An article published this year in the American Journal of Health-Systems Pharmacy defined stress ulcers as “acute superficial inflammatory lesions of the gastric mucosa induced when an individual is subjected to abnormally high physiologic demands.”1

These stress ulcers are believed to be caused by an imbalance between gastric acid production and the normal physiologic protective mucosal mechanisms in the gastrointestinal (GI) tract. Reduction of blood flow to the gastric mucosa may also lead to ischemic damage to the GI mucosa.

The development of stress ulcers, or stress-related mucosal disease (SRMD), occurs in 75% to 100% of critically ill patients within 24 hours of intensive care unit (ICU) admission. Although bleeding risk has decreased over the years, mortality from stress-related bleeding nears 50%. According a peer-reviewed guideline from the American Society of Health-System Pharmacists (ASHP), indications for SRMD in the ICU setting include:2

• Coagulopathy;
• Mechanical ventilation longer than 48 hours;
• History of GI ulceration or bleeding within one year of the current admission;
• Glasgow Coma score of 10 or less (or if unable to obey simple commands);
• Thermal injury to more than 35% of the body surface area;
• Partial hepatectomy;
• Multiple trauma;
• Transplantation perioperatively in the ICU;
• Spinal cord injury;
• Hepatic failure; and
• Two or more of the following risk factors: sepsis, ICU stay of a week or longer, occult bleeding for more than six days, or high-dose corticosteroids (more than 250 mg a day of hydrocortisone or the equivalent).

Other risk factors for SRMD in ICU patients include multiorgan failure, chronic renal failure, major surgical procedures, shock, and tetraplegia.3,4

Recommended SRMD prophylaxis agents should be institution-based, taking into account the administration route (e.g., functioning GI tract), daily dosing regimens, adverse effect profile, drug interactions, and total costs. Classes that can be used include sucralfate, antacids, H2 receptor antagonists (H2RA), and proton-pump inhibitors (PPIs).

Some patients may prefer the oral route. Some agents can be given in solution or suspension and administered via a nasogastric tube—but be aware of drug interactions. There are limited comparative data for preventing SRMD with these classes. The H2RA and PPI classes of agents are available in intravenous forms, which may be preferable in critically ill patients. However, none of the PPIs are FDA-approved for SRMD prophylaxis.

In the general patient population, SRMD prophylaxis with H2RAs or PPIs is common in 30% to 50% of patients without clear evidence of benefit. Qadeer, et al., identified a 0.4% bleeding rate in their retrospective case-control study of nearly 18,000 patients over a four-year period. In their study, the key risk factor for development of nosocomial GI bleeding was treatment with full-dose anticoagulation or clopidogrel.

Another concern they identified is that when a patient commences an SRMD prophylaxis agent in the hospital, they continue on it post-discharge when it is not needed. This creates an unnecessary cost burden and risks adverse drug interactions.

Todd Janicki, MD, and Scott Stewart, MD, both with the department of medicine at the State University of New York at Buffalo, this year reported on a review of evidence for SRMD prophylaxis in general medicine patients from the peer-reviewed literature.5 They found limited data, identifying only five citations meeting their evaluation criteria. Two of these studies noted only a 3% to 6% reduction in clinically significant bleeding utilizing SRMD prophylaxis. TH

Michele Kaufman is a clinical/managed care consultant and medical writer based in New York City.

New Indications

The two oldest low molecular heparin (LMWH) injection products, Fragmin (dalteparin, Pfizer) and Lovenox (enoxaparin, Sanofi-Aventis) have each added new indications to their U.S. labels. Fragmin is now indicated for extended treatment of symptomatic venous thromboembolism (VTE) including both proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE) to reduce VTE recurrence in patients with cancer.

Its other FDA-approved uses:

• Prophylaxis of DVT (which may lead to PE) in patients undergoing hip replacement surgery;
• Prophylaxis of DVT in patients undergoing abdominal surgery who are at risk for thromboembolic (TE) complications;
• Prophylaxis of DVT in patients who are at-risk for TE complications due to severely restricted mobility during acute illness; and
• Prophylaxis of ischemic complications due to unstable angina and non-Q-wave myocardial infarction (MI) when used along with aspirin.

Lovenox is now also indicated for treatment of patients with acute ST-segment elevation MI (STEMI), managed medically or with subsequent percutaneous coronary intervention (PCI).

Its other FDA-approved uses:

• Prophylaxis of DVT in abdominal surgery;
• Prophylaxis of DVT in hip replacement surgery;
• Prophylaxis of DVT in knee replacement surgery;
• Prophylaxis of DVT in medical patients with severely restricted mobility during acute illness;
• Inpatient treatment of acute DVT with or without PE;
• Outpatient treatment of acute DVT without PE; and
• Prophylaxis of ischemic complication of unstable angina and non-Q-wave STEMI managed medically or with subsequent PCI.

References

1. Grube RRA, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health-Syst Pharm. 2007;64:1396-400.
2. ASHP Commission on Therapeutics. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health-Syst Pharm. 1999;56:347-379.
3. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006;1(1):13-20.
4. Weinhouse GL, Manaker S. Stress ulcer prophylaxis in the intensive care unit. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, Mass. 2007.
5. Janicki T, Stewart S. Stress-ulcer prophylaxis for general medical patients: a review of the evidence. J Hosp Med. 2007;2(2):86-92.

An article published this year in the American Journal of Health-Systems Pharmacy defined stress ulcers as “acute superficial inflammatory lesions of the gastric mucosa induced when an individual is subjected to abnormally high physiologic demands.”1

These stress ulcers are believed to be caused by an imbalance between gastric acid production and the normal physiologic protective mucosal mechanisms in the gastrointestinal (GI) tract. Reduction of blood flow to the gastric mucosa may also lead to ischemic damage to the GI mucosa.

The development of stress ulcers, or stress-related mucosal disease (SRMD), occurs in 75% to 100% of critically ill patients within 24 hours of intensive care unit (ICU) admission. Although bleeding risk has decreased over the years, mortality from stress-related bleeding nears 50%. According a peer-reviewed guideline from the American Society of Health-System Pharmacists (ASHP), indications for SRMD in the ICU setting include:2

• Coagulopathy;
• Mechanical ventilation longer than 48 hours;
• History of GI ulceration or bleeding within one year of the current admission;
• Glasgow Coma score of 10 or less (or if unable to obey simple commands);
• Thermal injury to more than 35% of the body surface area;
• Partial hepatectomy;
• Multiple trauma;
• Transplantation perioperatively in the ICU;
• Spinal cord injury;
• Hepatic failure; and
• Two or more of the following risk factors: sepsis, ICU stay of a week or longer, occult bleeding for more than six days, or high-dose corticosteroids (more than 250 mg a day of hydrocortisone or the equivalent).

Other risk factors for SRMD in ICU patients include multiorgan failure, chronic renal failure, major surgical procedures, shock, and tetraplegia.3,4

Recommended SRMD prophylaxis agents should be institution-based, taking into account the administration route (e.g., functioning GI tract), daily dosing regimens, adverse effect profile, drug interactions, and total costs. Classes that can be used include sucralfate, antacids, H2 receptor antagonists (H2RA), and proton-pump inhibitors (PPIs).

Some patients may prefer the oral route. Some agents can be given in solution or suspension and administered via a nasogastric tube—but be aware of drug interactions. There are limited comparative data for preventing SRMD with these classes. The H2RA and PPI classes of agents are available in intravenous forms, which may be preferable in critically ill patients. However, none of the PPIs are FDA-approved for SRMD prophylaxis.

In the general patient population, SRMD prophylaxis with H2RAs or PPIs is common in 30% to 50% of patients without clear evidence of benefit. Qadeer, et al., identified a 0.4% bleeding rate in their retrospective case-control study of nearly 18,000 patients over a four-year period. In their study, the key risk factor for development of nosocomial GI bleeding was treatment with full-dose anticoagulation or clopidogrel.

Another concern they identified is that when a patient commences an SRMD prophylaxis agent in the hospital, they continue on it post-discharge when it is not needed. This creates an unnecessary cost burden and risks adverse drug interactions.

Todd Janicki, MD, and Scott Stewart, MD, both with the department of medicine at the State University of New York at Buffalo, this year reported on a review of evidence for SRMD prophylaxis in general medicine patients from the peer-reviewed literature.5 They found limited data, identifying only five citations meeting their evaluation criteria. Two of these studies noted only a 3% to 6% reduction in clinically significant bleeding utilizing SRMD prophylaxis. TH

Michele Kaufman is a clinical/managed care consultant and medical writer based in New York City.

New Indications

The two oldest low molecular heparin (LMWH) injection products, Fragmin (dalteparin, Pfizer) and Lovenox (enoxaparin, Sanofi-Aventis) have each added new indications to their U.S. labels. Fragmin is now indicated for extended treatment of symptomatic venous thromboembolism (VTE) including both proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE) to reduce VTE recurrence in patients with cancer.

Its other FDA-approved uses:

• Prophylaxis of DVT (which may lead to PE) in patients undergoing hip replacement surgery;
• Prophylaxis of DVT in patients undergoing abdominal surgery who are at risk for thromboembolic (TE) complications;
• Prophylaxis of DVT in patients who are at-risk for TE complications due to severely restricted mobility during acute illness; and
• Prophylaxis of ischemic complications due to unstable angina and non-Q-wave myocardial infarction (MI) when used along with aspirin.

Lovenox is now also indicated for treatment of patients with acute ST-segment elevation MI (STEMI), managed medically or with subsequent percutaneous coronary intervention (PCI).

Its other FDA-approved uses:

• Prophylaxis of DVT in abdominal surgery;
• Prophylaxis of DVT in hip replacement surgery;
• Prophylaxis of DVT in knee replacement surgery;
• Prophylaxis of DVT in medical patients with severely restricted mobility during acute illness;
• Inpatient treatment of acute DVT with or without PE;
• Outpatient treatment of acute DVT without PE; and
• Prophylaxis of ischemic complication of unstable angina and non-Q-wave STEMI managed medically or with subsequent PCI.

References

1. Grube RRA, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health-Syst Pharm. 2007;64:1396-400.
2. ASHP Commission on Therapeutics. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health-Syst Pharm. 1999;56:347-379.
3. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006;1(1):13-20.
4. Weinhouse GL, Manaker S. Stress ulcer prophylaxis in the intensive care unit. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, Mass. 2007.
5. Janicki T, Stewart S. Stress-ulcer prophylaxis for general medical patients: a review of the evidence. J Hosp Med. 2007;2(2):86-92.

An article published this year in the American Journal of Health-Systems Pharmacy defined stress ulcers as “acute superficial inflammatory lesions of the gastric mucosa induced when an individual is subjected to abnormally high physiologic demands.”1

These stress ulcers are believed to be caused by an imbalance between gastric acid production and the normal physiologic protective mucosal mechanisms in the gastrointestinal (GI) tract. Reduction of blood flow to the gastric mucosa may also lead to ischemic damage to the GI mucosa.

The development of stress ulcers, or stress-related mucosal disease (SRMD), occurs in 75% to 100% of critically ill patients within 24 hours of intensive care unit (ICU) admission. Although bleeding risk has decreased over the years, mortality from stress-related bleeding nears 50%. According a peer-reviewed guideline from the American Society of Health-System Pharmacists (ASHP), indications for SRMD in the ICU setting include:2

• Coagulopathy;
• Mechanical ventilation longer than 48 hours;
• History of GI ulceration or bleeding within one year of the current admission;
• Glasgow Coma score of 10 or less (or if unable to obey simple commands);
• Thermal injury to more than 35% of the body surface area;
• Partial hepatectomy;
• Multiple trauma;
• Transplantation perioperatively in the ICU;
• Spinal cord injury;
• Hepatic failure; and
• Two or more of the following risk factors: sepsis, ICU stay of a week or longer, occult bleeding for more than six days, or high-dose corticosteroids (more than 250 mg a day of hydrocortisone or the equivalent).

Other risk factors for SRMD in ICU patients include multiorgan failure, chronic renal failure, major surgical procedures, shock, and tetraplegia.3,4

Recommended SRMD prophylaxis agents should be institution-based, taking into account the administration route (e.g., functioning GI tract), daily dosing regimens, adverse effect profile, drug interactions, and total costs. Classes that can be used include sucralfate, antacids, H2 receptor antagonists (H2RA), and proton-pump inhibitors (PPIs).

Some patients may prefer the oral route. Some agents can be given in solution or suspension and administered via a nasogastric tube—but be aware of drug interactions. There are limited comparative data for preventing SRMD with these classes. The H2RA and PPI classes of agents are available in intravenous forms, which may be preferable in critically ill patients. However, none of the PPIs are FDA-approved for SRMD prophylaxis.

In the general patient population, SRMD prophylaxis with H2RAs or PPIs is common in 30% to 50% of patients without clear evidence of benefit. Qadeer, et al., identified a 0.4% bleeding rate in their retrospective case-control study of nearly 18,000 patients over a four-year period. In their study, the key risk factor for development of nosocomial GI bleeding was treatment with full-dose anticoagulation or clopidogrel.

Another concern they identified is that when a patient commences an SRMD prophylaxis agent in the hospital, they continue on it post-discharge when it is not needed. This creates an unnecessary cost burden and risks adverse drug interactions.

Todd Janicki, MD, and Scott Stewart, MD, both with the department of medicine at the State University of New York at Buffalo, this year reported on a review of evidence for SRMD prophylaxis in general medicine patients from the peer-reviewed literature.5 They found limited data, identifying only five citations meeting their evaluation criteria. Two of these studies noted only a 3% to 6% reduction in clinically significant bleeding utilizing SRMD prophylaxis. TH

Michele Kaufman is a clinical/managed care consultant and medical writer based in New York City.

New Indications

The two oldest low molecular heparin (LMWH) injection products, Fragmin (dalteparin, Pfizer) and Lovenox (enoxaparin, Sanofi-Aventis) have each added new indications to their U.S. labels. Fragmin is now indicated for extended treatment of symptomatic venous thromboembolism (VTE) including both proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE) to reduce VTE recurrence in patients with cancer.

Its other FDA-approved uses:

• Prophylaxis of DVT (which may lead to PE) in patients undergoing hip replacement surgery;
• Prophylaxis of DVT in patients undergoing abdominal surgery who are at risk for thromboembolic (TE) complications;
• Prophylaxis of DVT in patients who are at-risk for TE complications due to severely restricted mobility during acute illness; and
• Prophylaxis of ischemic complications due to unstable angina and non-Q-wave myocardial infarction (MI) when used along with aspirin.

Lovenox is now also indicated for treatment of patients with acute ST-segment elevation MI (STEMI), managed medically or with subsequent percutaneous coronary intervention (PCI).

Its other FDA-approved uses:

• Prophylaxis of DVT in abdominal surgery;
• Prophylaxis of DVT in hip replacement surgery;
• Prophylaxis of DVT in knee replacement surgery;
• Prophylaxis of DVT in medical patients with severely restricted mobility during acute illness;
• Inpatient treatment of acute DVT with or without PE;
• Outpatient treatment of acute DVT without PE; and
• Prophylaxis of ischemic complication of unstable angina and non-Q-wave STEMI managed medically or with subsequent PCI.

References

1. Grube RRA, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health-Syst Pharm. 2007;64:1396-400.
2. ASHP Commission on Therapeutics. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health-Syst Pharm. 1999;56:347-379.
3. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006;1(1):13-20.
4. Weinhouse GL, Manaker S. Stress ulcer prophylaxis in the intensive care unit. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, Mass. 2007.
5. Janicki T, Stewart S. Stress-ulcer prophylaxis for general medical patients: a review of the evidence. J Hosp Med. 2007;2(2):86-92.

In This Edition

• Pay-for-performance associated with limited benefits on quality in acute myocardial infarction patients.
• Meta-analysis finds increased risk of acute myocardial infarction with use of rosiglitazone.
• Rosiglitazone increases risk of heart failure, but not acute myocardial infarction or death, interim analysis shows.
• Surgery versus prolonged conservative treatment for severe sciatica.
• Predicting poor outcomes in upper gastrointestinal bleeds.
• Discharging patients with unresolved medical issues.

Does Pay for Performance Improve Hospital Quality?

Background: In 2003, the Centers for Medicare and Medicaid Services (CMS) instituted a pay-for-performance (P4P) pilot program in which participating hospitals would be reimbursed more if they met specific quality standards of care for patients with certain conditions, including acute myocardial infarction (AMI). It is unknown if this type of financial incentive produces improvements in the processes or outcomes of care.

Study design: Observational cohort.

Setting: 500 hospitals across the U.S.

Synopsis: This study compared compliance with CMS quality indicators in the treatment of more than 100,000 patients with acute non-ST-elevation myocardial infarction at 54 participating and 446 non-participating hospitals in the P4P pilot. They found no significant difference in mortality or in a composite measure of the six quality indicators but a slight improvement in two of the six quality indicators (aspirin at discharge and smoking cessation counseling). They did not find that P4P adversely affected indicators not subject to financial incentives.

Bottom line: P4P is associated with limited improvements in compliance with CMS quality indicators in patients with AMI.

Citation: Glickman SW, Ou F-S, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007 Jun;297(21):2373-2380.

Is Rosiglitazone Associated with Adverse Cardiovascular Outcomes in a Meta-analysis?

Background: Rosiglitazone (Avandia) is one of two approved oral thiazolidinedione drugs used for diabetic control. Muraglitazar, another thiazolidinedione drug, was not approved for market due to adverse cardiovascular outcomes. The cardiovascular effects of rosiglitazone had not previously been evaluated.

Study design: Meta-analysis.

Setting: All clinical trials (published and unpublished) involving rosiglitazone.

Synopsis: The authors reviewed data from all randomized trials of rosiglitazone versus placebo or other drugs for at least 24 weeks. From the 42 included trials (including more than 28,000 patients) researchers found a statistically significant increased risk of the odds of AMI (odds ratio 1.43, confidence interval 1.03-1.98) in the rosiglitazone group, and a non-significant risk of death from any cardiovascular cause (odds ratio 1.64, confidence interval 0.98-2.74) and all-cause mortality (odds ratio 1.18, confidence interval 0.89-1.55). The meta-analysis was criticized due to the small number of events (fewer than 100 acute AMIs in each group) and lack of patient-level data, but one expert wrote that “in view of the potential cardiovascular risks and in the absence of evidence of other health advantages ... the rationale for prescribing rosiglitazone at this time is unclear.”

The study raised larger concerns regarding Food and Drug Administration drug approvals, because the drug was approved due to its effect on lowering blood sugar levels (a surrogate outcome) without enough scrutiny of other patient outcomes.

Bottom line: Rosiglitazone is associated with increased risk of AMI. Alternative oral agents should be considered first for blood sugar control in diabetics.

Citation: Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun;356(24):2457-2471.

Editorial: Psaty BM, Furberg CD. Rosiglitazone and cardiovascular risk. N Engl J Med. 2007 Jun;356(24):2522-2524.

Is Rosiglitazone Associated with Adverse Cardiovascular Outcomes in Interim Analysis?

Background: In response to a meta-analysis, an interim analysis of an ongoing open-label manufacturer-sponsored trial was undertaken to determine the cardiovascular risks of rosiglitazone.

Study design: Unplanned interim analysis of a randomized, multicenter, open-label, non-inferiority trial.

Subjects: Outpatient, inadequately controlled type 2 diabetics.

Synopsis: This was an unplanned interim analysis of an open-label manufacturer-sponsored trial. There were 4,447 inadequately controlled type 2 diabetics on either metformin or sulfonylurea. The patients were randomized to receive both drugs (controls) or add-on rosiglitazone. After a mean follow up of 3.75 years, there was no statistically significant difference between the groups in the primary end point (hospitalization or death from cardiovascular causes), or other end points (MI and death from cardiovascular causes or any cause). However, rosiglitazone was associated with an increased risk of heart failure (hazard ratio 2.15, confidence interval 1.30-3.57). Because this was an unplanned interim analysis for a trial expected to continue for six years, experts caution that the results are inconclusive due to low statistical significance and small event rates.

Bottom line: Rosiglitazone is associated with an increased risk of heart failure, but the risks of hospitalization, death, and acute MI remain unclear.

Citation: Home PD, Phil D, Pockock SJ, et al. Rosiglitazone evaluated for cardiovascular outcomes—an interim analysis. N Engl J Med. 2007 Jul;357(1):28-38.

How Often do Discharged Patients with Unresolved Medical Issues Require Outpatient Workups?

Background: Patients are often discharged from the hospital with incomplete workups, but it is unknown how often and what factors affect the completion of the intended workup.

Study design: Retrospective cohort.

Setting: Single institution teaching hospital.

Synopsis: The authors evaluated the inpatient and outpatient medical records of all patients discharged from the medicine or geriatric service over 18 months. Of almost 700 discharges, 28% of the patients had outpatient workups recommended (48% diagnostic procedures, 35% referrals, and 17% lab tests) by the discharging physician. Completion of the workup did not occur 36% of the time, and the likelihood of non-completion increased with time to the first follow-up appointment and lack of availability of the discharge summary.

Bottom line: Outpatient workups are intended in almost a third of discharged patient, the completion of which can likely be enhanced by timely follow-up and discharge summary availability.

Citation: Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167(12):1305-1311.

Can We Predict Patients at Low Risk for Compli-cations from Acute Upper Gastrointestinal Bleeds?

Background: Although multiple risk-prediction scales exist for patients with upper gastrointestinal (UGI) bleeds, few have been prospectively validated or widely used in clinical practice.

Study design: Prospective cohort.

Setting: Veterans Affairs (VA) hospitals.

Synopsis: VA researchers created and validated a risk predictor in 391 patients with acute upper gastrointestinal bleeding. Data from the derivation set (two-thirds of the patients) was used to create the model tested on the validation set (one-third of the patients). Outcome one (re-bleeding, need for intervention to stop bleeding, or all-cause hospital mortality) was predicted by an APACHE score >11, stigmata of recent bleeding, or varices. Outcome two (outcome one plus new/worsening co-morbidity) was predicted by the above three factors plus an unstable co-morbidity at admission. In the validation group, outcome one occurred in 1%, 5%, and 25% of patients with zero, one, and two or more factors. Outcome two occurred in 6%, 18%, and 49%, respectively. A score of zero accurately identified 93% and 91% of patients for outcomes one and two. The authors speculated that these patients could be safely treated as outpatients. The study excluded patients on anticoagulation, and this VA cohort (99% male) may not be generalizable to other populations.

Bottom line: This validated prediction model can accurately predict more than 90% of patients at low-risk of poor outcomes with UGI bleeding, which could be used to stratify patients in need of hospital admission.

Citation: Imperiale TF, Dominitz JA, Provenzale DT, et al. Predicting poor outcome from acute upper gastrointestinal hemorrhage. Arch Intern Med. 2007 Jun;167(12):1291-1296.

Does Surgery or Conservative Therapy Improve Symptoms of Sciatica Faster?

Background: The optimal timing and benefit of lumbar-disk surgery in patients with symptomatic lumbar disk herniation is unknown.

Study design: Multicenter randomized trial.

Setting: Netherlands.

Synopsis: 283 patients with severe sciatica were randomly chosen to receive early surgery or conservative treatment (with surgery as needed) for six to 12 weeks. The methods for determining the three primary outcomes were: score on the Roland Disability Questionnaire, leg pain score, and self-report of perceived recovery. At one year, 89% of the surgery group and 39% of the control group underwent surgery after a mean of 2.2 and 18.7 weeks, respectively. There was no difference between the groups in the disability score, but time to relief of leg pain and recovery was faster in the surgery group. At one year, 95% in each group reported perceived recovery.

Bottom line: Rates of pain relief and perceived recovery are faster with early surgery than conservative treatment in patients with severe sciatica, but one-year recovery rates are the same. TH

Citation: Peul WC, Van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. NEJM. 2007 May;356(22):2245-2256.

In This Edition

• Pay-for-performance associated with limited benefits on quality in acute myocardial infarction patients.
• Meta-analysis finds increased risk of acute myocardial infarction with use of rosiglitazone.
• Rosiglitazone increases risk of heart failure, but not acute myocardial infarction or death, interim analysis shows.
• Surgery versus prolonged conservative treatment for severe sciatica.
• Predicting poor outcomes in upper gastrointestinal bleeds.
• Discharging patients with unresolved medical issues.

Does Pay for Performance Improve Hospital Quality?

Background: In 2003, the Centers for Medicare and Medicaid Services (CMS) instituted a pay-for-performance (P4P) pilot program in which participating hospitals would be reimbursed more if they met specific quality standards of care for patients with certain conditions, including acute myocardial infarction (AMI). It is unknown if this type of financial incentive produces improvements in the processes or outcomes of care.

Study design: Observational cohort.

Setting: 500 hospitals across the U.S.

Synopsis: This study compared compliance with CMS quality indicators in the treatment of more than 100,000 patients with acute non-ST-elevation myocardial infarction at 54 participating and 446 non-participating hospitals in the P4P pilot. They found no significant difference in mortality or in a composite measure of the six quality indicators but a slight improvement in two of the six quality indicators (aspirin at discharge and smoking cessation counseling). They did not find that P4P adversely affected indicators not subject to financial incentives.

Bottom line: P4P is associated with limited improvements in compliance with CMS quality indicators in patients with AMI.

Citation: Glickman SW, Ou F-S, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007 Jun;297(21):2373-2380.

Is Rosiglitazone Associated with Adverse Cardiovascular Outcomes in a Meta-analysis?

Background: Rosiglitazone (Avandia) is one of two approved oral thiazolidinedione drugs used for diabetic control. Muraglitazar, another thiazolidinedione drug, was not approved for market due to adverse cardiovascular outcomes. The cardiovascular effects of rosiglitazone had not previously been evaluated.

Study design: Meta-analysis.

Setting: All clinical trials (published and unpublished) involving rosiglitazone.

Synopsis: The authors reviewed data from all randomized trials of rosiglitazone versus placebo or other drugs for at least 24 weeks. From the 42 included trials (including more than 28,000 patients) researchers found a statistically significant increased risk of the odds of AMI (odds ratio 1.43, confidence interval 1.03-1.98) in the rosiglitazone group, and a non-significant risk of death from any cardiovascular cause (odds ratio 1.64, confidence interval 0.98-2.74) and all-cause mortality (odds ratio 1.18, confidence interval 0.89-1.55). The meta-analysis was criticized due to the small number of events (fewer than 100 acute AMIs in each group) and lack of patient-level data, but one expert wrote that “in view of the potential cardiovascular risks and in the absence of evidence of other health advantages ... the rationale for prescribing rosiglitazone at this time is unclear.”

The study raised larger concerns regarding Food and Drug Administration drug approvals, because the drug was approved due to its effect on lowering blood sugar levels (a surrogate outcome) without enough scrutiny of other patient outcomes.

Bottom line: Rosiglitazone is associated with increased risk of AMI. Alternative oral agents should be considered first for blood sugar control in diabetics.

Citation: Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun;356(24):2457-2471.

Editorial: Psaty BM, Furberg CD. Rosiglitazone and cardiovascular risk. N Engl J Med. 2007 Jun;356(24):2522-2524.

Is Rosiglitazone Associated with Adverse Cardiovascular Outcomes in Interim Analysis?

Background: In response to a meta-analysis, an interim analysis of an ongoing open-label manufacturer-sponsored trial was undertaken to determine the cardiovascular risks of rosiglitazone.

Study design: Unplanned interim analysis of a randomized, multicenter, open-label, non-inferiority trial.

Subjects: Outpatient, inadequately controlled type 2 diabetics.

Synopsis: This was an unplanned interim analysis of an open-label manufacturer-sponsored trial. There were 4,447 inadequately controlled type 2 diabetics on either metformin or sulfonylurea. The patients were randomized to receive both drugs (controls) or add-on rosiglitazone. After a mean follow up of 3.75 years, there was no statistically significant difference between the groups in the primary end point (hospitalization or death from cardiovascular causes), or other end points (MI and death from cardiovascular causes or any cause). However, rosiglitazone was associated with an increased risk of heart failure (hazard ratio 2.15, confidence interval 1.30-3.57). Because this was an unplanned interim analysis for a trial expected to continue for six years, experts caution that the results are inconclusive due to low statistical significance and small event rates.

Bottom line: Rosiglitazone is associated with an increased risk of heart failure, but the risks of hospitalization, death, and acute MI remain unclear.

Citation: Home PD, Phil D, Pockock SJ, et al. Rosiglitazone evaluated for cardiovascular outcomes—an interim analysis. N Engl J Med. 2007 Jul;357(1):28-38.

How Often do Discharged Patients with Unresolved Medical Issues Require Outpatient Workups?

Background: Patients are often discharged from the hospital with incomplete workups, but it is unknown how often and what factors affect the completion of the intended workup.

Study design: Retrospective cohort.

Setting: Single institution teaching hospital.

Synopsis: The authors evaluated the inpatient and outpatient medical records of all patients discharged from the medicine or geriatric service over 18 months. Of almost 700 discharges, 28% of the patients had outpatient workups recommended (48% diagnostic procedures, 35% referrals, and 17% lab tests) by the discharging physician. Completion of the workup did not occur 36% of the time, and the likelihood of non-completion increased with time to the first follow-up appointment and lack of availability of the discharge summary.

Bottom line: Outpatient workups are intended in almost a third of discharged patient, the completion of which can likely be enhanced by timely follow-up and discharge summary availability.

Citation: Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167(12):1305-1311.

Can We Predict Patients at Low Risk for Compli-cations from Acute Upper Gastrointestinal Bleeds?

Background: Although multiple risk-prediction scales exist for patients with upper gastrointestinal (UGI) bleeds, few have been prospectively validated or widely used in clinical practice.

Study design: Prospective cohort.

Setting: Veterans Affairs (VA) hospitals.

Synopsis: VA researchers created and validated a risk predictor in 391 patients with acute upper gastrointestinal bleeding. Data from the derivation set (two-thirds of the patients) was used to create the model tested on the validation set (one-third of the patients). Outcome one (re-bleeding, need for intervention to stop bleeding, or all-cause hospital mortality) was predicted by an APACHE score >11, stigmata of recent bleeding, or varices. Outcome two (outcome one plus new/worsening co-morbidity) was predicted by the above three factors plus an unstable co-morbidity at admission. In the validation group, outcome one occurred in 1%, 5%, and 25% of patients with zero, one, and two or more factors. Outcome two occurred in 6%, 18%, and 49%, respectively. A score of zero accurately identified 93% and 91% of patients for outcomes one and two. The authors speculated that these patients could be safely treated as outpatients. The study excluded patients on anticoagulation, and this VA cohort (99% male) may not be generalizable to other populations.

Bottom line: This validated prediction model can accurately predict more than 90% of patients at low-risk of poor outcomes with UGI bleeding, which could be used to stratify patients in need of hospital admission.

Citation: Imperiale TF, Dominitz JA, Provenzale DT, et al. Predicting poor outcome from acute upper gastrointestinal hemorrhage. Arch Intern Med. 2007 Jun;167(12):1291-1296.

Does Surgery or Conservative Therapy Improve Symptoms of Sciatica Faster?

Background: The optimal timing and benefit of lumbar-disk surgery in patients with symptomatic lumbar disk herniation is unknown.

Study design: Multicenter randomized trial.

Setting: Netherlands.

Synopsis: 283 patients with severe sciatica were randomly chosen to receive early surgery or conservative treatment (with surgery as needed) for six to 12 weeks. The methods for determining the three primary outcomes were: score on the Roland Disability Questionnaire, leg pain score, and self-report of perceived recovery. At one year, 89% of the surgery group and 39% of the control group underwent surgery after a mean of 2.2 and 18.7 weeks, respectively. There was no difference between the groups in the disability score, but time to relief of leg pain and recovery was faster in the surgery group. At one year, 95% in each group reported perceived recovery.

Bottom line: Rates of pain relief and perceived recovery are faster with early surgery than conservative treatment in patients with severe sciatica, but one-year recovery rates are the same. TH

Citation: Peul WC, Van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. NEJM. 2007 May;356(22):2245-2256.

In This Edition

• Pay-for-performance associated with limited benefits on quality in acute myocardial infarction patients.
• Meta-analysis finds increased risk of acute myocardial infarction with use of rosiglitazone.
• Rosiglitazone increases risk of heart failure, but not acute myocardial infarction or death, interim analysis shows.
• Surgery versus prolonged conservative treatment for severe sciatica.
• Predicting poor outcomes in upper gastrointestinal bleeds.
• Discharging patients with unresolved medical issues.

Does Pay for Performance Improve Hospital Quality?

Background: In 2003, the Centers for Medicare and Medicaid Services (CMS) instituted a pay-for-performance (P4P) pilot program in which participating hospitals would be reimbursed more if they met specific quality standards of care for patients with certain conditions, including acute myocardial infarction (AMI). It is unknown if this type of financial incentive produces improvements in the processes or outcomes of care.

Study design: Observational cohort.

Setting: 500 hospitals across the U.S.

Synopsis: This study compared compliance with CMS quality indicators in the treatment of more than 100,000 patients with acute non-ST-elevation myocardial infarction at 54 participating and 446 non-participating hospitals in the P4P pilot. They found no significant difference in mortality or in a composite measure of the six quality indicators but a slight improvement in two of the six quality indicators (aspirin at discharge and smoking cessation counseling). They did not find that P4P adversely affected indicators not subject to financial incentives.

Bottom line: P4P is associated with limited improvements in compliance with CMS quality indicators in patients with AMI.

Citation: Glickman SW, Ou F-S, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007 Jun;297(21):2373-2380.

Is Rosiglitazone Associated with Adverse Cardiovascular Outcomes in a Meta-analysis?

Background: Rosiglitazone (Avandia) is one of two approved oral thiazolidinedione drugs used for diabetic control. Muraglitazar, another thiazolidinedione drug, was not approved for market due to adverse cardiovascular outcomes. The cardiovascular effects of rosiglitazone had not previously been evaluated.

Study design: Meta-analysis.

Setting: All clinical trials (published and unpublished) involving rosiglitazone.

Synopsis: The authors reviewed data from all randomized trials of rosiglitazone versus placebo or other drugs for at least 24 weeks. From the 42 included trials (including more than 28,000 patients) researchers found a statistically significant increased risk of the odds of AMI (odds ratio 1.43, confidence interval 1.03-1.98) in the rosiglitazone group, and a non-significant risk of death from any cardiovascular cause (odds ratio 1.64, confidence interval 0.98-2.74) and all-cause mortality (odds ratio 1.18, confidence interval 0.89-1.55). The meta-analysis was criticized due to the small number of events (fewer than 100 acute AMIs in each group) and lack of patient-level data, but one expert wrote that “in view of the potential cardiovascular risks and in the absence of evidence of other health advantages ... the rationale for prescribing rosiglitazone at this time is unclear.”

The study raised larger concerns regarding Food and Drug Administration drug approvals, because the drug was approved due to its effect on lowering blood sugar levels (a surrogate outcome) without enough scrutiny of other patient outcomes.

Bottom line: Rosiglitazone is associated with increased risk of AMI. Alternative oral agents should be considered first for blood sugar control in diabetics.

Citation: Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun;356(24):2457-2471.

Editorial: Psaty BM, Furberg CD. Rosiglitazone and cardiovascular risk. N Engl J Med. 2007 Jun;356(24):2522-2524.

Is Rosiglitazone Associated with Adverse Cardiovascular Outcomes in Interim Analysis?

Background: In response to a meta-analysis, an interim analysis of an ongoing open-label manufacturer-sponsored trial was undertaken to determine the cardiovascular risks of rosiglitazone.

Study design: Unplanned interim analysis of a randomized, multicenter, open-label, non-inferiority trial.

Subjects: Outpatient, inadequately controlled type 2 diabetics.

Synopsis: This was an unplanned interim analysis of an open-label manufacturer-sponsored trial. There were 4,447 inadequately controlled type 2 diabetics on either metformin or sulfonylurea. The patients were randomized to receive both drugs (controls) or add-on rosiglitazone. After a mean follow up of 3.75 years, there was no statistically significant difference between the groups in the primary end point (hospitalization or death from cardiovascular causes), or other end points (MI and death from cardiovascular causes or any cause). However, rosiglitazone was associated with an increased risk of heart failure (hazard ratio 2.15, confidence interval 1.30-3.57). Because this was an unplanned interim analysis for a trial expected to continue for six years, experts caution that the results are inconclusive due to low statistical significance and small event rates.

Bottom line: Rosiglitazone is associated with an increased risk of heart failure, but the risks of hospitalization, death, and acute MI remain unclear.

Citation: Home PD, Phil D, Pockock SJ, et al. Rosiglitazone evaluated for cardiovascular outcomes—an interim analysis. N Engl J Med. 2007 Jul;357(1):28-38.

How Often do Discharged Patients with Unresolved Medical Issues Require Outpatient Workups?

Background: Patients are often discharged from the hospital with incomplete workups, but it is unknown how often and what factors affect the completion of the intended workup.

Study design: Retrospective cohort.

Setting: Single institution teaching hospital.

Synopsis: The authors evaluated the inpatient and outpatient medical records of all patients discharged from the medicine or geriatric service over 18 months. Of almost 700 discharges, 28% of the patients had outpatient workups recommended (48% diagnostic procedures, 35% referrals, and 17% lab tests) by the discharging physician. Completion of the workup did not occur 36% of the time, and the likelihood of non-completion increased with time to the first follow-up appointment and lack of availability of the discharge summary.

Bottom line: Outpatient workups are intended in almost a third of discharged patient, the completion of which can likely be enhanced by timely follow-up and discharge summary availability.

Citation: Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167(12):1305-1311.

Can We Predict Patients at Low Risk for Compli-cations from Acute Upper Gastrointestinal Bleeds?

Background: Although multiple risk-prediction scales exist for patients with upper gastrointestinal (UGI) bleeds, few have been prospectively validated or widely used in clinical practice.

Study design: Prospective cohort.

Setting: Veterans Affairs (VA) hospitals.

Synopsis: VA researchers created and validated a risk predictor in 391 patients with acute upper gastrointestinal bleeding. Data from the derivation set (two-thirds of the patients) was used to create the model tested on the validation set (one-third of the patients). Outcome one (re-bleeding, need for intervention to stop bleeding, or all-cause hospital mortality) was predicted by an APACHE score >11, stigmata of recent bleeding, or varices. Outcome two (outcome one plus new/worsening co-morbidity) was predicted by the above three factors plus an unstable co-morbidity at admission. In the validation group, outcome one occurred in 1%, 5%, and 25% of patients with zero, one, and two or more factors. Outcome two occurred in 6%, 18%, and 49%, respectively. A score of zero accurately identified 93% and 91% of patients for outcomes one and two. The authors speculated that these patients could be safely treated as outpatients. The study excluded patients on anticoagulation, and this VA cohort (99% male) may not be generalizable to other populations.

Bottom line: This validated prediction model can accurately predict more than 90% of patients at low-risk of poor outcomes with UGI bleeding, which could be used to stratify patients in need of hospital admission.

Citation: Imperiale TF, Dominitz JA, Provenzale DT, et al. Predicting poor outcome from acute upper gastrointestinal hemorrhage. Arch Intern Med. 2007 Jun;167(12):1291-1296.

Does Surgery or Conservative Therapy Improve Symptoms of Sciatica Faster?

Background: The optimal timing and benefit of lumbar-disk surgery in patients with symptomatic lumbar disk herniation is unknown.

Study design: Multicenter randomized trial.

Setting: Netherlands.

Synopsis: 283 patients with severe sciatica were randomly chosen to receive early surgery or conservative treatment (with surgery as needed) for six to 12 weeks. The methods for determining the three primary outcomes were: score on the Roland Disability Questionnaire, leg pain score, and self-report of perceived recovery. At one year, 89% of the surgery group and 39% of the control group underwent surgery after a mean of 2.2 and 18.7 weeks, respectively. There was no difference between the groups in the disability score, but time to relief of leg pain and recovery was faster in the surgery group. At one year, 95% in each group reported perceived recovery.

Bottom line: Rates of pain relief and perceived recovery are faster with early surgery than conservative treatment in patients with severe sciatica, but one-year recovery rates are the same. TH

Citation: Peul WC, Van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. NEJM. 2007 May;356(22):2245-2256.

The Performance and Standards Task Force (PSTF) was formed a little more than a year ago after SHM leadership recognized the need for a coordinated approach to working with external organizations in the performance and standards quality arena.

As SHM’s senior adviser for quality standards and compliance, I work with PSTF Chairman Patrick Torcson, MD, (medical director of hospital medicine at the St. Tammany Parish Hospital in Covington, La.) along with senior staff and leadership of the Public Policy Committee (PPC). We monitor the performance and quality landscape at national organizations charged with measuring development and building consensus. We also develop relationships with other professional medical societies and organizations.

Chapters Summary

Chicago

The Chicago Chapter of SHM met June 7. Attendees came from organizations such as Signature Healthcare Solutions, Advocate Healthcare, Northwestern University, and University of Chicago. The meeting began with an update from the SHM national annual meeting given by Chapter President Tarek Karaman, MD, lead hospitalist, Advocate Health Centers, and hospitalist program director, Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago. This was followed by a presentation on DVT/pulmonary embolism prophylaxis and treatment from SHM board member Alpesh Amin, MD, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. For the first time, the chapter had a panel discussion with two primary care physicians from Northwestern University. John Butter, MD, and Sean O’Conner, MD, shared their thoughts regarding the interaction between primary care physicians and hospitalists. Ideas were given on how to strengthen working relationships between the two.

St. Louis

SHM’s St. Louis chapter met June 11. Michael Cox, MD, gave a presentation on DVT prevention and treatment followed by a presentation given by SHM CEO Larry Wellikson, MD, on the challenges and opportunities for hospital medicine. The meeting was attended by more than 50 hospitalists from the greater St. Louis area, as well as numerous hospital administrative personnel, vice presidents of medical affairs, and internal medicine residents. The presentation was well received, and numerous individuals spoke with Dr. Wellikson after the presentation. Dr. Wellikson also met with leaders of various hospitalist groups to discuss topics of interest and ways to energize the local chapter. Six hospitalist groups attended. The group discussed challenges in recruitment and in training internists to be true hospitalists.

Since its inception in spring 2006, the PSTF has become engaged in the American Medical Association’s (AMA) Physician Consortium for Performance Improvement (PCPI) and the National Quality Forum (NQF). The NQF is a nonprofit organization instructed by Congress to endorse consensus-based national standards for measurement and public reporting of healthcare performance data. Specifically, NQF aims to influence the development of physician-level performance measures as part of the Centers for Medicare and Medicaid Service’s (CMS) Physician Quality Reporting Initiative (PQRI).

By joining the PCPI, SHM has aligned with other medical specialties to develop performance measures in geriatrics, emergency medicine, outpatient parenteral antimicrobial therapy, and facets of anesthesiology such as perioperative normothermia and critical care.

Additionally, SHM has given feedback during public comment periods on perioperative care, chronic kidney disease, and other measures. The task force continues to evaluate which workgroups it should appoint members to participate in, depending on the topic.

SHM leadership has continued to foster relationships with CMS by sending letters in support of the 2007 PQRI. SHM was able to influence changes to the 2007 measure specifications so hospitalists would have measures to report. Of the 74 measures included in the PQRI, 11 have specifications allowing reporting by hospitalists, underscoring the importance of SHM’s influence and participation in the PCPI process.

Dr. Torcson and Eric Siegal, MD, (regional medical director, Cogent Healthcare, Madison, Wis.) co-chaired a CMS-led SHM member conference call focused on PQRI and how it affects hospitalists. The program was well received by SHM members.

When SHM became a member of the NQF last summer, it nominated several members who were selected to participate on various technical advisory panels overseeing work on the development of consensus standards for hospital care. This project, sponsored by the Agency for Healthcare Research and Quality (AHRQ), is addressing patient safety, pediatrics, and inpatient care.

Last fall, SHM sent Mark Williams, MD (professor of medicine at Emory University School of Medicine in Atlanta and editor of The Journal of Hospital Medicine) to the NQF’s 7th Annual Meeting, a National Policy Conference on Quality. The meeting featured plenary sessions that focused on issues at the forefront of policy discussions, including incentivizing healthcare quality improvement, the role of policymakers, leading professional and trade associations in improving healthcare quality, and efforts under way in the federal government to foster healthcare improvements.

This fall, Greg Seymann, MD, will attend the 8th Annual Meeting. Dr. Seymann is an assistant professor with the Department of Medicine, Hospital Medicine Program, at the University of California San Diego Medical Center.

Goals for 2008, Beyond

By taking an active role in the performance and standard arena, SHM senior staff and leadership have been able to build key relationships. This has paved the way for influencing the current physician reporting program and taking the lead on developing measures that will most reflect hospital medicine in the future.

The task force intends to be at the helm of the development of performance measures that more accurately reflect services provided by hospitalists. Senior staff and leadership have discussed this goal with several national stakeholders including the PCPI and the NQF, whose senior staff have supported its agenda.

In July, SHM, along with the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM), and the American Geriatrics Society (AGS), formed a steering committee to convene a transitions of care consensus conference. This multispecialty, multidisciplinary group reviewed the principles and standards that came from the ABIM Foundation’s Stepping Up to the Plate (SUTTP) Alliance, which met this spring. SHM and PCPI are working to form an expert workgroup that will develop six to eight care transitions measures for inclusion in the 2009 PQRI.

SHM also is exploring collaboration with the American Hospital Association and its Hospital Quality Alliance (HQA), which coordinates the promotion of quality measurement, transparency, and improvement in the hospital setting.

In addition to its work with these external national groups, task force members would also like to start a resource room on the SHM Web site, www.hospitalmedicine.org, which would be devoted to member efforts in research related to quality and performance standards, as well as the member go-to place for tools and references on best practices in performance standards and pay for reporting initiatives.

Finally, Dr. Torcson hopes to shape and disseminate a national research agenda for hospitalist performance measurement and reporting. TH

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SHM Behind the Scenes

Quality is our Middle Name

By Geri Barnes

The Education and Quality Initiatives Department’s (EQID) mission is to lead and manage an integrative program that brings resources to improve patient care. With the help of many individuals and partner organizations, SHM is working toward improved care for inpatients. Let’s review our progress as we begin the second quarter of SHM’s fiscal year.

Educational Programs

Our focus over the past few months has been the development of “Hospital Medicine 2008,” which will be held April 3-5 in San Diego. Under the leadership of Sylvia McKean, MD, head of the hospitalist service at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School in Boston, the Annual Meeting Committee has developed an innovative program. The session will include a new evidence-based rapid fire track and a new teaching skills pre-course for academic and clinical educators. EQID obtains CMEs, communicates with faculty, and fine-tunes logistical efforts.

Leadership Academy Level I is a mainstay of SHM’s educational efforts. EQID supports Eric Howell, MD, chair of the Leadership Committee, as it focuses on addressing attendee input and encouraging the revision of the program in a continuous quality improvement effort. Dr. Howell is director of the Collaborative Inpatient Medicine Service and director of the Zieve Medical Services for Johns Hopkins Bayview Medical Center in Baltimore.

Along with Level I, Leadership Academy Level II will be presented again this year Nov. 5-8 in San Antonio. It builds on the success of last fall’s first offering by expanding on the concepts presented in the Level I academy.

A new educational initiative, supported by Sanofi-Aventis, provides three training sessions at regional chapters or other designated meetings across the country. The meetings educate hospitalists on best practices for glycemic control, prevention of venous thromboembolism, and transitions of care. Meetings will highlight successful interventions as outlined in the respective quality improvement (QI) implementation guides and resource rooms. Meetings will aim to include 20 to 50 participants.

The last piece of the SHM Heart Failure Quality Improvement Initiative is in its final planning stages, and a third CME module for Team Communications as it relates to the heart failure patient will be developed in the coming months. This initiative is supported in part by Scios Inc. and led by Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.

Quality Initiatives

Over the past several years, SHM has developed initiatives that range from convening a panel to assess the state of the art of a QI intervention to developing a Web-based resource room. Projects EQID is involved with:

• SHM is in the early stages of a three-year effort to develop resources and programs for improving hospital care transitions for older adults. This is supported through a major grant from the John A. Hartford Foundation in New York City, under the leadership of Mark Williams, MD, and Eric Coleman, MD, MPH. Dr. Williams is chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and editor of the Journal of Hospital Medicine. Dr. Coleman is associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora.
• “The Heart Failure Quality Improvement Implementation Guide” has been updated. The Heart Failure Resource Room on SHM’s Web site has been redesigned to make it easier for visitors who wish to follow the process of developing a QI intervention related to care of the hospitalized heart failure patient. We are communicating these changes to the hospital medicine community. Supported in part by Scios Inc., based in Mountain View, Calif., this effort includes presentations at regional meetings. This project was led by Nurcan Ilksoy, MD, assistant professor of Medicine at Emory University School of Medicine in Atlanta.
• The VTE Prevention Colla­borative is open to all members implementing a QI program to combat venous thromboembolism in the hospitalized patient. The Sanofi-Aventis-supported collaborative uses seasoned QI leaders as mentors. Greg Maynard, MD, MS, and Jason Stein, MD, lead the enrollees through the QI process. The mentees have the benefit of regularly scheduled calls to ask questions and receive instant feedback on their process and progress. An add-on to this program, funded by the Kettering Foundation of Dayton, Ohio, provides the opportunity for on-site consultations. Dr. Maynard is head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego. Dr. Stein is a hospitalist at Atlanta’s Emory University Hospital, assistant professor of Medicine at Emory University School of Medicine, and director of Quality Improvement for the Emory Hospital Medicine Unit.
• An expert panel convened in July to kick off development of an Acute Coronary Syndrome Resource Room and determine the content the resource room will cover. Content address diagnosis and risk stratification, medication, interventional procedures, patient education, transitions, and care coordination. This initiative is being led by Chad Whelan, MD, and is supported in part by Bristol-Myers Squibb Company, New York City. Dr. Whelan is an academic hospitalist and an assistant professor of medicine at University of Chicago in the Section of General Internal Medicine.
• SHM often studies strategies to improve patient satisfaction, outcomes, length of stay, and other important metrics. An expert panel assesses observation units as they contribute to improved treatment of patients with acute decompensated heart failure, chest pain, and other clinical conditions such as asthma. A white paper is pending on the use and value of observation units. Support for the meeting and development and distribution of the white paper was provided by Scios Inc.

Committee Support

A major staff role is the support of the Education and Hospital Quality and Patient Safety (HQPS) committees, the groups that direct and drive SHM in these important areas. The Education Committee, led by Chairman Bill Rifkin, MD, assistant professor of medicine at Yale University School of Medicine in New Haven, Conn., is focusing on:

• Developing the teaching skills pre-course that will be presented at the 2008 Annual Meeting;
• Defining a workable strategy to promote The Core Competencies in Hospital Medicine;
• Developing educational and/or communication modalities that support maintenance of certification; and
• Further defining the direction of the committee to meet members’ educational needs.

Janet Nagamine, MD, leads the HQPS Committee in the following priorities:

• Planning and holding a quality summit to define goals and priorities for the next three to five years;
• Submitting a grant application to AHRQ to support a multidisciplinary conference in the area of medication reconciliation;
• Developing SHM’s role in care transitions;
• Reviewing quality pre-course information and determining the curriculum for ‘‘Hospital Medicine 2008”; and
• Developing the Quality track for ‘‘Hospital Medicine 2008.”

The Performance and Standards Task Force (PSTF) was formed a little more than a year ago after SHM leadership recognized the need for a coordinated approach to working with external organizations in the performance and standards quality arena.

As SHM’s senior adviser for quality standards and compliance, I work with PSTF Chairman Patrick Torcson, MD, (medical director of hospital medicine at the St. Tammany Parish Hospital in Covington, La.) along with senior staff and leadership of the Public Policy Committee (PPC). We monitor the performance and quality landscape at national organizations charged with measuring development and building consensus. We also develop relationships with other professional medical societies and organizations.

Chapters Summary

Chicago

The Chicago Chapter of SHM met June 7. Attendees came from organizations such as Signature Healthcare Solutions, Advocate Healthcare, Northwestern University, and University of Chicago. The meeting began with an update from the SHM national annual meeting given by Chapter President Tarek Karaman, MD, lead hospitalist, Advocate Health Centers, and hospitalist program director, Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago. This was followed by a presentation on DVT/pulmonary embolism prophylaxis and treatment from SHM board member Alpesh Amin, MD, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. For the first time, the chapter had a panel discussion with two primary care physicians from Northwestern University. John Butter, MD, and Sean O’Conner, MD, shared their thoughts regarding the interaction between primary care physicians and hospitalists. Ideas were given on how to strengthen working relationships between the two.

St. Louis

SHM’s St. Louis chapter met June 11. Michael Cox, MD, gave a presentation on DVT prevention and treatment followed by a presentation given by SHM CEO Larry Wellikson, MD, on the challenges and opportunities for hospital medicine. The meeting was attended by more than 50 hospitalists from the greater St. Louis area, as well as numerous hospital administrative personnel, vice presidents of medical affairs, and internal medicine residents. The presentation was well received, and numerous individuals spoke with Dr. Wellikson after the presentation. Dr. Wellikson also met with leaders of various hospitalist groups to discuss topics of interest and ways to energize the local chapter. Six hospitalist groups attended. The group discussed challenges in recruitment and in training internists to be true hospitalists.

Since its inception in spring 2006, the PSTF has become engaged in the American Medical Association’s (AMA) Physician Consortium for Performance Improvement (PCPI) and the National Quality Forum (NQF). The NQF is a nonprofit organization instructed by Congress to endorse consensus-based national standards for measurement and public reporting of healthcare performance data. Specifically, NQF aims to influence the development of physician-level performance measures as part of the Centers for Medicare and Medicaid Service’s (CMS) Physician Quality Reporting Initiative (PQRI).

By joining the PCPI, SHM has aligned with other medical specialties to develop performance measures in geriatrics, emergency medicine, outpatient parenteral antimicrobial therapy, and facets of anesthesiology such as perioperative normothermia and critical care.

Additionally, SHM has given feedback during public comment periods on perioperative care, chronic kidney disease, and other measures. The task force continues to evaluate which workgroups it should appoint members to participate in, depending on the topic.

SHM leadership has continued to foster relationships with CMS by sending letters in support of the 2007 PQRI. SHM was able to influence changes to the 2007 measure specifications so hospitalists would have measures to report. Of the 74 measures included in the PQRI, 11 have specifications allowing reporting by hospitalists, underscoring the importance of SHM’s influence and participation in the PCPI process.

Dr. Torcson and Eric Siegal, MD, (regional medical director, Cogent Healthcare, Madison, Wis.) co-chaired a CMS-led SHM member conference call focused on PQRI and how it affects hospitalists. The program was well received by SHM members.

When SHM became a member of the NQF last summer, it nominated several members who were selected to participate on various technical advisory panels overseeing work on the development of consensus standards for hospital care. This project, sponsored by the Agency for Healthcare Research and Quality (AHRQ), is addressing patient safety, pediatrics, and inpatient care.

Last fall, SHM sent Mark Williams, MD (professor of medicine at Emory University School of Medicine in Atlanta and editor of The Journal of Hospital Medicine) to the NQF’s 7th Annual Meeting, a National Policy Conference on Quality. The meeting featured plenary sessions that focused on issues at the forefront of policy discussions, including incentivizing healthcare quality improvement, the role of policymakers, leading professional and trade associations in improving healthcare quality, and efforts under way in the federal government to foster healthcare improvements.

This fall, Greg Seymann, MD, will attend the 8th Annual Meeting. Dr. Seymann is an assistant professor with the Department of Medicine, Hospital Medicine Program, at the University of California San Diego Medical Center.

Goals for 2008, Beyond

By taking an active role in the performance and standard arena, SHM senior staff and leadership have been able to build key relationships. This has paved the way for influencing the current physician reporting program and taking the lead on developing measures that will most reflect hospital medicine in the future.

The task force intends to be at the helm of the development of performance measures that more accurately reflect services provided by hospitalists. Senior staff and leadership have discussed this goal with several national stakeholders including the PCPI and the NQF, whose senior staff have supported its agenda.

In July, SHM, along with the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM), and the American Geriatrics Society (AGS), formed a steering committee to convene a transitions of care consensus conference. This multispecialty, multidisciplinary group reviewed the principles and standards that came from the ABIM Foundation’s Stepping Up to the Plate (SUTTP) Alliance, which met this spring. SHM and PCPI are working to form an expert workgroup that will develop six to eight care transitions measures for inclusion in the 2009 PQRI.

SHM also is exploring collaboration with the American Hospital Association and its Hospital Quality Alliance (HQA), which coordinates the promotion of quality measurement, transparency, and improvement in the hospital setting.

In addition to its work with these external national groups, task force members would also like to start a resource room on the SHM Web site, www.hospitalmedicine.org, which would be devoted to member efforts in research related to quality and performance standards, as well as the member go-to place for tools and references on best practices in performance standards and pay for reporting initiatives.

Finally, Dr. Torcson hopes to shape and disseminate a national research agenda for hospitalist performance measurement and reporting. TH

click for large version

click for large version

SHM Behind the Scenes

Quality is our Middle Name

By Geri Barnes

The Education and Quality Initiatives Department’s (EQID) mission is to lead and manage an integrative program that brings resources to improve patient care. With the help of many individuals and partner organizations, SHM is working toward improved care for inpatients. Let’s review our progress as we begin the second quarter of SHM’s fiscal year.

Educational Programs

Our focus over the past few months has been the development of “Hospital Medicine 2008,” which will be held April 3-5 in San Diego. Under the leadership of Sylvia McKean, MD, head of the hospitalist service at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School in Boston, the Annual Meeting Committee has developed an innovative program. The session will include a new evidence-based rapid fire track and a new teaching skills pre-course for academic and clinical educators. EQID obtains CMEs, communicates with faculty, and fine-tunes logistical efforts.

Leadership Academy Level I is a mainstay of SHM’s educational efforts. EQID supports Eric Howell, MD, chair of the Leadership Committee, as it focuses on addressing attendee input and encouraging the revision of the program in a continuous quality improvement effort. Dr. Howell is director of the Collaborative Inpatient Medicine Service and director of the Zieve Medical Services for Johns Hopkins Bayview Medical Center in Baltimore.

Along with Level I, Leadership Academy Level II will be presented again this year Nov. 5-8 in San Antonio. It builds on the success of last fall’s first offering by expanding on the concepts presented in the Level I academy.

A new educational initiative, supported by Sanofi-Aventis, provides three training sessions at regional chapters or other designated meetings across the country. The meetings educate hospitalists on best practices for glycemic control, prevention of venous thromboembolism, and transitions of care. Meetings will highlight successful interventions as outlined in the respective quality improvement (QI) implementation guides and resource rooms. Meetings will aim to include 20 to 50 participants.

The last piece of the SHM Heart Failure Quality Improvement Initiative is in its final planning stages, and a third CME module for Team Communications as it relates to the heart failure patient will be developed in the coming months. This initiative is supported in part by Scios Inc. and led by Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.

Quality Initiatives

Over the past several years, SHM has developed initiatives that range from convening a panel to assess the state of the art of a QI intervention to developing a Web-based resource room. Projects EQID is involved with:

• SHM is in the early stages of a three-year effort to develop resources and programs for improving hospital care transitions for older adults. This is supported through a major grant from the John A. Hartford Foundation in New York City, under the leadership of Mark Williams, MD, and Eric Coleman, MD, MPH. Dr. Williams is chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and editor of the Journal of Hospital Medicine. Dr. Coleman is associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora.
• “The Heart Failure Quality Improvement Implementation Guide” has been updated. The Heart Failure Resource Room on SHM’s Web site has been redesigned to make it easier for visitors who wish to follow the process of developing a QI intervention related to care of the hospitalized heart failure patient. We are communicating these changes to the hospital medicine community. Supported in part by Scios Inc., based in Mountain View, Calif., this effort includes presentations at regional meetings. This project was led by Nurcan Ilksoy, MD, assistant professor of Medicine at Emory University School of Medicine in Atlanta.
• The VTE Prevention Colla­borative is open to all members implementing a QI program to combat venous thromboembolism in the hospitalized patient. The Sanofi-Aventis-supported collaborative uses seasoned QI leaders as mentors. Greg Maynard, MD, MS, and Jason Stein, MD, lead the enrollees through the QI process. The mentees have the benefit of regularly scheduled calls to ask questions and receive instant feedback on their process and progress. An add-on to this program, funded by the Kettering Foundation of Dayton, Ohio, provides the opportunity for on-site consultations. Dr. Maynard is head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego. Dr. Stein is a hospitalist at Atlanta’s Emory University Hospital, assistant professor of Medicine at Emory University School of Medicine, and director of Quality Improvement for the Emory Hospital Medicine Unit.
• An expert panel convened in July to kick off development of an Acute Coronary Syndrome Resource Room and determine the content the resource room will cover. Content address diagnosis and risk stratification, medication, interventional procedures, patient education, transitions, and care coordination. This initiative is being led by Chad Whelan, MD, and is supported in part by Bristol-Myers Squibb Company, New York City. Dr. Whelan is an academic hospitalist and an assistant professor of medicine at University of Chicago in the Section of General Internal Medicine.
• SHM often studies strategies to improve patient satisfaction, outcomes, length of stay, and other important metrics. An expert panel assesses observation units as they contribute to improved treatment of patients with acute decompensated heart failure, chest pain, and other clinical conditions such as asthma. A white paper is pending on the use and value of observation units. Support for the meeting and development and distribution of the white paper was provided by Scios Inc.

Committee Support

A major staff role is the support of the Education and Hospital Quality and Patient Safety (HQPS) committees, the groups that direct and drive SHM in these important areas. The Education Committee, led by Chairman Bill Rifkin, MD, assistant professor of medicine at Yale University School of Medicine in New Haven, Conn., is focusing on:

• Developing the teaching skills pre-course that will be presented at the 2008 Annual Meeting;
• Defining a workable strategy to promote The Core Competencies in Hospital Medicine;
• Developing educational and/or communication modalities that support maintenance of certification; and
• Further defining the direction of the committee to meet members’ educational needs.

Janet Nagamine, MD, leads the HQPS Committee in the following priorities:

• Planning and holding a quality summit to define goals and priorities for the next three to five years;
• Submitting a grant application to AHRQ to support a multidisciplinary conference in the area of medication reconciliation;
• Developing SHM’s role in care transitions;
• Reviewing quality pre-course information and determining the curriculum for ‘‘Hospital Medicine 2008”; and
• Developing the Quality track for ‘‘Hospital Medicine 2008.”

The Performance and Standards Task Force (PSTF) was formed a little more than a year ago after SHM leadership recognized the need for a coordinated approach to working with external organizations in the performance and standards quality arena.

As SHM’s senior adviser for quality standards and compliance, I work with PSTF Chairman Patrick Torcson, MD, (medical director of hospital medicine at the St. Tammany Parish Hospital in Covington, La.) along with senior staff and leadership of the Public Policy Committee (PPC). We monitor the performance and quality landscape at national organizations charged with measuring development and building consensus. We also develop relationships with other professional medical societies and organizations.

Chapters Summary

Chicago

The Chicago Chapter of SHM met June 7. Attendees came from organizations such as Signature Healthcare Solutions, Advocate Healthcare, Northwestern University, and University of Chicago. The meeting began with an update from the SHM national annual meeting given by Chapter President Tarek Karaman, MD, lead hospitalist, Advocate Health Centers, and hospitalist program director, Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago. This was followed by a presentation on DVT/pulmonary embolism prophylaxis and treatment from SHM board member Alpesh Amin, MD, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. For the first time, the chapter had a panel discussion with two primary care physicians from Northwestern University. John Butter, MD, and Sean O’Conner, MD, shared their thoughts regarding the interaction between primary care physicians and hospitalists. Ideas were given on how to strengthen working relationships between the two.

St. Louis

SHM’s St. Louis chapter met June 11. Michael Cox, MD, gave a presentation on DVT prevention and treatment followed by a presentation given by SHM CEO Larry Wellikson, MD, on the challenges and opportunities for hospital medicine. The meeting was attended by more than 50 hospitalists from the greater St. Louis area, as well as numerous hospital administrative personnel, vice presidents of medical affairs, and internal medicine residents. The presentation was well received, and numerous individuals spoke with Dr. Wellikson after the presentation. Dr. Wellikson also met with leaders of various hospitalist groups to discuss topics of interest and ways to energize the local chapter. Six hospitalist groups attended. The group discussed challenges in recruitment and in training internists to be true hospitalists.

Since its inception in spring 2006, the PSTF has become engaged in the American Medical Association’s (AMA) Physician Consortium for Performance Improvement (PCPI) and the National Quality Forum (NQF). The NQF is a nonprofit organization instructed by Congress to endorse consensus-based national standards for measurement and public reporting of healthcare performance data. Specifically, NQF aims to influence the development of physician-level performance measures as part of the Centers for Medicare and Medicaid Service’s (CMS) Physician Quality Reporting Initiative (PQRI).

By joining the PCPI, SHM has aligned with other medical specialties to develop performance measures in geriatrics, emergency medicine, outpatient parenteral antimicrobial therapy, and facets of anesthesiology such as perioperative normothermia and critical care.

Additionally, SHM has given feedback during public comment periods on perioperative care, chronic kidney disease, and other measures. The task force continues to evaluate which workgroups it should appoint members to participate in, depending on the topic.

SHM leadership has continued to foster relationships with CMS by sending letters in support of the 2007 PQRI. SHM was able to influence changes to the 2007 measure specifications so hospitalists would have measures to report. Of the 74 measures included in the PQRI, 11 have specifications allowing reporting by hospitalists, underscoring the importance of SHM’s influence and participation in the PCPI process.

Dr. Torcson and Eric Siegal, MD, (regional medical director, Cogent Healthcare, Madison, Wis.) co-chaired a CMS-led SHM member conference call focused on PQRI and how it affects hospitalists. The program was well received by SHM members.

When SHM became a member of the NQF last summer, it nominated several members who were selected to participate on various technical advisory panels overseeing work on the development of consensus standards for hospital care. This project, sponsored by the Agency for Healthcare Research and Quality (AHRQ), is addressing patient safety, pediatrics, and inpatient care.

Last fall, SHM sent Mark Williams, MD (professor of medicine at Emory University School of Medicine in Atlanta and editor of The Journal of Hospital Medicine) to the NQF’s 7th Annual Meeting, a National Policy Conference on Quality. The meeting featured plenary sessions that focused on issues at the forefront of policy discussions, including incentivizing healthcare quality improvement, the role of policymakers, leading professional and trade associations in improving healthcare quality, and efforts under way in the federal government to foster healthcare improvements.

This fall, Greg Seymann, MD, will attend the 8th Annual Meeting. Dr. Seymann is an assistant professor with the Department of Medicine, Hospital Medicine Program, at the University of California San Diego Medical Center.

Goals for 2008, Beyond

By taking an active role in the performance and standard arena, SHM senior staff and leadership have been able to build key relationships. This has paved the way for influencing the current physician reporting program and taking the lead on developing measures that will most reflect hospital medicine in the future.

The task force intends to be at the helm of the development of performance measures that more accurately reflect services provided by hospitalists. Senior staff and leadership have discussed this goal with several national stakeholders including the PCPI and the NQF, whose senior staff have supported its agenda.

In July, SHM, along with the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM), and the American Geriatrics Society (AGS), formed a steering committee to convene a transitions of care consensus conference. This multispecialty, multidisciplinary group reviewed the principles and standards that came from the ABIM Foundation’s Stepping Up to the Plate (SUTTP) Alliance, which met this spring. SHM and PCPI are working to form an expert workgroup that will develop six to eight care transitions measures for inclusion in the 2009 PQRI.

SHM also is exploring collaboration with the American Hospital Association and its Hospital Quality Alliance (HQA), which coordinates the promotion of quality measurement, transparency, and improvement in the hospital setting.

In addition to its work with these external national groups, task force members would also like to start a resource room on the SHM Web site, www.hospitalmedicine.org, which would be devoted to member efforts in research related to quality and performance standards, as well as the member go-to place for tools and references on best practices in performance standards and pay for reporting initiatives.

Finally, Dr. Torcson hopes to shape and disseminate a national research agenda for hospitalist performance measurement and reporting. TH

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SHM Behind the Scenes

Quality is our Middle Name

By Geri Barnes

The Education and Quality Initiatives Department’s (EQID) mission is to lead and manage an integrative program that brings resources to improve patient care. With the help of many individuals and partner organizations, SHM is working toward improved care for inpatients. Let’s review our progress as we begin the second quarter of SHM’s fiscal year.

Educational Programs

Our focus over the past few months has been the development of “Hospital Medicine 2008,” which will be held April 3-5 in San Diego. Under the leadership of Sylvia McKean, MD, head of the hospitalist service at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School in Boston, the Annual Meeting Committee has developed an innovative program. The session will include a new evidence-based rapid fire track and a new teaching skills pre-course for academic and clinical educators. EQID obtains CMEs, communicates with faculty, and fine-tunes logistical efforts.

Leadership Academy Level I is a mainstay of SHM’s educational efforts. EQID supports Eric Howell, MD, chair of the Leadership Committee, as it focuses on addressing attendee input and encouraging the revision of the program in a continuous quality improvement effort. Dr. Howell is director of the Collaborative Inpatient Medicine Service and director of the Zieve Medical Services for Johns Hopkins Bayview Medical Center in Baltimore.

Along with Level I, Leadership Academy Level II will be presented again this year Nov. 5-8 in San Antonio. It builds on the success of last fall’s first offering by expanding on the concepts presented in the Level I academy.

A new educational initiative, supported by Sanofi-Aventis, provides three training sessions at regional chapters or other designated meetings across the country. The meetings educate hospitalists on best practices for glycemic control, prevention of venous thromboembolism, and transitions of care. Meetings will highlight successful interventions as outlined in the respective quality improvement (QI) implementation guides and resource rooms. Meetings will aim to include 20 to 50 participants.

The last piece of the SHM Heart Failure Quality Improvement Initiative is in its final planning stages, and a third CME module for Team Communications as it relates to the heart failure patient will be developed in the coming months. This initiative is supported in part by Scios Inc. and led by Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.

Quality Initiatives

Over the past several years, SHM has developed initiatives that range from convening a panel to assess the state of the art of a QI intervention to developing a Web-based resource room. Projects EQID is involved with:

• SHM is in the early stages of a three-year effort to develop resources and programs for improving hospital care transitions for older adults. This is supported through a major grant from the John A. Hartford Foundation in New York City, under the leadership of Mark Williams, MD, and Eric Coleman, MD, MPH. Dr. Williams is chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and editor of the Journal of Hospital Medicine. Dr. Coleman is associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora.
• “The Heart Failure Quality Improvement Implementation Guide” has been updated. The Heart Failure Resource Room on SHM’s Web site has been redesigned to make it easier for visitors who wish to follow the process of developing a QI intervention related to care of the hospitalized heart failure patient. We are communicating these changes to the hospital medicine community. Supported in part by Scios Inc., based in Mountain View, Calif., this effort includes presentations at regional meetings. This project was led by Nurcan Ilksoy, MD, assistant professor of Medicine at Emory University School of Medicine in Atlanta.
• The VTE Prevention Colla­borative is open to all members implementing a QI program to combat venous thromboembolism in the hospitalized patient. The Sanofi-Aventis-supported collaborative uses seasoned QI leaders as mentors. Greg Maynard, MD, MS, and Jason Stein, MD, lead the enrollees through the QI process. The mentees have the benefit of regularly scheduled calls to ask questions and receive instant feedback on their process and progress. An add-on to this program, funded by the Kettering Foundation of Dayton, Ohio, provides the opportunity for on-site consultations. Dr. Maynard is head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego. Dr. Stein is a hospitalist at Atlanta’s Emory University Hospital, assistant professor of Medicine at Emory University School of Medicine, and director of Quality Improvement for the Emory Hospital Medicine Unit.
• An expert panel convened in July to kick off development of an Acute Coronary Syndrome Resource Room and determine the content the resource room will cover. Content address diagnosis and risk stratification, medication, interventional procedures, patient education, transitions, and care coordination. This initiative is being led by Chad Whelan, MD, and is supported in part by Bristol-Myers Squibb Company, New York City. Dr. Whelan is an academic hospitalist and an assistant professor of medicine at University of Chicago in the Section of General Internal Medicine.
• SHM often studies strategies to improve patient satisfaction, outcomes, length of stay, and other important metrics. An expert panel assesses observation units as they contribute to improved treatment of patients with acute decompensated heart failure, chest pain, and other clinical conditions such as asthma. A white paper is pending on the use and value of observation units. Support for the meeting and development and distribution of the white paper was provided by Scios Inc.

Committee Support

A major staff role is the support of the Education and Hospital Quality and Patient Safety (HQPS) committees, the groups that direct and drive SHM in these important areas. The Education Committee, led by Chairman Bill Rifkin, MD, assistant professor of medicine at Yale University School of Medicine in New Haven, Conn., is focusing on:

• Developing the teaching skills pre-course that will be presented at the 2008 Annual Meeting;
• Defining a workable strategy to promote The Core Competencies in Hospital Medicine;
• Developing educational and/or communication modalities that support maintenance of certification; and
• Further defining the direction of the committee to meet members’ educational needs.

Janet Nagamine, MD, leads the HQPS Committee in the following priorities:

• Planning and holding a quality summit to define goals and priorities for the next three to five years;
• Submitting a grant application to AHRQ to support a multidisciplinary conference in the area of medication reconciliation;
• Developing SHM’s role in care transitions;
• Reviewing quality pre-course information and determining the curriculum for ‘‘Hospital Medicine 2008”; and
• Developing the Quality track for ‘‘Hospital Medicine 2008.”

Within hospital medicine lives a small subspecialty that addresses a specific and real need in today’s hospitals: psychiatric hospitalists. These physicians provide medical and psychiatric care to hospitalized patients, negating the need for a referral to a psychiatrist.

“There’s little or no compensation for a psychiatrist consultation on a medical patient, so they don’t want to do it,” says Robert P. Albanese, MD, associate professor of psychiatry and medicine at Medical University of South Carolina (MUSC) in Charleston. A psychiatric hospitalist can diagnose and treat medical conditions as well as often overlooked or untreated conditions, such as schizophrenia, major depression, and delirium, as well as substance abuse issues.

Many hospitalized patients with these problems are either on Medicare or uninsured; some are homeless. Because these patients seek emergency care for advanced diseases, general hospitalists are likely to treat their medical problems.

A small percentage of medical facilities across the U.S. have hired psychiatric hospitalists to screen patients, provide psychiatric consults, and take pressure off other hospital staff, including general hospitalists. This summer, St. Luke’s Episcopal Hospital in Houston added a psychiatric hospitalist to its team of five hospitalists and plans to hire a second.

While the job market for psychiatric hospitalists will never come close to the meteoric rise in general hospitalist positions, Dr. Albanese says: “I think we’re on the threshold of some growth. We’ll see more small, community-based hospitals starting psychiatric programs.”

Built-In Roadblocks

Psychiatric hospitalists are limited partly because hospitals don’t have the patient load to necessitate hiring them.

“Back in the ’50s, there were around 650,000 hospital beds for patients with mental illness,” says Dr. Albanese. “Today, it’s estimated that there are between 25,000 and 45,000, according to the National Alliance on Mental Illness [NAMI].”

That drastic reduction is in state psychiatric facilities. Across the U.S., state budget cuts have resulted in mass closings of public psychiatric hospitals over the past 40 years—and the so-called “deinstitutionalization” of patients—while remaining state facilities have suffered significant cuts in funding. According to NAMI, there were 50,000 mentally ill homeless people in California because of deinstitutionalization between 1957 and 1988.

“There’s not a lot out there on psychiatric hospitalists because there aren’t many beds—they’ve kicked out [the patients],” explains Dr. Albanese. “Time’s arrow points to no major increase in the number of beds any time soon. This is a big problem everywhere because there are still a lot of psychiatric patients out there.”

Another factor keeping the number of psychiatric hospitalists fairly static is that most psychiatric medical students aren’t interested in inpatient care, says Dr. Albanese.

Dual-Boarded Specialists

According to the Accreditation Council for Graduate Medical Education, 29 universities offer a combined residency program in internal medicine and psychiatry or family medicine and psychiatry. Dr. Albanese’s university, MUSC, is one of them.

“Our focus is on training young physicians who are interested in becoming dual-boarded to work in a psychiatric setting,” he says. “We’re looking at hospital psychiatry as a special area within our expertise.”

MUSC’s program is highly selective. “We have a five-year residency, and we take two medical students each year,” says Dr. Albanese. “I believe that Rush-Presbyterian in Chicago has the largest program. They take four students per year.”

Despite the lack of beds for mentally ill patients, Dr. Albanese hopes for more psychiatric hospitalists to address those patients’ needs.

“These patients have such a shortened life expectancy, I think there will be increased focus on meeting their needs,” he says. He points to an article in USA Today from May 3, “Mentally ill die 25 year earlier on average,” that documented the trend. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

Within hospital medicine lives a small subspecialty that addresses a specific and real need in today’s hospitals: psychiatric hospitalists. These physicians provide medical and psychiatric care to hospitalized patients, negating the need for a referral to a psychiatrist.

“There’s little or no compensation for a psychiatrist consultation on a medical patient, so they don’t want to do it,” says Robert P. Albanese, MD, associate professor of psychiatry and medicine at Medical University of South Carolina (MUSC) in Charleston. A psychiatric hospitalist can diagnose and treat medical conditions as well as often overlooked or untreated conditions, such as schizophrenia, major depression, and delirium, as well as substance abuse issues.

Many hospitalized patients with these problems are either on Medicare or uninsured; some are homeless. Because these patients seek emergency care for advanced diseases, general hospitalists are likely to treat their medical problems.

A small percentage of medical facilities across the U.S. have hired psychiatric hospitalists to screen patients, provide psychiatric consults, and take pressure off other hospital staff, including general hospitalists. This summer, St. Luke’s Episcopal Hospital in Houston added a psychiatric hospitalist to its team of five hospitalists and plans to hire a second.

While the job market for psychiatric hospitalists will never come close to the meteoric rise in general hospitalist positions, Dr. Albanese says: “I think we’re on the threshold of some growth. We’ll see more small, community-based hospitals starting psychiatric programs.”

Built-In Roadblocks

Psychiatric hospitalists are limited partly because hospitals don’t have the patient load to necessitate hiring them.

“Back in the ’50s, there were around 650,000 hospital beds for patients with mental illness,” says Dr. Albanese. “Today, it’s estimated that there are between 25,000 and 45,000, according to the National Alliance on Mental Illness [NAMI].”

That drastic reduction is in state psychiatric facilities. Across the U.S., state budget cuts have resulted in mass closings of public psychiatric hospitals over the past 40 years—and the so-called “deinstitutionalization” of patients—while remaining state facilities have suffered significant cuts in funding. According to NAMI, there were 50,000 mentally ill homeless people in California because of deinstitutionalization between 1957 and 1988.

“There’s not a lot out there on psychiatric hospitalists because there aren’t many beds—they’ve kicked out [the patients],” explains Dr. Albanese. “Time’s arrow points to no major increase in the number of beds any time soon. This is a big problem everywhere because there are still a lot of psychiatric patients out there.”

Another factor keeping the number of psychiatric hospitalists fairly static is that most psychiatric medical students aren’t interested in inpatient care, says Dr. Albanese.

Dual-Boarded Specialists

According to the Accreditation Council for Graduate Medical Education, 29 universities offer a combined residency program in internal medicine and psychiatry or family medicine and psychiatry. Dr. Albanese’s university, MUSC, is one of them.

“Our focus is on training young physicians who are interested in becoming dual-boarded to work in a psychiatric setting,” he says. “We’re looking at hospital psychiatry as a special area within our expertise.”

MUSC’s program is highly selective. “We have a five-year residency, and we take two medical students each year,” says Dr. Albanese. “I believe that Rush-Presbyterian in Chicago has the largest program. They take four students per year.”

Despite the lack of beds for mentally ill patients, Dr. Albanese hopes for more psychiatric hospitalists to address those patients’ needs.

“These patients have such a shortened life expectancy, I think there will be increased focus on meeting their needs,” he says. He points to an article in USA Today from May 3, “Mentally ill die 25 year earlier on average,” that documented the trend. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

Within hospital medicine lives a small subspecialty that addresses a specific and real need in today’s hospitals: psychiatric hospitalists. These physicians provide medical and psychiatric care to hospitalized patients, negating the need for a referral to a psychiatrist.

“There’s little or no compensation for a psychiatrist consultation on a medical patient, so they don’t want to do it,” says Robert P. Albanese, MD, associate professor of psychiatry and medicine at Medical University of South Carolina (MUSC) in Charleston. A psychiatric hospitalist can diagnose and treat medical conditions as well as often overlooked or untreated conditions, such as schizophrenia, major depression, and delirium, as well as substance abuse issues.

Many hospitalized patients with these problems are either on Medicare or uninsured; some are homeless. Because these patients seek emergency care for advanced diseases, general hospitalists are likely to treat their medical problems.

A small percentage of medical facilities across the U.S. have hired psychiatric hospitalists to screen patients, provide psychiatric consults, and take pressure off other hospital staff, including general hospitalists. This summer, St. Luke’s Episcopal Hospital in Houston added a psychiatric hospitalist to its team of five hospitalists and plans to hire a second.

While the job market for psychiatric hospitalists will never come close to the meteoric rise in general hospitalist positions, Dr. Albanese says: “I think we’re on the threshold of some growth. We’ll see more small, community-based hospitals starting psychiatric programs.”

Built-In Roadblocks

Psychiatric hospitalists are limited partly because hospitals don’t have the patient load to necessitate hiring them.

“Back in the ’50s, there were around 650,000 hospital beds for patients with mental illness,” says Dr. Albanese. “Today, it’s estimated that there are between 25,000 and 45,000, according to the National Alliance on Mental Illness [NAMI].”

That drastic reduction is in state psychiatric facilities. Across the U.S., state budget cuts have resulted in mass closings of public psychiatric hospitals over the past 40 years—and the so-called “deinstitutionalization” of patients—while remaining state facilities have suffered significant cuts in funding. According to NAMI, there were 50,000 mentally ill homeless people in California because of deinstitutionalization between 1957 and 1988.

“There’s not a lot out there on psychiatric hospitalists because there aren’t many beds—they’ve kicked out [the patients],” explains Dr. Albanese. “Time’s arrow points to no major increase in the number of beds any time soon. This is a big problem everywhere because there are still a lot of psychiatric patients out there.”

Another factor keeping the number of psychiatric hospitalists fairly static is that most psychiatric medical students aren’t interested in inpatient care, says Dr. Albanese.

Dual-Boarded Specialists

According to the Accreditation Council for Graduate Medical Education, 29 universities offer a combined residency program in internal medicine and psychiatry or family medicine and psychiatry. Dr. Albanese’s university, MUSC, is one of them.

“Our focus is on training young physicians who are interested in becoming dual-boarded to work in a psychiatric setting,” he says. “We’re looking at hospital psychiatry as a special area within our expertise.”

MUSC’s program is highly selective. “We have a five-year residency, and we take two medical students each year,” says Dr. Albanese. “I believe that Rush-Presbyterian in Chicago has the largest program. They take four students per year.”

Despite the lack of beds for mentally ill patients, Dr. Albanese hopes for more psychiatric hospitalists to address those patients’ needs.

“These patients have such a shortened life expectancy, I think there will be increased focus on meeting their needs,” he says. He points to an article in USA Today from May 3, “Mentally ill die 25 year earlier on average,” that documented the trend. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

When Manjusha Gupte, MD, had her second child, she realized that parenting and working full-time as a hospitalist was going to be too much.

“My husband is a hospitalist as well, so since there’s two in the family, we needed to get our time a little better situated with the kids,” she says.

She and another hospitalist, also a mother, approached their program director at Gaston Memorial Hospital, a busy community hospital in Gastonia, N.C., about going part-time.

Since then, the two physicians have shared a full-time job. Dr. Gupte works three or four consecutive shifts a week, two weeks a month. She still sees a full complement of patients—about 20 at a time—and she gets to spend more time with her daughter, 4, and her son, almost 2.

“Most hospitalist programs are scared,” Dr. Gupte says. “They think there won’t be continuity of care for patients, or it’s going to be disruptive to other doctors who are full-time. I have not yet heard of anybody complaining about continuity of care.”

Even though hiring part-timers and job-sharers raises these and other concerns, it’s increasingly important to offer this kind of scheduling flexibility, industry experts say.

“Hospital medicine, more than many other specialty, tends to attract people who care a lot about lifestyle,” says Leslie Flores, MHA, Nelson/Flores Associates. “A practice that isn’t willing to be flexible and consider part-time is sort of shooting itself in the foot.”

Before deciding whether to hire part-time or job-sharing hospitalists, there are many factors to consider, such as how to handle benefits and malpractice insurance and how to make sure a part-timer with a private practice doesn’t draw patients away from the hospital’s crew of referring doctors—intentionally or not.

There are benefits to the hospital: It’s easier to provide vacation and gap coverage, it’s less likely the full-time hospitalists will burn out, and in some cases, a part-time specialist can provide services the hospital didn’t offer.

“We’re real advocates of part-time hospitalists,” Flores says. “I think the benefits really outweigh the risks.”

The Benefits

A part-time hospitalist can be anyone from a physician who cuts back to 75% of her hours so she can spend more time with her kids, to a resident or fellow who signs up for a few shifts a month. A job-sharer splits a full-time job with another physician, sometimes sharing office space and even a malpractice insurance policy.

Part-timers can free full-time hospitalists to participate on committees, conduct research, teach, attend a conference or seminar, take a sabbatical, or simply pursue outside interests, says Kenneth Simone, DO, who founded and served as director for 10 years of a hospitalist program in Maine. He is now president of Hospitalist and Practice Solutions, a consultancy, in Brewer, Maine.

“Also, they’re extremely helpful when the practice is in an expansion mode,” Dr. Simone says. “If they want to bring in two or three more referring providers’ practices, you can utilize the part-timers to help with the extra work so you don’t overwork your staff.”

Though it’s less common these days, a new hospitalist program may meet with resistance from local doctors. Offering those doctors part-time shifts can help ease the transition.

“They’re worried about what’s going to happen to their inpatient skills, what their patients may think, and their income,” says Steven Nahm, vice president of the Camden Group, a hospitalist consultancy and management company with offices in Chicago and El Segundo, Calif. As part-timers, these doctors keep current with inpatient care and can gauge the impact of the program on their practices.

A respected local physician who comes in part-time also lends credibility and gives medical staff a greater sense of confidence in the program, Nahm says. Dr. Simone calls these part-timers ambassadors.

One Example

The hospitalist program at Hudson Valley Hospital Center in Cortlandt Manor, N.Y., began in July 2005 at the request of local doctors. The program, Hospital Medicine Associates, contracts with the hospital and has its own billing system. It has eight full-time hospitalists, and as of about six months ago, four hospitalists sharing two full-time positions. They even share malpractice insurance because New York state law allows for half-policies. The part-timers work under pro-rated policies because they work fewer hours.

Allowing doctors to job-share seemed like common sense, says Richard Becker, MD, who leads the program.

“If you have good physicians, you want to keep them,” he says. “Having two doctors share shifts gives you flexibility. If one is sick or ill or on vacation, the other can come in and take care of it. You never have to worry about that position.”

While most programs have a few part-time physicians, it’s rare to see a program fully staffed by part-timers or job-sharers, Nahm says.

“Generally, they’re transition steps toward a program staffed by full-time hospitalists,” he says.

It can take more than a year to staff a program, especially for medical centers that aren’t in a city with a medical school. Now that more hospitals want to start hospitalist programs—and quickly—it helps to bring in part-timers to support an incomplete team, says Betty Abbott, chief operating officer of Eagle Hospital Physicians in Atlanta, Ga., a hospitalist consultancy that serves the southeast and Atlantic states.

“It used to be you had three to nine months to start a program, and now many people are saying, ‘We’d like to have it next Monday,’ ” Abbott says.

Some smaller or rural hospitals run part-time-only hospitalist programs because it’s the only option that makes economic sense, or because they have trouble recruiting full-time hospitalists. In these cases, part-timers can give a much-needed boost to admissions.

“The doctors typically in the community don’t want to work on weekends,” says Alan Himmelstein, FACMPE, president of Hospital Care Consultants Inc. (HCC) in San Antonio, Texas. “So if they see a patient in their office on a Thursday that has pneumonia, they will opt to either transfer to a bigger city, or treat the patient in an outpatient setting, which is not optimal. With the hospitalist there, the hospital can take that patient.”

Competition, Commitment

Two of the major concerns about part-time and job-sharing hospitalists are that they won’t be as committed to the program as other hospitalists, or that they’ll attract patients to their own private practice—away from referring physicians.

“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.

“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?

“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”

Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.

“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”

To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.

“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”

Continuity of Care

Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.

If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.

To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.

“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.

“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”

Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.

Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.

“The nature of our job is such that it’s fairly easy to coordinate that,” says Daniel J. Brotman, MD, FACP, director of the hospitalist program there. “It creates sort of auxiliary staffing.”

The hospitalist program at Johns Hopkins started in 2002. Part-timers tend to work nights and weekends and get a lot of flexibility; they sign up for shifts instead of working a guaranteed schedule. Continuity of care is rarely an issue because full-time staff provides that, Dr. Brotman says.

“We divide labor into somebody who’s doing admissions and someone who’s taking care of the patients day to day,” he says. “The person who’s doing admissions can be anybody who’s competent to do so and doesn’t need to be someone who’s available the next day to take care of the patients.”

So far, hand-offs have been smooth, Dr. Brotman says, partly because the transfer of information about Hopkins’ complex tertiary-care patients is thorough by necessity. While good communication is important for all hospitalists, it’s especially important for part-timers and job-sharers, Dr. Simone says. In addition to requiring thorough notes and communication, he suggests finding out ahead of time whether a part-timer will be available to answer questions during off hours.

“Are they flexible so they can come in a heartbeat if you need them?” Dr. Simone says. By the same token, referring physicians have to commit to doing a verbal hand-off to the hospitalists, and hospitalists have to commit to sending a report when the patients are handed back, Abbott says.

When HCC tried establishing a hospitalist program that covered only weekend shifts, Himmelstein says, tight turnarounds on Monday mornings and spotty cell phone service in rural areas made it too hard to coordinate hand-offs.

Other Issues

There are other factors to consider before bringing in full-time hospitalists or job-shares, such as billing.

“They’re working as a hospitalist for a week, and one of their private patients comes in to be admitted,” Nahm says. “Are they seeing that patient as a hospitalist or are they seeing that patient outside of the program, as their own patient?”

The same issue can come up with a pulmonary or infectious disease specialist, for example. If she consults on other patients during her shift, is she doing so as a hospitalist or in her private practice?

“I find it best if you just take the philosophy that you’re buying this physician’s time, and anything this physician does on the clock for you is considered a service of the hospitalist group—and all billing and collection and revenue, in other words, go back to the hospitalist group,” Nahm says.

Also, a part-time hospitalist may face competing demands for his or her time.

“Sometimes they come in and they’re lacking focus because they’re tired—they’ve been up all night moonlighting in the ED,” Dr. Simone says. “Or they pace themselves because they know tomorrow and for the next four days, they’re on call for their private practice.”

Despite the practical issues part-timers bring, Dr. Simone points out, they tend to increase a program’s flexibility and efficiency, allow the hospital to offer more value, lower burnout, and increase job satisfaction.

Dr. Gupte wants more programs to start hiring part-time hospitalists—especially to help families like hers, where both parents are busy physicians.

“I think that makes a big difference in family care,” she says. “People sometimes think that we won’t be as intense or as focused when you’re doing the part-time thing. I don’t think that’s true.” TH

Liz Tascio is a freelance journalist based in New York City.

When Manjusha Gupte, MD, had her second child, she realized that parenting and working full-time as a hospitalist was going to be too much.

“My husband is a hospitalist as well, so since there’s two in the family, we needed to get our time a little better situated with the kids,” she says.

She and another hospitalist, also a mother, approached their program director at Gaston Memorial Hospital, a busy community hospital in Gastonia, N.C., about going part-time.

Since then, the two physicians have shared a full-time job. Dr. Gupte works three or four consecutive shifts a week, two weeks a month. She still sees a full complement of patients—about 20 at a time—and she gets to spend more time with her daughter, 4, and her son, almost 2.

“Most hospitalist programs are scared,” Dr. Gupte says. “They think there won’t be continuity of care for patients, or it’s going to be disruptive to other doctors who are full-time. I have not yet heard of anybody complaining about continuity of care.”

Even though hiring part-timers and job-sharers raises these and other concerns, it’s increasingly important to offer this kind of scheduling flexibility, industry experts say.

“Hospital medicine, more than many other specialty, tends to attract people who care a lot about lifestyle,” says Leslie Flores, MHA, Nelson/Flores Associates. “A practice that isn’t willing to be flexible and consider part-time is sort of shooting itself in the foot.”

Before deciding whether to hire part-time or job-sharing hospitalists, there are many factors to consider, such as how to handle benefits and malpractice insurance and how to make sure a part-timer with a private practice doesn’t draw patients away from the hospital’s crew of referring doctors—intentionally or not.

There are benefits to the hospital: It’s easier to provide vacation and gap coverage, it’s less likely the full-time hospitalists will burn out, and in some cases, a part-time specialist can provide services the hospital didn’t offer.

“We’re real advocates of part-time hospitalists,” Flores says. “I think the benefits really outweigh the risks.”

The Benefits

A part-time hospitalist can be anyone from a physician who cuts back to 75% of her hours so she can spend more time with her kids, to a resident or fellow who signs up for a few shifts a month. A job-sharer splits a full-time job with another physician, sometimes sharing office space and even a malpractice insurance policy.

Part-timers can free full-time hospitalists to participate on committees, conduct research, teach, attend a conference or seminar, take a sabbatical, or simply pursue outside interests, says Kenneth Simone, DO, who founded and served as director for 10 years of a hospitalist program in Maine. He is now president of Hospitalist and Practice Solutions, a consultancy, in Brewer, Maine.

“Also, they’re extremely helpful when the practice is in an expansion mode,” Dr. Simone says. “If they want to bring in two or three more referring providers’ practices, you can utilize the part-timers to help with the extra work so you don’t overwork your staff.”

Though it’s less common these days, a new hospitalist program may meet with resistance from local doctors. Offering those doctors part-time shifts can help ease the transition.

“They’re worried about what’s going to happen to their inpatient skills, what their patients may think, and their income,” says Steven Nahm, vice president of the Camden Group, a hospitalist consultancy and management company with offices in Chicago and El Segundo, Calif. As part-timers, these doctors keep current with inpatient care and can gauge the impact of the program on their practices.

A respected local physician who comes in part-time also lends credibility and gives medical staff a greater sense of confidence in the program, Nahm says. Dr. Simone calls these part-timers ambassadors.

One Example

The hospitalist program at Hudson Valley Hospital Center in Cortlandt Manor, N.Y., began in July 2005 at the request of local doctors. The program, Hospital Medicine Associates, contracts with the hospital and has its own billing system. It has eight full-time hospitalists, and as of about six months ago, four hospitalists sharing two full-time positions. They even share malpractice insurance because New York state law allows for half-policies. The part-timers work under pro-rated policies because they work fewer hours.

Allowing doctors to job-share seemed like common sense, says Richard Becker, MD, who leads the program.

“If you have good physicians, you want to keep them,” he says. “Having two doctors share shifts gives you flexibility. If one is sick or ill or on vacation, the other can come in and take care of it. You never have to worry about that position.”

While most programs have a few part-time physicians, it’s rare to see a program fully staffed by part-timers or job-sharers, Nahm says.

“Generally, they’re transition steps toward a program staffed by full-time hospitalists,” he says.

It can take more than a year to staff a program, especially for medical centers that aren’t in a city with a medical school. Now that more hospitals want to start hospitalist programs—and quickly—it helps to bring in part-timers to support an incomplete team, says Betty Abbott, chief operating officer of Eagle Hospital Physicians in Atlanta, Ga., a hospitalist consultancy that serves the southeast and Atlantic states.

“It used to be you had three to nine months to start a program, and now many people are saying, ‘We’d like to have it next Monday,’ ” Abbott says.

Some smaller or rural hospitals run part-time-only hospitalist programs because it’s the only option that makes economic sense, or because they have trouble recruiting full-time hospitalists. In these cases, part-timers can give a much-needed boost to admissions.

“The doctors typically in the community don’t want to work on weekends,” says Alan Himmelstein, FACMPE, president of Hospital Care Consultants Inc. (HCC) in San Antonio, Texas. “So if they see a patient in their office on a Thursday that has pneumonia, they will opt to either transfer to a bigger city, or treat the patient in an outpatient setting, which is not optimal. With the hospitalist there, the hospital can take that patient.”

Competition, Commitment

Two of the major concerns about part-time and job-sharing hospitalists are that they won’t be as committed to the program as other hospitalists, or that they’ll attract patients to their own private practice—away from referring physicians.

“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.

“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?

“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”

Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.

“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”

To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.

“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”

Continuity of Care

Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.

If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.

To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.

“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.

“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”

Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.

Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.

“The nature of our job is such that it’s fairly easy to coordinate that,” says Daniel J. Brotman, MD, FACP, director of the hospitalist program there. “It creates sort of auxiliary staffing.”

The hospitalist program at Johns Hopkins started in 2002. Part-timers tend to work nights and weekends and get a lot of flexibility; they sign up for shifts instead of working a guaranteed schedule. Continuity of care is rarely an issue because full-time staff provides that, Dr. Brotman says.

“We divide labor into somebody who’s doing admissions and someone who’s taking care of the patients day to day,” he says. “The person who’s doing admissions can be anybody who’s competent to do so and doesn’t need to be someone who’s available the next day to take care of the patients.”

So far, hand-offs have been smooth, Dr. Brotman says, partly because the transfer of information about Hopkins’ complex tertiary-care patients is thorough by necessity. While good communication is important for all hospitalists, it’s especially important for part-timers and job-sharers, Dr. Simone says. In addition to requiring thorough notes and communication, he suggests finding out ahead of time whether a part-timer will be available to answer questions during off hours.

“Are they flexible so they can come in a heartbeat if you need them?” Dr. Simone says. By the same token, referring physicians have to commit to doing a verbal hand-off to the hospitalists, and hospitalists have to commit to sending a report when the patients are handed back, Abbott says.

When HCC tried establishing a hospitalist program that covered only weekend shifts, Himmelstein says, tight turnarounds on Monday mornings and spotty cell phone service in rural areas made it too hard to coordinate hand-offs.

Other Issues

There are other factors to consider before bringing in full-time hospitalists or job-shares, such as billing.

“They’re working as a hospitalist for a week, and one of their private patients comes in to be admitted,” Nahm says. “Are they seeing that patient as a hospitalist or are they seeing that patient outside of the program, as their own patient?”

The same issue can come up with a pulmonary or infectious disease specialist, for example. If she consults on other patients during her shift, is she doing so as a hospitalist or in her private practice?

“I find it best if you just take the philosophy that you’re buying this physician’s time, and anything this physician does on the clock for you is considered a service of the hospitalist group—and all billing and collection and revenue, in other words, go back to the hospitalist group,” Nahm says.

Also, a part-time hospitalist may face competing demands for his or her time.

“Sometimes they come in and they’re lacking focus because they’re tired—they’ve been up all night moonlighting in the ED,” Dr. Simone says. “Or they pace themselves because they know tomorrow and for the next four days, they’re on call for their private practice.”

Despite the practical issues part-timers bring, Dr. Simone points out, they tend to increase a program’s flexibility and efficiency, allow the hospital to offer more value, lower burnout, and increase job satisfaction.

Dr. Gupte wants more programs to start hiring part-time hospitalists—especially to help families like hers, where both parents are busy physicians.

“I think that makes a big difference in family care,” she says. “People sometimes think that we won’t be as intense or as focused when you’re doing the part-time thing. I don’t think that’s true.” TH

Liz Tascio is a freelance journalist based in New York City.

When Manjusha Gupte, MD, had her second child, she realized that parenting and working full-time as a hospitalist was going to be too much.

“My husband is a hospitalist as well, so since there’s two in the family, we needed to get our time a little better situated with the kids,” she says.

She and another hospitalist, also a mother, approached their program director at Gaston Memorial Hospital, a busy community hospital in Gastonia, N.C., about going part-time.

Since then, the two physicians have shared a full-time job. Dr. Gupte works three or four consecutive shifts a week, two weeks a month. She still sees a full complement of patients—about 20 at a time—and she gets to spend more time with her daughter, 4, and her son, almost 2.

“Most hospitalist programs are scared,” Dr. Gupte says. “They think there won’t be continuity of care for patients, or it’s going to be disruptive to other doctors who are full-time. I have not yet heard of anybody complaining about continuity of care.”

Even though hiring part-timers and job-sharers raises these and other concerns, it’s increasingly important to offer this kind of scheduling flexibility, industry experts say.

“Hospital medicine, more than many other specialty, tends to attract people who care a lot about lifestyle,” says Leslie Flores, MHA, Nelson/Flores Associates. “A practice that isn’t willing to be flexible and consider part-time is sort of shooting itself in the foot.”

Before deciding whether to hire part-time or job-sharing hospitalists, there are many factors to consider, such as how to handle benefits and malpractice insurance and how to make sure a part-timer with a private practice doesn’t draw patients away from the hospital’s crew of referring doctors—intentionally or not.

There are benefits to the hospital: It’s easier to provide vacation and gap coverage, it’s less likely the full-time hospitalists will burn out, and in some cases, a part-time specialist can provide services the hospital didn’t offer.

“We’re real advocates of part-time hospitalists,” Flores says. “I think the benefits really outweigh the risks.”

The Benefits

A part-time hospitalist can be anyone from a physician who cuts back to 75% of her hours so she can spend more time with her kids, to a resident or fellow who signs up for a few shifts a month. A job-sharer splits a full-time job with another physician, sometimes sharing office space and even a malpractice insurance policy.

Part-timers can free full-time hospitalists to participate on committees, conduct research, teach, attend a conference or seminar, take a sabbatical, or simply pursue outside interests, says Kenneth Simone, DO, who founded and served as director for 10 years of a hospitalist program in Maine. He is now president of Hospitalist and Practice Solutions, a consultancy, in Brewer, Maine.

“Also, they’re extremely helpful when the practice is in an expansion mode,” Dr. Simone says. “If they want to bring in two or three more referring providers’ practices, you can utilize the part-timers to help with the extra work so you don’t overwork your staff.”

Though it’s less common these days, a new hospitalist program may meet with resistance from local doctors. Offering those doctors part-time shifts can help ease the transition.

“They’re worried about what’s going to happen to their inpatient skills, what their patients may think, and their income,” says Steven Nahm, vice president of the Camden Group, a hospitalist consultancy and management company with offices in Chicago and El Segundo, Calif. As part-timers, these doctors keep current with inpatient care and can gauge the impact of the program on their practices.

A respected local physician who comes in part-time also lends credibility and gives medical staff a greater sense of confidence in the program, Nahm says. Dr. Simone calls these part-timers ambassadors.

One Example

The hospitalist program at Hudson Valley Hospital Center in Cortlandt Manor, N.Y., began in July 2005 at the request of local doctors. The program, Hospital Medicine Associates, contracts with the hospital and has its own billing system. It has eight full-time hospitalists, and as of about six months ago, four hospitalists sharing two full-time positions. They even share malpractice insurance because New York state law allows for half-policies. The part-timers work under pro-rated policies because they work fewer hours.

Allowing doctors to job-share seemed like common sense, says Richard Becker, MD, who leads the program.

“If you have good physicians, you want to keep them,” he says. “Having two doctors share shifts gives you flexibility. If one is sick or ill or on vacation, the other can come in and take care of it. You never have to worry about that position.”

While most programs have a few part-time physicians, it’s rare to see a program fully staffed by part-timers or job-sharers, Nahm says.

“Generally, they’re transition steps toward a program staffed by full-time hospitalists,” he says.

It can take more than a year to staff a program, especially for medical centers that aren’t in a city with a medical school. Now that more hospitals want to start hospitalist programs—and quickly—it helps to bring in part-timers to support an incomplete team, says Betty Abbott, chief operating officer of Eagle Hospital Physicians in Atlanta, Ga., a hospitalist consultancy that serves the southeast and Atlantic states.

“It used to be you had three to nine months to start a program, and now many people are saying, ‘We’d like to have it next Monday,’ ” Abbott says.

Some smaller or rural hospitals run part-time-only hospitalist programs because it’s the only option that makes economic sense, or because they have trouble recruiting full-time hospitalists. In these cases, part-timers can give a much-needed boost to admissions.

“The doctors typically in the community don’t want to work on weekends,” says Alan Himmelstein, FACMPE, president of Hospital Care Consultants Inc. (HCC) in San Antonio, Texas. “So if they see a patient in their office on a Thursday that has pneumonia, they will opt to either transfer to a bigger city, or treat the patient in an outpatient setting, which is not optimal. With the hospitalist there, the hospital can take that patient.”

Competition, Commitment

Two of the major concerns about part-time and job-sharing hospitalists are that they won’t be as committed to the program as other hospitalists, or that they’ll attract patients to their own private practice—away from referring physicians.

“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.

“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?

“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”

Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.

“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”

To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.

“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”

Continuity of Care

Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.

If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.

To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.

“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.

“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”

Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.

Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.

“The nature of our job is such that it’s fairly easy to coordinate that,” says Daniel J. Brotman, MD, FACP, director of the hospitalist program there. “It creates sort of auxiliary staffing.”

The hospitalist program at Johns Hopkins started in 2002. Part-timers tend to work nights and weekends and get a lot of flexibility; they sign up for shifts instead of working a guaranteed schedule. Continuity of care is rarely an issue because full-time staff provides that, Dr. Brotman says.

“We divide labor into somebody who’s doing admissions and someone who’s taking care of the patients day to day,” he says. “The person who’s doing admissions can be anybody who’s competent to do so and doesn’t need to be someone who’s available the next day to take care of the patients.”

So far, hand-offs have been smooth, Dr. Brotman says, partly because the transfer of information about Hopkins’ complex tertiary-care patients is thorough by necessity. While good communication is important for all hospitalists, it’s especially important for part-timers and job-sharers, Dr. Simone says. In addition to requiring thorough notes and communication, he suggests finding out ahead of time whether a part-timer will be available to answer questions during off hours.

“Are they flexible so they can come in a heartbeat if you need them?” Dr. Simone says. By the same token, referring physicians have to commit to doing a verbal hand-off to the hospitalists, and hospitalists have to commit to sending a report when the patients are handed back, Abbott says.

When HCC tried establishing a hospitalist program that covered only weekend shifts, Himmelstein says, tight turnarounds on Monday mornings and spotty cell phone service in rural areas made it too hard to coordinate hand-offs.

Other Issues

There are other factors to consider before bringing in full-time hospitalists or job-shares, such as billing.

“They’re working as a hospitalist for a week, and one of their private patients comes in to be admitted,” Nahm says. “Are they seeing that patient as a hospitalist or are they seeing that patient outside of the program, as their own patient?”

The same issue can come up with a pulmonary or infectious disease specialist, for example. If she consults on other patients during her shift, is she doing so as a hospitalist or in her private practice?

“I find it best if you just take the philosophy that you’re buying this physician’s time, and anything this physician does on the clock for you is considered a service of the hospitalist group—and all billing and collection and revenue, in other words, go back to the hospitalist group,” Nahm says.

Also, a part-time hospitalist may face competing demands for his or her time.

“Sometimes they come in and they’re lacking focus because they’re tired—they’ve been up all night moonlighting in the ED,” Dr. Simone says. “Or they pace themselves because they know tomorrow and for the next four days, they’re on call for their private practice.”

Despite the practical issues part-timers bring, Dr. Simone points out, they tend to increase a program’s flexibility and efficiency, allow the hospital to offer more value, lower burnout, and increase job satisfaction.

Dr. Gupte wants more programs to start hiring part-time hospitalists—especially to help families like hers, where both parents are busy physicians.

“I think that makes a big difference in family care,” she says. “People sometimes think that we won’t be as intense or as focused when you’re doing the part-time thing. I don’t think that’s true.” TH

Liz Tascio is a freelance journalist based in New York City.

As the field of hospital medicine grows, some hospitalists are gravitating toward subspecialty services. In recent years we’ve witnessed a proliferation of ‘ists’: There are now surgicalists, laborists, psychiatric hospitalists—even hepa-hospitalists.

The numbers of “hyphenate hospitalists” are not tracked by SHM, but the subspecialization trend highlights raises questions about hospital medicine’s evolution. Among the issues:

• What does this growth of hospitalist subspecialists foreshadow about the strength of the hospitalist movement?
• Does subspecialization always convey positive changes for the hospitalist?
• Do physicians risk trade-offs when their hospital medicine practices are rooted solely in one subspecialty?
• What about retaining the opportunity to see and treat a variety of patients and conditions—presumably one of the initial attractions of a career in internal medicine and family medicine?

The founder of hospital medicine, a noted pediatric hospitalist, the chair of the SHM’s membership committee, and a former hepa-hospitalist recently shared their experiences and views on these issues.

Success Spreads

Hospital medicine pioneer Robert M. Wachter, MD, has observed at his and other hospitals the increasing dependence on hospitalists’ services.

“Hospitalists have traditionally done more than just take care of medical patients,” says Dr. Wachter, professor and chief of the division of hospital medicine, associate chairman, department of medicine, chief of the medical service at the University of California San Francisco (UCSF), and author of the upcoming blog “Wachter’s World.” “They’ve always done medical consultations and helped to take care of sick patients with surgical, gynecological, and psychiatric issues.” But now, he says, “The demand for hospitalist services is almost limitless.”

At UCSF, he reports, hospitalists now manage the medical problems of patients on the complex heart failure service, the bone marrow transplant service, and the neurosurgical and orthopedic services. Dr. Wachter views the trend of using hospitalists in a variety of subspecialty services as “one of the most exciting developments for the field—it is taking the field to a whole new level of importance and growth.” That’s because it signals recognition that the concept of hospital medicine has value “for virtually every patient sick enough to be in the building,” he says.

Ambiguity of Terms

Not only are hospitalists increasingly present in subspecialty services, but some specialist services are reorganizing according to the hospitalist model. This may create complexities regarding hospital medicine’s core identity, according to Dr. Wachter.

For instance, at UCSF, there are generalist surgeons who have organized a hospitalist service, providing on-call responsiveness, triage for specialized surgical problems, and a breadth of care and coordination typical of the hospital medicine model. Separately, there are also internal medicine hospitalists who serve on the surgery service. “I think there is going to be some ambiguity about roles until we clean up the language,” remarks Dr. Wachter. For instance: “Is the hospitalist on the surgery service still a generalist who takes on the role of subspecialist by caring for a more specialized population? And, what do you call the specialist surgeon who takes on a more hospitalist role?”

Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”

Best Use of Skills?

Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.

Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”

Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.

“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.

“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”

Satisfying in the Long Run?

Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”

Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.

The Pediatrics Picture

The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2

In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.

Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.

In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.

The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).

Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”

One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.

Future Configurations

To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.

“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”

As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”

Rotating hospitalists to specialty and subspecialty services for 25% of their time in the hospital, as the UCSF Neurosurgery hospitalists do, might be one way to preserve the traditional general medical model to which many internal medicine hospitalists still gravitate. “This could be an interesting, specialized niche practice, but would not be the bulk of what they do,” says Dr. Wachter.

Dr. Frost agrees that the key to addressing the challenge of subspecialization lies in building this type of work into the context of a larger hospital medicine program. “Rotating all members of a hospital medicine group through a subspecialty experience for a portion of their overall time may be the way to go,” he notes.

Dr. Friedly cautions that certain subspecialist services, such as liver transplant, may not embrace the multidisciplinary hospital medicine model, so it remains to be seen if the effort can evolve to be truly collaborative. Her advice to younger residents just entering hospital medicine? “Hospitalist medicine has unlimited possibilities as a career choice, especially if you enjoyed being an internal medicine resident. Be careful, however, to avoid a setting where you risk losing your hard-earned skills while also being treated like a ‘perma-resident.’ Starting out in a more traditional hospitalist program to learn solid hospitalist ‘tricks of the trade,’ then transitioning to a subspecialty program where you can offer your skills, rather than the other way around, may be the more sustainable, long-term option.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Ogershok PR, Li X, Palmer HC, et al. Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.” Clin Pediatr. 2001 Dec.;40(12): 653-660.
2. Tenner PA, Dibrell H, Taylor RP. Improved survival with hospitalists in a pediatric intensive care unit.” Crit Care Med. 2003 Mar;31(3):847-852.
3. Melzer SM, Molteni, RA, Marcuse EK, et al. Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis. Pediatrics. 2001 Jul;108(1);79-84.

As the field of hospital medicine grows, some hospitalists are gravitating toward subspecialty services. In recent years we’ve witnessed a proliferation of ‘ists’: There are now surgicalists, laborists, psychiatric hospitalists—even hepa-hospitalists.

The numbers of “hyphenate hospitalists” are not tracked by SHM, but the subspecialization trend highlights raises questions about hospital medicine’s evolution. Among the issues:

• What does this growth of hospitalist subspecialists foreshadow about the strength of the hospitalist movement?
• Does subspecialization always convey positive changes for the hospitalist?
• Do physicians risk trade-offs when their hospital medicine practices are rooted solely in one subspecialty?
• What about retaining the opportunity to see and treat a variety of patients and conditions—presumably one of the initial attractions of a career in internal medicine and family medicine?

The founder of hospital medicine, a noted pediatric hospitalist, the chair of the SHM’s membership committee, and a former hepa-hospitalist recently shared their experiences and views on these issues.

Success Spreads

Hospital medicine pioneer Robert M. Wachter, MD, has observed at his and other hospitals the increasing dependence on hospitalists’ services.

“Hospitalists have traditionally done more than just take care of medical patients,” says Dr. Wachter, professor and chief of the division of hospital medicine, associate chairman, department of medicine, chief of the medical service at the University of California San Francisco (UCSF), and author of the upcoming blog “Wachter’s World.” “They’ve always done medical consultations and helped to take care of sick patients with surgical, gynecological, and psychiatric issues.” But now, he says, “The demand for hospitalist services is almost limitless.”

At UCSF, he reports, hospitalists now manage the medical problems of patients on the complex heart failure service, the bone marrow transplant service, and the neurosurgical and orthopedic services. Dr. Wachter views the trend of using hospitalists in a variety of subspecialty services as “one of the most exciting developments for the field—it is taking the field to a whole new level of importance and growth.” That’s because it signals recognition that the concept of hospital medicine has value “for virtually every patient sick enough to be in the building,” he says.

Ambiguity of Terms

Not only are hospitalists increasingly present in subspecialty services, but some specialist services are reorganizing according to the hospitalist model. This may create complexities regarding hospital medicine’s core identity, according to Dr. Wachter.

For instance, at UCSF, there are generalist surgeons who have organized a hospitalist service, providing on-call responsiveness, triage for specialized surgical problems, and a breadth of care and coordination typical of the hospital medicine model. Separately, there are also internal medicine hospitalists who serve on the surgery service. “I think there is going to be some ambiguity about roles until we clean up the language,” remarks Dr. Wachter. For instance: “Is the hospitalist on the surgery service still a generalist who takes on the role of subspecialist by caring for a more specialized population? And, what do you call the specialist surgeon who takes on a more hospitalist role?”

Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”

Best Use of Skills?

Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.

Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”

Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.

“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.

“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”

Satisfying in the Long Run?

Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”

Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.

The Pediatrics Picture

The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2

In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.

Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.

In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.

The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).

Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”

One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.

Future Configurations

To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.

“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”

As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”

Rotating hospitalists to specialty and subspecialty services for 25% of their time in the hospital, as the UCSF Neurosurgery hospitalists do, might be one way to preserve the traditional general medical model to which many internal medicine hospitalists still gravitate. “This could be an interesting, specialized niche practice, but would not be the bulk of what they do,” says Dr. Wachter.

Dr. Frost agrees that the key to addressing the challenge of subspecialization lies in building this type of work into the context of a larger hospital medicine program. “Rotating all members of a hospital medicine group through a subspecialty experience for a portion of their overall time may be the way to go,” he notes.

Dr. Friedly cautions that certain subspecialist services, such as liver transplant, may not embrace the multidisciplinary hospital medicine model, so it remains to be seen if the effort can evolve to be truly collaborative. Her advice to younger residents just entering hospital medicine? “Hospitalist medicine has unlimited possibilities as a career choice, especially if you enjoyed being an internal medicine resident. Be careful, however, to avoid a setting where you risk losing your hard-earned skills while also being treated like a ‘perma-resident.’ Starting out in a more traditional hospitalist program to learn solid hospitalist ‘tricks of the trade,’ then transitioning to a subspecialty program where you can offer your skills, rather than the other way around, may be the more sustainable, long-term option.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Ogershok PR, Li X, Palmer HC, et al. Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.” Clin Pediatr. 2001 Dec.;40(12): 653-660.
2. Tenner PA, Dibrell H, Taylor RP. Improved survival with hospitalists in a pediatric intensive care unit.” Crit Care Med. 2003 Mar;31(3):847-852.
3. Melzer SM, Molteni, RA, Marcuse EK, et al. Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis. Pediatrics. 2001 Jul;108(1);79-84.

As the field of hospital medicine grows, some hospitalists are gravitating toward subspecialty services. In recent years we’ve witnessed a proliferation of ‘ists’: There are now surgicalists, laborists, psychiatric hospitalists—even hepa-hospitalists.

The numbers of “hyphenate hospitalists” are not tracked by SHM, but the subspecialization trend highlights raises questions about hospital medicine’s evolution. Among the issues:

• What does this growth of hospitalist subspecialists foreshadow about the strength of the hospitalist movement?
• Does subspecialization always convey positive changes for the hospitalist?
• Do physicians risk trade-offs when their hospital medicine practices are rooted solely in one subspecialty?
• What about retaining the opportunity to see and treat a variety of patients and conditions—presumably one of the initial attractions of a career in internal medicine and family medicine?

The founder of hospital medicine, a noted pediatric hospitalist, the chair of the SHM’s membership committee, and a former hepa-hospitalist recently shared their experiences and views on these issues.

Success Spreads

Hospital medicine pioneer Robert M. Wachter, MD, has observed at his and other hospitals the increasing dependence on hospitalists’ services.

“Hospitalists have traditionally done more than just take care of medical patients,” says Dr. Wachter, professor and chief of the division of hospital medicine, associate chairman, department of medicine, chief of the medical service at the University of California San Francisco (UCSF), and author of the upcoming blog “Wachter’s World.” “They’ve always done medical consultations and helped to take care of sick patients with surgical, gynecological, and psychiatric issues.” But now, he says, “The demand for hospitalist services is almost limitless.”

At UCSF, he reports, hospitalists now manage the medical problems of patients on the complex heart failure service, the bone marrow transplant service, and the neurosurgical and orthopedic services. Dr. Wachter views the trend of using hospitalists in a variety of subspecialty services as “one of the most exciting developments for the field—it is taking the field to a whole new level of importance and growth.” That’s because it signals recognition that the concept of hospital medicine has value “for virtually every patient sick enough to be in the building,” he says.

Ambiguity of Terms

Not only are hospitalists increasingly present in subspecialty services, but some specialist services are reorganizing according to the hospitalist model. This may create complexities regarding hospital medicine’s core identity, according to Dr. Wachter.

For instance, at UCSF, there are generalist surgeons who have organized a hospitalist service, providing on-call responsiveness, triage for specialized surgical problems, and a breadth of care and coordination typical of the hospital medicine model. Separately, there are also internal medicine hospitalists who serve on the surgery service. “I think there is going to be some ambiguity about roles until we clean up the language,” remarks Dr. Wachter. For instance: “Is the hospitalist on the surgery service still a generalist who takes on the role of subspecialist by caring for a more specialized population? And, what do you call the specialist surgeon who takes on a more hospitalist role?”

Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”

Best Use of Skills?

Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.

Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”

Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.

“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.

“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”

Satisfying in the Long Run?

Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”

Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.

The Pediatrics Picture

The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2

In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.

Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.

In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.

The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).

Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”

One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.

Future Configurations

To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.

“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”

As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”

Rotating hospitalists to specialty and subspecialty services for 25% of their time in the hospital, as the UCSF Neurosurgery hospitalists do, might be one way to preserve the traditional general medical model to which many internal medicine hospitalists still gravitate. “This could be an interesting, specialized niche practice, but would not be the bulk of what they do,” says Dr. Wachter.

Dr. Frost agrees that the key to addressing the challenge of subspecialization lies in building this type of work into the context of a larger hospital medicine program. “Rotating all members of a hospital medicine group through a subspecialty experience for a portion of their overall time may be the way to go,” he notes.

Dr. Friedly cautions that certain subspecialist services, such as liver transplant, may not embrace the multidisciplinary hospital medicine model, so it remains to be seen if the effort can evolve to be truly collaborative. Her advice to younger residents just entering hospital medicine? “Hospitalist medicine has unlimited possibilities as a career choice, especially if you enjoyed being an internal medicine resident. Be careful, however, to avoid a setting where you risk losing your hard-earned skills while also being treated like a ‘perma-resident.’ Starting out in a more traditional hospitalist program to learn solid hospitalist ‘tricks of the trade,’ then transitioning to a subspecialty program where you can offer your skills, rather than the other way around, may be the more sustainable, long-term option.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. Ogershok PR, Li X, Palmer HC, et al. Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.” Clin Pediatr. 2001 Dec.;40(12): 653-660.
2. Tenner PA, Dibrell H, Taylor RP. Improved survival with hospitalists in a pediatric intensive care unit.” Crit Care Med. 2003 Mar;31(3):847-852.
3. Melzer SM, Molteni, RA, Marcuse EK, et al. Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis. Pediatrics. 2001 Jul;108(1);79-84.