.

“Engaging the audience successfully in the first one to three minutes is unbelievably important because unless you get them to care enough to listen at the outset, you’ve lost them for the rest of the talk,” he says. He believes only about one in 100 speakers do this well. “I assume the audience is not really with me and that I need to actively engage them—and I make sure they know enough to care about the topic. I start with the reasonable assumption that I know more and care more about my topic than they do. Make sure you give them enough background to get them started.”

Fledgling speakers can try capturing their audience’s attention by starting with a joke, story, dramatic anecdote, or shocking data. Starting your presentation with a bang, says Dr. Wachter, “is a learnable skill, and it’s a lot easier when you’re addressing a small group of people you know.”

Spice up dry information: If you’re stuck with a topic you fear is too boring to engage, find a “hook” to draw the audience in. Dr. Wachter suggests, “When you explain facts, use analogy and metaphors, and use graphics only when appropriate,” he suggests.

Find your voice: A tricky thing for new speakers is controlling their voice and using it to maintain interest. Avoid using a monotone—a common effect of reading from notes or slides.

“It’s important to work on your cadence and on the pitch and tone of your voice,” advises Dr. Wiese. “I think speaking is similar to music. Music has rest notes for a reason: to augment what you just said and to set up what you’re about to say. Try replacing the “ums” and “uhs” you use while you’re thinking about what to say next with silence. The audience will be riveted.”

Go easy on the PowerPoint: Don’t rely on your slides or flipchart to influence or engage your audience. Make eye contact with individuals and in a small group; touch a shoulder or two. “The truth is that most people use PowerPoint slides because they didn’t practice their talk,” says Dr. Wiese. “Turn away from your slides and talk person to person—you’ll be much more compelling.”

Speaking Opportunities

For an ambitious hospitalist, opportunities are abundant. “Find the residency director at the nearest program and tell them you’d like to give a conference for free,” Dr. Wiese recommends. “I guarantee this will get you 20 or 30 offers.”

He says national and regional organizations are great opportunities to get involved. “All it really takes is to attend the meetings, find the people doing the talks and tell them that you want an opportunity to hone your speaking skills,” he notes.

If you’re convinced that practicing your speaking skills will help you influence committees, enhance your reputation and improve your career possibilities, then take Dr. Wiese’s advice and get ready to launch your speaking career. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

By putting a little time and effort into your presentation skills, you can become more persuasive and effective in your day-to-day job—and even advance your career and reputation.

For hospitalists, with their often-heavy committee load and frequent formal or informal teaching conversations, addressing groups is part of the job.

“At the end of the day, hospitalists are advocates—whether for quality improvement or patient-care issues,” says Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate director of student programs, internal medicine. “And most of their advocacy efforts [are] going to be person-to-person, verbal discussions, where their passion and conviction can come through.”

Even if you’re never asked to present at a national meeting, you are likely to address a lot of committees, teams, and task forces in your career.

“It’s important to realize that people’s time is valuable in committee meetings,” stresses Dr. Wiese. “You have to be able to speak clearly, concisely, and to the point to make your case effectively.”

Learn by Listening

If you haven’t had much experience addressing groups or you feel your presentation skills are lacking, there are simple steps to become comfortable—even accomplished—at speaking.

“Most effective speakers are partly born but mostly made,” says Robert Wachter, MD, co-founder of SHM, frequent keynote speaker and professor and associate chairman of the Department of Medicine at the University of California, San Francisco.

Becoming an effective speaker may require formal training, perhaps from a course or a book. But one step every aspiring speaker can easily take is to listen to other speakers—a lot of them.

While working on his own presentation skills, Dr. Wachter says: “I learned to be a shameless mimic and thief. Even now, when I hear a good lecture, I always ask myself what that person did really well, and can I do that, too. And when I hear a crummy speaker, I wonder what I would tell them to them improve.”

Dr. Wiese does the same thing. “My strategy is to learn from every talk I sit in on,” he says. “Watch how the speaker is performing—not just at medical meetings, but also on TV. In this election year there are a lot of opportunities to listen to speeches. Note good speakers’ cadence, pitch and tone, and borrow from them.”

Simple Secrets

Effective speaking is built on some basic tenets. “There are fundamental skills that most speakers don’t use—you’d be surprised how basic these skills are,” says Dr. Wiese. These basics include:

Practice makes perfect: No matter how confident you are of your material, practice. Whether you’ll teach, speak to a quality-improvement committee or address a national group, make an outline and run through your speech. “There’s no talk I give without at least sitting down an hour beforehand to think through what I’m going to say,” says Dr. Wiese.

Give it all you’ve got: “When you’re asked to address a group, you have to convince yourself that this is the most important talk you’ve ever given,” stresses Dr. Wiese. “Your belief in this will give you the passion and commitment to your topic that comes out in how you speak.”

Start strong: Getting your audience’s interest and attention immediately is crucial.

“Engaging the audience successfully in the first one to three minutes is unbelievably important because unless you get them to care enough to listen at the outset, you’ve lost them for the rest of the talk,” he says. He believes only about one in 100 speakers do this well. “I assume the audience is not really with me and that I need to actively engage them—and I make sure they know enough to care about the topic. I start with the reasonable assumption that I know more and care more about my topic than they do. Make sure you give them enough background to get them started.”

Fledgling speakers can try capturing their audience’s attention by starting with a joke, story, dramatic anecdote, or shocking data. Starting your presentation with a bang, says Dr. Wachter, “is a learnable skill, and it’s a lot easier when you’re addressing a small group of people you know.”

Spice up dry information: If you’re stuck with a topic you fear is too boring to engage, find a “hook” to draw the audience in. Dr. Wachter suggests, “When you explain facts, use analogy and metaphors, and use graphics only when appropriate,” he suggests.

Find your voice: A tricky thing for new speakers is controlling their voice and using it to maintain interest. Avoid using a monotone—a common effect of reading from notes or slides.

“It’s important to work on your cadence and on the pitch and tone of your voice,” advises Dr. Wiese. “I think speaking is similar to music. Music has rest notes for a reason: to augment what you just said and to set up what you’re about to say. Try replacing the “ums” and “uhs” you use while you’re thinking about what to say next with silence. The audience will be riveted.”

Go easy on the PowerPoint: Don’t rely on your slides or flipchart to influence or engage your audience. Make eye contact with individuals and in a small group; touch a shoulder or two. “The truth is that most people use PowerPoint slides because they didn’t practice their talk,” says Dr. Wiese. “Turn away from your slides and talk person to person—you’ll be much more compelling.”

Speaking Opportunities

For an ambitious hospitalist, opportunities are abundant. “Find the residency director at the nearest program and tell them you’d like to give a conference for free,” Dr. Wiese recommends. “I guarantee this will get you 20 or 30 offers.”

He says national and regional organizations are great opportunities to get involved. “All it really takes is to attend the meetings, find the people doing the talks and tell them that you want an opportunity to hone your speaking skills,” he notes.

If you’re convinced that practicing your speaking skills will help you influence committees, enhance your reputation and improve your career possibilities, then take Dr. Wiese’s advice and get ready to launch your speaking career. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

By putting a little time and effort into your presentation skills, you can become more persuasive and effective in your day-to-day job—and even advance your career and reputation.

For hospitalists, with their often-heavy committee load and frequent formal or informal teaching conversations, addressing groups is part of the job.

“At the end of the day, hospitalists are advocates—whether for quality improvement or patient-care issues,” says Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate director of student programs, internal medicine. “And most of their advocacy efforts [are] going to be person-to-person, verbal discussions, where their passion and conviction can come through.”

Even if you’re never asked to present at a national meeting, you are likely to address a lot of committees, teams, and task forces in your career.

“It’s important to realize that people’s time is valuable in committee meetings,” stresses Dr. Wiese. “You have to be able to speak clearly, concisely, and to the point to make your case effectively.”

Learn by Listening

If you haven’t had much experience addressing groups or you feel your presentation skills are lacking, there are simple steps to become comfortable—even accomplished—at speaking.

“Most effective speakers are partly born but mostly made,” says Robert Wachter, MD, co-founder of SHM, frequent keynote speaker and professor and associate chairman of the Department of Medicine at the University of California, San Francisco.

Becoming an effective speaker may require formal training, perhaps from a course or a book. But one step every aspiring speaker can easily take is to listen to other speakers—a lot of them.

While working on his own presentation skills, Dr. Wachter says: “I learned to be a shameless mimic and thief. Even now, when I hear a good lecture, I always ask myself what that person did really well, and can I do that, too. And when I hear a crummy speaker, I wonder what I would tell them to them improve.”

Dr. Wiese does the same thing. “My strategy is to learn from every talk I sit in on,” he says. “Watch how the speaker is performing—not just at medical meetings, but also on TV. In this election year there are a lot of opportunities to listen to speeches. Note good speakers’ cadence, pitch and tone, and borrow from them.”

Simple Secrets

Effective speaking is built on some basic tenets. “There are fundamental skills that most speakers don’t use—you’d be surprised how basic these skills are,” says Dr. Wiese. These basics include:

Practice makes perfect: No matter how confident you are of your material, practice. Whether you’ll teach, speak to a quality-improvement committee or address a national group, make an outline and run through your speech. “There’s no talk I give without at least sitting down an hour beforehand to think through what I’m going to say,” says Dr. Wiese.

Give it all you’ve got: “When you’re asked to address a group, you have to convince yourself that this is the most important talk you’ve ever given,” stresses Dr. Wiese. “Your belief in this will give you the passion and commitment to your topic that comes out in how you speak.”

Start strong: Getting your audience’s interest and attention immediately is crucial.

“Engaging the audience successfully in the first one to three minutes is unbelievably important because unless you get them to care enough to listen at the outset, you’ve lost them for the rest of the talk,” he says. He believes only about one in 100 speakers do this well. “I assume the audience is not really with me and that I need to actively engage them—and I make sure they know enough to care about the topic. I start with the reasonable assumption that I know more and care more about my topic than they do. Make sure you give them enough background to get them started.”

Fledgling speakers can try capturing their audience’s attention by starting with a joke, story, dramatic anecdote, or shocking data. Starting your presentation with a bang, says Dr. Wachter, “is a learnable skill, and it’s a lot easier when you’re addressing a small group of people you know.”

Spice up dry information: If you’re stuck with a topic you fear is too boring to engage, find a “hook” to draw the audience in. Dr. Wachter suggests, “When you explain facts, use analogy and metaphors, and use graphics only when appropriate,” he suggests.

Find your voice: A tricky thing for new speakers is controlling their voice and using it to maintain interest. Avoid using a monotone—a common effect of reading from notes or slides.

“It’s important to work on your cadence and on the pitch and tone of your voice,” advises Dr. Wiese. “I think speaking is similar to music. Music has rest notes for a reason: to augment what you just said and to set up what you’re about to say. Try replacing the “ums” and “uhs” you use while you’re thinking about what to say next with silence. The audience will be riveted.”

Go easy on the PowerPoint: Don’t rely on your slides or flipchart to influence or engage your audience. Make eye contact with individuals and in a small group; touch a shoulder or two. “The truth is that most people use PowerPoint slides because they didn’t practice their talk,” says Dr. Wiese. “Turn away from your slides and talk person to person—you’ll be much more compelling.”

Speaking Opportunities

For an ambitious hospitalist, opportunities are abundant. “Find the residency director at the nearest program and tell them you’d like to give a conference for free,” Dr. Wiese recommends. “I guarantee this will get you 20 or 30 offers.”

He says national and regional organizations are great opportunities to get involved. “All it really takes is to attend the meetings, find the people doing the talks and tell them that you want an opportunity to hone your speaking skills,” he notes.

If you’re convinced that practicing your speaking skills will help you influence committees, enhance your reputation and improve your career possibilities, then take Dr. Wiese’s advice and get ready to launch your speaking career. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

Elderly inpatients’ risk of receiving potentially inappropriate medication (PIM) varies widely depending on where in the country they’re hospitalized and the specialty of their attending physicians, according to a study in the March-April edition of the Journal of Hospital Medicine.

Hospitalists may be encouraged by the fact that they, along with geriatricians, internists, and family physicians, were less likely than cardiologists to prescribe PIMs. Still, the major take-home message of the study is to “examine your individual practice and think about whether it’s appropriate to prescribe these medications,” says lead author Michael Rothberg, MD, assistant professor of medicine at Tufts University School of Medicine in Boston.

PIM use was highest in hospitals in the South. There, 55% of elderly patients received at least one PIM, compared with 34% of patients in Northeastern hospitals, where PIM use was lowest. The exact reason for this discrepancy is not known, but Dr. Rothberg hypothesizes that “we tend to prescribe like people in our hospital and like people in our region.” In other words, “it has to do with learning from the people around us.”

Most interesting to him is the wide variation in prescribing practices among individual doctors—even within the same specialty. “The decision to prescribe a drug is based on the individual provider and has to do with how you as a doctor feel about these drugs,” he explains. Although nearly half of all of the patients had received at least one PIM, there were seven hospitals in which those drugs never were prescribed. Somehow, “they found a way to care for people without [those medications],” he points out.

PIM use has been examined among elderly outpatients and nursing home residents, but only a handful of small studies have looked at the problem in hospital inpatients, says Dr. Rothberg. He and his coauthors used data from hospitals across the United States participating in Perspective, a database developed by Charlotte, N.C.-based Premier to measure quality and healthcare utilization.

The survey included patients 65 years or older admitted between Sept. 1, 2002, and June 30, 2005. Their principal diagnoses were acute myocardial infarction, chronic obstructive pulmonary disease, chest pain, community acquired pneumonia, congestive heart failure, ischemic stroke, or urinary tract infection. Surgical patients were excluded. Using the 2002 update of the Beers criteria for PIM use in older adults, the authors identified the total number of PIMs administered to each patient during his or her hospital stay. They further classified each PIM as high- or low-severity, based on the expert consensus expressed in the 1997 update of the Beers criteria.

Data were available on 493,971 patients from 384 hospitals. Of those individuals, 49% received at least one PIM, and 6% received three or more. Thirty-eight percent of patients received at least one PIM with a high severity rating.

The three agents most likely to be prescribed were promethazine, diphenhydramine, and propoxyphene—probably because these drugs treat the problems most commonly encountered in hospitals, such as allergies, sleep problems, nausea, and pain, Dr. Rothberg says.

Hospital region emerged as the most important predictor of PIM use. Compared with patients in the Midwest, patients in the South had an odds ratio of 1.63 of receiving a high-severity PIM. The odds ratio for patients in the West was 1.43. Patients in the Northeast had an odds ratio of 0.85.

The median rate of prescribing high-severity PIMs was lowest among geriatricians, at 24%. Rates among hospitalists, internists, and family physicians were 33% to 36%. Cardiologists had the highest rate: 48% prescribed at least one high-severity PIM.

click for large version

Interestingly, older patient age also was associated with a lower risk of PIM use. Of patients 85 or older, 42% received at least one PIM, compared with 53% of patients age 65 to 74 (p<0.0001). This suggests that “doctors are aware that the older patients are more frail and vulnerable” and take extra care to avoid prescribing PIMs to people in that age range, Dr. Rothberg says. A diagnosis of stroke or chronic obstructive pulmonary disease also was associated with a lower risk of receiving a PIM—further evidence that “doctors were, to some extent, taking patient factors into account” when prescribing medication.

PIM use among inpatients, as reported in this study, far exceeds the rates published for elders dwelling in the community or in nursing homes, writes Daniel S. Budnitz, MD, MPH, in an editorial accompanying the study.

The wide variation in prescribing practices means each facility must monitor its use of PIMs, just as individual hospitals monitor antibiotic use and resistance, advises Dr. Budnitz, a medical officer in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. He also points out that the evidence that PIMs cause clinically significant adverse events is “weak and based largely on observational studies with inconsistent results.” The drugs in the Beers criteria are “potentially” inappropriate, he says, but some centers have recategorized them as “ ‘always avoid’ medications, ‘rarely acceptable’ medications, and medications which, indeed, have ‘some indications’ for use in older adults.” Thus, some variation among hospitals may be acceptable.

Rather than concentrate on the Beers criteria, hospitalists should focus “on identifying and mitigating the most common and most severe adverse drug events occurring in their hospitals,” such as bleeding from anticoagulants, hypoglycemic events from insulin, and oversedation from opioid analgesics, Dr. Budnitz points out. TH

Norra MacReady is a medical writer based in California.

Elderly inpatients’ risk of receiving potentially inappropriate medication (PIM) varies widely depending on where in the country they’re hospitalized and the specialty of their attending physicians, according to a study in the March-April edition of the Journal of Hospital Medicine.

Hospitalists may be encouraged by the fact that they, along with geriatricians, internists, and family physicians, were less likely than cardiologists to prescribe PIMs. Still, the major take-home message of the study is to “examine your individual practice and think about whether it’s appropriate to prescribe these medications,” says lead author Michael Rothberg, MD, assistant professor of medicine at Tufts University School of Medicine in Boston.

PIM use was highest in hospitals in the South. There, 55% of elderly patients received at least one PIM, compared with 34% of patients in Northeastern hospitals, where PIM use was lowest. The exact reason for this discrepancy is not known, but Dr. Rothberg hypothesizes that “we tend to prescribe like people in our hospital and like people in our region.” In other words, “it has to do with learning from the people around us.”

Most interesting to him is the wide variation in prescribing practices among individual doctors—even within the same specialty. “The decision to prescribe a drug is based on the individual provider and has to do with how you as a doctor feel about these drugs,” he explains. Although nearly half of all of the patients had received at least one PIM, there were seven hospitals in which those drugs never were prescribed. Somehow, “they found a way to care for people without [those medications],” he points out.

PIM use has been examined among elderly outpatients and nursing home residents, but only a handful of small studies have looked at the problem in hospital inpatients, says Dr. Rothberg. He and his coauthors used data from hospitals across the United States participating in Perspective, a database developed by Charlotte, N.C.-based Premier to measure quality and healthcare utilization.

The survey included patients 65 years or older admitted between Sept. 1, 2002, and June 30, 2005. Their principal diagnoses were acute myocardial infarction, chronic obstructive pulmonary disease, chest pain, community acquired pneumonia, congestive heart failure, ischemic stroke, or urinary tract infection. Surgical patients were excluded. Using the 2002 update of the Beers criteria for PIM use in older adults, the authors identified the total number of PIMs administered to each patient during his or her hospital stay. They further classified each PIM as high- or low-severity, based on the expert consensus expressed in the 1997 update of the Beers criteria.

Data were available on 493,971 patients from 384 hospitals. Of those individuals, 49% received at least one PIM, and 6% received three or more. Thirty-eight percent of patients received at least one PIM with a high severity rating.

The three agents most likely to be prescribed were promethazine, diphenhydramine, and propoxyphene—probably because these drugs treat the problems most commonly encountered in hospitals, such as allergies, sleep problems, nausea, and pain, Dr. Rothberg says.

Hospital region emerged as the most important predictor of PIM use. Compared with patients in the Midwest, patients in the South had an odds ratio of 1.63 of receiving a high-severity PIM. The odds ratio for patients in the West was 1.43. Patients in the Northeast had an odds ratio of 0.85.

The median rate of prescribing high-severity PIMs was lowest among geriatricians, at 24%. Rates among hospitalists, internists, and family physicians were 33% to 36%. Cardiologists had the highest rate: 48% prescribed at least one high-severity PIM.

click for large version

Interestingly, older patient age also was associated with a lower risk of PIM use. Of patients 85 or older, 42% received at least one PIM, compared with 53% of patients age 65 to 74 (p<0.0001). This suggests that “doctors are aware that the older patients are more frail and vulnerable” and take extra care to avoid prescribing PIMs to people in that age range, Dr. Rothberg says. A diagnosis of stroke or chronic obstructive pulmonary disease also was associated with a lower risk of receiving a PIM—further evidence that “doctors were, to some extent, taking patient factors into account” when prescribing medication.

PIM use among inpatients, as reported in this study, far exceeds the rates published for elders dwelling in the community or in nursing homes, writes Daniel S. Budnitz, MD, MPH, in an editorial accompanying the study.

The wide variation in prescribing practices means each facility must monitor its use of PIMs, just as individual hospitals monitor antibiotic use and resistance, advises Dr. Budnitz, a medical officer in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. He also points out that the evidence that PIMs cause clinically significant adverse events is “weak and based largely on observational studies with inconsistent results.” The drugs in the Beers criteria are “potentially” inappropriate, he says, but some centers have recategorized them as “ ‘always avoid’ medications, ‘rarely acceptable’ medications, and medications which, indeed, have ‘some indications’ for use in older adults.” Thus, some variation among hospitals may be acceptable.

Rather than concentrate on the Beers criteria, hospitalists should focus “on identifying and mitigating the most common and most severe adverse drug events occurring in their hospitals,” such as bleeding from anticoagulants, hypoglycemic events from insulin, and oversedation from opioid analgesics, Dr. Budnitz points out. TH

Norra MacReady is a medical writer based in California.

Elderly inpatients’ risk of receiving potentially inappropriate medication (PIM) varies widely depending on where in the country they’re hospitalized and the specialty of their attending physicians, according to a study in the March-April edition of the Journal of Hospital Medicine.

Hospitalists may be encouraged by the fact that they, along with geriatricians, internists, and family physicians, were less likely than cardiologists to prescribe PIMs. Still, the major take-home message of the study is to “examine your individual practice and think about whether it’s appropriate to prescribe these medications,” says lead author Michael Rothberg, MD, assistant professor of medicine at Tufts University School of Medicine in Boston.

PIM use was highest in hospitals in the South. There, 55% of elderly patients received at least one PIM, compared with 34% of patients in Northeastern hospitals, where PIM use was lowest. The exact reason for this discrepancy is not known, but Dr. Rothberg hypothesizes that “we tend to prescribe like people in our hospital and like people in our region.” In other words, “it has to do with learning from the people around us.”

Most interesting to him is the wide variation in prescribing practices among individual doctors—even within the same specialty. “The decision to prescribe a drug is based on the individual provider and has to do with how you as a doctor feel about these drugs,” he explains. Although nearly half of all of the patients had received at least one PIM, there were seven hospitals in which those drugs never were prescribed. Somehow, “they found a way to care for people without [those medications],” he points out.

PIM use has been examined among elderly outpatients and nursing home residents, but only a handful of small studies have looked at the problem in hospital inpatients, says Dr. Rothberg. He and his coauthors used data from hospitals across the United States participating in Perspective, a database developed by Charlotte, N.C.-based Premier to measure quality and healthcare utilization.

The survey included patients 65 years or older admitted between Sept. 1, 2002, and June 30, 2005. Their principal diagnoses were acute myocardial infarction, chronic obstructive pulmonary disease, chest pain, community acquired pneumonia, congestive heart failure, ischemic stroke, or urinary tract infection. Surgical patients were excluded. Using the 2002 update of the Beers criteria for PIM use in older adults, the authors identified the total number of PIMs administered to each patient during his or her hospital stay. They further classified each PIM as high- or low-severity, based on the expert consensus expressed in the 1997 update of the Beers criteria.

Data were available on 493,971 patients from 384 hospitals. Of those individuals, 49% received at least one PIM, and 6% received three or more. Thirty-eight percent of patients received at least one PIM with a high severity rating.

The three agents most likely to be prescribed were promethazine, diphenhydramine, and propoxyphene—probably because these drugs treat the problems most commonly encountered in hospitals, such as allergies, sleep problems, nausea, and pain, Dr. Rothberg says.

Hospital region emerged as the most important predictor of PIM use. Compared with patients in the Midwest, patients in the South had an odds ratio of 1.63 of receiving a high-severity PIM. The odds ratio for patients in the West was 1.43. Patients in the Northeast had an odds ratio of 0.85.

The median rate of prescribing high-severity PIMs was lowest among geriatricians, at 24%. Rates among hospitalists, internists, and family physicians were 33% to 36%. Cardiologists had the highest rate: 48% prescribed at least one high-severity PIM.

click for large version

Interestingly, older patient age also was associated with a lower risk of PIM use. Of patients 85 or older, 42% received at least one PIM, compared with 53% of patients age 65 to 74 (p<0.0001). This suggests that “doctors are aware that the older patients are more frail and vulnerable” and take extra care to avoid prescribing PIMs to people in that age range, Dr. Rothberg says. A diagnosis of stroke or chronic obstructive pulmonary disease also was associated with a lower risk of receiving a PIM—further evidence that “doctors were, to some extent, taking patient factors into account” when prescribing medication.

PIM use among inpatients, as reported in this study, far exceeds the rates published for elders dwelling in the community or in nursing homes, writes Daniel S. Budnitz, MD, MPH, in an editorial accompanying the study.

The wide variation in prescribing practices means each facility must monitor its use of PIMs, just as individual hospitals monitor antibiotic use and resistance, advises Dr. Budnitz, a medical officer in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. He also points out that the evidence that PIMs cause clinically significant adverse events is “weak and based largely on observational studies with inconsistent results.” The drugs in the Beers criteria are “potentially” inappropriate, he says, but some centers have recategorized them as “ ‘always avoid’ medications, ‘rarely acceptable’ medications, and medications which, indeed, have ‘some indications’ for use in older adults.” Thus, some variation among hospitals may be acceptable.

Rather than concentrate on the Beers criteria, hospitalists should focus “on identifying and mitigating the most common and most severe adverse drug events occurring in their hospitals,” such as bleeding from anticoagulants, hypoglycemic events from insulin, and oversedation from opioid analgesics, Dr. Budnitz points out. TH

Norra MacReady is a medical writer based in California.

Venous thromboembolism (VTE) affects more than 2 million Americans every year.1 Pulmonary embolism (PE) is one of the most common preventable causes of in-hospital deaths in the United States. Clinical manifestations of PE may be the first indication the patient has a VTE, and fatal PEs occur in at least 75% of hospitalized medical patients. More than 300,000 patients die from PE each year—an estimated incidence of 10%. This makes VTE prevention a top patient-safety goal in hospitals.2,3

Thromboprophylaxis can be accomplished with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH; e.g., enoxaparin, dalteparin, tinzaparin) or heparinoid, or a selective factor Xa inhibitor (e.g., fondaparinux).4 For long-term treatment, oral warfarin is often used. Doses and duration of prophylaxis and treatment regimens vary.

Current guidelines should be reviewed for specific recommendations. Two current guidelines are the American College of Chest Physicians (ACCP) Seventh Conference on the Prevention of VTE and the American Society of Clinical Oncology (ASCO) Guideline for VTE prophylaxis and treatment in oncology patients. Although guidelines are available, thromboprophylaxis continues to baffle many healthcare providers. There are many advantages to thromboprophylaxis including the prevention of significant morbidity, prevention of PE, decreases in resource consumption, and decreases in the long-term clinical and economic sequelae.

The ACCP notes that most surgical patients will require thromboprophylaxis. Contraindications need to be evaluated prior to antithrombotic/anticoagulant use. Additionally, all trauma patients with at least one VTE risk factor should receive thromboprophylaxis. Acutely ill patients hospitalized with congestive heart failure or severe respiratory distress or who are confined to bed and have one or more additional risk factors, should receive VTE prophylaxis. Additionally, most patients upon admission to an intensive-care unit should be assessed for VTE risk and receive thromboprophylaxis as required.

VTE is a major complication in up to 20% of cancer patients, with hospitalized oncology patients and those undergoing treatment at the highest risk. Some of the newer drug treatments used in these patients have higher VTE rates (e.g., bevacizumab, thalidomide, lenalidomide). These patients need to be carefully evaluated for VTE prophylaxis and closely monitored.5

Generally, in hospitalized patients with cancer, VTE prophylaxis should be considered with UFH, LMWH, or fondaparinux, in the absence of bleeding or other contraindications to anticoagulation. Relative contraindications to anticoagulation include (but are not limited to):

• Active uncontrolled bleeding;
• Active cerebrovascular hemorrhage;
• Dissecting or cerebral aneurysm;
• Bacterial endocarditis;
• Pericarditis;
• Active peptic or gastrointestinal ulceration;
• Severe uncontrolled or malignant hypertension;
• Severe head trauma;
• Pregnancy (warfarin contraindication);
• Heparin-induced thrombocytopenia (heparin, LMWH); and
• Epidural catheter placement.

These same contraindications can be applied to the non-oncology patient, as well.

An important aspect of VTE management is the “Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians on the Diagnosis of VTE from the Annals of Family Medicine.” Consult this for a review of diagnostic tests for VTE.

Thromboprophylaxis is a necessity in a number of at-risk hospitalized patients. Knowing which patients will benefit, and the contraindications for use, will improve patient outcomes. Consult current guidelines for diagnosis recommendations as well as agents of choice, dosing regimens, and therapy duration. TH

Michele B. Kaufman is registered pharmacist based in New York City.

References

1. DVT: Assess Your Patients’ Risk, Take Preventive Measures. ASHP Foundation Discoveries, Summer 2007;19(1):1,5. Available at www.ashpfoundation.org/MainMenuCategories/AboutUs/Newsletter/DiscoveriesSummer2007.aspx. Last accessed Nov. 26, 2007.
2. Geertz WH, Pineo Graham F, Heit JA et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338-400.
3. Wein L, Wein S, Haas SJ, et al. Pharmacological venous thromboembolism prophylaxis in hospitalized medical patients, a meta-analysis of randomized controlled trials. Arch Intern Med. 2007;167:1476-1486.
4. Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol. 2007;25(34): 5490–5505.
5. Qaseem A, Snow V, Barry P for the Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Vein Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007;5:57-62.

Venous thromboembolism (VTE) affects more than 2 million Americans every year.1 Pulmonary embolism (PE) is one of the most common preventable causes of in-hospital deaths in the United States. Clinical manifestations of PE may be the first indication the patient has a VTE, and fatal PEs occur in at least 75% of hospitalized medical patients. More than 300,000 patients die from PE each year—an estimated incidence of 10%. This makes VTE prevention a top patient-safety goal in hospitals.2,3

Thromboprophylaxis can be accomplished with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH; e.g., enoxaparin, dalteparin, tinzaparin) or heparinoid, or a selective factor Xa inhibitor (e.g., fondaparinux).4 For long-term treatment, oral warfarin is often used. Doses and duration of prophylaxis and treatment regimens vary.

Current guidelines should be reviewed for specific recommendations. Two current guidelines are the American College of Chest Physicians (ACCP) Seventh Conference on the Prevention of VTE and the American Society of Clinical Oncology (ASCO) Guideline for VTE prophylaxis and treatment in oncology patients. Although guidelines are available, thromboprophylaxis continues to baffle many healthcare providers. There are many advantages to thromboprophylaxis including the prevention of significant morbidity, prevention of PE, decreases in resource consumption, and decreases in the long-term clinical and economic sequelae.

The ACCP notes that most surgical patients will require thromboprophylaxis. Contraindications need to be evaluated prior to antithrombotic/anticoagulant use. Additionally, all trauma patients with at least one VTE risk factor should receive thromboprophylaxis. Acutely ill patients hospitalized with congestive heart failure or severe respiratory distress or who are confined to bed and have one or more additional risk factors, should receive VTE prophylaxis. Additionally, most patients upon admission to an intensive-care unit should be assessed for VTE risk and receive thromboprophylaxis as required.

VTE is a major complication in up to 20% of cancer patients, with hospitalized oncology patients and those undergoing treatment at the highest risk. Some of the newer drug treatments used in these patients have higher VTE rates (e.g., bevacizumab, thalidomide, lenalidomide). These patients need to be carefully evaluated for VTE prophylaxis and closely monitored.5

Generally, in hospitalized patients with cancer, VTE prophylaxis should be considered with UFH, LMWH, or fondaparinux, in the absence of bleeding or other contraindications to anticoagulation. Relative contraindications to anticoagulation include (but are not limited to):

• Active uncontrolled bleeding;
• Active cerebrovascular hemorrhage;
• Dissecting or cerebral aneurysm;
• Bacterial endocarditis;
• Pericarditis;
• Active peptic or gastrointestinal ulceration;
• Severe uncontrolled or malignant hypertension;
• Severe head trauma;
• Pregnancy (warfarin contraindication);
• Heparin-induced thrombocytopenia (heparin, LMWH); and
• Epidural catheter placement.

These same contraindications can be applied to the non-oncology patient, as well.

An important aspect of VTE management is the “Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians on the Diagnosis of VTE from the Annals of Family Medicine.” Consult this for a review of diagnostic tests for VTE.

Thromboprophylaxis is a necessity in a number of at-risk hospitalized patients. Knowing which patients will benefit, and the contraindications for use, will improve patient outcomes. Consult current guidelines for diagnosis recommendations as well as agents of choice, dosing regimens, and therapy duration. TH

Michele B. Kaufman is registered pharmacist based in New York City.

References

1. DVT: Assess Your Patients’ Risk, Take Preventive Measures. ASHP Foundation Discoveries, Summer 2007;19(1):1,5. Available at www.ashpfoundation.org/MainMenuCategories/AboutUs/Newsletter/DiscoveriesSummer2007.aspx. Last accessed Nov. 26, 2007.
2. Geertz WH, Pineo Graham F, Heit JA et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338-400.
3. Wein L, Wein S, Haas SJ, et al. Pharmacological venous thromboembolism prophylaxis in hospitalized medical patients, a meta-analysis of randomized controlled trials. Arch Intern Med. 2007;167:1476-1486.
4. Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol. 2007;25(34): 5490–5505.
5. Qaseem A, Snow V, Barry P for the Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Vein Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007;5:57-62.

Venous thromboembolism (VTE) affects more than 2 million Americans every year.1 Pulmonary embolism (PE) is one of the most common preventable causes of in-hospital deaths in the United States. Clinical manifestations of PE may be the first indication the patient has a VTE, and fatal PEs occur in at least 75% of hospitalized medical patients. More than 300,000 patients die from PE each year—an estimated incidence of 10%. This makes VTE prevention a top patient-safety goal in hospitals.2,3

Thromboprophylaxis can be accomplished with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH; e.g., enoxaparin, dalteparin, tinzaparin) or heparinoid, or a selective factor Xa inhibitor (e.g., fondaparinux).4 For long-term treatment, oral warfarin is often used. Doses and duration of prophylaxis and treatment regimens vary.

Current guidelines should be reviewed for specific recommendations. Two current guidelines are the American College of Chest Physicians (ACCP) Seventh Conference on the Prevention of VTE and the American Society of Clinical Oncology (ASCO) Guideline for VTE prophylaxis and treatment in oncology patients. Although guidelines are available, thromboprophylaxis continues to baffle many healthcare providers. There are many advantages to thromboprophylaxis including the prevention of significant morbidity, prevention of PE, decreases in resource consumption, and decreases in the long-term clinical and economic sequelae.

The ACCP notes that most surgical patients will require thromboprophylaxis. Contraindications need to be evaluated prior to antithrombotic/anticoagulant use. Additionally, all trauma patients with at least one VTE risk factor should receive thromboprophylaxis. Acutely ill patients hospitalized with congestive heart failure or severe respiratory distress or who are confined to bed and have one or more additional risk factors, should receive VTE prophylaxis. Additionally, most patients upon admission to an intensive-care unit should be assessed for VTE risk and receive thromboprophylaxis as required.

VTE is a major complication in up to 20% of cancer patients, with hospitalized oncology patients and those undergoing treatment at the highest risk. Some of the newer drug treatments used in these patients have higher VTE rates (e.g., bevacizumab, thalidomide, lenalidomide). These patients need to be carefully evaluated for VTE prophylaxis and closely monitored.5

Generally, in hospitalized patients with cancer, VTE prophylaxis should be considered with UFH, LMWH, or fondaparinux, in the absence of bleeding or other contraindications to anticoagulation. Relative contraindications to anticoagulation include (but are not limited to):

• Active uncontrolled bleeding;
• Active cerebrovascular hemorrhage;
• Dissecting or cerebral aneurysm;
• Bacterial endocarditis;
• Pericarditis;
• Active peptic or gastrointestinal ulceration;
• Severe uncontrolled or malignant hypertension;
• Severe head trauma;
• Pregnancy (warfarin contraindication);
• Heparin-induced thrombocytopenia (heparin, LMWH); and
• Epidural catheter placement.

These same contraindications can be applied to the non-oncology patient, as well.

An important aspect of VTE management is the “Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians on the Diagnosis of VTE from the Annals of Family Medicine.” Consult this for a review of diagnostic tests for VTE.

Thromboprophylaxis is a necessity in a number of at-risk hospitalized patients. Knowing which patients will benefit, and the contraindications for use, will improve patient outcomes. Consult current guidelines for diagnosis recommendations as well as agents of choice, dosing regimens, and therapy duration. TH

Michele B. Kaufman is registered pharmacist based in New York City.

References

1. DVT: Assess Your Patients’ Risk, Take Preventive Measures. ASHP Foundation Discoveries, Summer 2007;19(1):1,5. Available at www.ashpfoundation.org/MainMenuCategories/AboutUs/Newsletter/DiscoveriesSummer2007.aspx. Last accessed Nov. 26, 2007.
2. Geertz WH, Pineo Graham F, Heit JA et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338-400.
3. Wein L, Wein S, Haas SJ, et al. Pharmacological venous thromboembolism prophylaxis in hospitalized medical patients, a meta-analysis of randomized controlled trials. Arch Intern Med. 2007;167:1476-1486.
4. Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol. 2007;25(34): 5490–5505.
5. Qaseem A, Snow V, Barry P for the Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Vein Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007;5:57-62.

Literature at a Glance

A guide to this month’s abstracts

• Steroids reduce mortality only in patients with confirmed bacterial meningitis.
• Probiotics can be useful in the treatment of acute diarrhea in children.
• CT pulmonary angiography is not inferior to V/Q scanning for exclusion of PE.
• Hospitalist care results in shorter LOS compared with care by traditional general internists and family practice physicians.
• The early risk of stroke after TIA is approximately 15% to 20% at 90 days after the sentinel event.
• Different anti-thrombotic strategies produce no difference in outcomes of early acute coronary syndromes.
• The risk of fatal PE is highest in the first year after medication is stopped.
• Beers criteria medications are associated with fewer ED visits by elderly patients compared with warfarin, digoxin, and insulin.

Do Steroids Affect the Outcome in Patients with Meningitis?

Background: Pyogenic (bacterial) meningitis has high morbidity and mortality. Studies suggest some benefit of steroids in children but provide limited evidence for adult use.

Study design: Intention-to-treat, randomized control trial.

Setting: Single hospital in Vietnam.

Synopsis: Of 435 patients older than 14 with suspected meningitis all received lumbar puncture with randomization to IV dexamethasone or placebo for four days. Results showed 69% of patients had definite meningitis, 28.3% were probable, and 2.8% had an alternative diagnosis based on culture results.

The primary outcome was death after one month, which did not differ among groups (risk ratio [RR] 0.79, confidence interval [CI] 0.45-1.39).

Predefined subgroup analysis of patients with definitive meningitis showed a significant reduction in mortality at one month (RR 0.43, CI 0.2-0.94) and death/disability at six months (odds ratio [OR] 0.56, CI 0.32-0.98).

In patients with probable meningitis, those who received steroids demonstrated a trend toward harm (OR 2.65, CI 0.73-9.63).

Probable versus definite meningitis was determined retrospectively based on cultures. The most common isolate was Streptococcus suis.

Bottom line: This study provides some evidence for using steroids in adults with confirmed bacterial meningitis. Clinical application is limited by bacterial epidemiology and the difficulty of prospectively separating patients who would benefit from those who might be harmed.

Citation: Nguyen TH, Tran TH, Thwaites G, et. al. Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med. 2007;357:2431-2439.

Which Probiotic Preparations Best Reduce the Duration of Acute Diarrhea in Children?

Background: Probiotics have been suggested as an adjunctive therapy to reduce the severity and duration of acute diarrhea in children. However, there are no clear data to suggest if specific probiotic agents are superior to others.

Study design: Prospective single-blind, randomized, controlled trial.

Setting: Outpatient primary care in Naples, Italy.

Synopsis: This study compared five commercially available probiotic preparations (mix of Lactobacillus delbrueckii var bulgaricus/Streptococcus thermophilus/L. acidophilus/ Bifido-bacterium bifidum; L. rhamnosus strain GG; Saccharomyces boulardii; Bacillus clausii; or Enterococcus faecium SF68) and a control group in the treatment of outpatient acute diarrhea in 571 children age 3 months to 36 months.

The primary outcomes were the duration of diarrhea and the number and consistency of stools. The groups receiving Lactobacillus GG and the mixture had a shorter total duration of diarrhea (78.5 and 70 hours, respectively), decreased total number of stools, and improved stool consistency when compared with the control (115.5 hours). The other therapies showed no improvement over the control group. These data report on products commercially available in Italy, which may differ greatly from products available locally.

Bottom line: Probiotic preparations for the treatment of acute diarrhea in children should be chosen based on effectiveness data.

Citation: Canani RB, Cirillo P, Terrin G, et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations. BMJ 2007;335:340-345.

Is CTPA a Reliable Alternative to V/Q Scan for Diagnosing PE?

Background: Computed tomography pulmonary angiogram (CTPA) has replaced ventilation/perfusion (V/Q) scanning at many hospitals as the test of choice for ruling out pulmonary embolism (PE). But limited clinical data compare CTPA with V/Q scanning in those suspected of having venous thromboembolism (VTE).

Study design: Randomized, investigator blinded, controlled trial.

Setting: The emergency departments (ED), inpatient wards, and outpatient clinics of five academic centers.

Synopsis: In the study, 1,411 patients were enrolled from five medical centers. Of 694 patients randomized to CTPA, 133 (19.2%) were diagnosed with VTE in the initial evaluation period, while 101 of 712 patients (14.2%) receiving a V/Q scan were diagnosed with VTE.

Patients not initially diagnosed with VTE were monitored. At three-month follow-up, 0.4% of the CTPA group and 1.0% of the V/Q group had a diagnosed VTE.

The overall rate of VTE found in the initial diagnostic period was significantly greater in patients randomized to CTPA (19.2% vs. 14.2%; difference, 5.0%; 95% CI; 1.1% to 8.9% p=.01). This suggests CTPA has a higher false positive rate or detects clinically insignificant thrombi.

Bottom line: CTPA was not inferior to V/Q scanning for excluding clinically meaningful PE, but CTPA diagnosed about 30% more patients with VTE than did V/Q scanning.

Citation: Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs. ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298(23):2743-2753.

Does the Hospitalist Model Improve Length of Stay, Quality, and Cost of Care?

Background: The hospitalist model, with increased physician availability and expertise but greater discontinuity of care, is becoming more prevalent in U.S. medicine. What little is known about how this model will affect patient care is derived from a number of small studies.

Study design: Retrospective cohort study.

Setting: 45 small to midsize, predominantly nonteaching hospitals throughout the U.S.

Synopsis: Using the Premier Healthcare Informatics database, this study examined information on 76,926 patients admitted for seven common diagnoses to one of three services: hospitalist, general internist, or family physician. Analysis showed that patients on a hospitalist service had a 0.4-day shorter length of stay (p<0.001) compared with those on a general internist or family physician service.

The cost to patients cared for by a hospitalist was lower than the cost of family physicians ($125 less, p=0.33) and internists ($268 less, p=0.02). There was no difference found in death rate or 14-day readmission rate among the three services.

Given the retrospective design of this study, no causal relationship can be deduced. This study is further limited by its lack of specific data on the physicians categorized into one of the three groups solely by administrative data. The authors had concerns that the biases inherent to the retrospective nature of their work accounted for the significant difference found between hospitalists and internists.

Bottom line: The hospitalist model is associated with modest improvements in length of stay as compared with traditional inpatient approaches.

Citation: Lindenauer PK, Rothberg MB, Pekow PS, et. al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007;357:2589-2600.

What Is the Stroke Risk Soon after TIA, and What Factors Drive the Variability of Previous Findings?

Background: Many studies have attempted to estimate the risk of stroke in the early period after a transient ischemic attack (TIA). These studies vary widely in their calculation of the estimated risk. Further, the clinical and methodological factors underlying this variability are unclear.

Study design: Systematic review and meta-analysis.

Setting: Community and hospital.

Synopsis: Searching the Coch­rane review database, MEDLINE, EMBASE, CINAHL, and BIOSIS, 11 studies from 1973 to 2006 were included for meta-analysis, selected from 694 potential candidate studies identified on initial screening. The studies ranged in size from 62 to 2,285 patients.

The pooled estimate of risk for stroke following TIA was found to be 3.5%, 8%, and 9.2% at two, 30, and 90 days following TIA, respectively. However, there was significant heterogeneity for all periods considered (p<0.001).

Outcome ascertainment was identified as a major source of methodological heterogeneity. When risk of stroke at follow-up was determined by passive ascertainment (e.g., administrative documentation) the early risk of stroke was 3.1% two days after TIA, 6.4% at 30 days, and 8.7% at 90 days. But active ascertainment (e.g., direct, personal contact with study participants) determined stroke risk to be 9.9%, 13.4%, and 17.4% at two, 30, and 90 days after TIA, respectively.

Bottom line: Based on analysis of completed studies that included directly observed follow-up of study participants, the early risk of stroke after TIA is approximately 15% to 20% at 90 days following the sentinel event.

Citation: Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA. Early risk of stroke after transient ischemic attack. Arch Intern Med. 2007;167:2417-2422.

What Is the 1-year Ischemia and Mortality Rate for Three Anti-thrombotic Therapies for Early Invasive Management of ACS?

Background: Early interventional or surgical revascularization has improved morbidity and mortality in patients with acute coronary syndrome (ACS). The optimal anti-thrombotic regimen to reduce late ischemic and death rates has not been determined.

Study design: Prospective, open-label randomized control trial.

Setting: 450 academic and community-based institutions in 17 countries.

Synopsis: A total of 13,819 patients were enrolled between August 2003 and December 2005. They were assigned to heparin plus glycoprotein (GP) IIb/IIIa inhibitors (n=4,603), bivalirudin (Angiomax) plus IIb/IIIa inhibitors (n=4,604), or bivalirudin monotherapy (n=4,612).

For patients receiving GP IIb/IIIa inhibitors, a 2x2 factorial design assigned half the heparin and bivalirudin groups to routine upstream GP inhibitor administration (4,605 patients). The other half received selective GP IIb/IIIa inhibitors administration if PCI was indicated (4,602 patients).

At one year, there was no statistically significant difference in ischemia or mortality rate among the three therapy groups. No difference in ischemia rate was detected between the two GP IIb/IIIa inhibitor utilization strategies.

Since the hypotheses and the power for the one-year analysis in this trial were not prospectively determined, the results are considered to be exploratory and hypothesis generating.

Bottom line: At one year, there is no statistically significant difference in ischemia or mortality rate for the three antithrombotic regiments and the two glycoprotein utilization strategies.

Citation: Stone GW, Ware JH, Bertrand ME, et. al. Antithrombotic strategies in patients with acute coronary syndromes undergoing early invasive management. One-year results from the ACUITY trial. JAMA 2007;298:2497-2505.

What Is the PE Risk after Discontinuing Anticoagulation in Patients with Symptomatic VTE?

Background: The natural history of patients with symptomatic VTE who have completed anticoagulation is not well understood.

Study design: Inception cohort using pooled data from a prospective cohort study and one arm of an open-label randomized trial.

Setting: Academic medical centers in Canada, Sweden, and Italy.

Synopsis: Using pooled data from two previous studies, 2,052 patients with a first diagnosis of symptomatic VTE (lower-extremity deep-vein thrombosis [DVT], PE, or both) were evaluated for fatal PE after a standard course of therapy (mean of six months) with a vitamin K antagonist.

Patients were followed for up to 120 months. The investigators found an annual event risk of 0.19-0.49 per 100 person-years for fatal PE. Patients with prolonged immobility, active cancer, and thrombophilia were excluded, as were those with recurrent acute DVT.

Secondary analysis revealed an incidence of any fatal, definite or probable PE within the first year of discontinuing therapy of 0.35%-0.81%.

After the first year, the annual event risk ranged from 0.15-0.40 events per 100 person-years. Patients with advanced age, idiopathic VTE as well as those presenting with PE had higher rates of fatal PE.

Bottom line: There is a real though small (less than 1%) risk of fatal PE in the first year following discontinuation of anticoagulation for the first VTE episode. The optimal course of treatment for patients with idiopathic VTE is yet to be determined.

Citation: Douketis JD, Gu CS, Schulman S, et al. The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Intern Med. 2007;147(11):766-774.

Do the Beers Criteria Predict ED Visits Associated with Adverse Drug Events?

Background: Adverse drug events are common in the elderly. The Beers criteria are a consensus-based list of 41 medications that are considered inappropriate for use in older adults and often lead to poor outcomes.

Study design: Retrospective medical record review and data analysis.

Setting: Three nationally representative, U.S. public health surveillance systems: the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System (NEISS-CADES), 2004-2005; the National Ambulatory Medical Care Survey (NAMCS), 2004; and National Hospital Ambulatory Medical Care Survey (NHAMCS), 2004.

Synopsis: Using data collected from ED visits at 58 hospitals in the NEISS-CADES system, this study estimated that 177,504 visits for adverse drug events occur annually in the United States. Only 8.8% of such visits were attributable to the 41 medications included in the Beers criteria. Three drug classes (anticoagulant and antiplatelet agents, antidiabetic agents, and narrow therapeutic index agents) accounted for nearly half of all such ED visits. Warfarin (17.3%), insulin (13%), and digoxin (3.2%) were the most commonly implicated medications, collectively accounting for 33% of visits (CI, 27.8% to 38.7%).

This study suggests that because of the common use and high risk of adverse events associated with these three drugs, interventions targeting their use may prevent ED visits for adverse drug events in the elderly, compared with interventions aimed at reducing the use of medications identified in the Beers criteria.

This study only included adverse drug events identified in the ED and relied on the diagnosis and documentation of such events by the ED physician.

Bottom line: Beers criteria medications, although considered inappropriate for use in the elderly, were associated with significantly fewer ED visits for adverse events compared with warfarin, digoxin, and insulin.

Citation: Budnitz DS, Shehab N, Kegler SR, et. al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:755-765. TH

Literature at a Glance

A guide to this month’s abstracts

• Steroids reduce mortality only in patients with confirmed bacterial meningitis.
• Probiotics can be useful in the treatment of acute diarrhea in children.
• CT pulmonary angiography is not inferior to V/Q scanning for exclusion of PE.
• Hospitalist care results in shorter LOS compared with care by traditional general internists and family practice physicians.
• The early risk of stroke after TIA is approximately 15% to 20% at 90 days after the sentinel event.
• Different anti-thrombotic strategies produce no difference in outcomes of early acute coronary syndromes.
• The risk of fatal PE is highest in the first year after medication is stopped.
• Beers criteria medications are associated with fewer ED visits by elderly patients compared with warfarin, digoxin, and insulin.

Do Steroids Affect the Outcome in Patients with Meningitis?

Background: Pyogenic (bacterial) meningitis has high morbidity and mortality. Studies suggest some benefit of steroids in children but provide limited evidence for adult use.

Study design: Intention-to-treat, randomized control trial.

Setting: Single hospital in Vietnam.

Synopsis: Of 435 patients older than 14 with suspected meningitis all received lumbar puncture with randomization to IV dexamethasone or placebo for four days. Results showed 69% of patients had definite meningitis, 28.3% were probable, and 2.8% had an alternative diagnosis based on culture results.

The primary outcome was death after one month, which did not differ among groups (risk ratio [RR] 0.79, confidence interval [CI] 0.45-1.39).

Predefined subgroup analysis of patients with definitive meningitis showed a significant reduction in mortality at one month (RR 0.43, CI 0.2-0.94) and death/disability at six months (odds ratio [OR] 0.56, CI 0.32-0.98).

In patients with probable meningitis, those who received steroids demonstrated a trend toward harm (OR 2.65, CI 0.73-9.63).

Probable versus definite meningitis was determined retrospectively based on cultures. The most common isolate was Streptococcus suis.

Bottom line: This study provides some evidence for using steroids in adults with confirmed bacterial meningitis. Clinical application is limited by bacterial epidemiology and the difficulty of prospectively separating patients who would benefit from those who might be harmed.

Citation: Nguyen TH, Tran TH, Thwaites G, et. al. Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med. 2007;357:2431-2439.

Which Probiotic Preparations Best Reduce the Duration of Acute Diarrhea in Children?

Background: Probiotics have been suggested as an adjunctive therapy to reduce the severity and duration of acute diarrhea in children. However, there are no clear data to suggest if specific probiotic agents are superior to others.

Study design: Prospective single-blind, randomized, controlled trial.

Setting: Outpatient primary care in Naples, Italy.

Synopsis: This study compared five commercially available probiotic preparations (mix of Lactobacillus delbrueckii var bulgaricus/Streptococcus thermophilus/L. acidophilus/ Bifido-bacterium bifidum; L. rhamnosus strain GG; Saccharomyces boulardii; Bacillus clausii; or Enterococcus faecium SF68) and a control group in the treatment of outpatient acute diarrhea in 571 children age 3 months to 36 months.

The primary outcomes were the duration of diarrhea and the number and consistency of stools. The groups receiving Lactobacillus GG and the mixture had a shorter total duration of diarrhea (78.5 and 70 hours, respectively), decreased total number of stools, and improved stool consistency when compared with the control (115.5 hours). The other therapies showed no improvement over the control group. These data report on products commercially available in Italy, which may differ greatly from products available locally.

Bottom line: Probiotic preparations for the treatment of acute diarrhea in children should be chosen based on effectiveness data.

Citation: Canani RB, Cirillo P, Terrin G, et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations. BMJ 2007;335:340-345.

Is CTPA a Reliable Alternative to V/Q Scan for Diagnosing PE?

Background: Computed tomography pulmonary angiogram (CTPA) has replaced ventilation/perfusion (V/Q) scanning at many hospitals as the test of choice for ruling out pulmonary embolism (PE). But limited clinical data compare CTPA with V/Q scanning in those suspected of having venous thromboembolism (VTE).

Study design: Randomized, investigator blinded, controlled trial.

Setting: The emergency departments (ED), inpatient wards, and outpatient clinics of five academic centers.

Synopsis: In the study, 1,411 patients were enrolled from five medical centers. Of 694 patients randomized to CTPA, 133 (19.2%) were diagnosed with VTE in the initial evaluation period, while 101 of 712 patients (14.2%) receiving a V/Q scan were diagnosed with VTE.

Patients not initially diagnosed with VTE were monitored. At three-month follow-up, 0.4% of the CTPA group and 1.0% of the V/Q group had a diagnosed VTE.

The overall rate of VTE found in the initial diagnostic period was significantly greater in patients randomized to CTPA (19.2% vs. 14.2%; difference, 5.0%; 95% CI; 1.1% to 8.9% p=.01). This suggests CTPA has a higher false positive rate or detects clinically insignificant thrombi.

Bottom line: CTPA was not inferior to V/Q scanning for excluding clinically meaningful PE, but CTPA diagnosed about 30% more patients with VTE than did V/Q scanning.

Citation: Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs. ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298(23):2743-2753.

Does the Hospitalist Model Improve Length of Stay, Quality, and Cost of Care?

Background: The hospitalist model, with increased physician availability and expertise but greater discontinuity of care, is becoming more prevalent in U.S. medicine. What little is known about how this model will affect patient care is derived from a number of small studies.

Study design: Retrospective cohort study.

Setting: 45 small to midsize, predominantly nonteaching hospitals throughout the U.S.

Synopsis: Using the Premier Healthcare Informatics database, this study examined information on 76,926 patients admitted for seven common diagnoses to one of three services: hospitalist, general internist, or family physician. Analysis showed that patients on a hospitalist service had a 0.4-day shorter length of stay (p<0.001) compared with those on a general internist or family physician service.

The cost to patients cared for by a hospitalist was lower than the cost of family physicians ($125 less, p=0.33) and internists ($268 less, p=0.02). There was no difference found in death rate or 14-day readmission rate among the three services.

Given the retrospective design of this study, no causal relationship can be deduced. This study is further limited by its lack of specific data on the physicians categorized into one of the three groups solely by administrative data. The authors had concerns that the biases inherent to the retrospective nature of their work accounted for the significant difference found between hospitalists and internists.

Bottom line: The hospitalist model is associated with modest improvements in length of stay as compared with traditional inpatient approaches.

Citation: Lindenauer PK, Rothberg MB, Pekow PS, et. al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007;357:2589-2600.

What Is the Stroke Risk Soon after TIA, and What Factors Drive the Variability of Previous Findings?

Background: Many studies have attempted to estimate the risk of stroke in the early period after a transient ischemic attack (TIA). These studies vary widely in their calculation of the estimated risk. Further, the clinical and methodological factors underlying this variability are unclear.

Study design: Systematic review and meta-analysis.

Setting: Community and hospital.

Synopsis: Searching the Coch­rane review database, MEDLINE, EMBASE, CINAHL, and BIOSIS, 11 studies from 1973 to 2006 were included for meta-analysis, selected from 694 potential candidate studies identified on initial screening. The studies ranged in size from 62 to 2,285 patients.

The pooled estimate of risk for stroke following TIA was found to be 3.5%, 8%, and 9.2% at two, 30, and 90 days following TIA, respectively. However, there was significant heterogeneity for all periods considered (p<0.001).

Outcome ascertainment was identified as a major source of methodological heterogeneity. When risk of stroke at follow-up was determined by passive ascertainment (e.g., administrative documentation) the early risk of stroke was 3.1% two days after TIA, 6.4% at 30 days, and 8.7% at 90 days. But active ascertainment (e.g., direct, personal contact with study participants) determined stroke risk to be 9.9%, 13.4%, and 17.4% at two, 30, and 90 days after TIA, respectively.

Bottom line: Based on analysis of completed studies that included directly observed follow-up of study participants, the early risk of stroke after TIA is approximately 15% to 20% at 90 days following the sentinel event.

Citation: Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA. Early risk of stroke after transient ischemic attack. Arch Intern Med. 2007;167:2417-2422.

What Is the 1-year Ischemia and Mortality Rate for Three Anti-thrombotic Therapies for Early Invasive Management of ACS?

Background: Early interventional or surgical revascularization has improved morbidity and mortality in patients with acute coronary syndrome (ACS). The optimal anti-thrombotic regimen to reduce late ischemic and death rates has not been determined.

Study design: Prospective, open-label randomized control trial.

Setting: 450 academic and community-based institutions in 17 countries.

Synopsis: A total of 13,819 patients were enrolled between August 2003 and December 2005. They were assigned to heparin plus glycoprotein (GP) IIb/IIIa inhibitors (n=4,603), bivalirudin (Angiomax) plus IIb/IIIa inhibitors (n=4,604), or bivalirudin monotherapy (n=4,612).

For patients receiving GP IIb/IIIa inhibitors, a 2x2 factorial design assigned half the heparin and bivalirudin groups to routine upstream GP inhibitor administration (4,605 patients). The other half received selective GP IIb/IIIa inhibitors administration if PCI was indicated (4,602 patients).

At one year, there was no statistically significant difference in ischemia or mortality rate among the three therapy groups. No difference in ischemia rate was detected between the two GP IIb/IIIa inhibitor utilization strategies.

Since the hypotheses and the power for the one-year analysis in this trial were not prospectively determined, the results are considered to be exploratory and hypothesis generating.

Bottom line: At one year, there is no statistically significant difference in ischemia or mortality rate for the three antithrombotic regiments and the two glycoprotein utilization strategies.

Citation: Stone GW, Ware JH, Bertrand ME, et. al. Antithrombotic strategies in patients with acute coronary syndromes undergoing early invasive management. One-year results from the ACUITY trial. JAMA 2007;298:2497-2505.

What Is the PE Risk after Discontinuing Anticoagulation in Patients with Symptomatic VTE?

Background: The natural history of patients with symptomatic VTE who have completed anticoagulation is not well understood.

Study design: Inception cohort using pooled data from a prospective cohort study and one arm of an open-label randomized trial.

Setting: Academic medical centers in Canada, Sweden, and Italy.

Synopsis: Using pooled data from two previous studies, 2,052 patients with a first diagnosis of symptomatic VTE (lower-extremity deep-vein thrombosis [DVT], PE, or both) were evaluated for fatal PE after a standard course of therapy (mean of six months) with a vitamin K antagonist.

Patients were followed for up to 120 months. The investigators found an annual event risk of 0.19-0.49 per 100 person-years for fatal PE. Patients with prolonged immobility, active cancer, and thrombophilia were excluded, as were those with recurrent acute DVT.

Secondary analysis revealed an incidence of any fatal, definite or probable PE within the first year of discontinuing therapy of 0.35%-0.81%.

After the first year, the annual event risk ranged from 0.15-0.40 events per 100 person-years. Patients with advanced age, idiopathic VTE as well as those presenting with PE had higher rates of fatal PE.

Bottom line: There is a real though small (less than 1%) risk of fatal PE in the first year following discontinuation of anticoagulation for the first VTE episode. The optimal course of treatment for patients with idiopathic VTE is yet to be determined.

Citation: Douketis JD, Gu CS, Schulman S, et al. The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Intern Med. 2007;147(11):766-774.

Do the Beers Criteria Predict ED Visits Associated with Adverse Drug Events?

Background: Adverse drug events are common in the elderly. The Beers criteria are a consensus-based list of 41 medications that are considered inappropriate for use in older adults and often lead to poor outcomes.

Study design: Retrospective medical record review and data analysis.

Setting: Three nationally representative, U.S. public health surveillance systems: the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System (NEISS-CADES), 2004-2005; the National Ambulatory Medical Care Survey (NAMCS), 2004; and National Hospital Ambulatory Medical Care Survey (NHAMCS), 2004.

Synopsis: Using data collected from ED visits at 58 hospitals in the NEISS-CADES system, this study estimated that 177,504 visits for adverse drug events occur annually in the United States. Only 8.8% of such visits were attributable to the 41 medications included in the Beers criteria. Three drug classes (anticoagulant and antiplatelet agents, antidiabetic agents, and narrow therapeutic index agents) accounted for nearly half of all such ED visits. Warfarin (17.3%), insulin (13%), and digoxin (3.2%) were the most commonly implicated medications, collectively accounting for 33% of visits (CI, 27.8% to 38.7%).

This study suggests that because of the common use and high risk of adverse events associated with these three drugs, interventions targeting their use may prevent ED visits for adverse drug events in the elderly, compared with interventions aimed at reducing the use of medications identified in the Beers criteria.

This study only included adverse drug events identified in the ED and relied on the diagnosis and documentation of such events by the ED physician.

Bottom line: Beers criteria medications, although considered inappropriate for use in the elderly, were associated with significantly fewer ED visits for adverse events compared with warfarin, digoxin, and insulin.

Citation: Budnitz DS, Shehab N, Kegler SR, et. al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:755-765. TH

Literature at a Glance

A guide to this month’s abstracts

• Steroids reduce mortality only in patients with confirmed bacterial meningitis.
• Probiotics can be useful in the treatment of acute diarrhea in children.
• CT pulmonary angiography is not inferior to V/Q scanning for exclusion of PE.
• Hospitalist care results in shorter LOS compared with care by traditional general internists and family practice physicians.
• The early risk of stroke after TIA is approximately 15% to 20% at 90 days after the sentinel event.
• Different anti-thrombotic strategies produce no difference in outcomes of early acute coronary syndromes.
• The risk of fatal PE is highest in the first year after medication is stopped.
• Beers criteria medications are associated with fewer ED visits by elderly patients compared with warfarin, digoxin, and insulin.

Do Steroids Affect the Outcome in Patients with Meningitis?

Background: Pyogenic (bacterial) meningitis has high morbidity and mortality. Studies suggest some benefit of steroids in children but provide limited evidence for adult use.

Study design: Intention-to-treat, randomized control trial.

Setting: Single hospital in Vietnam.

Synopsis: Of 435 patients older than 14 with suspected meningitis all received lumbar puncture with randomization to IV dexamethasone or placebo for four days. Results showed 69% of patients had definite meningitis, 28.3% were probable, and 2.8% had an alternative diagnosis based on culture results.

The primary outcome was death after one month, which did not differ among groups (risk ratio [RR] 0.79, confidence interval [CI] 0.45-1.39).

Predefined subgroup analysis of patients with definitive meningitis showed a significant reduction in mortality at one month (RR 0.43, CI 0.2-0.94) and death/disability at six months (odds ratio [OR] 0.56, CI 0.32-0.98).

In patients with probable meningitis, those who received steroids demonstrated a trend toward harm (OR 2.65, CI 0.73-9.63).

Probable versus definite meningitis was determined retrospectively based on cultures. The most common isolate was Streptococcus suis.

Bottom line: This study provides some evidence for using steroids in adults with confirmed bacterial meningitis. Clinical application is limited by bacterial epidemiology and the difficulty of prospectively separating patients who would benefit from those who might be harmed.

Citation: Nguyen TH, Tran TH, Thwaites G, et. al. Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med. 2007;357:2431-2439.

Which Probiotic Preparations Best Reduce the Duration of Acute Diarrhea in Children?

Background: Probiotics have been suggested as an adjunctive therapy to reduce the severity and duration of acute diarrhea in children. However, there are no clear data to suggest if specific probiotic agents are superior to others.

Study design: Prospective single-blind, randomized, controlled trial.

Setting: Outpatient primary care in Naples, Italy.

Synopsis: This study compared five commercially available probiotic preparations (mix of Lactobacillus delbrueckii var bulgaricus/Streptococcus thermophilus/L. acidophilus/ Bifido-bacterium bifidum; L. rhamnosus strain GG; Saccharomyces boulardii; Bacillus clausii; or Enterococcus faecium SF68) and a control group in the treatment of outpatient acute diarrhea in 571 children age 3 months to 36 months.

The primary outcomes were the duration of diarrhea and the number and consistency of stools. The groups receiving Lactobacillus GG and the mixture had a shorter total duration of diarrhea (78.5 and 70 hours, respectively), decreased total number of stools, and improved stool consistency when compared with the control (115.5 hours). The other therapies showed no improvement over the control group. These data report on products commercially available in Italy, which may differ greatly from products available locally.

Bottom line: Probiotic preparations for the treatment of acute diarrhea in children should be chosen based on effectiveness data.

Citation: Canani RB, Cirillo P, Terrin G, et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations. BMJ 2007;335:340-345.

Is CTPA a Reliable Alternative to V/Q Scan for Diagnosing PE?

Background: Computed tomography pulmonary angiogram (CTPA) has replaced ventilation/perfusion (V/Q) scanning at many hospitals as the test of choice for ruling out pulmonary embolism (PE). But limited clinical data compare CTPA with V/Q scanning in those suspected of having venous thromboembolism (VTE).

Study design: Randomized, investigator blinded, controlled trial.

Setting: The emergency departments (ED), inpatient wards, and outpatient clinics of five academic centers.

Synopsis: In the study, 1,411 patients were enrolled from five medical centers. Of 694 patients randomized to CTPA, 133 (19.2%) were diagnosed with VTE in the initial evaluation period, while 101 of 712 patients (14.2%) receiving a V/Q scan were diagnosed with VTE.

Patients not initially diagnosed with VTE were monitored. At three-month follow-up, 0.4% of the CTPA group and 1.0% of the V/Q group had a diagnosed VTE.

The overall rate of VTE found in the initial diagnostic period was significantly greater in patients randomized to CTPA (19.2% vs. 14.2%; difference, 5.0%; 95% CI; 1.1% to 8.9% p=.01). This suggests CTPA has a higher false positive rate or detects clinically insignificant thrombi.

Bottom line: CTPA was not inferior to V/Q scanning for excluding clinically meaningful PE, but CTPA diagnosed about 30% more patients with VTE than did V/Q scanning.

Citation: Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs. ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298(23):2743-2753.

Does the Hospitalist Model Improve Length of Stay, Quality, and Cost of Care?

Background: The hospitalist model, with increased physician availability and expertise but greater discontinuity of care, is becoming more prevalent in U.S. medicine. What little is known about how this model will affect patient care is derived from a number of small studies.

Study design: Retrospective cohort study.

Setting: 45 small to midsize, predominantly nonteaching hospitals throughout the U.S.

Synopsis: Using the Premier Healthcare Informatics database, this study examined information on 76,926 patients admitted for seven common diagnoses to one of three services: hospitalist, general internist, or family physician. Analysis showed that patients on a hospitalist service had a 0.4-day shorter length of stay (p<0.001) compared with those on a general internist or family physician service.

The cost to patients cared for by a hospitalist was lower than the cost of family physicians ($125 less, p=0.33) and internists ($268 less, p=0.02). There was no difference found in death rate or 14-day readmission rate among the three services.

Given the retrospective design of this study, no causal relationship can be deduced. This study is further limited by its lack of specific data on the physicians categorized into one of the three groups solely by administrative data. The authors had concerns that the biases inherent to the retrospective nature of their work accounted for the significant difference found between hospitalists and internists.

Bottom line: The hospitalist model is associated with modest improvements in length of stay as compared with traditional inpatient approaches.

Citation: Lindenauer PK, Rothberg MB, Pekow PS, et. al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007;357:2589-2600.

What Is the Stroke Risk Soon after TIA, and What Factors Drive the Variability of Previous Findings?

Background: Many studies have attempted to estimate the risk of stroke in the early period after a transient ischemic attack (TIA). These studies vary widely in their calculation of the estimated risk. Further, the clinical and methodological factors underlying this variability are unclear.

Study design: Systematic review and meta-analysis.

Setting: Community and hospital.

Synopsis: Searching the Coch­rane review database, MEDLINE, EMBASE, CINAHL, and BIOSIS, 11 studies from 1973 to 2006 were included for meta-analysis, selected from 694 potential candidate studies identified on initial screening. The studies ranged in size from 62 to 2,285 patients.

The pooled estimate of risk for stroke following TIA was found to be 3.5%, 8%, and 9.2% at two, 30, and 90 days following TIA, respectively. However, there was significant heterogeneity for all periods considered (p<0.001).

Outcome ascertainment was identified as a major source of methodological heterogeneity. When risk of stroke at follow-up was determined by passive ascertainment (e.g., administrative documentation) the early risk of stroke was 3.1% two days after TIA, 6.4% at 30 days, and 8.7% at 90 days. But active ascertainment (e.g., direct, personal contact with study participants) determined stroke risk to be 9.9%, 13.4%, and 17.4% at two, 30, and 90 days after TIA, respectively.

Bottom line: Based on analysis of completed studies that included directly observed follow-up of study participants, the early risk of stroke after TIA is approximately 15% to 20% at 90 days following the sentinel event.

Citation: Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA. Early risk of stroke after transient ischemic attack. Arch Intern Med. 2007;167:2417-2422.

What Is the 1-year Ischemia and Mortality Rate for Three Anti-thrombotic Therapies for Early Invasive Management of ACS?

Background: Early interventional or surgical revascularization has improved morbidity and mortality in patients with acute coronary syndrome (ACS). The optimal anti-thrombotic regimen to reduce late ischemic and death rates has not been determined.

Study design: Prospective, open-label randomized control trial.

Setting: 450 academic and community-based institutions in 17 countries.

Synopsis: A total of 13,819 patients were enrolled between August 2003 and December 2005. They were assigned to heparin plus glycoprotein (GP) IIb/IIIa inhibitors (n=4,603), bivalirudin (Angiomax) plus IIb/IIIa inhibitors (n=4,604), or bivalirudin monotherapy (n=4,612).

For patients receiving GP IIb/IIIa inhibitors, a 2x2 factorial design assigned half the heparin and bivalirudin groups to routine upstream GP inhibitor administration (4,605 patients). The other half received selective GP IIb/IIIa inhibitors administration if PCI was indicated (4,602 patients).

At one year, there was no statistically significant difference in ischemia or mortality rate among the three therapy groups. No difference in ischemia rate was detected between the two GP IIb/IIIa inhibitor utilization strategies.

Since the hypotheses and the power for the one-year analysis in this trial were not prospectively determined, the results are considered to be exploratory and hypothesis generating.

Bottom line: At one year, there is no statistically significant difference in ischemia or mortality rate for the three antithrombotic regiments and the two glycoprotein utilization strategies.

Citation: Stone GW, Ware JH, Bertrand ME, et. al. Antithrombotic strategies in patients with acute coronary syndromes undergoing early invasive management. One-year results from the ACUITY trial. JAMA 2007;298:2497-2505.

What Is the PE Risk after Discontinuing Anticoagulation in Patients with Symptomatic VTE?

Background: The natural history of patients with symptomatic VTE who have completed anticoagulation is not well understood.

Study design: Inception cohort using pooled data from a prospective cohort study and one arm of an open-label randomized trial.

Setting: Academic medical centers in Canada, Sweden, and Italy.

Synopsis: Using pooled data from two previous studies, 2,052 patients with a first diagnosis of symptomatic VTE (lower-extremity deep-vein thrombosis [DVT], PE, or both) were evaluated for fatal PE after a standard course of therapy (mean of six months) with a vitamin K antagonist.

Patients were followed for up to 120 months. The investigators found an annual event risk of 0.19-0.49 per 100 person-years for fatal PE. Patients with prolonged immobility, active cancer, and thrombophilia were excluded, as were those with recurrent acute DVT.

Secondary analysis revealed an incidence of any fatal, definite or probable PE within the first year of discontinuing therapy of 0.35%-0.81%.

After the first year, the annual event risk ranged from 0.15-0.40 events per 100 person-years. Patients with advanced age, idiopathic VTE as well as those presenting with PE had higher rates of fatal PE.

Bottom line: There is a real though small (less than 1%) risk of fatal PE in the first year following discontinuation of anticoagulation for the first VTE episode. The optimal course of treatment for patients with idiopathic VTE is yet to be determined.

Citation: Douketis JD, Gu CS, Schulman S, et al. The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Intern Med. 2007;147(11):766-774.

Do the Beers Criteria Predict ED Visits Associated with Adverse Drug Events?

Background: Adverse drug events are common in the elderly. The Beers criteria are a consensus-based list of 41 medications that are considered inappropriate for use in older adults and often lead to poor outcomes.

Study design: Retrospective medical record review and data analysis.

Setting: Three nationally representative, U.S. public health surveillance systems: the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System (NEISS-CADES), 2004-2005; the National Ambulatory Medical Care Survey (NAMCS), 2004; and National Hospital Ambulatory Medical Care Survey (NHAMCS), 2004.

Synopsis: Using data collected from ED visits at 58 hospitals in the NEISS-CADES system, this study estimated that 177,504 visits for adverse drug events occur annually in the United States. Only 8.8% of such visits were attributable to the 41 medications included in the Beers criteria. Three drug classes (anticoagulant and antiplatelet agents, antidiabetic agents, and narrow therapeutic index agents) accounted for nearly half of all such ED visits. Warfarin (17.3%), insulin (13%), and digoxin (3.2%) were the most commonly implicated medications, collectively accounting for 33% of visits (CI, 27.8% to 38.7%).

This study suggests that because of the common use and high risk of adverse events associated with these three drugs, interventions targeting their use may prevent ED visits for adverse drug events in the elderly, compared with interventions aimed at reducing the use of medications identified in the Beers criteria.

This study only included adverse drug events identified in the ED and relied on the diagnosis and documentation of such events by the ED physician.

Bottom line: Beers criteria medications, although considered inappropriate for use in the elderly, were associated with significantly fewer ED visits for adverse events compared with warfarin, digoxin, and insulin.

Citation: Budnitz DS, Shehab N, Kegler SR, et. al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147:755-765. TH

Dr. Auerbach

Before Andy Auerbach, MD, MPH, concludes a four-year term as chair of SHM’s Research Committee, I talked with him about his perspective on hospital medicine research. Dr. Auerbach is an associate professor of medicine at the University of California, San Francisco.

He received a career development award from the National Institutes of Health (NIH) early in his career and is the principal investigator of an R01 research project grant from the NHLBI titled “Improving use of perioperative beta-blockers through a multidimensional QI program.”

He is also a co-author of “Outcomes of Patients Treated by Hospitalists, General Internists, and Family Physicians” in the December 2007 New England Journal of Medicine, which found statistically significant differences in length of stay and cost. He received his medical degree from Dartmouth Medical School in Hanover, N.H., and did his residency training in internal medicine at Yale New Haven Hospital in Connecticut. He completed an MPH in clinical epidemiology at the Harvard School of Public Health in Boston in 1998.

Q: So, is academia as glamorous as it sounds?

Dr. Auerbach: Way more glamorous—you should see my office. And yes, we are in a white tower.

Q: How did you get your start in research?

Dr. Auerbach: I actually started out my research fellowship wanting to be a cardiologist and go into the cath lab while developing the skills to participate in and teach research methods. I found I really enjoyed the work, particularly the creative and entrepreneurial aspects of developing a project or grant and seeing it through to completion.

Q: What are the research options for hospitalists practicing in nonteaching settings?

Dr. Auerbach: I think the most straightforward way to participate in research is to partner with a clinical research organization to help enroll patients in their trials. While you don’t get the opportunity to design the study, you do get to get a feel for consent/enrollment and internal review board [IRB] processes. 

The next best way to get involved with research is to partner with a researcher—and this need not be a hospitalist—at your site or very near by. Many QI projects are close to being research-ready and may provide an opportunity to make that work count twice. But it will require you to learn about analytic methods.

I’d also be remiss if I didn’t mention the value of other very useful academic products—rigorous reports of a QI intervention (think of both success and failure stories) and patient case reports. If well referenced and used as teaching documents, these can be very useful ways to advance knowledge.

Q: Are there any particular prerequisites in terms of training that you find especially helpful as you conduct your research? 

Dr. Auerbach: It is hard to be a capital-R “Researcher” and compete for career development grants and NIH funding without some advanced [degrees] and a clinical research fellowship. I hesitate to call these prerequisites, but they are nearly so. 

Q: What do you like best about your career as a hospitalist?

Dr. Auerbach: I really like acute care medicine, but didn’t want to subspecialize—otherwise I’d be wearing lead in a cath lab now. I also like the questions and processes in the hospital a bit more than the clinic setting.

Q: Who are your mentors and how did you find them? 

Dr. Auerbach: I’ve had a remarkable set of mentors from fellowship [Mary Beth Hamel, Roger Davis, Russ Phillips] through my early career [Lee Goldman, Bob Wachter, Ralph Gonzales]. Now that I am early-mid career, I’m trying to pass their teaching on.

Q: Any advice for hospitalists interested in research but daunted by the prospect of starting their own studies?

Dr. Auerbach: If you want to do a scholarly/academic project to round out your personal/career satisfaction, I think the daunting nature of research can be overcome with the right questions and right support—and by defining what these are well before you actually dive into a dataset or implementation project. You also have to decide how much satisfaction you will get from the project in the end compared to the incremental nights/weekends you will spend to plan and execute your project—not to mention publish.

If you are thinking of research as a career, be aware of what makes you happy. If you like to write, enjoy the process of hypothesis generating/testing, and take rejection well you may be happy as a researcher. There are still plenty of nights/weekends to be spent, though.

Making a switch from full-time clinical or administrative work to research means making a very big commitment to going back to get the skills as part of a fellowship.

Q: Do researchers interested in quality improvement questions still have to run their work past the IRB?

Dr. Auerbach: Unfortunately this is now an area of uncertainty for people—unnecessarily so. Until recent events, IRBs have not required approval for QI projects that seek to enhance care according to an evidence-based standard, especially if that standard is endorsed by the institution. If you plan to publish your findings—particularly if you talk to or touch patients, or collect personal health information—I think it is nearly always wise to at least call your local IRB to ask for how you can or should conduct the study. This is best done before you start the project, obviously.

If you want to publish your results using deidentified data after the project is done, our IRB would say that is exempt from review [e.g., no need for approval]. But I think even this case would be worth a phone call to ensure your IRB feels similarly.

Whether or not you get IRB approval, be very aware of how and where you store data. TH

Dr. Auerbach

Before Andy Auerbach, MD, MPH, concludes a four-year term as chair of SHM’s Research Committee, I talked with him about his perspective on hospital medicine research. Dr. Auerbach is an associate professor of medicine at the University of California, San Francisco.

He received a career development award from the National Institutes of Health (NIH) early in his career and is the principal investigator of an R01 research project grant from the NHLBI titled “Improving use of perioperative beta-blockers through a multidimensional QI program.”

He is also a co-author of “Outcomes of Patients Treated by Hospitalists, General Internists, and Family Physicians” in the December 2007 New England Journal of Medicine, which found statistically significant differences in length of stay and cost. He received his medical degree from Dartmouth Medical School in Hanover, N.H., and did his residency training in internal medicine at Yale New Haven Hospital in Connecticut. He completed an MPH in clinical epidemiology at the Harvard School of Public Health in Boston in 1998.

Q: So, is academia as glamorous as it sounds?

Dr. Auerbach: Way more glamorous—you should see my office. And yes, we are in a white tower.

Q: How did you get your start in research?

Dr. Auerbach: I actually started out my research fellowship wanting to be a cardiologist and go into the cath lab while developing the skills to participate in and teach research methods. I found I really enjoyed the work, particularly the creative and entrepreneurial aspects of developing a project or grant and seeing it through to completion.

Q: What are the research options for hospitalists practicing in nonteaching settings?

Dr. Auerbach: I think the most straightforward way to participate in research is to partner with a clinical research organization to help enroll patients in their trials. While you don’t get the opportunity to design the study, you do get to get a feel for consent/enrollment and internal review board [IRB] processes. 

The next best way to get involved with research is to partner with a researcher—and this need not be a hospitalist—at your site or very near by. Many QI projects are close to being research-ready and may provide an opportunity to make that work count twice. But it will require you to learn about analytic methods.

I’d also be remiss if I didn’t mention the value of other very useful academic products—rigorous reports of a QI intervention (think of both success and failure stories) and patient case reports. If well referenced and used as teaching documents, these can be very useful ways to advance knowledge.

Q: Are there any particular prerequisites in terms of training that you find especially helpful as you conduct your research? 

Dr. Auerbach: It is hard to be a capital-R “Researcher” and compete for career development grants and NIH funding without some advanced [degrees] and a clinical research fellowship. I hesitate to call these prerequisites, but they are nearly so. 

Q: What do you like best about your career as a hospitalist?

Dr. Auerbach: I really like acute care medicine, but didn’t want to subspecialize—otherwise I’d be wearing lead in a cath lab now. I also like the questions and processes in the hospital a bit more than the clinic setting.

Q: Who are your mentors and how did you find them? 

Dr. Auerbach: I’ve had a remarkable set of mentors from fellowship [Mary Beth Hamel, Roger Davis, Russ Phillips] through my early career [Lee Goldman, Bob Wachter, Ralph Gonzales]. Now that I am early-mid career, I’m trying to pass their teaching on.

Q: Any advice for hospitalists interested in research but daunted by the prospect of starting their own studies?

Dr. Auerbach: If you want to do a scholarly/academic project to round out your personal/career satisfaction, I think the daunting nature of research can be overcome with the right questions and right support—and by defining what these are well before you actually dive into a dataset or implementation project. You also have to decide how much satisfaction you will get from the project in the end compared to the incremental nights/weekends you will spend to plan and execute your project—not to mention publish.

If you are thinking of research as a career, be aware of what makes you happy. If you like to write, enjoy the process of hypothesis generating/testing, and take rejection well you may be happy as a researcher. There are still plenty of nights/weekends to be spent, though.

Making a switch from full-time clinical or administrative work to research means making a very big commitment to going back to get the skills as part of a fellowship.

Q: Do researchers interested in quality improvement questions still have to run their work past the IRB?

Dr. Auerbach: Unfortunately this is now an area of uncertainty for people—unnecessarily so. Until recent events, IRBs have not required approval for QI projects that seek to enhance care according to an evidence-based standard, especially if that standard is endorsed by the institution. If you plan to publish your findings—particularly if you talk to or touch patients, or collect personal health information—I think it is nearly always wise to at least call your local IRB to ask for how you can or should conduct the study. This is best done before you start the project, obviously.

If you want to publish your results using deidentified data after the project is done, our IRB would say that is exempt from review [e.g., no need for approval]. But I think even this case would be worth a phone call to ensure your IRB feels similarly.

Whether or not you get IRB approval, be very aware of how and where you store data. TH

Dr. Auerbach

Before Andy Auerbach, MD, MPH, concludes a four-year term as chair of SHM’s Research Committee, I talked with him about his perspective on hospital medicine research. Dr. Auerbach is an associate professor of medicine at the University of California, San Francisco.

He received a career development award from the National Institutes of Health (NIH) early in his career and is the principal investigator of an R01 research project grant from the NHLBI titled “Improving use of perioperative beta-blockers through a multidimensional QI program.”

He is also a co-author of “Outcomes of Patients Treated by Hospitalists, General Internists, and Family Physicians” in the December 2007 New England Journal of Medicine, which found statistically significant differences in length of stay and cost. He received his medical degree from Dartmouth Medical School in Hanover, N.H., and did his residency training in internal medicine at Yale New Haven Hospital in Connecticut. He completed an MPH in clinical epidemiology at the Harvard School of Public Health in Boston in 1998.

Q: So, is academia as glamorous as it sounds?

Dr. Auerbach: Way more glamorous—you should see my office. And yes, we are in a white tower.

Q: How did you get your start in research?

Dr. Auerbach: I actually started out my research fellowship wanting to be a cardiologist and go into the cath lab while developing the skills to participate in and teach research methods. I found I really enjoyed the work, particularly the creative and entrepreneurial aspects of developing a project or grant and seeing it through to completion.

Q: What are the research options for hospitalists practicing in nonteaching settings?

Dr. Auerbach: I think the most straightforward way to participate in research is to partner with a clinical research organization to help enroll patients in their trials. While you don’t get the opportunity to design the study, you do get to get a feel for consent/enrollment and internal review board [IRB] processes. 

The next best way to get involved with research is to partner with a researcher—and this need not be a hospitalist—at your site or very near by. Many QI projects are close to being research-ready and may provide an opportunity to make that work count twice. But it will require you to learn about analytic methods.

I’d also be remiss if I didn’t mention the value of other very useful academic products—rigorous reports of a QI intervention (think of both success and failure stories) and patient case reports. If well referenced and used as teaching documents, these can be very useful ways to advance knowledge.

Q: Are there any particular prerequisites in terms of training that you find especially helpful as you conduct your research? 

Dr. Auerbach: It is hard to be a capital-R “Researcher” and compete for career development grants and NIH funding without some advanced [degrees] and a clinical research fellowship. I hesitate to call these prerequisites, but they are nearly so. 

Q: What do you like best about your career as a hospitalist?

Dr. Auerbach: I really like acute care medicine, but didn’t want to subspecialize—otherwise I’d be wearing lead in a cath lab now. I also like the questions and processes in the hospital a bit more than the clinic setting.

Q: Who are your mentors and how did you find them? 

Dr. Auerbach: I’ve had a remarkable set of mentors from fellowship [Mary Beth Hamel, Roger Davis, Russ Phillips] through my early career [Lee Goldman, Bob Wachter, Ralph Gonzales]. Now that I am early-mid career, I’m trying to pass their teaching on.

Q: Any advice for hospitalists interested in research but daunted by the prospect of starting their own studies?

Dr. Auerbach: If you want to do a scholarly/academic project to round out your personal/career satisfaction, I think the daunting nature of research can be overcome with the right questions and right support—and by defining what these are well before you actually dive into a dataset or implementation project. You also have to decide how much satisfaction you will get from the project in the end compared to the incremental nights/weekends you will spend to plan and execute your project—not to mention publish.

If you are thinking of research as a career, be aware of what makes you happy. If you like to write, enjoy the process of hypothesis generating/testing, and take rejection well you may be happy as a researcher. There are still plenty of nights/weekends to be spent, though.

Making a switch from full-time clinical or administrative work to research means making a very big commitment to going back to get the skills as part of a fellowship.

Q: Do researchers interested in quality improvement questions still have to run their work past the IRB?

Dr. Auerbach: Unfortunately this is now an area of uncertainty for people—unnecessarily so. Until recent events, IRBs have not required approval for QI projects that seek to enhance care according to an evidence-based standard, especially if that standard is endorsed by the institution. If you plan to publish your findings—particularly if you talk to or touch patients, or collect personal health information—I think it is nearly always wise to at least call your local IRB to ask for how you can or should conduct the study. This is best done before you start the project, obviously.

If you want to publish your results using deidentified data after the project is done, our IRB would say that is exempt from review [e.g., no need for approval]. But I think even this case would be worth a phone call to ensure your IRB feels similarly.

Whether or not you get IRB approval, be very aware of how and where you store data. TH

The Career Satisfaction Task Force has focused on two key areas this year to build upon the work that resulted in last year’s white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction.”

The paper outlined a framework for hospital medicine program leaders and hospitalists to identify important components of matching individuals and programs for the best job fit.

This year, the task force is working to bring the white paper to life and moving it from a conceptual framework to demonstrating how to use it to solve real issues facing programs and individuals.

The first of these projects was a Webinar led by SHM Senior Vice President Joe Miller, Sylvia McKean, MD (course director of Hospital Medicine 2008), and Win Whitcomb, MD (a co-founder of SHM). Each of them has held leadership roles on this task force. About 80 people participated in the December event, and more than three-fourths of attendees rated it highly.

At last year’s Annual Meeting in Dallas, the white paper was presented in a task force workshop. In keeping with our aim to bring the framework to life, this year’s workshop will use real case studies to demonstrate how to use bring the concepts to solutions. The workshop will be facilitated by Chad Whelan, MD, assistant professor of medicine and director of the Hospitalists Scholars Training Program, University of Chicago. Discussing key concepts will be Doug Carlson, MD, associate professor, Pediatrics Division, Washington University School of Medicine in St. Louis, and Tosha Wetterneck, MD, University of Wisconsin Hospital/Clinics, Madison. Drs. Carlson and Wetterneck made significant contributions to the white paper. In this highly interactive workshop, case studies that demonstrate challenges with workload/scheduling and autonomy will be discussed. Drs. Carlson and Wetterneck will lead the participants through discussions aimed at identifying the root causes of struggle and potential solutions for the program.

In the coming months, we hope to develop a series of articles to be published in The Hospitalist addressing the issues of greatest importance for career satisfaction.

The task force realizes there may be opportunities to add knowledge about career satisfaction and provide a valuable service to SHM member. We are in the early stages of developing a survey geared to further clarifying the most important factors in making satisfying career matches as well as providing detailed feedback about programs to their leaders. We are seeking funding to enable us to begin this exciting work.

The Career Satisfaction Task Force has focused on two key areas this year to build upon the work that resulted in last year’s white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction.”

The paper outlined a framework for hospital medicine program leaders and hospitalists to identify important components of matching individuals and programs for the best job fit.

This year, the task force is working to bring the white paper to life and moving it from a conceptual framework to demonstrating how to use it to solve real issues facing programs and individuals.

The first of these projects was a Webinar led by SHM Senior Vice President Joe Miller, Sylvia McKean, MD (course director of Hospital Medicine 2008), and Win Whitcomb, MD (a co-founder of SHM). Each of them has held leadership roles on this task force. About 80 people participated in the December event, and more than three-fourths of attendees rated it highly.

At last year’s Annual Meeting in Dallas, the white paper was presented in a task force workshop. In keeping with our aim to bring the framework to life, this year’s workshop will use real case studies to demonstrate how to use bring the concepts to solutions. The workshop will be facilitated by Chad Whelan, MD, assistant professor of medicine and director of the Hospitalists Scholars Training Program, University of Chicago. Discussing key concepts will be Doug Carlson, MD, associate professor, Pediatrics Division, Washington University School of Medicine in St. Louis, and Tosha Wetterneck, MD, University of Wisconsin Hospital/Clinics, Madison. Drs. Carlson and Wetterneck made significant contributions to the white paper. In this highly interactive workshop, case studies that demonstrate challenges with workload/scheduling and autonomy will be discussed. Drs. Carlson and Wetterneck will lead the participants through discussions aimed at identifying the root causes of struggle and potential solutions for the program.

In the coming months, we hope to develop a series of articles to be published in The Hospitalist addressing the issues of greatest importance for career satisfaction.

The task force realizes there may be opportunities to add knowledge about career satisfaction and provide a valuable service to SHM member. We are in the early stages of developing a survey geared to further clarifying the most important factors in making satisfying career matches as well as providing detailed feedback about programs to their leaders. We are seeking funding to enable us to begin this exciting work.

The Career Satisfaction Task Force has focused on two key areas this year to build upon the work that resulted in last year’s white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction.”

The paper outlined a framework for hospital medicine program leaders and hospitalists to identify important components of matching individuals and programs for the best job fit.

This year, the task force is working to bring the white paper to life and moving it from a conceptual framework to demonstrating how to use it to solve real issues facing programs and individuals.

The first of these projects was a Webinar led by SHM Senior Vice President Joe Miller, Sylvia McKean, MD (course director of Hospital Medicine 2008), and Win Whitcomb, MD (a co-founder of SHM). Each of them has held leadership roles on this task force. About 80 people participated in the December event, and more than three-fourths of attendees rated it highly.

At last year’s Annual Meeting in Dallas, the white paper was presented in a task force workshop. In keeping with our aim to bring the framework to life, this year’s workshop will use real case studies to demonstrate how to use bring the concepts to solutions. The workshop will be facilitated by Chad Whelan, MD, assistant professor of medicine and director of the Hospitalists Scholars Training Program, University of Chicago. Discussing key concepts will be Doug Carlson, MD, associate professor, Pediatrics Division, Washington University School of Medicine in St. Louis, and Tosha Wetterneck, MD, University of Wisconsin Hospital/Clinics, Madison. Drs. Carlson and Wetterneck made significant contributions to the white paper. In this highly interactive workshop, case studies that demonstrate challenges with workload/scheduling and autonomy will be discussed. Drs. Carlson and Wetterneck will lead the participants through discussions aimed at identifying the root causes of struggle and potential solutions for the program.

In the coming months, we hope to develop a series of articles to be published in The Hospitalist addressing the issues of greatest importance for career satisfaction.

The task force realizes there may be opportunities to add knowledge about career satisfaction and provide a valuable service to SHM member. We are in the early stages of developing a survey geared to further clarifying the most important factors in making satisfying career matches as well as providing detailed feedback about programs to their leaders. We are seeking funding to enable us to begin this exciting work.

Attendees at this year’s SHM Annual Meeting in San Diego brought with them exciting news of international developments that might broaden the scope of the specialty.

For example, Efren Manjarrez, MD, director of clinical operations for the division of hospital medicine of the Leonard M. Miller School of Medicine at the University of Miami, recently discovered a 500-plus-bed facility at the Universidad de Navarra during his trip to Pamplona, Spain.

Because Dr. Manjarrez is bilingual, past SHM President Mark Williams, MD, professor and chief of the division of hospital medicine at the Northwestern University Feinberg School of Medicine in Chicago, asked him to give a lecture.

“[The Universidad de Navarra] has one of the top two medical schools in Spain and they had the very first symposium on the management of the hospitalized patient,” Dr. Manjarrez says. “They had the very first hospitalist conference in Spain and quite possibly in Europe.”

While in Spain, Dr. Manjarrez realized hospitalists there were “at the grassroots level, where we were about 10 to 12 years ago,” just starting to have a few hospital medical units. The clinic in at the Universidad de Navarra had about five units, and there was a small hospitalist group near Valencia, as well.

Dr. Manjarrez

Dr. Manjarrez is highly complimentary of the university’s “top-flight medical school,” where he said doctors perform liver transplants.

“They could compete favorably with any city in the United States,” he notes. “They’re interested in organizing hospitalists like Mark Williams and what people ahead of me did for SHM.”

Dr. Manjarrez and Dr. Williams have discussed what will happen with the hospital medicine movement internationally. They forecast that the work begun in the U.S. will globalize fairly soon.

“The Spaniards are very, very on the ball to ask us over there to see what’s going on to get a jump on it,” Dr. Manjarrez says. “SHM needs to start thinking ahead and have an international chapter and plan international meetings abroad to have SHM’s message spread globally. The time is ripe to export what SHM and hospital medicine is doing here”

Dr. Manjarrez notes that Argentina has small pockets of hospitalists. And, Guilherme Brauner Barcellos MD, specialist in internal medicine and intensive care at the Nossa Senhora de Conceicao Hospital in Brazil, is excited about the establishment of a hospital medicine program there. He finds the attempts to develop the specialty in his country “fascinating and challenging.”

“The implementation of hospital medicine, especially those aspects that involve more than just having a general medicine physician dealing with inpatient care, is brand new in Brazil,” Dr. Barcellos says. “We understand there is a long journey ahead.”

Dr. Barcellos is president of the recently formed Brazilian Society of Hospital Medicine and became a member of SHM last year, attending May’s meeting in Dallas. He says the number of hospitalists in Brazil is limited, but “a rapid expansion is predicted.”

“As in the U.S. several years ago, the case for hospitalists in Brazil is still being made,” he notes. “We did a hospital medicine meeting last October, and it led to the formation of the Brazilian Society of Hospital Medicine. We definitely fostered the discussion about the specialty and the model in Brazil.”

He hopes more people will talk about the topic through the new group’s Web site (www.medicinahospitalar.com.br) and in hospitals throughout the country.

“Before the year of 2005, the majority of people here didn’t know about the hospitalists,” he explains. “After that, we had a period in which people were confused, thinking hospitalists were the same as doctors who work in the rapid response teams only. Currently, everybody at least knows about hospital medicine.”

Dr. Williams notes that hospital medicine organizations are forming in Chile, Argentina, Australia, and New Zealand.

Dr. Barcellos believes hospitals across his country “will awake to hospital medicine” when they realize that traditional models aren’t property servicing hospitalized patients anymore. “Much of what is present is wrong, obsolete or out of time, and we should try new attempts to create a different organization,” he says. TH

Molly R. Okeon is a journalist based in California.

Attendees at this year’s SHM Annual Meeting in San Diego brought with them exciting news of international developments that might broaden the scope of the specialty.

For example, Efren Manjarrez, MD, director of clinical operations for the division of hospital medicine of the Leonard M. Miller School of Medicine at the University of Miami, recently discovered a 500-plus-bed facility at the Universidad de Navarra during his trip to Pamplona, Spain.

Because Dr. Manjarrez is bilingual, past SHM President Mark Williams, MD, professor and chief of the division of hospital medicine at the Northwestern University Feinberg School of Medicine in Chicago, asked him to give a lecture.

“[The Universidad de Navarra] has one of the top two medical schools in Spain and they had the very first symposium on the management of the hospitalized patient,” Dr. Manjarrez says. “They had the very first hospitalist conference in Spain and quite possibly in Europe.”

While in Spain, Dr. Manjarrez realized hospitalists there were “at the grassroots level, where we were about 10 to 12 years ago,” just starting to have a few hospital medical units. The clinic in at the Universidad de Navarra had about five units, and there was a small hospitalist group near Valencia, as well.

Dr. Manjarrez

Dr. Manjarrez is highly complimentary of the university’s “top-flight medical school,” where he said doctors perform liver transplants.

“They could compete favorably with any city in the United States,” he notes. “They’re interested in organizing hospitalists like Mark Williams and what people ahead of me did for SHM.”

Dr. Manjarrez and Dr. Williams have discussed what will happen with the hospital medicine movement internationally. They forecast that the work begun in the U.S. will globalize fairly soon.

“The Spaniards are very, very on the ball to ask us over there to see what’s going on to get a jump on it,” Dr. Manjarrez says. “SHM needs to start thinking ahead and have an international chapter and plan international meetings abroad to have SHM’s message spread globally. The time is ripe to export what SHM and hospital medicine is doing here”

Dr. Manjarrez notes that Argentina has small pockets of hospitalists. And, Guilherme Brauner Barcellos MD, specialist in internal medicine and intensive care at the Nossa Senhora de Conceicao Hospital in Brazil, is excited about the establishment of a hospital medicine program there. He finds the attempts to develop the specialty in his country “fascinating and challenging.”

“The implementation of hospital medicine, especially those aspects that involve more than just having a general medicine physician dealing with inpatient care, is brand new in Brazil,” Dr. Barcellos says. “We understand there is a long journey ahead.”

Dr. Barcellos is president of the recently formed Brazilian Society of Hospital Medicine and became a member of SHM last year, attending May’s meeting in Dallas. He says the number of hospitalists in Brazil is limited, but “a rapid expansion is predicted.”

“As in the U.S. several years ago, the case for hospitalists in Brazil is still being made,” he notes. “We did a hospital medicine meeting last October, and it led to the formation of the Brazilian Society of Hospital Medicine. We definitely fostered the discussion about the specialty and the model in Brazil.”

He hopes more people will talk about the topic through the new group’s Web site (www.medicinahospitalar.com.br) and in hospitals throughout the country.

“Before the year of 2005, the majority of people here didn’t know about the hospitalists,” he explains. “After that, we had a period in which people were confused, thinking hospitalists were the same as doctors who work in the rapid response teams only. Currently, everybody at least knows about hospital medicine.”

Dr. Williams notes that hospital medicine organizations are forming in Chile, Argentina, Australia, and New Zealand.

Dr. Barcellos believes hospitals across his country “will awake to hospital medicine” when they realize that traditional models aren’t property servicing hospitalized patients anymore. “Much of what is present is wrong, obsolete or out of time, and we should try new attempts to create a different organization,” he says. TH

Molly R. Okeon is a journalist based in California.

Attendees at this year’s SHM Annual Meeting in San Diego brought with them exciting news of international developments that might broaden the scope of the specialty.

For example, Efren Manjarrez, MD, director of clinical operations for the division of hospital medicine of the Leonard M. Miller School of Medicine at the University of Miami, recently discovered a 500-plus-bed facility at the Universidad de Navarra during his trip to Pamplona, Spain.

Because Dr. Manjarrez is bilingual, past SHM President Mark Williams, MD, professor and chief of the division of hospital medicine at the Northwestern University Feinberg School of Medicine in Chicago, asked him to give a lecture.

“[The Universidad de Navarra] has one of the top two medical schools in Spain and they had the very first symposium on the management of the hospitalized patient,” Dr. Manjarrez says. “They had the very first hospitalist conference in Spain and quite possibly in Europe.”

While in Spain, Dr. Manjarrez realized hospitalists there were “at the grassroots level, where we were about 10 to 12 years ago,” just starting to have a few hospital medical units. The clinic in at the Universidad de Navarra had about five units, and there was a small hospitalist group near Valencia, as well.

Dr. Manjarrez

Dr. Manjarrez is highly complimentary of the university’s “top-flight medical school,” where he said doctors perform liver transplants.

“They could compete favorably with any city in the United States,” he notes. “They’re interested in organizing hospitalists like Mark Williams and what people ahead of me did for SHM.”

Dr. Manjarrez and Dr. Williams have discussed what will happen with the hospital medicine movement internationally. They forecast that the work begun in the U.S. will globalize fairly soon.

“The Spaniards are very, very on the ball to ask us over there to see what’s going on to get a jump on it,” Dr. Manjarrez says. “SHM needs to start thinking ahead and have an international chapter and plan international meetings abroad to have SHM’s message spread globally. The time is ripe to export what SHM and hospital medicine is doing here”

Dr. Manjarrez notes that Argentina has small pockets of hospitalists. And, Guilherme Brauner Barcellos MD, specialist in internal medicine and intensive care at the Nossa Senhora de Conceicao Hospital in Brazil, is excited about the establishment of a hospital medicine program there. He finds the attempts to develop the specialty in his country “fascinating and challenging.”

“The implementation of hospital medicine, especially those aspects that involve more than just having a general medicine physician dealing with inpatient care, is brand new in Brazil,” Dr. Barcellos says. “We understand there is a long journey ahead.”

Dr. Barcellos is president of the recently formed Brazilian Society of Hospital Medicine and became a member of SHM last year, attending May’s meeting in Dallas. He says the number of hospitalists in Brazil is limited, but “a rapid expansion is predicted.”

“As in the U.S. several years ago, the case for hospitalists in Brazil is still being made,” he notes. “We did a hospital medicine meeting last October, and it led to the formation of the Brazilian Society of Hospital Medicine. We definitely fostered the discussion about the specialty and the model in Brazil.”

He hopes more people will talk about the topic through the new group’s Web site (www.medicinahospitalar.com.br) and in hospitals throughout the country.

“Before the year of 2005, the majority of people here didn’t know about the hospitalists,” he explains. “After that, we had a period in which people were confused, thinking hospitalists were the same as doctors who work in the rapid response teams only. Currently, everybody at least knows about hospital medicine.”

Dr. Williams notes that hospital medicine organizations are forming in Chile, Argentina, Australia, and New Zealand.

Dr. Barcellos believes hospitals across his country “will awake to hospital medicine” when they realize that traditional models aren’t property servicing hospitalized patients anymore. “Much of what is present is wrong, obsolete or out of time, and we should try new attempts to create a different organization,” he says. TH

Molly R. Okeon is a journalist based in California.