A. Maria Hester, MD

On one of my recent Internet excursions I spent some time on a highly useful website, Hospital Compare. This site is sponsored by Medicare.gov and provides a plethora of useful information for health care consumers who want to know quality metrics on health care facilities in their area. There is quality data on over 4,000 Medicare-certified hospitals across the country.

Hospital Compare is a very user-friendly site. Even those among us who are not so Web savvy can navigate this site in a snap. Just type in your zip code and up pops a list of hospitals in your specified area. You can even narrow your search by requesting what type of hospital you are interested in – acute care Veterans Affairs, acute care, children’s, or critical care access hospitals.

Next, putting a check in the boxes next to hospitals you want to compare produces a grid describing the different facilities. Users can find out which hospitals provide emergency services and whether lab results can be tracked between visits.

Of more interest to hospitalists is the next tab: Patient Survey Results. Here you can find out how well physicians and nurses on your staff communicated with patients during their hospitalization versus how well other health care providers in your region performed.

Courtesy of Medicare.gov

Scrolling through the tabs, you will then find tabs for Timely & Effective Care, which compares inpatient core measures, such as the percentage of patients with MI given aspirin at discharge and the percentage of heart failure patients receiving an ACE inhibitor or an angiotensin receptor blocker. Users can even find out the average wait time in the ED prior to being admitted to a particular hospital.

There is information on how to save money on prescription drugs, advanced directives and long term care, Medicare rights and forms, readmissions, hospital complications, 30-day death rates, health care–associated infections, and much more. While perusing that site, I also came upon yet another great site, Nursing Home Compare. Medicare.gov’s Nursing Home Compareis also chock-full of information for patients and family members who want to find the best care possible. Not only does it rate nursing homes, it gives ratings for rehabilitation facilities as well.

I was shocked to find out that one nursing home near my home had a terrible health inspection rating, while another one close by received flying colors for this metric. This type of information is invaluable for patients who are already sick and vulnerable. This site even provides information about fire safety ratings and details of health inspection reports and complaints.

Patients often ask me what I think about various facilities in the area, and I have had very little valuable information to offer them. It seemed like I always deferred that question to the social worker. Now, I can refer them to this website to help them make very important choices for their health care as well as care for their loved ones.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

On one of my recent Internet excursions I spent some time on a highly useful website, Hospital Compare. This site is sponsored by Medicare.gov and provides a plethora of useful information for health care consumers who want to know quality metrics on health care facilities in their area. There is quality data on over 4,000 Medicare-certified hospitals across the country.

Hospital Compare is a very user-friendly site. Even those among us who are not so Web savvy can navigate this site in a snap. Just type in your zip code and up pops a list of hospitals in your specified area. You can even narrow your search by requesting what type of hospital you are interested in – acute care Veterans Affairs, acute care, children’s, or critical care access hospitals.

Next, putting a check in the boxes next to hospitals you want to compare produces a grid describing the different facilities. Users can find out which hospitals provide emergency services and whether lab results can be tracked between visits.

Of more interest to hospitalists is the next tab: Patient Survey Results. Here you can find out how well physicians and nurses on your staff communicated with patients during their hospitalization versus how well other health care providers in your region performed.

Courtesy of Medicare.gov

Scrolling through the tabs, you will then find tabs for Timely & Effective Care, which compares inpatient core measures, such as the percentage of patients with MI given aspirin at discharge and the percentage of heart failure patients receiving an ACE inhibitor or an angiotensin receptor blocker. Users can even find out the average wait time in the ED prior to being admitted to a particular hospital.

There is information on how to save money on prescription drugs, advanced directives and long term care, Medicare rights and forms, readmissions, hospital complications, 30-day death rates, health care–associated infections, and much more. While perusing that site, I also came upon yet another great site, Nursing Home Compare. Medicare.gov’s Nursing Home Compareis also chock-full of information for patients and family members who want to find the best care possible. Not only does it rate nursing homes, it gives ratings for rehabilitation facilities as well.

I was shocked to find out that one nursing home near my home had a terrible health inspection rating, while another one close by received flying colors for this metric. This type of information is invaluable for patients who are already sick and vulnerable. This site even provides information about fire safety ratings and details of health inspection reports and complaints.

Patients often ask me what I think about various facilities in the area, and I have had very little valuable information to offer them. It seemed like I always deferred that question to the social worker. Now, I can refer them to this website to help them make very important choices for their health care as well as care for their loved ones.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

On one of my recent Internet excursions I spent some time on a highly useful website, Hospital Compare. This site is sponsored by Medicare.gov and provides a plethora of useful information for health care consumers who want to know quality metrics on health care facilities in their area. There is quality data on over 4,000 Medicare-certified hospitals across the country.

Hospital Compare is a very user-friendly site. Even those among us who are not so Web savvy can navigate this site in a snap. Just type in your zip code and up pops a list of hospitals in your specified area. You can even narrow your search by requesting what type of hospital you are interested in – acute care Veterans Affairs, acute care, children’s, or critical care access hospitals.

Next, putting a check in the boxes next to hospitals you want to compare produces a grid describing the different facilities. Users can find out which hospitals provide emergency services and whether lab results can be tracked between visits.

Of more interest to hospitalists is the next tab: Patient Survey Results. Here you can find out how well physicians and nurses on your staff communicated with patients during their hospitalization versus how well other health care providers in your region performed.

Courtesy of Medicare.gov

Scrolling through the tabs, you will then find tabs for Timely & Effective Care, which compares inpatient core measures, such as the percentage of patients with MI given aspirin at discharge and the percentage of heart failure patients receiving an ACE inhibitor or an angiotensin receptor blocker. Users can even find out the average wait time in the ED prior to being admitted to a particular hospital.

There is information on how to save money on prescription drugs, advanced directives and long term care, Medicare rights and forms, readmissions, hospital complications, 30-day death rates, health care–associated infections, and much more. While perusing that site, I also came upon yet another great site, Nursing Home Compare. Medicare.gov’s Nursing Home Compareis also chock-full of information for patients and family members who want to find the best care possible. Not only does it rate nursing homes, it gives ratings for rehabilitation facilities as well.

I was shocked to find out that one nursing home near my home had a terrible health inspection rating, while another one close by received flying colors for this metric. This type of information is invaluable for patients who are already sick and vulnerable. This site even provides information about fire safety ratings and details of health inspection reports and complaints.

Patients often ask me what I think about various facilities in the area, and I have had very little valuable information to offer them. It seemed like I always deferred that question to the social worker. Now, I can refer them to this website to help them make very important choices for their health care as well as care for their loved ones.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

Is your hospital going to the dogs? Perhaps, that is, if your hospital administrators believe in AAT.

That’s not a new randomized placebo-controlled trial for a nifty new medication? Far less complex, it is the simple acronym for animal-assisted therapy, a novel therapeutic modality that is spreading across the country.

Dan/freedigitalphotos.net

I was surprised the first time I saw a canine proudly strutting down the hall of a hospital like he belonged there, but it makes perfect sense. Numerous studies have shown the positive psychological, physical, and even survival benefits of pet ownership. For many, their pet is a beloved member of the family.

But does AAT really work? Apparently so.

Northwest Community Hospital in Arlington Heights, Ill., utilizes AAT regularly to improve both the emotional and physical well-being of its patients. The renowned UCLA Medical Center has gone four-legged. The UCLA People-Animal Connection (PAC) is one of America’s most comprehensive animal-assisted therapy and activity programs. Even the Joint Commission uses PAC’s protocols to promote AAT, both here and abroad.

According to research published in the American Journal of Critical Care (2008;17:373-6), the benefits of AAT are primarily the result of "contact comfort," a tactile process during which unconditional attachment bonds form between humans and animals, leading to relaxation by reducing cardiovascular reactivity to stress. AAT was found to improve hemodynamics in patients with advanced heart failure by reducing right atrial pressure, both systolic and diastolic pulmonary artery pressure, pulmonary capillary wedge pressure, and neurohormone levels.

So the next time you see a dog and his owner stroll down the halls of your hospital, step aside. They have an important job to do as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Is your hospital going to the dogs? Perhaps, that is, if your hospital administrators believe in AAT.

That’s not a new randomized placebo-controlled trial for a nifty new medication? Far less complex, it is the simple acronym for animal-assisted therapy, a novel therapeutic modality that is spreading across the country.

Dan/freedigitalphotos.net

I was surprised the first time I saw a canine proudly strutting down the hall of a hospital like he belonged there, but it makes perfect sense. Numerous studies have shown the positive psychological, physical, and even survival benefits of pet ownership. For many, their pet is a beloved member of the family.

But does AAT really work? Apparently so.

Northwest Community Hospital in Arlington Heights, Ill., utilizes AAT regularly to improve both the emotional and physical well-being of its patients. The renowned UCLA Medical Center has gone four-legged. The UCLA People-Animal Connection (PAC) is one of America’s most comprehensive animal-assisted therapy and activity programs. Even the Joint Commission uses PAC’s protocols to promote AAT, both here and abroad.

According to research published in the American Journal of Critical Care (2008;17:373-6), the benefits of AAT are primarily the result of "contact comfort," a tactile process during which unconditional attachment bonds form between humans and animals, leading to relaxation by reducing cardiovascular reactivity to stress. AAT was found to improve hemodynamics in patients with advanced heart failure by reducing right atrial pressure, both systolic and diastolic pulmonary artery pressure, pulmonary capillary wedge pressure, and neurohormone levels.

So the next time you see a dog and his owner stroll down the halls of your hospital, step aside. They have an important job to do as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Is your hospital going to the dogs? Perhaps, that is, if your hospital administrators believe in AAT.

That’s not a new randomized placebo-controlled trial for a nifty new medication? Far less complex, it is the simple acronym for animal-assisted therapy, a novel therapeutic modality that is spreading across the country.

Dan/freedigitalphotos.net

I was surprised the first time I saw a canine proudly strutting down the hall of a hospital like he belonged there, but it makes perfect sense. Numerous studies have shown the positive psychological, physical, and even survival benefits of pet ownership. For many, their pet is a beloved member of the family.

But does AAT really work? Apparently so.

Northwest Community Hospital in Arlington Heights, Ill., utilizes AAT regularly to improve both the emotional and physical well-being of its patients. The renowned UCLA Medical Center has gone four-legged. The UCLA People-Animal Connection (PAC) is one of America’s most comprehensive animal-assisted therapy and activity programs. Even the Joint Commission uses PAC’s protocols to promote AAT, both here and abroad.

According to research published in the American Journal of Critical Care (2008;17:373-6), the benefits of AAT are primarily the result of "contact comfort," a tactile process during which unconditional attachment bonds form between humans and animals, leading to relaxation by reducing cardiovascular reactivity to stress. AAT was found to improve hemodynamics in patients with advanced heart failure by reducing right atrial pressure, both systolic and diastolic pulmonary artery pressure, pulmonary capillary wedge pressure, and neurohormone levels.

So the next time you see a dog and his owner stroll down the halls of your hospital, step aside. They have an important job to do as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Recently, hospitalists around the country gathered together at Hospital Medicine 2013 to gain new and practical clinical insights we can use to optimize the medical care we provide to our patients, imbibe new research on the horizon, master clinical care guidelines, and sometimes, just relax and enjoy meeting new colleagues from around the country – naturally, comparing notes on how their practices stack up to our own. You could even pick up a book or two geared to hospitalists. I bought "Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine" and "Becoming a Consummate Clinician: What Every Student, House Office, and Hospital Practitioner Needs to Know." Learning just doesn’t get any better than this.

Information abounded, challenges were issued, and I think most of us learned how much we really need to learn more about. I believe we were thoroughly challenged to look at our current practice style, incorporate our new knowledge, and take our clinical acumen to the next level.

The first challenge began when I had to roll out of bed around 5 a.m. to prepare to make the hour-long drive down I-95 to the conference site at National Harbor, Md., to attend a 7:40 a.m. lecture: "Pain Management for the Hospitalist." I have not a single regret. It was well worth the bleary ride. I think many hospitalists share my concerns about overmedicating patients on the one hand, and being on guard for true drug seekers on the other.

My main takeaway was that when a patient is truly in pain, narcotic pain medication can be titrated up much more quickly than most of us currently feel comfortable with.

The lecture was presented by Dr. Eric Roeland of the University of Carolina, San Diego, who said that he sometimes doubles narcotic analgesics every 10 minutes under certain circumstances. Some participants were shocked (including me). He orders a dose of pain medication and then checks on the patient around the time of CMax (maximum concentration of the drug). For IV pain medications, this is approximately 10 minutes, for SC/IM it is 30 minutes, and for PO/PR it is 60 minutes. If his patient has not gotten pain relief by CMax, he orders twice the dose and checks back in again at the next CMax. If the patient still has no relief, Dr. Roeland will order four times the initial dose.

He stated that since sedation comes before respiratory depression, he feels comfortable increasing narcotics rapidly in patients who are "alert and playing Atari" or are otherwise highly functional. (I didn’t know Atari was still on the market.)

Click here for the presentation slides from this lecture and here for others.

Hope to see you next year when Hospital Medicine meets in Las Vegas!

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Recently, hospitalists around the country gathered together at Hospital Medicine 2013 to gain new and practical clinical insights we can use to optimize the medical care we provide to our patients, imbibe new research on the horizon, master clinical care guidelines, and sometimes, just relax and enjoy meeting new colleagues from around the country – naturally, comparing notes on how their practices stack up to our own. You could even pick up a book or two geared to hospitalists. I bought "Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine" and "Becoming a Consummate Clinician: What Every Student, House Office, and Hospital Practitioner Needs to Know." Learning just doesn’t get any better than this.

Information abounded, challenges were issued, and I think most of us learned how much we really need to learn more about. I believe we were thoroughly challenged to look at our current practice style, incorporate our new knowledge, and take our clinical acumen to the next level.

The first challenge began when I had to roll out of bed around 5 a.m. to prepare to make the hour-long drive down I-95 to the conference site at National Harbor, Md., to attend a 7:40 a.m. lecture: "Pain Management for the Hospitalist." I have not a single regret. It was well worth the bleary ride. I think many hospitalists share my concerns about overmedicating patients on the one hand, and being on guard for true drug seekers on the other.

My main takeaway was that when a patient is truly in pain, narcotic pain medication can be titrated up much more quickly than most of us currently feel comfortable with.

The lecture was presented by Dr. Eric Roeland of the University of Carolina, San Diego, who said that he sometimes doubles narcotic analgesics every 10 minutes under certain circumstances. Some participants were shocked (including me). He orders a dose of pain medication and then checks on the patient around the time of CMax (maximum concentration of the drug). For IV pain medications, this is approximately 10 minutes, for SC/IM it is 30 minutes, and for PO/PR it is 60 minutes. If his patient has not gotten pain relief by CMax, he orders twice the dose and checks back in again at the next CMax. If the patient still has no relief, Dr. Roeland will order four times the initial dose.

He stated that since sedation comes before respiratory depression, he feels comfortable increasing narcotics rapidly in patients who are "alert and playing Atari" or are otherwise highly functional. (I didn’t know Atari was still on the market.)

Click here for the presentation slides from this lecture and here for others.

Hope to see you next year when Hospital Medicine meets in Las Vegas!

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Recently, hospitalists around the country gathered together at Hospital Medicine 2013 to gain new and practical clinical insights we can use to optimize the medical care we provide to our patients, imbibe new research on the horizon, master clinical care guidelines, and sometimes, just relax and enjoy meeting new colleagues from around the country – naturally, comparing notes on how their practices stack up to our own. You could even pick up a book or two geared to hospitalists. I bought "Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine" and "Becoming a Consummate Clinician: What Every Student, House Office, and Hospital Practitioner Needs to Know." Learning just doesn’t get any better than this.

Information abounded, challenges were issued, and I think most of us learned how much we really need to learn more about. I believe we were thoroughly challenged to look at our current practice style, incorporate our new knowledge, and take our clinical acumen to the next level.

The first challenge began when I had to roll out of bed around 5 a.m. to prepare to make the hour-long drive down I-95 to the conference site at National Harbor, Md., to attend a 7:40 a.m. lecture: "Pain Management for the Hospitalist." I have not a single regret. It was well worth the bleary ride. I think many hospitalists share my concerns about overmedicating patients on the one hand, and being on guard for true drug seekers on the other.

My main takeaway was that when a patient is truly in pain, narcotic pain medication can be titrated up much more quickly than most of us currently feel comfortable with.

The lecture was presented by Dr. Eric Roeland of the University of Carolina, San Diego, who said that he sometimes doubles narcotic analgesics every 10 minutes under certain circumstances. Some participants were shocked (including me). He orders a dose of pain medication and then checks on the patient around the time of CMax (maximum concentration of the drug). For IV pain medications, this is approximately 10 minutes, for SC/IM it is 30 minutes, and for PO/PR it is 60 minutes. If his patient has not gotten pain relief by CMax, he orders twice the dose and checks back in again at the next CMax. If the patient still has no relief, Dr. Roeland will order four times the initial dose.

He stated that since sedation comes before respiratory depression, he feels comfortable increasing narcotics rapidly in patients who are "alert and playing Atari" or are otherwise highly functional. (I didn’t know Atari was still on the market.)

Click here for the presentation slides from this lecture and here for others.

Hope to see you next year when Hospital Medicine meets in Las Vegas!

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Who knew?

I was almost speechless when the federal government released data that show striking variation across America, and even within individual communities, in what hospitals charge patients. The 100 most frequently billed discharges of 2011 are represented in the data, and the associated DRGs represent close to 7 million discharges.

President Obama promised more transparency in and by government, and this headline from the Washington Post about CMS’s data-sharing move makes it crystal clear for all to see: "One hospital charges $8,000 – another, $38,000." Yes, for the same service. But that is just the tip of the iceberg. The article goes on to note that, according to hospitals’ once-secret "chargemaster" lists, the cost of joint replacements ranged from $5,304 in Ada, Okla., to a whopping $223,373 in Monterey, Calif. And, while a case of uncomplicated pneumonia may cost only $5,093 in Water Valley, Miss., you better hope you are not visiting Philadelphia when you get sick, or you can plan to tack on additional $119,000 to that bill. Surely, it is not the cost of the medications that accounts for this vast difference. National guidelines for treating pneumonia apply to all 50 states, so the care should be comparable. So what accounts for the extremes in hospital charges?

Okay, there’s the cost-of-living factor, and thus the hospitals’ overhead is undoubtedly drastically different in small-town U.S.A. vs. a popular metropolis, but it is shocking that this gap is so huge. While I have always known that there were differences in charges for medical services based on where you go, I never imagined such a stark contrast in the price tag for the same service in the same country – and sometimes even in the same city. As if the medical profession were not already struggling with its reputation eyes of the public. These data really paint of negative picture of the medical community.

So, what is the real significance of the discrepancy in these charges? For many with good insurance, nothing. Insurance companies decide what they are willing to pay for a given billing code and, typically, the rest is written off. Patients are not liable for the difference. Not quite true if you are uninsured.

Though the American Hospital Association states that centers often provide assistance to patients with meager finances, those who are most vulnerable and least able to pay for medical care may end up with the entire bill, frequently a bill that they will never be able to pay. That bill may eventually cause them to file for bankruptcy, which will adversely affect their lives and their children’s lives for many years to come – all because they became sick and assumed that the quality of care and the price for services rendered would be reasonable and comparable across all institutions.

While some may cringe at the revelation of the price discrepancy, I am glad this information came to light. Now consumers will be able to compare hospitals’ pricing as well as their quality measures and make better decisions about which hospital is best for them.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS. This blog, "Teachable Moments," appears regularly in Hospitalist News.

Who knew?

I was almost speechless when the federal government released data that show striking variation across America, and even within individual communities, in what hospitals charge patients. The 100 most frequently billed discharges of 2011 are represented in the data, and the associated DRGs represent close to 7 million discharges.

President Obama promised more transparency in and by government, and this headline from the Washington Post about CMS’s data-sharing move makes it crystal clear for all to see: "One hospital charges $8,000 – another, $38,000." Yes, for the same service. But that is just the tip of the iceberg. The article goes on to note that, according to hospitals’ once-secret "chargemaster" lists, the cost of joint replacements ranged from $5,304 in Ada, Okla., to a whopping $223,373 in Monterey, Calif. And, while a case of uncomplicated pneumonia may cost only $5,093 in Water Valley, Miss., you better hope you are not visiting Philadelphia when you get sick, or you can plan to tack on additional $119,000 to that bill. Surely, it is not the cost of the medications that accounts for this vast difference. National guidelines for treating pneumonia apply to all 50 states, so the care should be comparable. So what accounts for the extremes in hospital charges?

Okay, there’s the cost-of-living factor, and thus the hospitals’ overhead is undoubtedly drastically different in small-town U.S.A. vs. a popular metropolis, but it is shocking that this gap is so huge. While I have always known that there were differences in charges for medical services based on where you go, I never imagined such a stark contrast in the price tag for the same service in the same country – and sometimes even in the same city. As if the medical profession were not already struggling with its reputation eyes of the public. These data really paint of negative picture of the medical community.

So, what is the real significance of the discrepancy in these charges? For many with good insurance, nothing. Insurance companies decide what they are willing to pay for a given billing code and, typically, the rest is written off. Patients are not liable for the difference. Not quite true if you are uninsured.

Though the American Hospital Association states that centers often provide assistance to patients with meager finances, those who are most vulnerable and least able to pay for medical care may end up with the entire bill, frequently a bill that they will never be able to pay. That bill may eventually cause them to file for bankruptcy, which will adversely affect their lives and their children’s lives for many years to come – all because they became sick and assumed that the quality of care and the price for services rendered would be reasonable and comparable across all institutions.

While some may cringe at the revelation of the price discrepancy, I am glad this information came to light. Now consumers will be able to compare hospitals’ pricing as well as their quality measures and make better decisions about which hospital is best for them.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS. This blog, "Teachable Moments," appears regularly in Hospitalist News.

Who knew?

I was almost speechless when the federal government released data that show striking variation across America, and even within individual communities, in what hospitals charge patients. The 100 most frequently billed discharges of 2011 are represented in the data, and the associated DRGs represent close to 7 million discharges.

President Obama promised more transparency in and by government, and this headline from the Washington Post about CMS’s data-sharing move makes it crystal clear for all to see: "One hospital charges $8,000 – another, $38,000." Yes, for the same service. But that is just the tip of the iceberg. The article goes on to note that, according to hospitals’ once-secret "chargemaster" lists, the cost of joint replacements ranged from $5,304 in Ada, Okla., to a whopping $223,373 in Monterey, Calif. And, while a case of uncomplicated pneumonia may cost only $5,093 in Water Valley, Miss., you better hope you are not visiting Philadelphia when you get sick, or you can plan to tack on additional $119,000 to that bill. Surely, it is not the cost of the medications that accounts for this vast difference. National guidelines for treating pneumonia apply to all 50 states, so the care should be comparable. So what accounts for the extremes in hospital charges?

Okay, there’s the cost-of-living factor, and thus the hospitals’ overhead is undoubtedly drastically different in small-town U.S.A. vs. a popular metropolis, but it is shocking that this gap is so huge. While I have always known that there were differences in charges for medical services based on where you go, I never imagined such a stark contrast in the price tag for the same service in the same country – and sometimes even in the same city. As if the medical profession were not already struggling with its reputation eyes of the public. These data really paint of negative picture of the medical community.

So, what is the real significance of the discrepancy in these charges? For many with good insurance, nothing. Insurance companies decide what they are willing to pay for a given billing code and, typically, the rest is written off. Patients are not liable for the difference. Not quite true if you are uninsured.

Though the American Hospital Association states that centers often provide assistance to patients with meager finances, those who are most vulnerable and least able to pay for medical care may end up with the entire bill, frequently a bill that they will never be able to pay. That bill may eventually cause them to file for bankruptcy, which will adversely affect their lives and their children’s lives for many years to come – all because they became sick and assumed that the quality of care and the price for services rendered would be reasonable and comparable across all institutions.

While some may cringe at the revelation of the price discrepancy, I am glad this information came to light. Now consumers will be able to compare hospitals’ pricing as well as their quality measures and make better decisions about which hospital is best for them.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS. This blog, "Teachable Moments," appears regularly in Hospitalist News.

Where do you want to die? Strange question, indeed, and one most of us would rather not think about, but one day we all will take our final breath and pass on from life as we know it.

While most people died at home at the turn of the 20th century, by the 1960s, more than two-thirds of deaths occurred in institutions. The birth of the hospice movement in the 1970s did swing the pendulum somewhat back toward death at home, the place preferred by the vast majority of people surveyed, but most people still die in an institution setting, according to an article in April issue of Journal of Hospital Medicine called "Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults."

"In this observational study of 458 ethnically diverse, mostly male patients of low socioeconomic status, the vast majority (75%) expressed their desire to pass away at home, 10% wanted to spend their last days in a hospital setting, 6% preferred a nursing home, and 4% wanted to die while in an inpatient hospice facility. The remaining 5% either had no preference or refused to answer (J. Hosp. Med. 2013 April;8:178-83).

During the period of this study, 123 participants died. Unfortunately, only 37% died where wanted to.

The dying process is a painful reality that affects not only the patient, but his or her entire family as well. This topic has been discussed in the medical literature for decades and rightly so. A 1984 article in the New England Journal of Medicine, "The physician’s responsibility toward hopelessly ill patients: A second look," addressed issues that are just as relevant today as they were decades ago. For instance, when physicians discuss life-threatening illnesses, are patients capable of truly accepting and processing the information? How much information should we give? What is the optimal timing for telling patients they are terminally ill and how do we give provide this devastating information in a compassionate manner that will not make them give up all hope? (N. Engl. J. Med. 1984; 310:955-9)

These and other questions commonly plague busy physicians. Nevertheless, if the results of the most recent study can be extrapolated to the population at large, and the majority of patients are not able to spend their last days where they choose, perhaps we as hospitalists can help swing the pendulum back in their favor by having the hard conversations with patients and their families earlier. Consulting social workers, case managers, and even hospice coordinators early in the process also can help patients and their families take important steps to plan for the final days and improve patients’ chances of actually passing away in the place where they feel most comfortable and least stressed.

The final days of life are very precious. We owe it to our patients to make them as happy and carefree as possible.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Where do you want to die? Strange question, indeed, and one most of us would rather not think about, but one day we all will take our final breath and pass on from life as we know it.

While most people died at home at the turn of the 20th century, by the 1960s, more than two-thirds of deaths occurred in institutions. The birth of the hospice movement in the 1970s did swing the pendulum somewhat back toward death at home, the place preferred by the vast majority of people surveyed, but most people still die in an institution setting, according to an article in April issue of Journal of Hospital Medicine called "Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults."

"In this observational study of 458 ethnically diverse, mostly male patients of low socioeconomic status, the vast majority (75%) expressed their desire to pass away at home, 10% wanted to spend their last days in a hospital setting, 6% preferred a nursing home, and 4% wanted to die while in an inpatient hospice facility. The remaining 5% either had no preference or refused to answer (J. Hosp. Med. 2013 April;8:178-83).

During the period of this study, 123 participants died. Unfortunately, only 37% died where wanted to.

The dying process is a painful reality that affects not only the patient, but his or her entire family as well. This topic has been discussed in the medical literature for decades and rightly so. A 1984 article in the New England Journal of Medicine, "The physician’s responsibility toward hopelessly ill patients: A second look," addressed issues that are just as relevant today as they were decades ago. For instance, when physicians discuss life-threatening illnesses, are patients capable of truly accepting and processing the information? How much information should we give? What is the optimal timing for telling patients they are terminally ill and how do we give provide this devastating information in a compassionate manner that will not make them give up all hope? (N. Engl. J. Med. 1984; 310:955-9)

These and other questions commonly plague busy physicians. Nevertheless, if the results of the most recent study can be extrapolated to the population at large, and the majority of patients are not able to spend their last days where they choose, perhaps we as hospitalists can help swing the pendulum back in their favor by having the hard conversations with patients and their families earlier. Consulting social workers, case managers, and even hospice coordinators early in the process also can help patients and their families take important steps to plan for the final days and improve patients’ chances of actually passing away in the place where they feel most comfortable and least stressed.

The final days of life are very precious. We owe it to our patients to make them as happy and carefree as possible.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Where do you want to die? Strange question, indeed, and one most of us would rather not think about, but one day we all will take our final breath and pass on from life as we know it.

While most people died at home at the turn of the 20th century, by the 1960s, more than two-thirds of deaths occurred in institutions. The birth of the hospice movement in the 1970s did swing the pendulum somewhat back toward death at home, the place preferred by the vast majority of people surveyed, but most people still die in an institution setting, according to an article in April issue of Journal of Hospital Medicine called "Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults."

"In this observational study of 458 ethnically diverse, mostly male patients of low socioeconomic status, the vast majority (75%) expressed their desire to pass away at home, 10% wanted to spend their last days in a hospital setting, 6% preferred a nursing home, and 4% wanted to die while in an inpatient hospice facility. The remaining 5% either had no preference or refused to answer (J. Hosp. Med. 2013 April;8:178-83).

During the period of this study, 123 participants died. Unfortunately, only 37% died where wanted to.

The dying process is a painful reality that affects not only the patient, but his or her entire family as well. This topic has been discussed in the medical literature for decades and rightly so. A 1984 article in the New England Journal of Medicine, "The physician’s responsibility toward hopelessly ill patients: A second look," addressed issues that are just as relevant today as they were decades ago. For instance, when physicians discuss life-threatening illnesses, are patients capable of truly accepting and processing the information? How much information should we give? What is the optimal timing for telling patients they are terminally ill and how do we give provide this devastating information in a compassionate manner that will not make them give up all hope? (N. Engl. J. Med. 1984; 310:955-9)

These and other questions commonly plague busy physicians. Nevertheless, if the results of the most recent study can be extrapolated to the population at large, and the majority of patients are not able to spend their last days where they choose, perhaps we as hospitalists can help swing the pendulum back in their favor by having the hard conversations with patients and their families earlier. Consulting social workers, case managers, and even hospice coordinators early in the process also can help patients and their families take important steps to plan for the final days and improve patients’ chances of actually passing away in the place where they feel most comfortable and least stressed.

The final days of life are very precious. We owe it to our patients to make them as happy and carefree as possible.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

The February 2013 issue of Health Affairs explores a surprisingly underutilized concept in health care that, until recently, has essentially been ignored – patient empowerment.

For some, this term may conjure up unpleasant memories of annoying encounters in which demanding patients (and family members) tried to dictate their own hospital course. Yet others may recall how some well-informed patients have helped them significantly expedite, as well as optimize, the care they provided.

In an article titled "What the Evidence Shows about Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs," the authors define patient activation as "the skills and confidence that equip patients to become actively engaged in their health care." The authors note that patients who are less "activated" are three times as likely to have their medical needs go unmet and twice as likely to delay medical care, when compared to patients who are more engaged. On the other hand, highly activated patients were found to be at least twice as likely to prepare questions for their doctors and seek out health information, including the quality of health care providers.

In another article in the same issue, "Rx for the ‘Blockbuster Drug’ of Patient Engagement," Susan Denzter noted that evidence is emerging that patients who are actively involved in their medical care have better outcomes and lower medical bills compared with those who are not.

The medical community is finally embracing this crucial issue. We have always known that well-informed patients can bolster their own health care – and make our lives much easier as well. But it seems that in our historically paternalistic health care system, doctors tightly held onto the reins and patients, patients blindly complied (or so we thought).

In 2000, I published "Your Family Medical Record: An Interactive Guide to Getting the Best Care," a book designed to address the tremendous void between how patients think and how we, their doctors, think. At that time, Americans had not yet grasped the importance of patient engagement, and my book is no longer in print. I was a doctor desperately trying to introduce the concept of patient engagement to the American public. At the time, I had high hopes of bridging important gaps by teaching patients easy-to-understand concepts about keeping and understanding their own health records and expediting their own care through applying basic "patient skills," such as how to prepare for visits in advance and how to think through their symptoms in a methodical, concise manner. Thirteen years later, I am thrilled to see others succeeding where I did not, for this concept is far too important to sweep under the carpet.

In the burgeoning age of the Affordable Care Act, physicians are challenged to seek innovative cost-effective new means by which we can optimize the medical care we provide. If we teach our patients a patient skill or two when time allows, we can play an important role in this important paradigm shift in the American health care system that over time will, undoubtedly, help lower health care costs and improve patient care.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. This blog, "Teachable Moments," appears regularly in Hospitalist News.

The February 2013 issue of Health Affairs explores a surprisingly underutilized concept in health care that, until recently, has essentially been ignored – patient empowerment.

For some, this term may conjure up unpleasant memories of annoying encounters in which demanding patients (and family members) tried to dictate their own hospital course. Yet others may recall how some well-informed patients have helped them significantly expedite, as well as optimize, the care they provided.

In an article titled "What the Evidence Shows about Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs," the authors define patient activation as "the skills and confidence that equip patients to become actively engaged in their health care." The authors note that patients who are less "activated" are three times as likely to have their medical needs go unmet and twice as likely to delay medical care, when compared to patients who are more engaged. On the other hand, highly activated patients were found to be at least twice as likely to prepare questions for their doctors and seek out health information, including the quality of health care providers.

In another article in the same issue, "Rx for the ‘Blockbuster Drug’ of Patient Engagement," Susan Denzter noted that evidence is emerging that patients who are actively involved in their medical care have better outcomes and lower medical bills compared with those who are not.

The medical community is finally embracing this crucial issue. We have always known that well-informed patients can bolster their own health care – and make our lives much easier as well. But it seems that in our historically paternalistic health care system, doctors tightly held onto the reins and patients, patients blindly complied (or so we thought).

In 2000, I published "Your Family Medical Record: An Interactive Guide to Getting the Best Care," a book designed to address the tremendous void between how patients think and how we, their doctors, think. At that time, Americans had not yet grasped the importance of patient engagement, and my book is no longer in print. I was a doctor desperately trying to introduce the concept of patient engagement to the American public. At the time, I had high hopes of bridging important gaps by teaching patients easy-to-understand concepts about keeping and understanding their own health records and expediting their own care through applying basic "patient skills," such as how to prepare for visits in advance and how to think through their symptoms in a methodical, concise manner. Thirteen years later, I am thrilled to see others succeeding where I did not, for this concept is far too important to sweep under the carpet.

In the burgeoning age of the Affordable Care Act, physicians are challenged to seek innovative cost-effective new means by which we can optimize the medical care we provide. If we teach our patients a patient skill or two when time allows, we can play an important role in this important paradigm shift in the American health care system that over time will, undoubtedly, help lower health care costs and improve patient care.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. This blog, "Teachable Moments," appears regularly in Hospitalist News.

The February 2013 issue of Health Affairs explores a surprisingly underutilized concept in health care that, until recently, has essentially been ignored – patient empowerment.

For some, this term may conjure up unpleasant memories of annoying encounters in which demanding patients (and family members) tried to dictate their own hospital course. Yet others may recall how some well-informed patients have helped them significantly expedite, as well as optimize, the care they provided.

In an article titled "What the Evidence Shows about Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs," the authors define patient activation as "the skills and confidence that equip patients to become actively engaged in their health care." The authors note that patients who are less "activated" are three times as likely to have their medical needs go unmet and twice as likely to delay medical care, when compared to patients who are more engaged. On the other hand, highly activated patients were found to be at least twice as likely to prepare questions for their doctors and seek out health information, including the quality of health care providers.

In another article in the same issue, "Rx for the ‘Blockbuster Drug’ of Patient Engagement," Susan Denzter noted that evidence is emerging that patients who are actively involved in their medical care have better outcomes and lower medical bills compared with those who are not.

The medical community is finally embracing this crucial issue. We have always known that well-informed patients can bolster their own health care – and make our lives much easier as well. But it seems that in our historically paternalistic health care system, doctors tightly held onto the reins and patients, patients blindly complied (or so we thought).

In 2000, I published "Your Family Medical Record: An Interactive Guide to Getting the Best Care," a book designed to address the tremendous void between how patients think and how we, their doctors, think. At that time, Americans had not yet grasped the importance of patient engagement, and my book is no longer in print. I was a doctor desperately trying to introduce the concept of patient engagement to the American public. At the time, I had high hopes of bridging important gaps by teaching patients easy-to-understand concepts about keeping and understanding their own health records and expediting their own care through applying basic "patient skills," such as how to prepare for visits in advance and how to think through their symptoms in a methodical, concise manner. Thirteen years later, I am thrilled to see others succeeding where I did not, for this concept is far too important to sweep under the carpet.

In the burgeoning age of the Affordable Care Act, physicians are challenged to seek innovative cost-effective new means by which we can optimize the medical care we provide. If we teach our patients a patient skill or two when time allows, we can play an important role in this important paradigm shift in the American health care system that over time will, undoubtedly, help lower health care costs and improve patient care.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. This blog, "Teachable Moments," appears regularly in Hospitalist News.

In 2000, the Institute of Medicine published an oft-cited report, "To Err Is Human: Building a Safer Health System – A Report of The Committee on Quality of Health Care in America." The report estimated that up to 98,000 patients die from preventable medical errors each year.

Many of us can remember the boot camp–like conditions of residency: working incredibly long shifts that made every part of our bodies (and brains) cry out for rest – even a 10-minute nap could bring much-needed relief.

I remember sometimes working 48- to 72-hour shifts, between my regular residency responsibilities and moonlighting in the VA emergency room. That seems like a lifetime ago, a lifetime I would not want to relive.

While we may have been trained to believe we can perform at our peak despite sleep deprivation, in reality many of us made mistakes, whether great or small, as a result of our highly stressed, sleep-deprived state. And if we are honest with ourselves, we would not want to be a patient who is cared for by any doctor whose mental facilities have been impaired due to lack of sleep. Finally, wisdom defeated pride and custom, and residents’ shifts have been limited, which was a true victory for patients and residents alike.

Subsequently, it was acknowledged that nurses also made errors when working in suboptimal conditions. A study in the New England Journal of Medicine found a significant association between low staffing and patient mortality ("Nurse Staffing and Inpatient Hospital Mortality," N. Engl. J. Med. 2011;364:1037-45).

Truth be told, we already knew that nurses and inexperienced resident physicians make mistakes when overwhelmed and overworked, but what about seasoned hospitalists? What about us? Do we honestly believe we are somehow immune to making medical errors because of years of experience?

A piece in the Jan. 28 edition of JAMA – "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists" – sheds light on how we really feel. The survey assessed hospitalists’ perceptions of the association between their workload and patient safety and quality-of-care measures during daytime shifts. The respondents’ average age was 38 years, median time in practice was 6 years, and median annual compensation was $180,000 (doi: 10.1001/jamainternmed.2013.1864).

Important study findings include the following:

• Forty percent of respondents reported that at least once per month, their census exceeded safe levels, and 36% of these noted they experienced unsafe levels multiple times per week.

• Fifteen patients per shift was the magic number that would optimize patient safety, regardless of any assistance doctors received, and that was assuming their shift was a purely clinical shift.

• More than 20% of hospitalists believe their average workload likely contributed to patient transfers, patient suffering, or even the death of patients. That was the most sobering finding of the study.

This study has profound implications for patient safety, and less importantly, patient satisfaction. The potential for unnecessary suffering, excessive medical costs, and unnecessary death is staggering. The actual number of physicians who are willing to admit their limitations is likely far lower than the actual number who experience these adverse effects, even if they are oblivious to their understandable limitations.

When the pager is going off incessantly while you are answering another call, and nurses are lined up to ask you questions about their patients, and, of course, you have a patient or two in the ER who need your attention, it is easy to get sidetracked. To err is human.

The bottom line is patients are the bottom line. They depend on us to provide safe, compassionate, high-quality health care. They literally entrust their lives to us, and we must honor that trust by speaking up if we feel like their safety is in jeopardy, and work with hospitalist directors and hospital administrators to create an environment in which patient safety is valued above all.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

In 2000, the Institute of Medicine published an oft-cited report, "To Err Is Human: Building a Safer Health System – A Report of The Committee on Quality of Health Care in America." The report estimated that up to 98,000 patients die from preventable medical errors each year.

Many of us can remember the boot camp–like conditions of residency: working incredibly long shifts that made every part of our bodies (and brains) cry out for rest – even a 10-minute nap could bring much-needed relief.

I remember sometimes working 48- to 72-hour shifts, between my regular residency responsibilities and moonlighting in the VA emergency room. That seems like a lifetime ago, a lifetime I would not want to relive.

While we may have been trained to believe we can perform at our peak despite sleep deprivation, in reality many of us made mistakes, whether great or small, as a result of our highly stressed, sleep-deprived state. And if we are honest with ourselves, we would not want to be a patient who is cared for by any doctor whose mental facilities have been impaired due to lack of sleep. Finally, wisdom defeated pride and custom, and residents’ shifts have been limited, which was a true victory for patients and residents alike.

Subsequently, it was acknowledged that nurses also made errors when working in suboptimal conditions. A study in the New England Journal of Medicine found a significant association between low staffing and patient mortality ("Nurse Staffing and Inpatient Hospital Mortality," N. Engl. J. Med. 2011;364:1037-45).

Truth be told, we already knew that nurses and inexperienced resident physicians make mistakes when overwhelmed and overworked, but what about seasoned hospitalists? What about us? Do we honestly believe we are somehow immune to making medical errors because of years of experience?

A piece in the Jan. 28 edition of JAMA – "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists" – sheds light on how we really feel. The survey assessed hospitalists’ perceptions of the association between their workload and patient safety and quality-of-care measures during daytime shifts. The respondents’ average age was 38 years, median time in practice was 6 years, and median annual compensation was $180,000 (doi: 10.1001/jamainternmed.2013.1864).

Important study findings include the following:

• Forty percent of respondents reported that at least once per month, their census exceeded safe levels, and 36% of these noted they experienced unsafe levels multiple times per week.

• Fifteen patients per shift was the magic number that would optimize patient safety, regardless of any assistance doctors received, and that was assuming their shift was a purely clinical shift.

• More than 20% of hospitalists believe their average workload likely contributed to patient transfers, patient suffering, or even the death of patients. That was the most sobering finding of the study.

This study has profound implications for patient safety, and less importantly, patient satisfaction. The potential for unnecessary suffering, excessive medical costs, and unnecessary death is staggering. The actual number of physicians who are willing to admit their limitations is likely far lower than the actual number who experience these adverse effects, even if they are oblivious to their understandable limitations.

When the pager is going off incessantly while you are answering another call, and nurses are lined up to ask you questions about their patients, and, of course, you have a patient or two in the ER who need your attention, it is easy to get sidetracked. To err is human.

The bottom line is patients are the bottom line. They depend on us to provide safe, compassionate, high-quality health care. They literally entrust their lives to us, and we must honor that trust by speaking up if we feel like their safety is in jeopardy, and work with hospitalist directors and hospital administrators to create an environment in which patient safety is valued above all.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

In 2000, the Institute of Medicine published an oft-cited report, "To Err Is Human: Building a Safer Health System – A Report of The Committee on Quality of Health Care in America." The report estimated that up to 98,000 patients die from preventable medical errors each year.

Many of us can remember the boot camp–like conditions of residency: working incredibly long shifts that made every part of our bodies (and brains) cry out for rest – even a 10-minute nap could bring much-needed relief.

I remember sometimes working 48- to 72-hour shifts, between my regular residency responsibilities and moonlighting in the VA emergency room. That seems like a lifetime ago, a lifetime I would not want to relive.

While we may have been trained to believe we can perform at our peak despite sleep deprivation, in reality many of us made mistakes, whether great or small, as a result of our highly stressed, sleep-deprived state. And if we are honest with ourselves, we would not want to be a patient who is cared for by any doctor whose mental facilities have been impaired due to lack of sleep. Finally, wisdom defeated pride and custom, and residents’ shifts have been limited, which was a true victory for patients and residents alike.

Subsequently, it was acknowledged that nurses also made errors when working in suboptimal conditions. A study in the New England Journal of Medicine found a significant association between low staffing and patient mortality ("Nurse Staffing and Inpatient Hospital Mortality," N. Engl. J. Med. 2011;364:1037-45).

Truth be told, we already knew that nurses and inexperienced resident physicians make mistakes when overwhelmed and overworked, but what about seasoned hospitalists? What about us? Do we honestly believe we are somehow immune to making medical errors because of years of experience?

A piece in the Jan. 28 edition of JAMA – "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists" – sheds light on how we really feel. The survey assessed hospitalists’ perceptions of the association between their workload and patient safety and quality-of-care measures during daytime shifts. The respondents’ average age was 38 years, median time in practice was 6 years, and median annual compensation was $180,000 (doi: 10.1001/jamainternmed.2013.1864).

Important study findings include the following:

• Forty percent of respondents reported that at least once per month, their census exceeded safe levels, and 36% of these noted they experienced unsafe levels multiple times per week.

• Fifteen patients per shift was the magic number that would optimize patient safety, regardless of any assistance doctors received, and that was assuming their shift was a purely clinical shift.

• More than 20% of hospitalists believe their average workload likely contributed to patient transfers, patient suffering, or even the death of patients. That was the most sobering finding of the study.

This study has profound implications for patient safety, and less importantly, patient satisfaction. The potential for unnecessary suffering, excessive medical costs, and unnecessary death is staggering. The actual number of physicians who are willing to admit their limitations is likely far lower than the actual number who experience these adverse effects, even if they are oblivious to their understandable limitations.

When the pager is going off incessantly while you are answering another call, and nurses are lined up to ask you questions about their patients, and, of course, you have a patient or two in the ER who need your attention, it is easy to get sidetracked. To err is human.

The bottom line is patients are the bottom line. They depend on us to provide safe, compassionate, high-quality health care. They literally entrust their lives to us, and we must honor that trust by speaking up if we feel like their safety is in jeopardy, and work with hospitalist directors and hospital administrators to create an environment in which patient safety is valued above all.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Most of us struggle to be proficient in that fine art of balancing high-quality, cost-effective medical care, patient and family satisfaction, and length of stay. One, or even two, of these without the other, just won’t cut muster these days, and with the CMS Hospital Readmissions Reduction Program, the pressure is on to cut readmissions within 30 days of discharge, or else! (Section 3025 of the Affordable Care Act requires the CMS to reduce payments to acute care hospitals with excessive readmission rates as of Oct. 1, 2012.)

Realistically, we all know that even if we provide the best medical care possible, there will always be patients with chronic, end-stage disease whom we will never "fix." The best we can do is optimize the quality of their lives until they die or are readmitted and the cycle begins again. But there may be much more we as hospitalists can do to optimize the overall care of our patients to improve their outcomes, and save our hospitals a great deal of money at the same time.

"Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk" an article published Jan. 10 in the New England Journal of Medicine, gives excellent insight into underappreciated factors that result in readmission to the hospital (N. Engl. J. Med. 2013;368:100-2). Approximately one-fifth of Medicare patients admitted to a hospital require readmission within 30 days, surprisingly often for conditions completely unrelated to the original reason for admission. For instance, among patients initially admitted for heart failure, only 37% of readmissions within 30 days were for worsening heart failure. Likewise, after a hospitalization for a COPD exacerbation, only 36% of readmissions within 30 days were for another exacerbation.

Regardless of the original reason for admission, common causes of readmission include infection, gastrointestinal conditions, metabolic derangements, mental illness, trauma, heart failure, COPD, and pneumonia. And, despite what would seem intuitive, the severity of the initial illness did not help predict which patients would require readmission.

Sleep deprivation is a major contributor to postdischarge morbidity. Polysomnographic studies have demonstrated a reduction in REM sleep and an increase in non-REM sleep in hospitalized patients. Sleep deprivation is known to adversely impact immune function, cardiac risk, and even the coagulation cascade, in addition to the more obvious things such as mental function, ability to ambulate safely, and emotional well-being.

Inadequate nutrition is another culprit. Between being NPO for procedures, which are commonly rescheduled, feeling too sick (or too groggy) to eat, and the increased catabolic demands of many acute illnesses, the pendulum often swings far away from a homeostasis into a potentially dangerous zone, despite how the patient may look at first glance. Some potential consequences of poor nutrition include impaired wound healing, increased infection risk, and decreased cardiac and respiratory function.

Other factors, such as uncontrolled pain, a host of new medications – with myriad side effects – and deconditioning from lying in bed for prolonged periods also play key roles in setting patients up for a potentially debilitating vulnerability that often results in yet another acute illness requiring hospitalization not long after their initial discharge.

We ought to start thinking about discharge planning when we first admit patients. Based on this article, we need to include innovative ways to decrease the posthospital syndrome. There are some simple things we can do: Optimize pain control, get them out of bed as soon as possible, and create an environment to facilitate peaceful sleep. For example, we can easily minimize interruptions during early morning hours for vital sign checks and blood draws in stable patients. (Do we really need routine follow-up lab to be drawn at 6 a.m. in every patient?)

We should all think about our workflow and what we can do differently to minimize the physiologic vulnerability of our patients at discharge so they can be safely discharged (and stay discharged).

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. 

Most of us struggle to be proficient in that fine art of balancing high-quality, cost-effective medical care, patient and family satisfaction, and length of stay. One, or even two, of these without the other, just won’t cut muster these days, and with the CMS Hospital Readmissions Reduction Program, the pressure is on to cut readmissions within 30 days of discharge, or else! (Section 3025 of the Affordable Care Act requires the CMS to reduce payments to acute care hospitals with excessive readmission rates as of Oct. 1, 2012.)

Realistically, we all know that even if we provide the best medical care possible, there will always be patients with chronic, end-stage disease whom we will never "fix." The best we can do is optimize the quality of their lives until they die or are readmitted and the cycle begins again. But there may be much more we as hospitalists can do to optimize the overall care of our patients to improve their outcomes, and save our hospitals a great deal of money at the same time.

"Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk" an article published Jan. 10 in the New England Journal of Medicine, gives excellent insight into underappreciated factors that result in readmission to the hospital (N. Engl. J. Med. 2013;368:100-2). Approximately one-fifth of Medicare patients admitted to a hospital require readmission within 30 days, surprisingly often for conditions completely unrelated to the original reason for admission. For instance, among patients initially admitted for heart failure, only 37% of readmissions within 30 days were for worsening heart failure. Likewise, after a hospitalization for a COPD exacerbation, only 36% of readmissions within 30 days were for another exacerbation.

Regardless of the original reason for admission, common causes of readmission include infection, gastrointestinal conditions, metabolic derangements, mental illness, trauma, heart failure, COPD, and pneumonia. And, despite what would seem intuitive, the severity of the initial illness did not help predict which patients would require readmission.

Sleep deprivation is a major contributor to postdischarge morbidity. Polysomnographic studies have demonstrated a reduction in REM sleep and an increase in non-REM sleep in hospitalized patients. Sleep deprivation is known to adversely impact immune function, cardiac risk, and even the coagulation cascade, in addition to the more obvious things such as mental function, ability to ambulate safely, and emotional well-being.

Inadequate nutrition is another culprit. Between being NPO for procedures, which are commonly rescheduled, feeling too sick (or too groggy) to eat, and the increased catabolic demands of many acute illnesses, the pendulum often swings far away from a homeostasis into a potentially dangerous zone, despite how the patient may look at first glance. Some potential consequences of poor nutrition include impaired wound healing, increased infection risk, and decreased cardiac and respiratory function.

Other factors, such as uncontrolled pain, a host of new medications – with myriad side effects – and deconditioning from lying in bed for prolonged periods also play key roles in setting patients up for a potentially debilitating vulnerability that often results in yet another acute illness requiring hospitalization not long after their initial discharge.

We ought to start thinking about discharge planning when we first admit patients. Based on this article, we need to include innovative ways to decrease the posthospital syndrome. There are some simple things we can do: Optimize pain control, get them out of bed as soon as possible, and create an environment to facilitate peaceful sleep. For example, we can easily minimize interruptions during early morning hours for vital sign checks and blood draws in stable patients. (Do we really need routine follow-up lab to be drawn at 6 a.m. in every patient?)

We should all think about our workflow and what we can do differently to minimize the physiologic vulnerability of our patients at discharge so they can be safely discharged (and stay discharged).

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. 

Most of us struggle to be proficient in that fine art of balancing high-quality, cost-effective medical care, patient and family satisfaction, and length of stay. One, or even two, of these without the other, just won’t cut muster these days, and with the CMS Hospital Readmissions Reduction Program, the pressure is on to cut readmissions within 30 days of discharge, or else! (Section 3025 of the Affordable Care Act requires the CMS to reduce payments to acute care hospitals with excessive readmission rates as of Oct. 1, 2012.)

Realistically, we all know that even if we provide the best medical care possible, there will always be patients with chronic, end-stage disease whom we will never "fix." The best we can do is optimize the quality of their lives until they die or are readmitted and the cycle begins again. But there may be much more we as hospitalists can do to optimize the overall care of our patients to improve their outcomes, and save our hospitals a great deal of money at the same time.

"Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk" an article published Jan. 10 in the New England Journal of Medicine, gives excellent insight into underappreciated factors that result in readmission to the hospital (N. Engl. J. Med. 2013;368:100-2). Approximately one-fifth of Medicare patients admitted to a hospital require readmission within 30 days, surprisingly often for conditions completely unrelated to the original reason for admission. For instance, among patients initially admitted for heart failure, only 37% of readmissions within 30 days were for worsening heart failure. Likewise, after a hospitalization for a COPD exacerbation, only 36% of readmissions within 30 days were for another exacerbation.

Regardless of the original reason for admission, common causes of readmission include infection, gastrointestinal conditions, metabolic derangements, mental illness, trauma, heart failure, COPD, and pneumonia. And, despite what would seem intuitive, the severity of the initial illness did not help predict which patients would require readmission.

Sleep deprivation is a major contributor to postdischarge morbidity. Polysomnographic studies have demonstrated a reduction in REM sleep and an increase in non-REM sleep in hospitalized patients. Sleep deprivation is known to adversely impact immune function, cardiac risk, and even the coagulation cascade, in addition to the more obvious things such as mental function, ability to ambulate safely, and emotional well-being.

Inadequate nutrition is another culprit. Between being NPO for procedures, which are commonly rescheduled, feeling too sick (or too groggy) to eat, and the increased catabolic demands of many acute illnesses, the pendulum often swings far away from a homeostasis into a potentially dangerous zone, despite how the patient may look at first glance. Some potential consequences of poor nutrition include impaired wound healing, increased infection risk, and decreased cardiac and respiratory function.

Other factors, such as uncontrolled pain, a host of new medications – with myriad side effects – and deconditioning from lying in bed for prolonged periods also play key roles in setting patients up for a potentially debilitating vulnerability that often results in yet another acute illness requiring hospitalization not long after their initial discharge.

We ought to start thinking about discharge planning when we first admit patients. Based on this article, we need to include innovative ways to decrease the posthospital syndrome. There are some simple things we can do: Optimize pain control, get them out of bed as soon as possible, and create an environment to facilitate peaceful sleep. For example, we can easily minimize interruptions during early morning hours for vital sign checks and blood draws in stable patients. (Do we really need routine follow-up lab to be drawn at 6 a.m. in every patient?)

We should all think about our workflow and what we can do differently to minimize the physiologic vulnerability of our patients at discharge so they can be safely discharged (and stay discharged).

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. 

"Seriously? ... Okay. Get a stat x-ray of the pelvis and hips and tell the family I’ll be up within 5 minutes."

You hang up the phone incredulous! After 4 weeks in the critical care unit, 2 weeks in a step-down unit, and an additional 8 days on the general medical ward, your patient was finally on the launching pad.

You had spent 90 minutes the night before meticulously reviewing every nursing note, physical therapy recommendation, and a myriad of consultants notes to make sure your discharge summary thoroughly reflected her very complicated hospital course. Last night, she was alert and chatting up a storm. At times, she did not even know if she would ever make it out of the hospital (and neither did you), and here it was, the long-awaited day of discharge, and she wakes up groggy and takes a bad fall on her way to the bathroom.

The list of possible explanations for her new-onset grogginess race through your mind. The likelihood of a stroke is remote. Her vital signs and morning labs are all normal. She was weaned off pain meds weeks ago, and her only complaint for the past few days had been insomnia, for which you ordered zolpidem PRN. Surely that could not be the culprit ... or could it?

Recent evidence shows that sleep aids containing the popular drug zolpidem may be linked to decreased alertness the morning after use, particularly the long-acting formulations. In some patients, blood levels of the drug may remain high enough to put patients at risk when performing tasks that require mental alertness. Evidence of this association was so compelling, the Food and Drug Administration recently announced that it is requiring manufacturers of Ambien, Ambien CR, Zolpimist, and Edluar, sleep aids that contain zolpidem, to lower recommended doses. Women are at particular risk, since they eliminate the drug more slowly than do men. Accordingly, the new FDA-recommended dose for women was cut in half – 5 mg for immediate-release products and 6.25 mg for extended-release products.

Of course, zolpidem is not alone in its propensity to cause grogginess. Virtually any sleep aid can do so because, well, that is what it they are designed to do – make patients sleepy.

This recent drug-safety information was so interesting because we often have a false sense of security when prescribing this drug, and we prescribe it very often. It is our "safer" alternative to valium-type medications. We are now encouraged to order a safer dose of this frequently prescribed drug.

I ordered a lower dose myself right after reading the latest FDA report.

The bottom line is that we need to be aware what this study showed so we can alter our prescribing habits and order the lower dose. All medications have the potential to have side effects in a minority of patients, but it is very important for us to know and react when new recommendations come out that have the potential to be so far reaching.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

"Seriously? ... Okay. Get a stat x-ray of the pelvis and hips and tell the family I’ll be up within 5 minutes."

You hang up the phone incredulous! After 4 weeks in the critical care unit, 2 weeks in a step-down unit, and an additional 8 days on the general medical ward, your patient was finally on the launching pad.

You had spent 90 minutes the night before meticulously reviewing every nursing note, physical therapy recommendation, and a myriad of consultants notes to make sure your discharge summary thoroughly reflected her very complicated hospital course. Last night, she was alert and chatting up a storm. At times, she did not even know if she would ever make it out of the hospital (and neither did you), and here it was, the long-awaited day of discharge, and she wakes up groggy and takes a bad fall on her way to the bathroom.

The list of possible explanations for her new-onset grogginess race through your mind. The likelihood of a stroke is remote. Her vital signs and morning labs are all normal. She was weaned off pain meds weeks ago, and her only complaint for the past few days had been insomnia, for which you ordered zolpidem PRN. Surely that could not be the culprit ... or could it?

Recent evidence shows that sleep aids containing the popular drug zolpidem may be linked to decreased alertness the morning after use, particularly the long-acting formulations. In some patients, blood levels of the drug may remain high enough to put patients at risk when performing tasks that require mental alertness. Evidence of this association was so compelling, the Food and Drug Administration recently announced that it is requiring manufacturers of Ambien, Ambien CR, Zolpimist, and Edluar, sleep aids that contain zolpidem, to lower recommended doses. Women are at particular risk, since they eliminate the drug more slowly than do men. Accordingly, the new FDA-recommended dose for women was cut in half – 5 mg for immediate-release products and 6.25 mg for extended-release products.

Of course, zolpidem is not alone in its propensity to cause grogginess. Virtually any sleep aid can do so because, well, that is what it they are designed to do – make patients sleepy.

This recent drug-safety information was so interesting because we often have a false sense of security when prescribing this drug, and we prescribe it very often. It is our "safer" alternative to valium-type medications. We are now encouraged to order a safer dose of this frequently prescribed drug.

I ordered a lower dose myself right after reading the latest FDA report.

The bottom line is that we need to be aware what this study showed so we can alter our prescribing habits and order the lower dose. All medications have the potential to have side effects in a minority of patients, but it is very important for us to know and react when new recommendations come out that have the potential to be so far reaching.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

"Seriously? ... Okay. Get a stat x-ray of the pelvis and hips and tell the family I’ll be up within 5 minutes."

You hang up the phone incredulous! After 4 weeks in the critical care unit, 2 weeks in a step-down unit, and an additional 8 days on the general medical ward, your patient was finally on the launching pad.

You had spent 90 minutes the night before meticulously reviewing every nursing note, physical therapy recommendation, and a myriad of consultants notes to make sure your discharge summary thoroughly reflected her very complicated hospital course. Last night, she was alert and chatting up a storm. At times, she did not even know if she would ever make it out of the hospital (and neither did you), and here it was, the long-awaited day of discharge, and she wakes up groggy and takes a bad fall on her way to the bathroom.

The list of possible explanations for her new-onset grogginess race through your mind. The likelihood of a stroke is remote. Her vital signs and morning labs are all normal. She was weaned off pain meds weeks ago, and her only complaint for the past few days had been insomnia, for which you ordered zolpidem PRN. Surely that could not be the culprit ... or could it?

Recent evidence shows that sleep aids containing the popular drug zolpidem may be linked to decreased alertness the morning after use, particularly the long-acting formulations. In some patients, blood levels of the drug may remain high enough to put patients at risk when performing tasks that require mental alertness. Evidence of this association was so compelling, the Food and Drug Administration recently announced that it is requiring manufacturers of Ambien, Ambien CR, Zolpimist, and Edluar, sleep aids that contain zolpidem, to lower recommended doses. Women are at particular risk, since they eliminate the drug more slowly than do men. Accordingly, the new FDA-recommended dose for women was cut in half – 5 mg for immediate-release products and 6.25 mg for extended-release products.

Of course, zolpidem is not alone in its propensity to cause grogginess. Virtually any sleep aid can do so because, well, that is what it they are designed to do – make patients sleepy.

This recent drug-safety information was so interesting because we often have a false sense of security when prescribing this drug, and we prescribe it very often. It is our "safer" alternative to valium-type medications. We are now encouraged to order a safer dose of this frequently prescribed drug.

I ordered a lower dose myself right after reading the latest FDA report.

The bottom line is that we need to be aware what this study showed so we can alter our prescribing habits and order the lower dose. All medications have the potential to have side effects in a minority of patients, but it is very important for us to know and react when new recommendations come out that have the potential to be so far reaching.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.