Brief Reports

While increasing evidence suggests that hyperglycemia during illness is associated with poor clinical outcome,1, 2 hyperglycemia in the hospital setting is often overlooked and unaddressed.3, 4 Early and intensive management of hyperglycemia may improve outcomes in hospitalized patients.57 Emergency Department (ED) glucose values may present an early opportunity to identify hyperglycemic patients as having unrecognized glucose intolerance and improve early glycemic control for hospitalized patients. Serum glucose values are available for 18% of 110 million annual ED visits in the United States, and many others undergo capillary glucose measurements.8 Although stressors and lack of fasting may contribute to ED hyperglycemia, communication and management should be similar.5 In this study, we hypothesized that in less than 20% of patients ED hyperglycemia would be recognized, communicated to patients, or they would receive ED treatment.

PATIENTS AND METHODS

RESULTS

During the data collection period, 27,688 (58%) ED visits had at least 1 serum glucose result. After excluding multiple glucose results for the same visit, the median glucose value was 106 mg/dL (range, 7‐2280 mg/dL); 3517 (13%) values were 140‐199 mg/dL, and 2304 (8%) values were 200 mg/dL. We located 385 of the 400 (96%) randomly selected charts. Interrater agreement for chart review was high (kappa = 0.91‐0.98).

Table 1 shows demographic characteristics and Table 2 shows clinical data of the sample, stratified by glucose group and charted diagnosis of diabetes. Overall, 55% of patients with glucose values 140‐199 mg/dL and 16% of patients with glucose 200 mg/dL had no prior diabetes diagnosis. Hyperglycemia was associated with sepsis for 22% of patients, infection without sepsis for 13% of patients, and traumatic injury for 19% of patients.

No patient received intravenous fluids with dextrose prior to initial serum glucose determination, and there was no difference in home corticosteroid use between groups (P = 0.23). Patients with known diabetes were more likely to receive insulin in the ED (P 0.01). Only 1 patient received an oral hypoglycemic agent in the ED. Three patients had documented hypoglycemia on capillary blood glucose during the ED stay, and no patients had hypoglycemia based on serum glucose during the ED or hospital stay. Among hospitalized patients, 61% had inpatient orders for diabetic‐consistent/carbohydrate‐consistent diet, 65% for capillary glucose tests daily, and 63% for sliding scale insulin.

We also present written discharge instructions data for 363 visits (253 inpatient and 110 ED) in Table 2; discharge instructions were not available for 22 visits (12 deaths during hospitalization, 10 missing instructions). New antidiabetic medications were prescribed for 42 (12%) patients, all from the inpatient setting. There was no difference between inpatient and ED communication of hyperglycemia (10% [95%CI, 7%‐14%] versus 9% [95%CI, 4%‐15%]) and recommendation for further outpatient testing (8% [95%CI, 4%‐11%] versus 4% [95%CI, 0%‐7%]) in written discharge instructions (P = 0.73 and 0.16, respectively). Compared to those with glucose 140‐199 mg/dL, patients with glucose 200 mg/dL were more likely to receive written communication of hyperglycemia (17% [95%CI, 11%‐22%] versus 3% [95%CI, 0%‐6%]) and recommendation for further outpatient testing (10% [95%CI, 6%‐14%] versus 3% [95%CI, 0%‐5%] (both, P 0.01).

DISCUSSION

Although noncritical ED glucose values may be overlooked, values sufficient to motivate inpatient and long‐term management are sometimes uncovered, and when unrecognized may be missed opportunities. Indeed, admission hyperglycemia has been linked to poor clinical outcomes in hospitalized patients for a variety of conditions, particularly for myocardial infarction, stroke, and critical illness.1215

In this study, we evaluated recognition, communication, and management of ED glucose values above a relatively conservative threshold of 140 mg/dL, occurring in 21% of ED glucose results. Diabetes screening thresholds for casual glucose values as low as 120 mg/dL,9 and intensive glycemic control in critically ill patients to a target as low as 110 mg/dL have been suggested.5 Nevertheless, only 16% of our sample received insulin in the ED for hyperglycemia, and hyperglycemia was charted as a diagnosis in only 9% of cases.

This is especially important because 77% of ED visits without hyperglycemia charted as a diagnosis resulted in hospitalization, and early glycemic control was infrequently initiated. Limited ED management of hyperglycemia may be driven by the presence of more critical management issues (eg, 54% of patients had concomitant infection or trauma), lack of familiarity with guidelines, which suggest treatment to glucose 140 mg/dL in critically ill patients and 180 mg/dL in all hospitalized patients,16 or fear of adverse events, such as hypoglycemia. Additionally, ED crowding has been shown to effect decreased quality and timeliness of treatment for pneumonia, and may have similar effects for hyperglycemia.17 Inpatient recognition of hyperglycemia, based on orders for diet, glucose checks, and insulin, appeared significantly better, but this did not translate to improved communication in written discharge instructions. Additionally, many hospitalized patients may spend many hours, or even days, in the ED waiting for beds, which currently is a missed opportunity to initiate early therapy.

Written discharge instructions informed less than 10% of patients of their hyperglycemia or outlined a plan for further evaluation and management. Our prior work suggests that nearly all (95%) ED patients want to be informed of elevated blood glucose and are willing to follow‐up, if instructed.18 The current data suggests that hyperglycemia in ED and hospitalized patients is frequently unrecognized and undertreated, and opportunities to institute an outpatient plan to address hyperglycemia are frequently missed.

This study has several potential limitations. This study was performed at a single academic center, which limits generalizability to other geographic areas and hospital types. Accuracy of abstracted data depended on chart review, which is limited by the possibility of missing, incomplete, or unreliable information. Standardized definitions and abstraction forms limited potential for bias, and high interrater agreement demonstrated internal reliability of the chart review. We considered only initial glucose values and were unable to determine nutritional status; it is possible that subsequent measurements were within an acceptable range. Conversely, hospitalized patients may have developed hyperglycemia subsequent to the initial glucose result, which would underestimate the scope of inpatient hyperglycemia. Also, because there are limited data for interpretation of ED hyperglycemia, we were unable to determine optimal glucose thresholds. Finally, we were unable to evaluate the content of verbal instructions or letters to outpatient providers, which limited our ability to fully describe communication of abnormal findings. However, patients do not often retain information in verbal instructions, in the context of new diagnoses and complex medical regimens.

In summary, recognition, management, and communication of ED hyperglycemia were suboptimal in our patient population and represent a missed opportunity. Enhanced recognition, management, and referral for hyperglycemia observed during usual ED care may provide an unobtrusive method to improve identification of undiagnosed diabetes/prediabetes and initiation of intensive glycemic control for hospitalized patients.

While increasing evidence suggests that hyperglycemia during illness is associated with poor clinical outcome,1, 2 hyperglycemia in the hospital setting is often overlooked and unaddressed.3, 4 Early and intensive management of hyperglycemia may improve outcomes in hospitalized patients.57 Emergency Department (ED) glucose values may present an early opportunity to identify hyperglycemic patients as having unrecognized glucose intolerance and improve early glycemic control for hospitalized patients. Serum glucose values are available for 18% of 110 million annual ED visits in the United States, and many others undergo capillary glucose measurements.8 Although stressors and lack of fasting may contribute to ED hyperglycemia, communication and management should be similar.5 In this study, we hypothesized that in less than 20% of patients ED hyperglycemia would be recognized, communicated to patients, or they would receive ED treatment.

PATIENTS AND METHODS

RESULTS

During the data collection period, 27,688 (58%) ED visits had at least 1 serum glucose result. After excluding multiple glucose results for the same visit, the median glucose value was 106 mg/dL (range, 7‐2280 mg/dL); 3517 (13%) values were 140‐199 mg/dL, and 2304 (8%) values were 200 mg/dL. We located 385 of the 400 (96%) randomly selected charts. Interrater agreement for chart review was high (kappa = 0.91‐0.98).

Table 1 shows demographic characteristics and Table 2 shows clinical data of the sample, stratified by glucose group and charted diagnosis of diabetes. Overall, 55% of patients with glucose values 140‐199 mg/dL and 16% of patients with glucose 200 mg/dL had no prior diabetes diagnosis. Hyperglycemia was associated with sepsis for 22% of patients, infection without sepsis for 13% of patients, and traumatic injury for 19% of patients.

No patient received intravenous fluids with dextrose prior to initial serum glucose determination, and there was no difference in home corticosteroid use between groups (P = 0.23). Patients with known diabetes were more likely to receive insulin in the ED (P 0.01). Only 1 patient received an oral hypoglycemic agent in the ED. Three patients had documented hypoglycemia on capillary blood glucose during the ED stay, and no patients had hypoglycemia based on serum glucose during the ED or hospital stay. Among hospitalized patients, 61% had inpatient orders for diabetic‐consistent/carbohydrate‐consistent diet, 65% for capillary glucose tests daily, and 63% for sliding scale insulin.

We also present written discharge instructions data for 363 visits (253 inpatient and 110 ED) in Table 2; discharge instructions were not available for 22 visits (12 deaths during hospitalization, 10 missing instructions). New antidiabetic medications were prescribed for 42 (12%) patients, all from the inpatient setting. There was no difference between inpatient and ED communication of hyperglycemia (10% [95%CI, 7%‐14%] versus 9% [95%CI, 4%‐15%]) and recommendation for further outpatient testing (8% [95%CI, 4%‐11%] versus 4% [95%CI, 0%‐7%]) in written discharge instructions (P = 0.73 and 0.16, respectively). Compared to those with glucose 140‐199 mg/dL, patients with glucose 200 mg/dL were more likely to receive written communication of hyperglycemia (17% [95%CI, 11%‐22%] versus 3% [95%CI, 0%‐6%]) and recommendation for further outpatient testing (10% [95%CI, 6%‐14%] versus 3% [95%CI, 0%‐5%] (both, P 0.01).

DISCUSSION

Although noncritical ED glucose values may be overlooked, values sufficient to motivate inpatient and long‐term management are sometimes uncovered, and when unrecognized may be missed opportunities. Indeed, admission hyperglycemia has been linked to poor clinical outcomes in hospitalized patients for a variety of conditions, particularly for myocardial infarction, stroke, and critical illness.1215

In this study, we evaluated recognition, communication, and management of ED glucose values above a relatively conservative threshold of 140 mg/dL, occurring in 21% of ED glucose results. Diabetes screening thresholds for casual glucose values as low as 120 mg/dL,9 and intensive glycemic control in critically ill patients to a target as low as 110 mg/dL have been suggested.5 Nevertheless, only 16% of our sample received insulin in the ED for hyperglycemia, and hyperglycemia was charted as a diagnosis in only 9% of cases.

This is especially important because 77% of ED visits without hyperglycemia charted as a diagnosis resulted in hospitalization, and early glycemic control was infrequently initiated. Limited ED management of hyperglycemia may be driven by the presence of more critical management issues (eg, 54% of patients had concomitant infection or trauma), lack of familiarity with guidelines, which suggest treatment to glucose 140 mg/dL in critically ill patients and 180 mg/dL in all hospitalized patients,16 or fear of adverse events, such as hypoglycemia. Additionally, ED crowding has been shown to effect decreased quality and timeliness of treatment for pneumonia, and may have similar effects for hyperglycemia.17 Inpatient recognition of hyperglycemia, based on orders for diet, glucose checks, and insulin, appeared significantly better, but this did not translate to improved communication in written discharge instructions. Additionally, many hospitalized patients may spend many hours, or even days, in the ED waiting for beds, which currently is a missed opportunity to initiate early therapy.

Written discharge instructions informed less than 10% of patients of their hyperglycemia or outlined a plan for further evaluation and management. Our prior work suggests that nearly all (95%) ED patients want to be informed of elevated blood glucose and are willing to follow‐up, if instructed.18 The current data suggests that hyperglycemia in ED and hospitalized patients is frequently unrecognized and undertreated, and opportunities to institute an outpatient plan to address hyperglycemia are frequently missed.

This study has several potential limitations. This study was performed at a single academic center, which limits generalizability to other geographic areas and hospital types. Accuracy of abstracted data depended on chart review, which is limited by the possibility of missing, incomplete, or unreliable information. Standardized definitions and abstraction forms limited potential for bias, and high interrater agreement demonstrated internal reliability of the chart review. We considered only initial glucose values and were unable to determine nutritional status; it is possible that subsequent measurements were within an acceptable range. Conversely, hospitalized patients may have developed hyperglycemia subsequent to the initial glucose result, which would underestimate the scope of inpatient hyperglycemia. Also, because there are limited data for interpretation of ED hyperglycemia, we were unable to determine optimal glucose thresholds. Finally, we were unable to evaluate the content of verbal instructions or letters to outpatient providers, which limited our ability to fully describe communication of abnormal findings. However, patients do not often retain information in verbal instructions, in the context of new diagnoses and complex medical regimens.

In summary, recognition, management, and communication of ED hyperglycemia were suboptimal in our patient population and represent a missed opportunity. Enhanced recognition, management, and referral for hyperglycemia observed during usual ED care may provide an unobtrusive method to improve identification of undiagnosed diabetes/prediabetes and initiation of intensive glycemic control for hospitalized patients.

While increasing evidence suggests that hyperglycemia during illness is associated with poor clinical outcome,1, 2 hyperglycemia in the hospital setting is often overlooked and unaddressed.3, 4 Early and intensive management of hyperglycemia may improve outcomes in hospitalized patients.57 Emergency Department (ED) glucose values may present an early opportunity to identify hyperglycemic patients as having unrecognized glucose intolerance and improve early glycemic control for hospitalized patients. Serum glucose values are available for 18% of 110 million annual ED visits in the United States, and many others undergo capillary glucose measurements.8 Although stressors and lack of fasting may contribute to ED hyperglycemia, communication and management should be similar.5 In this study, we hypothesized that in less than 20% of patients ED hyperglycemia would be recognized, communicated to patients, or they would receive ED treatment.

PATIENTS AND METHODS

RESULTS

During the data collection period, 27,688 (58%) ED visits had at least 1 serum glucose result. After excluding multiple glucose results for the same visit, the median glucose value was 106 mg/dL (range, 7‐2280 mg/dL); 3517 (13%) values were 140‐199 mg/dL, and 2304 (8%) values were 200 mg/dL. We located 385 of the 400 (96%) randomly selected charts. Interrater agreement for chart review was high (kappa = 0.91‐0.98).

Table 1 shows demographic characteristics and Table 2 shows clinical data of the sample, stratified by glucose group and charted diagnosis of diabetes. Overall, 55% of patients with glucose values 140‐199 mg/dL and 16% of patients with glucose 200 mg/dL had no prior diabetes diagnosis. Hyperglycemia was associated with sepsis for 22% of patients, infection without sepsis for 13% of patients, and traumatic injury for 19% of patients.

No patient received intravenous fluids with dextrose prior to initial serum glucose determination, and there was no difference in home corticosteroid use between groups (P = 0.23). Patients with known diabetes were more likely to receive insulin in the ED (P 0.01). Only 1 patient received an oral hypoglycemic agent in the ED. Three patients had documented hypoglycemia on capillary blood glucose during the ED stay, and no patients had hypoglycemia based on serum glucose during the ED or hospital stay. Among hospitalized patients, 61% had inpatient orders for diabetic‐consistent/carbohydrate‐consistent diet, 65% for capillary glucose tests daily, and 63% for sliding scale insulin.

We also present written discharge instructions data for 363 visits (253 inpatient and 110 ED) in Table 2; discharge instructions were not available for 22 visits (12 deaths during hospitalization, 10 missing instructions). New antidiabetic medications were prescribed for 42 (12%) patients, all from the inpatient setting. There was no difference between inpatient and ED communication of hyperglycemia (10% [95%CI, 7%‐14%] versus 9% [95%CI, 4%‐15%]) and recommendation for further outpatient testing (8% [95%CI, 4%‐11%] versus 4% [95%CI, 0%‐7%]) in written discharge instructions (P = 0.73 and 0.16, respectively). Compared to those with glucose 140‐199 mg/dL, patients with glucose 200 mg/dL were more likely to receive written communication of hyperglycemia (17% [95%CI, 11%‐22%] versus 3% [95%CI, 0%‐6%]) and recommendation for further outpatient testing (10% [95%CI, 6%‐14%] versus 3% [95%CI, 0%‐5%] (both, P 0.01).

DISCUSSION

Although noncritical ED glucose values may be overlooked, values sufficient to motivate inpatient and long‐term management are sometimes uncovered, and when unrecognized may be missed opportunities. Indeed, admission hyperglycemia has been linked to poor clinical outcomes in hospitalized patients for a variety of conditions, particularly for myocardial infarction, stroke, and critical illness.1215

In this study, we evaluated recognition, communication, and management of ED glucose values above a relatively conservative threshold of 140 mg/dL, occurring in 21% of ED glucose results. Diabetes screening thresholds for casual glucose values as low as 120 mg/dL,9 and intensive glycemic control in critically ill patients to a target as low as 110 mg/dL have been suggested.5 Nevertheless, only 16% of our sample received insulin in the ED for hyperglycemia, and hyperglycemia was charted as a diagnosis in only 9% of cases.

This is especially important because 77% of ED visits without hyperglycemia charted as a diagnosis resulted in hospitalization, and early glycemic control was infrequently initiated. Limited ED management of hyperglycemia may be driven by the presence of more critical management issues (eg, 54% of patients had concomitant infection or trauma), lack of familiarity with guidelines, which suggest treatment to glucose 140 mg/dL in critically ill patients and 180 mg/dL in all hospitalized patients,16 or fear of adverse events, such as hypoglycemia. Additionally, ED crowding has been shown to effect decreased quality and timeliness of treatment for pneumonia, and may have similar effects for hyperglycemia.17 Inpatient recognition of hyperglycemia, based on orders for diet, glucose checks, and insulin, appeared significantly better, but this did not translate to improved communication in written discharge instructions. Additionally, many hospitalized patients may spend many hours, or even days, in the ED waiting for beds, which currently is a missed opportunity to initiate early therapy.

Written discharge instructions informed less than 10% of patients of their hyperglycemia or outlined a plan for further evaluation and management. Our prior work suggests that nearly all (95%) ED patients want to be informed of elevated blood glucose and are willing to follow‐up, if instructed.18 The current data suggests that hyperglycemia in ED and hospitalized patients is frequently unrecognized and undertreated, and opportunities to institute an outpatient plan to address hyperglycemia are frequently missed.

This study has several potential limitations. This study was performed at a single academic center, which limits generalizability to other geographic areas and hospital types. Accuracy of abstracted data depended on chart review, which is limited by the possibility of missing, incomplete, or unreliable information. Standardized definitions and abstraction forms limited potential for bias, and high interrater agreement demonstrated internal reliability of the chart review. We considered only initial glucose values and were unable to determine nutritional status; it is possible that subsequent measurements were within an acceptable range. Conversely, hospitalized patients may have developed hyperglycemia subsequent to the initial glucose result, which would underestimate the scope of inpatient hyperglycemia. Also, because there are limited data for interpretation of ED hyperglycemia, we were unable to determine optimal glucose thresholds. Finally, we were unable to evaluate the content of verbal instructions or letters to outpatient providers, which limited our ability to fully describe communication of abnormal findings. However, patients do not often retain information in verbal instructions, in the context of new diagnoses and complex medical regimens.

In summary, recognition, management, and communication of ED hyperglycemia were suboptimal in our patient population and represent a missed opportunity. Enhanced recognition, management, and referral for hyperglycemia observed during usual ED care may provide an unobtrusive method to improve identification of undiagnosed diabetes/prediabetes and initiation of intensive glycemic control for hospitalized patients.

The Joint Commission's (TJC) National Patient Safety Goal (NPSG) #8Accurately and completely reconcile medications across the continuum of carechallenges hospitals to design and implement new medication management processes. With medication errors contributing to patient morbidity and mortality,1 establishing a comprehensive process for reconciling a patient's medications during the hospitalization episode is an important quality improvement and patient safety goal.

However, the current state of inpatient medication management is highly fragmented. Standard documentation is lacking, as is integration of information between care settings.2 There are now reports describing implementation of various medication reconciliation processes for admissions,3 transfers,4 and discharges.5

Hospitalists are well‐positioned to contribute to the implementation of medication reconciliation. Indeed, because TJC does not explicitly specify what type of health care provider (eg, physician, nurse, etc.) should assume responsibility for this process, institutions have designed workflows to suit their own needs, while striving to comply with national standards.

Given the complexity and lack of standardization around this NPSG, a survey was distributed to attendees of a Society of Hospital Medicine (SHM) national meeting to determine the various processes implemented thus far, and to ascertain existing challenges to implementation. We report here on the results.

METHODS

A survey tool (Appendix) was designed to query demographic and institutional factors, involvement in the process, and barriers to implementation of medication reconciliation. Surveys were included in all attendees' registration materials, resulting in the distributions of approximately 800 surveys.

Responses were entered into an Excel spreadsheet. Simple descriptive statistics were used to determine proportions for providers, processes, and barriers to implementation. Where appropriate, variables were dichotomized, allowing for paired t‐test analysis. Statistical significance was defined as a P value less than .05. Subgroup analyses by hospital type, provider type, and process method were performed.

RESULTS

A total of 295 completed surveys were collected. The responses are tabulated in Table 1.

DISCUSSION

Managing medication information for inpatients is an extremely complex task. On admission, home medication lists are often inaccurate or absent,6 requiring extra time and effort to discover this information. By discharge, medication regimens have frequently been altered,7 making communication of changes to the next provider essential. One study described myriad provider, patient, and health system issues in maintaining accurate outpatient medication lists.8 These issues are further compounded by the multiple prescribers, necessary hand‐offs, and formulary differences in the inpatient setting.

Over half of the hospitalists in this survey reported hospitalist involvement in design and implementation of medication reconciliation. Given the familiarity with hospital systems and inpatient workflow, hospitalists are well‐positioned to contribute to successful implementation. Nonetheless, many were unaware of efforts to implement this NPSG.

Measurement of both process and outcome measures is important when determining value in quality improvement. Beyond process measures, outcome measures such as adverse drug events, readmission rates, mortality, patient satisfaction, and outpatient provider satisfaction may be appropriate in evaluating medication reconciliation strategies. Even measuring the accuracy of the process with respect to the admission orders written would be a valuable source of information for further improvement. Unfortunately, respondents indicated that evaluation was occurring infrequently. Potentially more problematic is the apparent lack of clarity regarding identification of healthcare provider responsibility for specific process steps. By far the least uniformity is in the acquisition and documentation of the preadmission medication list. There is variability in who is assigned to perform this task, but a substantial number of respondents indicated that their process involved a shared responsibility between physicians and nurses. It is unclear whether this phenomenon reflects the complexity of inpatient medication information management, or is simply an attempt to distribute the work among providers. Sharing the work between physicians and nurses may increase the overall likelihood for compliance and possibly improve the safety and accuracy of the process, especially if the physicians and nurses take the medication history in a redundant fashion and share their findings. Conversely, compliance may decrease if each provider merely expects the other to complete the process. Optimally, an interdisciplinary workflow for medication history taking would be in place, involving both physicians and nurses, with the availability of pharmacist consultation in complex cases. However, our survey data suggest this is infrequent; resident physicians appear to be the ones shouldering substantial responsibility for medication reconciliation in tertiary academic centers. Further research into the accuracy of medication reconciliation processes involving different strategies for medication information collection would be useful.

We documented several barriers to successful implementation of medication reconciliation. Physicians cited a lack of medication knowledge on the part of the patient and unavailable prior medication lists as substantial barriers to success. Many medication reconciliation processes are limited by issues of poor health literacy or inadequate patient knowledge about medications. This lack of medication knowledge is especially problematic for patients new to a healthcare system. It will be important to implement processes that not only reconcile medications accurately, but also make medication information available for future care episodes.

Time required to complete the process was also important. Certain elements of the medication reconciliation process are new work, and integrating the process into existing workflows is crucial. Given the significant time commitment required, the rare involvement of pharmacists at most institutions is striking. It appears that hospital pharmacists do not currently own any of the medication reconciliation process steps at most facilities, despite having formal training in medication history‐taking. In the 2006 ASHP national hospital pharmacy survey, one‐third of pharmacists stated that there were not enough pharmacy resources to meet medication reconciliation demands; only 19% of those surveyed stated pharmacists provided medication education at discharge to more than 25% of their patients.9

This report has several limitations. The survey used was not comprehensive, and only represents a convenience sample of hospitalists attending anational meeting. Nearly 300 physicians responded, representing both teaching and private hospital settings. We consider the response rate of 37% reasonable for a survey of this nature, and the variety of processes described is likely indicative of the overall status of medication reconciliation implementation. The over‐representation of certain institutions in our survey is possible, especially those with large or influential hospital medicine programs. Our survey did not ask respondents to name their home institutions. In addition, this design is open to a convenience sample bias, in that surveying only national meeting attendees (rather than the entire SHM membership) risks overinclusion of those hospitalists involved in leadership roles and quality improvement projects. Despite this, the variety of processes described is likely indicative of the overall status of medication reconciliation implementation in mid‐2006. It is possible that processes have become more uniform nationwide in the interim.

Our survey results reflect the complexity surrounding medication reconciliation. It appears that full implementation has not yet occurred everywhere, significant barriers remain, and outcome measurement is limited. Importantly, physicians, nurses, and pharmacists do not have standardized roles. Responsibility for medication reconciliation has predominantly been added to the existing duties of inpatient physicians and nurses, with limited involvement of pharmacists. Hospitalists are well‐positioned to lead the ongoing implementation of medication reconciliation processes and should take advantage of their systems knowledge to effectively partner with other physicians, nurses, and pharmacists to achieve success in medication reconciliation.

The Joint Commission's (TJC) National Patient Safety Goal (NPSG) #8Accurately and completely reconcile medications across the continuum of carechallenges hospitals to design and implement new medication management processes. With medication errors contributing to patient morbidity and mortality,1 establishing a comprehensive process for reconciling a patient's medications during the hospitalization episode is an important quality improvement and patient safety goal.

However, the current state of inpatient medication management is highly fragmented. Standard documentation is lacking, as is integration of information between care settings.2 There are now reports describing implementation of various medication reconciliation processes for admissions,3 transfers,4 and discharges.5

Hospitalists are well‐positioned to contribute to the implementation of medication reconciliation. Indeed, because TJC does not explicitly specify what type of health care provider (eg, physician, nurse, etc.) should assume responsibility for this process, institutions have designed workflows to suit their own needs, while striving to comply with national standards.

Given the complexity and lack of standardization around this NPSG, a survey was distributed to attendees of a Society of Hospital Medicine (SHM) national meeting to determine the various processes implemented thus far, and to ascertain existing challenges to implementation. We report here on the results.

METHODS

A survey tool (Appendix) was designed to query demographic and institutional factors, involvement in the process, and barriers to implementation of medication reconciliation. Surveys were included in all attendees' registration materials, resulting in the distributions of approximately 800 surveys.

Responses were entered into an Excel spreadsheet. Simple descriptive statistics were used to determine proportions for providers, processes, and barriers to implementation. Where appropriate, variables were dichotomized, allowing for paired t‐test analysis. Statistical significance was defined as a P value less than .05. Subgroup analyses by hospital type, provider type, and process method were performed.

RESULTS

A total of 295 completed surveys were collected. The responses are tabulated in Table 1.

DISCUSSION

Managing medication information for inpatients is an extremely complex task. On admission, home medication lists are often inaccurate or absent,6 requiring extra time and effort to discover this information. By discharge, medication regimens have frequently been altered,7 making communication of changes to the next provider essential. One study described myriad provider, patient, and health system issues in maintaining accurate outpatient medication lists.8 These issues are further compounded by the multiple prescribers, necessary hand‐offs, and formulary differences in the inpatient setting.

Over half of the hospitalists in this survey reported hospitalist involvement in design and implementation of medication reconciliation. Given the familiarity with hospital systems and inpatient workflow, hospitalists are well‐positioned to contribute to successful implementation. Nonetheless, many were unaware of efforts to implement this NPSG.

Measurement of both process and outcome measures is important when determining value in quality improvement. Beyond process measures, outcome measures such as adverse drug events, readmission rates, mortality, patient satisfaction, and outpatient provider satisfaction may be appropriate in evaluating medication reconciliation strategies. Even measuring the accuracy of the process with respect to the admission orders written would be a valuable source of information for further improvement. Unfortunately, respondents indicated that evaluation was occurring infrequently. Potentially more problematic is the apparent lack of clarity regarding identification of healthcare provider responsibility for specific process steps. By far the least uniformity is in the acquisition and documentation of the preadmission medication list. There is variability in who is assigned to perform this task, but a substantial number of respondents indicated that their process involved a shared responsibility between physicians and nurses. It is unclear whether this phenomenon reflects the complexity of inpatient medication information management, or is simply an attempt to distribute the work among providers. Sharing the work between physicians and nurses may increase the overall likelihood for compliance and possibly improve the safety and accuracy of the process, especially if the physicians and nurses take the medication history in a redundant fashion and share their findings. Conversely, compliance may decrease if each provider merely expects the other to complete the process. Optimally, an interdisciplinary workflow for medication history taking would be in place, involving both physicians and nurses, with the availability of pharmacist consultation in complex cases. However, our survey data suggest this is infrequent; resident physicians appear to be the ones shouldering substantial responsibility for medication reconciliation in tertiary academic centers. Further research into the accuracy of medication reconciliation processes involving different strategies for medication information collection would be useful.

We documented several barriers to successful implementation of medication reconciliation. Physicians cited a lack of medication knowledge on the part of the patient and unavailable prior medication lists as substantial barriers to success. Many medication reconciliation processes are limited by issues of poor health literacy or inadequate patient knowledge about medications. This lack of medication knowledge is especially problematic for patients new to a healthcare system. It will be important to implement processes that not only reconcile medications accurately, but also make medication information available for future care episodes.

Time required to complete the process was also important. Certain elements of the medication reconciliation process are new work, and integrating the process into existing workflows is crucial. Given the significant time commitment required, the rare involvement of pharmacists at most institutions is striking. It appears that hospital pharmacists do not currently own any of the medication reconciliation process steps at most facilities, despite having formal training in medication history‐taking. In the 2006 ASHP national hospital pharmacy survey, one‐third of pharmacists stated that there were not enough pharmacy resources to meet medication reconciliation demands; only 19% of those surveyed stated pharmacists provided medication education at discharge to more than 25% of their patients.9

This report has several limitations. The survey used was not comprehensive, and only represents a convenience sample of hospitalists attending anational meeting. Nearly 300 physicians responded, representing both teaching and private hospital settings. We consider the response rate of 37% reasonable for a survey of this nature, and the variety of processes described is likely indicative of the overall status of medication reconciliation implementation. The over‐representation of certain institutions in our survey is possible, especially those with large or influential hospital medicine programs. Our survey did not ask respondents to name their home institutions. In addition, this design is open to a convenience sample bias, in that surveying only national meeting attendees (rather than the entire SHM membership) risks overinclusion of those hospitalists involved in leadership roles and quality improvement projects. Despite this, the variety of processes described is likely indicative of the overall status of medication reconciliation implementation in mid‐2006. It is possible that processes have become more uniform nationwide in the interim.

Our survey results reflect the complexity surrounding medication reconciliation. It appears that full implementation has not yet occurred everywhere, significant barriers remain, and outcome measurement is limited. Importantly, physicians, nurses, and pharmacists do not have standardized roles. Responsibility for medication reconciliation has predominantly been added to the existing duties of inpatient physicians and nurses, with limited involvement of pharmacists. Hospitalists are well‐positioned to lead the ongoing implementation of medication reconciliation processes and should take advantage of their systems knowledge to effectively partner with other physicians, nurses, and pharmacists to achieve success in medication reconciliation.

The Joint Commission's (TJC) National Patient Safety Goal (NPSG) #8Accurately and completely reconcile medications across the continuum of carechallenges hospitals to design and implement new medication management processes. With medication errors contributing to patient morbidity and mortality,1 establishing a comprehensive process for reconciling a patient's medications during the hospitalization episode is an important quality improvement and patient safety goal.

However, the current state of inpatient medication management is highly fragmented. Standard documentation is lacking, as is integration of information between care settings.2 There are now reports describing implementation of various medication reconciliation processes for admissions,3 transfers,4 and discharges.5

Hospitalists are well‐positioned to contribute to the implementation of medication reconciliation. Indeed, because TJC does not explicitly specify what type of health care provider (eg, physician, nurse, etc.) should assume responsibility for this process, institutions have designed workflows to suit their own needs, while striving to comply with national standards.

Given the complexity and lack of standardization around this NPSG, a survey was distributed to attendees of a Society of Hospital Medicine (SHM) national meeting to determine the various processes implemented thus far, and to ascertain existing challenges to implementation. We report here on the results.

METHODS

A survey tool (Appendix) was designed to query demographic and institutional factors, involvement in the process, and barriers to implementation of medication reconciliation. Surveys were included in all attendees' registration materials, resulting in the distributions of approximately 800 surveys.

Responses were entered into an Excel spreadsheet. Simple descriptive statistics were used to determine proportions for providers, processes, and barriers to implementation. Where appropriate, variables were dichotomized, allowing for paired t‐test analysis. Statistical significance was defined as a P value less than .05. Subgroup analyses by hospital type, provider type, and process method were performed.

RESULTS

A total of 295 completed surveys were collected. The responses are tabulated in Table 1.

DISCUSSION

Managing medication information for inpatients is an extremely complex task. On admission, home medication lists are often inaccurate or absent,6 requiring extra time and effort to discover this information. By discharge, medication regimens have frequently been altered,7 making communication of changes to the next provider essential. One study described myriad provider, patient, and health system issues in maintaining accurate outpatient medication lists.8 These issues are further compounded by the multiple prescribers, necessary hand‐offs, and formulary differences in the inpatient setting.

Over half of the hospitalists in this survey reported hospitalist involvement in design and implementation of medication reconciliation. Given the familiarity with hospital systems and inpatient workflow, hospitalists are well‐positioned to contribute to successful implementation. Nonetheless, many were unaware of efforts to implement this NPSG.

Measurement of both process and outcome measures is important when determining value in quality improvement. Beyond process measures, outcome measures such as adverse drug events, readmission rates, mortality, patient satisfaction, and outpatient provider satisfaction may be appropriate in evaluating medication reconciliation strategies. Even measuring the accuracy of the process with respect to the admission orders written would be a valuable source of information for further improvement. Unfortunately, respondents indicated that evaluation was occurring infrequently. Potentially more problematic is the apparent lack of clarity regarding identification of healthcare provider responsibility for specific process steps. By far the least uniformity is in the acquisition and documentation of the preadmission medication list. There is variability in who is assigned to perform this task, but a substantial number of respondents indicated that their process involved a shared responsibility between physicians and nurses. It is unclear whether this phenomenon reflects the complexity of inpatient medication information management, or is simply an attempt to distribute the work among providers. Sharing the work between physicians and nurses may increase the overall likelihood for compliance and possibly improve the safety and accuracy of the process, especially if the physicians and nurses take the medication history in a redundant fashion and share their findings. Conversely, compliance may decrease if each provider merely expects the other to complete the process. Optimally, an interdisciplinary workflow for medication history taking would be in place, involving both physicians and nurses, with the availability of pharmacist consultation in complex cases. However, our survey data suggest this is infrequent; resident physicians appear to be the ones shouldering substantial responsibility for medication reconciliation in tertiary academic centers. Further research into the accuracy of medication reconciliation processes involving different strategies for medication information collection would be useful.

We documented several barriers to successful implementation of medication reconciliation. Physicians cited a lack of medication knowledge on the part of the patient and unavailable prior medication lists as substantial barriers to success. Many medication reconciliation processes are limited by issues of poor health literacy or inadequate patient knowledge about medications. This lack of medication knowledge is especially problematic for patients new to a healthcare system. It will be important to implement processes that not only reconcile medications accurately, but also make medication information available for future care episodes.

Time required to complete the process was also important. Certain elements of the medication reconciliation process are new work, and integrating the process into existing workflows is crucial. Given the significant time commitment required, the rare involvement of pharmacists at most institutions is striking. It appears that hospital pharmacists do not currently own any of the medication reconciliation process steps at most facilities, despite having formal training in medication history‐taking. In the 2006 ASHP national hospital pharmacy survey, one‐third of pharmacists stated that there were not enough pharmacy resources to meet medication reconciliation demands; only 19% of those surveyed stated pharmacists provided medication education at discharge to more than 25% of their patients.9

This report has several limitations. The survey used was not comprehensive, and only represents a convenience sample of hospitalists attending anational meeting. Nearly 300 physicians responded, representing both teaching and private hospital settings. We consider the response rate of 37% reasonable for a survey of this nature, and the variety of processes described is likely indicative of the overall status of medication reconciliation implementation. The over‐representation of certain institutions in our survey is possible, especially those with large or influential hospital medicine programs. Our survey did not ask respondents to name their home institutions. In addition, this design is open to a convenience sample bias, in that surveying only national meeting attendees (rather than the entire SHM membership) risks overinclusion of those hospitalists involved in leadership roles and quality improvement projects. Despite this, the variety of processes described is likely indicative of the overall status of medication reconciliation implementation in mid‐2006. It is possible that processes have become more uniform nationwide in the interim.

Our survey results reflect the complexity surrounding medication reconciliation. It appears that full implementation has not yet occurred everywhere, significant barriers remain, and outcome measurement is limited. Importantly, physicians, nurses, and pharmacists do not have standardized roles. Responsibility for medication reconciliation has predominantly been added to the existing duties of inpatient physicians and nurses, with limited involvement of pharmacists. Hospitalists are well‐positioned to lead the ongoing implementation of medication reconciliation processes and should take advantage of their systems knowledge to effectively partner with other physicians, nurses, and pharmacists to achieve success in medication reconciliation.

Smoking represents the single most important cause of premature death and potentially lost years of life in the developing countries. Cigarette smoking causes more than 350,000 deaths each year in the United States and more than 4.9 million premature deaths worldwide.1 Death as a consequence of smoking is by no means limited to the elderly. Tobacco is the largest single cause of premature death and accounts for 3 of 10 of all deaths that occur among smokers and nonsmokers between the ages 35 and 69.2 Because most health professionals deal with different smoking‐related health problems, they make up the sector with the greatest potential to influence reducing smoking among their patients if they can show a positive attitude toward smoking‐cessation intervention.3 Tobacco smoking by health care workers has a negative influence on the general population.3, 4 The World Health Organization (WHO) has advocated that physicians should not smoke cigarettes, and surveys on this issue should be conducted among medical professionals.35 In Jordan, the prevalence of smoking is high and is increasing among women, but there are no data about the prevalence of smoking among physicians and other health care workers (HCWs).5 As members of an antismoking committee working at King Hussein Medical Center (KHMC) we realized that before applying any tobacco control strategy, it was important to understand the prevalence of smoking among HCWs at our center. To our knowledge, no representative survey of smoking among physicians in Jordan has been reported.

This study describes the prevalence of cigarettes smoking among HCWs in the largest tertiary‐care hospital in Jordan.

METHODS

The study was approved by the local ethics committee at KHMC and was conducted between June 1999 and September 1999. The study involved 600 representative samples of HCWs at KHMC. Subjects were divided into 3 groups according to their professions (physicians, nurses, and other professions). Each subject was interviewed personally. Questions were designed to obtain various demographic data and cigarette smoking characteristics. All other forms of tobacco consumption were not included into the questionnaire. Questions addressed various factors such as the age at which smoking was started and its duration and the number of cigarettes smoked per day. We defined smoking status as current smoker, occasional smoker, past smoker, or never smoker, according to WHO's 1995 definitions.4 Current smokers were those who had smoked at least 100 cigarettes and who were currently smoking on a daily basis. Occasional smokers were those who did not smoke daily. Past (ex‐)smokers were those nonsmokers who previously smoked every day for 6 months or more. The rate of cigarette smoking was calculated for each age group and for different medical specialties. Statistical analysis was performed with Statistical Package for Social Sciences 10.0 software (SPSS Inc., Chicago, IL). The ² test was used to determine statistical significance. The 2‐tailed significance level was set at 5% (P 0.05).

RESULTS

Among the 600 respondents, there were 310 women (52%) and 290 men (48%), of whom 260 (43%) were physicians, 250 (42%) were nurses, and 90 (15%) were other HCWs. The total prevalence of smoking was 65%, ranging from 10% in the dermatologist group to 75% in the family practitioner group. We learned that 52% of smokers started before age 21 and that 78% started their habit during the first 2 years of college. The most common motive for starting smoking was pleasure encouraged by peer influence. Eighty‐two percent of male HCWs smoked cigarettes compared with 47% of female HCWs. The prevalence of current smokers was 77% and 33% in men and women, respectively (P = .002). Forty‐three percent of women did not smoke cigarettes, whereas only 14% of men did not smoke (P = .002; Table 1). Smoking prevalence did not significantly differ between age groups (P = .38; Table 2). The highest rate of smoking was among current smokers age 3140 years (58%). Of the 260 physicians, 46% were smokers, (currently or occasionally), 29% were ex‐smokers, and 25% were nonsmokers. Sixty‐seven percent of physicians who were smokers smoked 1120 cigarettes/day. There were fewer current smokers among physicians than among other HCWs (46% versus 74%, respectively). The highest percentage of smokers in the physician group was observed among family practitioners working in the emergency room (75%). On the other hand, dermatologists had the lowest percentage (10%). Women in general had a lower prevalence than men in all categories. Of the female nurses, 17% were smokers, 13% were ex‐smokers, and 70% were nonsmokers. The smoking rate of female nurses fell below their male counterparts (17% and 49%, respectively; P = .002). Seventy‐eight percent of the nonsmoking physicians reported that they do ask their patients routinely about their smoking history and encourage them to discontinue this habit. Only 36% of the physicians who smoked provide such advice during their clinical practice.

DISCUSSION

Tobacco use, notably cigarette smoking, is the leading cause of an array of preventable diseases.12 It is estimated that approximately 30%40% of the adult population worldwide smokes. The situation is particularly alarming in adolescents.5, 6 The prevalence of smoking in developing countries now equals or exceeds the high smoking levels common in the United Kingdom 20 or 30 years ago.6 There is a significant difference in smoking prevalence between socioeconomic groups in the Western world. For professional people the prevalence is now 16%, whereas for unskilled manual workers the prevalence is 48%.7 HCWs are important opinion leaders in the community, and their behavior more than their words has a significant impact on the lifestyle of their patients.3, 89 It is therefore discouraging to learn that so many doctors and nurses still smoke. The smoking habits of health staff members may influence their attitudes toward patients.810 Numerous international studies have addressed the issue of smoking among physicians and other HCWs.816 In a study conducted by Ohida et al.,8 the prevalence of smoking among Japanese physicians was 27.1% for men and 6.8% for women, about half the general population in Japan (male, 54.0%; female, 14.5%). The prevalence of smoking varied in other industrialized countries: in the United States, the prevalence was 3% of men and 10% of women9; in the United Kingdom, it was 4% of men and 5% of women10; in France, 33% of men and 24% of women;11 and in the Netherlands, 41% of men and 24% of women12 Approximately 40% of Italian general practitioners and approximately 45% of their Spanish colleagues also smoke.13 There are limited published data addressing the issue of cigarette smoking among physicians and other HCWs in various Arab countries. Our results showed a higher rate of cigarette smoking among Jordanian physicians compared with that in the surrounding Arab countries.1416 Physicians at KHMC have a very high prevalence of cigarette smokingfar above the results reported in the above‐noted countries. It is comparable with that of unskilled manual workers in the Western world.2, 5 It has been reported that the highest smoking prevalence among young women in the East Mediterranean region occurs in Jordan.17 Our study showed that the smoking rate among women at KHMC, especially among nursing staff, is much lower than that of men, but this might change in the coming years if antismoking measures are not applied and directed toward younger generations. Smoking practice widely varies among the nonmedical KHMC staff and is reaching a very dangerous and worrisome level. This study was the first to be conducted to calculate the prevalence of smoking among HCWs at the largest tertiary‐care hospital in Jordan. A limitation of our study was that the number of responders included in this study might not fully represent the smoking status among HCWs in the country. However, the results raise some important issues to be discussed and analyzed further on a national level concerning this growing health problem. Physicians play an important role in accelerating the process of smoking cessation. Physicians should play an active role in the control of smoking by participating in public debate regarding smoking, both individually and through medical organizations. Nonsmoking physicians at KHMC were more active in asking patients about smoking habits than were those who smoked. The physician smokers were less critical of smoking than were the physician nonsmokers. Jordanian physicians do not fully comply with the rules against tobacco smoking in hospital. Smoking doctors frequently smoke in the hospital and do not counsel patients about smoking.10, 11, 13 Special effort is needed in the educational field concerning the issue of tobacco smoking for Jordanian physicians, and a strong initiative toward smoke‐free hospitals would help spread the message. To promote antismoking measures among doctors and nurses, it will be necessary to scrutinize the smoking habits and behavior of medical and nursing students18 and to conduct effective antismoking and health education activities before they acquire the smoking habit.

Smoking represents the single most important cause of premature death and potentially lost years of life in the developing countries. Cigarette smoking causes more than 350,000 deaths each year in the United States and more than 4.9 million premature deaths worldwide.1 Death as a consequence of smoking is by no means limited to the elderly. Tobacco is the largest single cause of premature death and accounts for 3 of 10 of all deaths that occur among smokers and nonsmokers between the ages 35 and 69.2 Because most health professionals deal with different smoking‐related health problems, they make up the sector with the greatest potential to influence reducing smoking among their patients if they can show a positive attitude toward smoking‐cessation intervention.3 Tobacco smoking by health care workers has a negative influence on the general population.3, 4 The World Health Organization (WHO) has advocated that physicians should not smoke cigarettes, and surveys on this issue should be conducted among medical professionals.35 In Jordan, the prevalence of smoking is high and is increasing among women, but there are no data about the prevalence of smoking among physicians and other health care workers (HCWs).5 As members of an antismoking committee working at King Hussein Medical Center (KHMC) we realized that before applying any tobacco control strategy, it was important to understand the prevalence of smoking among HCWs at our center. To our knowledge, no representative survey of smoking among physicians in Jordan has been reported.

This study describes the prevalence of cigarettes smoking among HCWs in the largest tertiary‐care hospital in Jordan.

METHODS

The study was approved by the local ethics committee at KHMC and was conducted between June 1999 and September 1999. The study involved 600 representative samples of HCWs at KHMC. Subjects were divided into 3 groups according to their professions (physicians, nurses, and other professions). Each subject was interviewed personally. Questions were designed to obtain various demographic data and cigarette smoking characteristics. All other forms of tobacco consumption were not included into the questionnaire. Questions addressed various factors such as the age at which smoking was started and its duration and the number of cigarettes smoked per day. We defined smoking status as current smoker, occasional smoker, past smoker, or never smoker, according to WHO's 1995 definitions.4 Current smokers were those who had smoked at least 100 cigarettes and who were currently smoking on a daily basis. Occasional smokers were those who did not smoke daily. Past (ex‐)smokers were those nonsmokers who previously smoked every day for 6 months or more. The rate of cigarette smoking was calculated for each age group and for different medical specialties. Statistical analysis was performed with Statistical Package for Social Sciences 10.0 software (SPSS Inc., Chicago, IL). The ² test was used to determine statistical significance. The 2‐tailed significance level was set at 5% (P 0.05).

RESULTS

Among the 600 respondents, there were 310 women (52%) and 290 men (48%), of whom 260 (43%) were physicians, 250 (42%) were nurses, and 90 (15%) were other HCWs. The total prevalence of smoking was 65%, ranging from 10% in the dermatologist group to 75% in the family practitioner group. We learned that 52% of smokers started before age 21 and that 78% started their habit during the first 2 years of college. The most common motive for starting smoking was pleasure encouraged by peer influence. Eighty‐two percent of male HCWs smoked cigarettes compared with 47% of female HCWs. The prevalence of current smokers was 77% and 33% in men and women, respectively (P = .002). Forty‐three percent of women did not smoke cigarettes, whereas only 14% of men did not smoke (P = .002; Table 1). Smoking prevalence did not significantly differ between age groups (P = .38; Table 2). The highest rate of smoking was among current smokers age 3140 years (58%). Of the 260 physicians, 46% were smokers, (currently or occasionally), 29% were ex‐smokers, and 25% were nonsmokers. Sixty‐seven percent of physicians who were smokers smoked 1120 cigarettes/day. There were fewer current smokers among physicians than among other HCWs (46% versus 74%, respectively). The highest percentage of smokers in the physician group was observed among family practitioners working in the emergency room (75%). On the other hand, dermatologists had the lowest percentage (10%). Women in general had a lower prevalence than men in all categories. Of the female nurses, 17% were smokers, 13% were ex‐smokers, and 70% were nonsmokers. The smoking rate of female nurses fell below their male counterparts (17% and 49%, respectively; P = .002). Seventy‐eight percent of the nonsmoking physicians reported that they do ask their patients routinely about their smoking history and encourage them to discontinue this habit. Only 36% of the physicians who smoked provide such advice during their clinical practice.

DISCUSSION

Tobacco use, notably cigarette smoking, is the leading cause of an array of preventable diseases.12 It is estimated that approximately 30%40% of the adult population worldwide smokes. The situation is particularly alarming in adolescents.5, 6 The prevalence of smoking in developing countries now equals or exceeds the high smoking levels common in the United Kingdom 20 or 30 years ago.6 There is a significant difference in smoking prevalence between socioeconomic groups in the Western world. For professional people the prevalence is now 16%, whereas for unskilled manual workers the prevalence is 48%.7 HCWs are important opinion leaders in the community, and their behavior more than their words has a significant impact on the lifestyle of their patients.3, 89 It is therefore discouraging to learn that so many doctors and nurses still smoke. The smoking habits of health staff members may influence their attitudes toward patients.810 Numerous international studies have addressed the issue of smoking among physicians and other HCWs.816 In a study conducted by Ohida et al.,8 the prevalence of smoking among Japanese physicians was 27.1% for men and 6.8% for women, about half the general population in Japan (male, 54.0%; female, 14.5%). The prevalence of smoking varied in other industrialized countries: in the United States, the prevalence was 3% of men and 10% of women9; in the United Kingdom, it was 4% of men and 5% of women10; in France, 33% of men and 24% of women;11 and in the Netherlands, 41% of men and 24% of women12 Approximately 40% of Italian general practitioners and approximately 45% of their Spanish colleagues also smoke.13 There are limited published data addressing the issue of cigarette smoking among physicians and other HCWs in various Arab countries. Our results showed a higher rate of cigarette smoking among Jordanian physicians compared with that in the surrounding Arab countries.1416 Physicians at KHMC have a very high prevalence of cigarette smokingfar above the results reported in the above‐noted countries. It is comparable with that of unskilled manual workers in the Western world.2, 5 It has been reported that the highest smoking prevalence among young women in the East Mediterranean region occurs in Jordan.17 Our study showed that the smoking rate among women at KHMC, especially among nursing staff, is much lower than that of men, but this might change in the coming years if antismoking measures are not applied and directed toward younger generations. Smoking practice widely varies among the nonmedical KHMC staff and is reaching a very dangerous and worrisome level. This study was the first to be conducted to calculate the prevalence of smoking among HCWs at the largest tertiary‐care hospital in Jordan. A limitation of our study was that the number of responders included in this study might not fully represent the smoking status among HCWs in the country. However, the results raise some important issues to be discussed and analyzed further on a national level concerning this growing health problem. Physicians play an important role in accelerating the process of smoking cessation. Physicians should play an active role in the control of smoking by participating in public debate regarding smoking, both individually and through medical organizations. Nonsmoking physicians at KHMC were more active in asking patients about smoking habits than were those who smoked. The physician smokers were less critical of smoking than were the physician nonsmokers. Jordanian physicians do not fully comply with the rules against tobacco smoking in hospital. Smoking doctors frequently smoke in the hospital and do not counsel patients about smoking.10, 11, 13 Special effort is needed in the educational field concerning the issue of tobacco smoking for Jordanian physicians, and a strong initiative toward smoke‐free hospitals would help spread the message. To promote antismoking measures among doctors and nurses, it will be necessary to scrutinize the smoking habits and behavior of medical and nursing students18 and to conduct effective antismoking and health education activities before they acquire the smoking habit.

Smoking represents the single most important cause of premature death and potentially lost years of life in the developing countries. Cigarette smoking causes more than 350,000 deaths each year in the United States and more than 4.9 million premature deaths worldwide.1 Death as a consequence of smoking is by no means limited to the elderly. Tobacco is the largest single cause of premature death and accounts for 3 of 10 of all deaths that occur among smokers and nonsmokers between the ages 35 and 69.2 Because most health professionals deal with different smoking‐related health problems, they make up the sector with the greatest potential to influence reducing smoking among their patients if they can show a positive attitude toward smoking‐cessation intervention.3 Tobacco smoking by health care workers has a negative influence on the general population.3, 4 The World Health Organization (WHO) has advocated that physicians should not smoke cigarettes, and surveys on this issue should be conducted among medical professionals.35 In Jordan, the prevalence of smoking is high and is increasing among women, but there are no data about the prevalence of smoking among physicians and other health care workers (HCWs).5 As members of an antismoking committee working at King Hussein Medical Center (KHMC) we realized that before applying any tobacco control strategy, it was important to understand the prevalence of smoking among HCWs at our center. To our knowledge, no representative survey of smoking among physicians in Jordan has been reported.

This study describes the prevalence of cigarettes smoking among HCWs in the largest tertiary‐care hospital in Jordan.

METHODS

The study was approved by the local ethics committee at KHMC and was conducted between June 1999 and September 1999. The study involved 600 representative samples of HCWs at KHMC. Subjects were divided into 3 groups according to their professions (physicians, nurses, and other professions). Each subject was interviewed personally. Questions were designed to obtain various demographic data and cigarette smoking characteristics. All other forms of tobacco consumption were not included into the questionnaire. Questions addressed various factors such as the age at which smoking was started and its duration and the number of cigarettes smoked per day. We defined smoking status as current smoker, occasional smoker, past smoker, or never smoker, according to WHO's 1995 definitions.4 Current smokers were those who had smoked at least 100 cigarettes and who were currently smoking on a daily basis. Occasional smokers were those who did not smoke daily. Past (ex‐)smokers were those nonsmokers who previously smoked every day for 6 months or more. The rate of cigarette smoking was calculated for each age group and for different medical specialties. Statistical analysis was performed with Statistical Package for Social Sciences 10.0 software (SPSS Inc., Chicago, IL). The ² test was used to determine statistical significance. The 2‐tailed significance level was set at 5% (P 0.05).

RESULTS

Among the 600 respondents, there were 310 women (52%) and 290 men (48%), of whom 260 (43%) were physicians, 250 (42%) were nurses, and 90 (15%) were other HCWs. The total prevalence of smoking was 65%, ranging from 10% in the dermatologist group to 75% in the family practitioner group. We learned that 52% of smokers started before age 21 and that 78% started their habit during the first 2 years of college. The most common motive for starting smoking was pleasure encouraged by peer influence. Eighty‐two percent of male HCWs smoked cigarettes compared with 47% of female HCWs. The prevalence of current smokers was 77% and 33% in men and women, respectively (P = .002). Forty‐three percent of women did not smoke cigarettes, whereas only 14% of men did not smoke (P = .002; Table 1). Smoking prevalence did not significantly differ between age groups (P = .38; Table 2). The highest rate of smoking was among current smokers age 3140 years (58%). Of the 260 physicians, 46% were smokers, (currently or occasionally), 29% were ex‐smokers, and 25% were nonsmokers. Sixty‐seven percent of physicians who were smokers smoked 1120 cigarettes/day. There were fewer current smokers among physicians than among other HCWs (46% versus 74%, respectively). The highest percentage of smokers in the physician group was observed among family practitioners working in the emergency room (75%). On the other hand, dermatologists had the lowest percentage (10%). Women in general had a lower prevalence than men in all categories. Of the female nurses, 17% were smokers, 13% were ex‐smokers, and 70% were nonsmokers. The smoking rate of female nurses fell below their male counterparts (17% and 49%, respectively; P = .002). Seventy‐eight percent of the nonsmoking physicians reported that they do ask their patients routinely about their smoking history and encourage them to discontinue this habit. Only 36% of the physicians who smoked provide such advice during their clinical practice.

DISCUSSION

Tobacco use, notably cigarette smoking, is the leading cause of an array of preventable diseases.12 It is estimated that approximately 30%40% of the adult population worldwide smokes. The situation is particularly alarming in adolescents.5, 6 The prevalence of smoking in developing countries now equals or exceeds the high smoking levels common in the United Kingdom 20 or 30 years ago.6 There is a significant difference in smoking prevalence between socioeconomic groups in the Western world. For professional people the prevalence is now 16%, whereas for unskilled manual workers the prevalence is 48%.7 HCWs are important opinion leaders in the community, and their behavior more than their words has a significant impact on the lifestyle of their patients.3, 89 It is therefore discouraging to learn that so many doctors and nurses still smoke. The smoking habits of health staff members may influence their attitudes toward patients.810 Numerous international studies have addressed the issue of smoking among physicians and other HCWs.816 In a study conducted by Ohida et al.,8 the prevalence of smoking among Japanese physicians was 27.1% for men and 6.8% for women, about half the general population in Japan (male, 54.0%; female, 14.5%). The prevalence of smoking varied in other industrialized countries: in the United States, the prevalence was 3% of men and 10% of women9; in the United Kingdom, it was 4% of men and 5% of women10; in France, 33% of men and 24% of women;11 and in the Netherlands, 41% of men and 24% of women12 Approximately 40% of Italian general practitioners and approximately 45% of their Spanish colleagues also smoke.13 There are limited published data addressing the issue of cigarette smoking among physicians and other HCWs in various Arab countries. Our results showed a higher rate of cigarette smoking among Jordanian physicians compared with that in the surrounding Arab countries.1416 Physicians at KHMC have a very high prevalence of cigarette smokingfar above the results reported in the above‐noted countries. It is comparable with that of unskilled manual workers in the Western world.2, 5 It has been reported that the highest smoking prevalence among young women in the East Mediterranean region occurs in Jordan.17 Our study showed that the smoking rate among women at KHMC, especially among nursing staff, is much lower than that of men, but this might change in the coming years if antismoking measures are not applied and directed toward younger generations. Smoking practice widely varies among the nonmedical KHMC staff and is reaching a very dangerous and worrisome level. This study was the first to be conducted to calculate the prevalence of smoking among HCWs at the largest tertiary‐care hospital in Jordan. A limitation of our study was that the number of responders included in this study might not fully represent the smoking status among HCWs in the country. However, the results raise some important issues to be discussed and analyzed further on a national level concerning this growing health problem. Physicians play an important role in accelerating the process of smoking cessation. Physicians should play an active role in the control of smoking by participating in public debate regarding smoking, both individually and through medical organizations. Nonsmoking physicians at KHMC were more active in asking patients about smoking habits than were those who smoked. The physician smokers were less critical of smoking than were the physician nonsmokers. Jordanian physicians do not fully comply with the rules against tobacco smoking in hospital. Smoking doctors frequently smoke in the hospital and do not counsel patients about smoking.10, 11, 13 Special effort is needed in the educational field concerning the issue of tobacco smoking for Jordanian physicians, and a strong initiative toward smoke‐free hospitals would help spread the message. To promote antismoking measures among doctors and nurses, it will be necessary to scrutinize the smoking habits and behavior of medical and nursing students18 and to conduct effective antismoking and health education activities before they acquire the smoking habit.

Clostridium difficileassociated disease (CDAD) is a well‐known complication of hospitalization and is the most frequently identified cause of nosocomial diarrhea that hospitalists encounter. Despite widespread epidemiologic attempts to control the disease, its prevalence and clinical severity appear to be increasing.1 The resulting social and economic consequences are profound. The estimated 3 million inpatient cases of CDAD a year result in an average increase in the length of stay of 3.6 days at a cost in inpatient health care of more than $1 billion.2

Early diagnosis of index cases is crucial. A diagnostic delay can result in a treatment delay for the index case, as well as in a delay in implementing isolation procedures to prevent horizontal transmission. Acquisition of CDAD is time dependent and occurs in 20% to 30% of hospitalized patients at a rate of approximately 8% per week.3, 4 This transmission is primarily a result of environmental contamination with CDAD spores, found on 59% of the hands of hospital personnel caring for infected patients, in 49% of rooms of symptomatic patients, and in 29% of rooms of asymptomatic carriers.5 Despite the need for early diagnosis, a study from the United Kingdom documented that the average time from the onset of diarrhea to sampling of CDAD patients is 4.7 days.6 An additional challenge for early diagnosis is the delay in microbiological confirmation of CDAD in a suspected patient. Cytotoxic assays, which have become the standard diagnostic technique for CDAD, exhibit excellent sensitivity and specificity but have a lengthy processing time, between 2 and 4 days. Although antigen detection assays can be rapidly performed, many have inadequate sensitivity and specificity.7

These issues of diagnostic and treatment delays are compounded in patients with recurrent CDAD. As many as 15%35% of patients with an initial CDAD infection will experience a recurrence, usually within 2 months. At least half these infections are a result of reinfection, not relapse.8 This implies that early detection and strict isolation of infected patients is essential for reducing the exposure of at‐risk patients to the disease. There is evidence that the burden of patients on the same ward simultaneously having CDAD increases a patient's risk of acquiring the disease.9 It is currently unknown if recurrent CDAD cases are diagnosed or treated earlier than initial cases. If not, this is a potentially important patient population for hospitalists to target for aggressive containment strategies. This study sought to determine the mean time to sampling and treatment in patients with recurrent CDAD infection compared with those in patients who are initially infected.

Design

The study cohort consisted of all adult patients more than 18 years old with CDAD (by ICD9 code) who had been hospitalized at Brigham and Women's Hospital between 1997 and 2004. Retrospectively, patients were identified through the Partners Healthcare Research Patient Data Repository (RPDR). The RPDR is a centralized clinical data registry that gathers data from various hospital legacy systems and was used to determine the patient demographics and first date of treatment (with vancomycin or metronidazole). Medical and microbiologic records were reviewed to determine the dates of cytotoxic assay submission and symptom onset. Symptoms were defined as diarrhea, abdominal pain/cramping, or radiological/colonoscopic evidence of colitis. Recurrence was defined as any repeat inpatient CDAD diagnosis within 2 months (regardless of admission diagnosis). Baseline characteristics in the recurrence and no‐recurrence populations were compared by the 2‐sided Student t test or the chi‐square test (for continuous and categorical variables, respectively). Mean time from symptom to sampling, from symptom to treatment, and from sampling to treatment were compared between initial and recurrent disease episodes by the 2‐sided Student t test. All P values .05 were considered significant. Institutional review board approval was obtained by Partners Healthcare.

RESULTS

Between 1997 and 2004 there were 1309 patients with an ICD9 code for CDAD, 151 of whom (12%) had a recurrence. Of these, 125 had 1 recurrence, 23 had 2 recurrences, and 3 had 3 recurrences. There were no significant differences between the groups in basic demographics (Table 1). The mean time to sampling was not significantly different between initial and recurrent CDAD hospital episodes (Table 2). However, the mean time to treatment (from symptoms and sampling) was shorter in recurrent episodes (Table 2). From 1997 to 2004 there was no significant reduction in time to sampling, but there was a significant reduction in time to treatment, from 3.89 days (19972000) to 2.30 days (2001 2004), P = .0012.

DISCUSSION

Clostridium difficileassociated disease (CDAD) has become a significant nosocomial infection in medical institutions, and recurrent CDAD is emerging as a disease of concern for hospitalists. Diagnostic delays represent a major epidemiologic problem, resulting in both delay of treatment delay of the index case and delay in implementing isolation procedures to prevent horizontal transmission. In this study, patients with recurrent disease did not have stool collected any earlier than did patients with their initial episode of CDAD, and these diagnostic delays did not change in successive eras. Recurrent disease patients did receive treatment earlier than did patients with initial episodes. Although this empiric treatment strategy is encouraging and likely reflects heightened awareness of the disease over time, the 2.5‐day span from symptoms to treatment is still a clinically significant delay. Also of concern is the range of time from symptoms to treatment, as long as 19 days in the recurrent treatment group. Although most patients were treated within 12 days, this variability represents the burden of infectious patients with the potential for infecting others. Targeting recurrent CDAD populations for early diagnosis, treatment, and isolation would almost certainly reduce the morbidity associated with horizontal transmission rates.9

This study had several limitations. Our data found a lower incidence of recurrent CDAD than previously published in the literature. This can be accounted for by the identification of cases by ICD9 code, which previously has been documented to underestimate true disease.10, 11 We also were not able to capture recurrent episodes in outpatients or episodes that occurred after the 2004 cohort, which underestimated the true frequency of recurrence. At worst, this underestimation could bias the results toward the null hypothesis. An additional limitation of the study was the assumption that time to treatment was accurately reflected by time to prescription of either vancomycin or flagyl. Some patients may have been treated by suspending treatment with the offending antibiotic along with watchful waiting, which is a reasonable strategy for patients with mild disease and is endorsed by the American College of Gastroenterology and the Society for Healthcare Epidemiology of America.12, 13 This would overestimate time to treatment for those individuals and would make time to treatment appear longer, but would not affect time to sampling. In addition, the symptoms collected from chart review were assumed to be a result of the patient's CDAD, but there is a chance that these symptoms such as diarrhea, abdominal pain, and cramping may have been a result of a different diagnosis. These data were also limited to a cohort from a single institution and may not reflect the patient characteristics or practice patterns at other institutions.

In conclusion, CDAD is a major contributor to morbidity from nosocomial infections, and recurrent CDAD patients are a likely source of horizontal disease transmission. This study documented that there are significant diagnostic and treatment delays, even in populations with recurrent disease. It is especially important that hospitalists take measures to improve the early diagnosis, treatment, and isolation of these patients in order to improve these deficiencies in care.

Clostridium difficileassociated disease (CDAD) is a well‐known complication of hospitalization and is the most frequently identified cause of nosocomial diarrhea that hospitalists encounter. Despite widespread epidemiologic attempts to control the disease, its prevalence and clinical severity appear to be increasing.1 The resulting social and economic consequences are profound. The estimated 3 million inpatient cases of CDAD a year result in an average increase in the length of stay of 3.6 days at a cost in inpatient health care of more than $1 billion.2

Early diagnosis of index cases is crucial. A diagnostic delay can result in a treatment delay for the index case, as well as in a delay in implementing isolation procedures to prevent horizontal transmission. Acquisition of CDAD is time dependent and occurs in 20% to 30% of hospitalized patients at a rate of approximately 8% per week.3, 4 This transmission is primarily a result of environmental contamination with CDAD spores, found on 59% of the hands of hospital personnel caring for infected patients, in 49% of rooms of symptomatic patients, and in 29% of rooms of asymptomatic carriers.5 Despite the need for early diagnosis, a study from the United Kingdom documented that the average time from the onset of diarrhea to sampling of CDAD patients is 4.7 days.6 An additional challenge for early diagnosis is the delay in microbiological confirmation of CDAD in a suspected patient. Cytotoxic assays, which have become the standard diagnostic technique for CDAD, exhibit excellent sensitivity and specificity but have a lengthy processing time, between 2 and 4 days. Although antigen detection assays can be rapidly performed, many have inadequate sensitivity and specificity.7

These issues of diagnostic and treatment delays are compounded in patients with recurrent CDAD. As many as 15%35% of patients with an initial CDAD infection will experience a recurrence, usually within 2 months. At least half these infections are a result of reinfection, not relapse.8 This implies that early detection and strict isolation of infected patients is essential for reducing the exposure of at‐risk patients to the disease. There is evidence that the burden of patients on the same ward simultaneously having CDAD increases a patient's risk of acquiring the disease.9 It is currently unknown if recurrent CDAD cases are diagnosed or treated earlier than initial cases. If not, this is a potentially important patient population for hospitalists to target for aggressive containment strategies. This study sought to determine the mean time to sampling and treatment in patients with recurrent CDAD infection compared with those in patients who are initially infected.

Design

The study cohort consisted of all adult patients more than 18 years old with CDAD (by ICD9 code) who had been hospitalized at Brigham and Women's Hospital between 1997 and 2004. Retrospectively, patients were identified through the Partners Healthcare Research Patient Data Repository (RPDR). The RPDR is a centralized clinical data registry that gathers data from various hospital legacy systems and was used to determine the patient demographics and first date of treatment (with vancomycin or metronidazole). Medical and microbiologic records were reviewed to determine the dates of cytotoxic assay submission and symptom onset. Symptoms were defined as diarrhea, abdominal pain/cramping, or radiological/colonoscopic evidence of colitis. Recurrence was defined as any repeat inpatient CDAD diagnosis within 2 months (regardless of admission diagnosis). Baseline characteristics in the recurrence and no‐recurrence populations were compared by the 2‐sided Student t test or the chi‐square test (for continuous and categorical variables, respectively). Mean time from symptom to sampling, from symptom to treatment, and from sampling to treatment were compared between initial and recurrent disease episodes by the 2‐sided Student t test. All P values .05 were considered significant. Institutional review board approval was obtained by Partners Healthcare.

RESULTS

Between 1997 and 2004 there were 1309 patients with an ICD9 code for CDAD, 151 of whom (12%) had a recurrence. Of these, 125 had 1 recurrence, 23 had 2 recurrences, and 3 had 3 recurrences. There were no significant differences between the groups in basic demographics (Table 1). The mean time to sampling was not significantly different between initial and recurrent CDAD hospital episodes (Table 2). However, the mean time to treatment (from symptoms and sampling) was shorter in recurrent episodes (Table 2). From 1997 to 2004 there was no significant reduction in time to sampling, but there was a significant reduction in time to treatment, from 3.89 days (19972000) to 2.30 days (2001 2004), P = .0012.

DISCUSSION

Clostridium difficileassociated disease (CDAD) has become a significant nosocomial infection in medical institutions, and recurrent CDAD is emerging as a disease of concern for hospitalists. Diagnostic delays represent a major epidemiologic problem, resulting in both delay of treatment delay of the index case and delay in implementing isolation procedures to prevent horizontal transmission. In this study, patients with recurrent disease did not have stool collected any earlier than did patients with their initial episode of CDAD, and these diagnostic delays did not change in successive eras. Recurrent disease patients did receive treatment earlier than did patients with initial episodes. Although this empiric treatment strategy is encouraging and likely reflects heightened awareness of the disease over time, the 2.5‐day span from symptoms to treatment is still a clinically significant delay. Also of concern is the range of time from symptoms to treatment, as long as 19 days in the recurrent treatment group. Although most patients were treated within 12 days, this variability represents the burden of infectious patients with the potential for infecting others. Targeting recurrent CDAD populations for early diagnosis, treatment, and isolation would almost certainly reduce the morbidity associated with horizontal transmission rates.9

This study had several limitations. Our data found a lower incidence of recurrent CDAD than previously published in the literature. This can be accounted for by the identification of cases by ICD9 code, which previously has been documented to underestimate true disease.10, 11 We also were not able to capture recurrent episodes in outpatients or episodes that occurred after the 2004 cohort, which underestimated the true frequency of recurrence. At worst, this underestimation could bias the results toward the null hypothesis. An additional limitation of the study was the assumption that time to treatment was accurately reflected by time to prescription of either vancomycin or flagyl. Some patients may have been treated by suspending treatment with the offending antibiotic along with watchful waiting, which is a reasonable strategy for patients with mild disease and is endorsed by the American College of Gastroenterology and the Society for Healthcare Epidemiology of America.12, 13 This would overestimate time to treatment for those individuals and would make time to treatment appear longer, but would not affect time to sampling. In addition, the symptoms collected from chart review were assumed to be a result of the patient's CDAD, but there is a chance that these symptoms such as diarrhea, abdominal pain, and cramping may have been a result of a different diagnosis. These data were also limited to a cohort from a single institution and may not reflect the patient characteristics or practice patterns at other institutions.

In conclusion, CDAD is a major contributor to morbidity from nosocomial infections, and recurrent CDAD patients are a likely source of horizontal disease transmission. This study documented that there are significant diagnostic and treatment delays, even in populations with recurrent disease. It is especially important that hospitalists take measures to improve the early diagnosis, treatment, and isolation of these patients in order to improve these deficiencies in care.

Clostridium difficileassociated disease (CDAD) is a well‐known complication of hospitalization and is the most frequently identified cause of nosocomial diarrhea that hospitalists encounter. Despite widespread epidemiologic attempts to control the disease, its prevalence and clinical severity appear to be increasing.1 The resulting social and economic consequences are profound. The estimated 3 million inpatient cases of CDAD a year result in an average increase in the length of stay of 3.6 days at a cost in inpatient health care of more than $1 billion.2

Early diagnosis of index cases is crucial. A diagnostic delay can result in a treatment delay for the index case, as well as in a delay in implementing isolation procedures to prevent horizontal transmission. Acquisition of CDAD is time dependent and occurs in 20% to 30% of hospitalized patients at a rate of approximately 8% per week.3, 4 This transmission is primarily a result of environmental contamination with CDAD spores, found on 59% of the hands of hospital personnel caring for infected patients, in 49% of rooms of symptomatic patients, and in 29% of rooms of asymptomatic carriers.5 Despite the need for early diagnosis, a study from the United Kingdom documented that the average time from the onset of diarrhea to sampling of CDAD patients is 4.7 days.6 An additional challenge for early diagnosis is the delay in microbiological confirmation of CDAD in a suspected patient. Cytotoxic assays, which have become the standard diagnostic technique for CDAD, exhibit excellent sensitivity and specificity but have a lengthy processing time, between 2 and 4 days. Although antigen detection assays can be rapidly performed, many have inadequate sensitivity and specificity.7

These issues of diagnostic and treatment delays are compounded in patients with recurrent CDAD. As many as 15%35% of patients with an initial CDAD infection will experience a recurrence, usually within 2 months. At least half these infections are a result of reinfection, not relapse.8 This implies that early detection and strict isolation of infected patients is essential for reducing the exposure of at‐risk patients to the disease. There is evidence that the burden of patients on the same ward simultaneously having CDAD increases a patient's risk of acquiring the disease.9 It is currently unknown if recurrent CDAD cases are diagnosed or treated earlier than initial cases. If not, this is a potentially important patient population for hospitalists to target for aggressive containment strategies. This study sought to determine the mean time to sampling and treatment in patients with recurrent CDAD infection compared with those in patients who are initially infected.

Design

The study cohort consisted of all adult patients more than 18 years old with CDAD (by ICD9 code) who had been hospitalized at Brigham and Women's Hospital between 1997 and 2004. Retrospectively, patients were identified through the Partners Healthcare Research Patient Data Repository (RPDR). The RPDR is a centralized clinical data registry that gathers data from various hospital legacy systems and was used to determine the patient demographics and first date of treatment (with vancomycin or metronidazole). Medical and microbiologic records were reviewed to determine the dates of cytotoxic assay submission and symptom onset. Symptoms were defined as diarrhea, abdominal pain/cramping, or radiological/colonoscopic evidence of colitis. Recurrence was defined as any repeat inpatient CDAD diagnosis within 2 months (regardless of admission diagnosis). Baseline characteristics in the recurrence and no‐recurrence populations were compared by the 2‐sided Student t test or the chi‐square test (for continuous and categorical variables, respectively). Mean time from symptom to sampling, from symptom to treatment, and from sampling to treatment were compared between initial and recurrent disease episodes by the 2‐sided Student t test. All P values .05 were considered significant. Institutional review board approval was obtained by Partners Healthcare.

RESULTS

Between 1997 and 2004 there were 1309 patients with an ICD9 code for CDAD, 151 of whom (12%) had a recurrence. Of these, 125 had 1 recurrence, 23 had 2 recurrences, and 3 had 3 recurrences. There were no significant differences between the groups in basic demographics (Table 1). The mean time to sampling was not significantly different between initial and recurrent CDAD hospital episodes (Table 2). However, the mean time to treatment (from symptoms and sampling) was shorter in recurrent episodes (Table 2). From 1997 to 2004 there was no significant reduction in time to sampling, but there was a significant reduction in time to treatment, from 3.89 days (19972000) to 2.30 days (2001 2004), P = .0012.

DISCUSSION

Clostridium difficileassociated disease (CDAD) has become a significant nosocomial infection in medical institutions, and recurrent CDAD is emerging as a disease of concern for hospitalists. Diagnostic delays represent a major epidemiologic problem, resulting in both delay of treatment delay of the index case and delay in implementing isolation procedures to prevent horizontal transmission. In this study, patients with recurrent disease did not have stool collected any earlier than did patients with their initial episode of CDAD, and these diagnostic delays did not change in successive eras. Recurrent disease patients did receive treatment earlier than did patients with initial episodes. Although this empiric treatment strategy is encouraging and likely reflects heightened awareness of the disease over time, the 2.5‐day span from symptoms to treatment is still a clinically significant delay. Also of concern is the range of time from symptoms to treatment, as long as 19 days in the recurrent treatment group. Although most patients were treated within 12 days, this variability represents the burden of infectious patients with the potential for infecting others. Targeting recurrent CDAD populations for early diagnosis, treatment, and isolation would almost certainly reduce the morbidity associated with horizontal transmission rates.9

This study had several limitations. Our data found a lower incidence of recurrent CDAD than previously published in the literature. This can be accounted for by the identification of cases by ICD9 code, which previously has been documented to underestimate true disease.10, 11 We also were not able to capture recurrent episodes in outpatients or episodes that occurred after the 2004 cohort, which underestimated the true frequency of recurrence. At worst, this underestimation could bias the results toward the null hypothesis. An additional limitation of the study was the assumption that time to treatment was accurately reflected by time to prescription of either vancomycin or flagyl. Some patients may have been treated by suspending treatment with the offending antibiotic along with watchful waiting, which is a reasonable strategy for patients with mild disease and is endorsed by the American College of Gastroenterology and the Society for Healthcare Epidemiology of America.12, 13 This would overestimate time to treatment for those individuals and would make time to treatment appear longer, but would not affect time to sampling. In addition, the symptoms collected from chart review were assumed to be a result of the patient's CDAD, but there is a chance that these symptoms such as diarrhea, abdominal pain, and cramping may have been a result of a different diagnosis. These data were also limited to a cohort from a single institution and may not reflect the patient characteristics or practice patterns at other institutions.

In conclusion, CDAD is a major contributor to morbidity from nosocomial infections, and recurrent CDAD patients are a likely source of horizontal disease transmission. This study documented that there are significant diagnostic and treatment delays, even in populations with recurrent disease. It is especially important that hospitalists take measures to improve the early diagnosis, treatment, and isolation of these patients in order to improve these deficiencies in care.

Peripheral arterial disease (PAD) is defined by the presence of stenosis or occlusion in peripheral arterial beds.1, 2 Based on large population‐based screening surveys, the prevalence of this disease ranges between 5.5% and 26.7% and is dependent on age, atherothrombotic risk factors, and the coexistence of other atherothrombotic diseases.35 Symptoms of PAD include mild to intermittent claudication, ischemic rest pain, and tissue loss.2 Disease severity is classified according to either Fontaine's stages or Rutherford categories. These categorization schema have value in improving communication between physicians, which is important in ensuring continuity of care between the inpatient and outpatient settings (Table 1).2

Patients with PAD are at increased risk of dying from or experiencing a cardiovascular event.68 Among patients diagnosed with PAD, coronary artery disease (CAD), or cerebrovascular disease (CVD), those with PAD have the highest 1‐year rate of cardiovascular death, MI, stroke, or vascular‐related hospitalization (Fig. 1).8 This risk is attributable in part to the high rate of association of PAD with other atherothrombotic diseases. The Reduction of Atherothrombosis for Continued Health (REACH) Registry found that approximately 60% of participants with documented PAD have polyvascular disease, defined by the coexistence of CAD and/or CVD. In comparison, 25% of participants with CAD and 40% of participants with CVD have polyvascular disease.8 Thus, PAD can be considered a powerful indicator of systemic atherothrombotic disease and a predictor of cardiovascular and cerebrovascular morbidity and mortality.1

Figure 1

Unfortunately, asymptomatic PAD is more common than its symptomatic counterpart.3 In addition, symptomatic patients often fail to notify their physicians about PAD‐associated symptoms because they attribute them to aging.3 As a result, this disease is underdiagnosed and undertreated.1 Accordingly, several medical associations and physician task forces have called for an increase in screening for PAD in at‐risk populations that include: patients older than 70, patients older than 50 who have concomitant atherothrombotic risk factors, and patients with atherothrombotic disease of single or multiple vascular beds.1, 9 In many cases hospitalists encounter patients at high‐risk for PAD whose DRG for admission might be unrelated to this disease. Nonetheless, hospitalists have the opportunity to improve patient outcomes by being capable of screening for undiagnosed PAD and initiating appropriate interventions to reduce the risk of life‐threatening cardiovascular events.

DIAGNOSIS

Peripheral arterial disease can be diagnosed by either noninvasive or invasive methods. The ankle‐to‐brachial index (ABI) is an accurate, practical, inexpensive, and noninvasive method for detecting PAD.1 The sensitivity of ABI in detecting PAD is 95% with 99% specificity,10 which makes the method superior to other indicators (eg, absence of a pedal pulse, presence of a femoral arterial bruit, slow venous filling, or cold/abnormally colored skin) assessed during a physical examination.11 Under normal conditions, the systolic pressure at the ankle should be equal to or greater than that recorded from the upper arm. As PAD narrows arteries, the systolic pressure decreases at sites distal to the area of arterial narrowing. A resting ABI is quantified by taking 2 readings each of ankle and brachial blood pressures with a handheld Doppler device while the patient is supine and dividing the highest ankle systolic pressure by the highest brachial pressure.12

An ABI between 0.9 and 1.30 is considered normal. Ratios between 0.7 and 0.89 indicate mild PAD, 0.4 and 0.69 moderate PAD, and an ABI 0.4 severe PAD when patients are more likely to have ischemic pain when at rest. An ABI > 1.3 usually indicates the presence of noncompressible vessels, which can be common in the elderly and patients with diabetes mellitus who have calcification of the distal arteries.1, 2 The ABI is also inversely related to the number of atherosclerotic risk factors and the risk of adverse cardiovascular events and death.6, 1316 To identify individuals with suspected or asymptomatic lower‐extremity PAD, ABI has a class I recommendation from the American College of Cardiology and American Heart Association (ACC/AHA) for patients who present with leg symptoms, who are 70 years and older, or who are 50 years and older with a history of smoking or diabetes.2 This enables physicians to make therapeutic interventions to reduce the risk of adverse vascular events in these patient cohorts.

Additional detection methods for PAD include measuring the ABI before and after exercise on a treadmill, if the patient is ambulatory, or exercise by performing 50 repetitions of raising the heels maximally off the floor, if the patient is not ambulatory. These tests determine the extent of claudication.2 Duplex ultrasound is used to establish the location and severity of stenosis and to follow PAD progression.2

Invasive evaluations for PAD are used primarily to confirm an initial diagnosis of PAD and assess its severity. These methods include a conventional angiogram, which is the most readily available and widely used technique for defining arterial stenosis. Magnetic resonance (MR) angiography with gadolinium and computed tomographic (CT) angiography are used to determine the location and degree of stenosis. Both MR and CT angiography have advantages and disadvantages but are considered interchangeable with one another in patients with contraindications to either method (Table 2).2

ANTIPLATELET THERAPY FOR REDUCTION OF VASCULAR EVENTS

Hospitalists utilize a wide array of therapies to treat and manage PAD. Acute complications of PAD may require interventions to prevent tissue loss or infection, revascularization procedures, or surgical amputation. Treatment of mild to moderate PAD focuses on atherothrombotic risk factor management, exercise therapy to improve limb function, and interventions to reduce the risk of adverse vascular events.2, 9 The remainder of this report focuses on the role of antiplatelet therapy (eg, aspirin and thienopyridines) in reducing the risk of vascular events in patients with PAD.

The Antiplatelet Trialists' Collaboration performed an overview analysis of randomized trials conducted prior to 1990 in order to determine the association of prolonged antiplatelet therapy with the occurrence of major vascular events. As a whole, therapies thought to act through inhibition of platelet aggregation, adhesion, or both reduced the incidence of vascular events by 33% in patients with PAD and those at high risk, and by 25% in all patient groups. Antiplatelet agents were also well tolerated; the absolute risk of fatal or nonmajor hemorrhage was low.17

A similar meta‐analysis was conducted of antiplatelet therapies in high‐risk patients with atherothrombosis by the Antithrombotic Trialists' Collaboration. Antiplatelet therapies taken together reduced the odds of patients experiencing vascular events by 22% (SE = 2%) across all trials and 23% (SE = 8%) in patients with PAD.18 Similar to the Antiplatelet Trialists' Collaboration study, the absolute risk of major and minor bleeding was low compared to the benefits of antiplatelet therapy.18 The results of these studies provide supporting evidence for the ACC/AHA class I recommendation for the use of antiplatelet therapy to reduce the risk of MI, stroke, or vascular death in patients with PAD.

The Antithrombotic Trialists' Collaboration also examined the risk reduction associated with a specific antiplatelet agent, aspirin. All doses of aspirin (75‐150, 160‐325, and 500‐1500 mg/day) reduced the odds by 23% (SE = 2%); high doses were no more effective than medium or low doses.18 Although the effects of aspirin was not analyzed in a subgroup analysis of patients with PAD, this study and others support the ACC/AHA class I recommendations for the use of aspirin to reduce the risk of MI, stroke, or vascular death in patients with PAD.2, 1921

The CAPRIE trial compared the efficacy of another antiplatelet agent, clopidogrel, against aspirin in patients with PAD.22 Patients with a history of recent ischemic stroke, MI, or symptomatic PAD were randomized to receive either clopidogrel (75 mg/day) or aspirin (325 mg/day) for 1‐3 years (mean follow‐up time, 1.91 years). Study outcomes were the incidence of nonfatal MI, ischemic stroke, hemorrhagic stroke, leg amputation, and vascular deaths. The absolute risk reduction for all patients was 8.7% (95% confidence interval [CI], 0.3%‐16.5%) in favor of clopidogrel over aspirin. Moreover, subgroup analysis in patients with PAD revealed that clopidogrel reduced the risk of a vascular event by 23.8% (95% CI, 8.9%‐36.2%; P = 0.0028) compared with aspirin (Fig. 2). Clopidogrel and aspirin had similar safety profiles, but other studies have revealed bleeding incidence is numerically greater in patients treated with clopidogrel.2224 Although the CAPRIE trial is the only study to date to compare the efficacy of clopidogrel over aspirin in reducing vascular event in patients with PAD, its outcomes underlie the class I ACC/AHA recommendation for clopidogrel (75 mg/day) as an effective alternative to aspirin to reduce the risk of MI, stroke, or death in patients with PAD.2

Figure 2

CONCLUSIONS

Despite the availability of accurate, practical, and inexpensive diagnostic testing, PAD remains underdiagnosed and undertreated. Early detection of PAD and subsequent intervention by hospitalists are important because peripheral arterial disease is strongly associated with an increased risk of mortality and morbidity from adverse vascular events. The ACC/AHA recommends screening for asymptomatic patients at risk for this disease so that therapies that reduce the risk of an MI, stroke, or vascular death can be administered immediately. Antiplatelet agents reduce the risk of adverse vascular events in patients with PAD. The use of aspirin or clopidogrel is recommended in this cohort of patients. However, further study is necessary to determine the efficacy and safety of combination therapy with aspirin and clopidogrel in patients with PAD. It is also important to note that coordination of care between hospitalists and cardiologists is critical in the management of patients with this disease. However, the appropriate handoff of patients between these 2 groups of physicians depends on the local expertise and support structure of these health care professionals. Thus, an interdisciplinary approach utilizing guideline‐based patient care will allow hospitalists to refer patients accordingly, ensuring optimal outcomes in patients with PAD.