Sherry Boschert

BELLEVUE, WASH.  – When tired parents complain that their child wakes up frequently at night – and wakes them up – you can offer them a hardball approach or softball approach to dealing with the problem.

The hardball approach is far more effective and more quickly resolves night wakings, but some parents find the idea of it intolerable. For them, there’s the softball approach, Dr. Charles H. Zeanah Jr. said at the annual meeting of the North Pacific Pediatric Society.

Photo credit: a-fitz/iStockphoto.com

The goal of both strategies is to teach the child to fall asleep on his or her own. Waking during the night is normal at age 3-6 months, and 30% of infants are "signalers" who cry and expect someone to respond. By 8 months of age, 60%-70% of infants self-soothe after waking during the night. Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, he said.

"Somewhere between 6 and 9 months of age, I may start to think of it as a disorder or impairment, not just for the child but [also] for the parent," said Dr. Zeanah, professor of clinical pediatrics and psychiatry and director of child and adolescent psychiatry at Tulane University, New Orleans.

First, take a good history of family structure and routines around bedtime, limit-setting behaviors, distress, what tactics the parents have tried, and whether the parents agree on what needs to be done.

"It’s amazing how many people don’t have a bedtime routine," he said. "The key question is, ‘Is the child put down while awake?’ " Learning how to fall asleep at bedtime on his or her own, without "signaling," allows the child to fall back asleep after waking during the night.

Before talking about the hardball or softball approach to teaching a child to fall asleep on his or her own, Dr. Zeanah plays a little "hard to get" with the parents, to assess their commitment to an intervention. He tells them that there’s no evidence that night wakings cause a mental illness or severely damage a child. "I know it’s annoying, but I’m not sure if you want to do something about this" night-waking problem, he says.

Tired parents usually do want to intervene.

The first steps are to create a set bedtime and establish a consistent bedtime routine (such as reading a story) that ends in the child’s room. Finish the routine before the child falls asleep.

Then he explains the hardball approach: If the child cries when you leave, wait 5 minutes, go back and soothe the child without using words (for instance, by patting or rubbing the child’s back), then leave again. If the child cries again, repeat until the child falls asleep. Over the ensuing days, gradually increase the 5-minute interval to longer stretches between soothings.

"The rigidity of this is the key," Dr. Zeanah said, and it works. In 30 years of practice, he has never seen a child last more than a week before learning to fall asleep on his or her own.

If a parent can’t handle letting the child cry because they fear the child is scared to be alone, he explains the softball approach: When the child cries, go in and sit in a chair next to the child’s bed without interacting with the child, which takes any fear out of the situation. Sit in the chair until the child falls asleep. The next night, move the chair a couple of feet toward the door. Move a little more toward the door each night until the chair is outside the door, but visible to the child when you sit in it. Then pull the chair back so just your knees are visible, and eventually so the parent can’t be seen.

"It’s not as effective" as the hardball approach, but helps in some cases, he said.

With either approach, he asks parents to call him early in the morning after the first night of the intervention to let him know how it went. Check in with parents frequently during the intervention to encourage them and make adjustments, he advised.

With the hardball approach, "by the third night, there’s usually no reason to call," he said.

Dr. Zeanah reported having no financial disclosures.

BELLEVUE, WASH.  – When tired parents complain that their child wakes up frequently at night – and wakes them up – you can offer them a hardball approach or softball approach to dealing with the problem.

The hardball approach is far more effective and more quickly resolves night wakings, but some parents find the idea of it intolerable. For them, there’s the softball approach, Dr. Charles H. Zeanah Jr. said at the annual meeting of the North Pacific Pediatric Society.

Photo credit: a-fitz/iStockphoto.com

The goal of both strategies is to teach the child to fall asleep on his or her own. Waking during the night is normal at age 3-6 months, and 30% of infants are "signalers" who cry and expect someone to respond. By 8 months of age, 60%-70% of infants self-soothe after waking during the night. Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, he said.

"Somewhere between 6 and 9 months of age, I may start to think of it as a disorder or impairment, not just for the child but [also] for the parent," said Dr. Zeanah, professor of clinical pediatrics and psychiatry and director of child and adolescent psychiatry at Tulane University, New Orleans.

First, take a good history of family structure and routines around bedtime, limit-setting behaviors, distress, what tactics the parents have tried, and whether the parents agree on what needs to be done.

"It’s amazing how many people don’t have a bedtime routine," he said. "The key question is, ‘Is the child put down while awake?’ " Learning how to fall asleep at bedtime on his or her own, without "signaling," allows the child to fall back asleep after waking during the night.

Before talking about the hardball or softball approach to teaching a child to fall asleep on his or her own, Dr. Zeanah plays a little "hard to get" with the parents, to assess their commitment to an intervention. He tells them that there’s no evidence that night wakings cause a mental illness or severely damage a child. "I know it’s annoying, but I’m not sure if you want to do something about this" night-waking problem, he says.

Tired parents usually do want to intervene.

The first steps are to create a set bedtime and establish a consistent bedtime routine (such as reading a story) that ends in the child’s room. Finish the routine before the child falls asleep.

Then he explains the hardball approach: If the child cries when you leave, wait 5 minutes, go back and soothe the child without using words (for instance, by patting or rubbing the child’s back), then leave again. If the child cries again, repeat until the child falls asleep. Over the ensuing days, gradually increase the 5-minute interval to longer stretches between soothings.

"The rigidity of this is the key," Dr. Zeanah said, and it works. In 30 years of practice, he has never seen a child last more than a week before learning to fall asleep on his or her own.

If a parent can’t handle letting the child cry because they fear the child is scared to be alone, he explains the softball approach: When the child cries, go in and sit in a chair next to the child’s bed without interacting with the child, which takes any fear out of the situation. Sit in the chair until the child falls asleep. The next night, move the chair a couple of feet toward the door. Move a little more toward the door each night until the chair is outside the door, but visible to the child when you sit in it. Then pull the chair back so just your knees are visible, and eventually so the parent can’t be seen.

"It’s not as effective" as the hardball approach, but helps in some cases, he said.

With either approach, he asks parents to call him early in the morning after the first night of the intervention to let him know how it went. Check in with parents frequently during the intervention to encourage them and make adjustments, he advised.

With the hardball approach, "by the third night, there’s usually no reason to call," he said.

Dr. Zeanah reported having no financial disclosures.

BELLEVUE, WASH.  – When tired parents complain that their child wakes up frequently at night – and wakes them up – you can offer them a hardball approach or softball approach to dealing with the problem.

The hardball approach is far more effective and more quickly resolves night wakings, but some parents find the idea of it intolerable. For them, there’s the softball approach, Dr. Charles H. Zeanah Jr. said at the annual meeting of the North Pacific Pediatric Society.

Photo credit: a-fitz/iStockphoto.com

The goal of both strategies is to teach the child to fall asleep on his or her own. Waking during the night is normal at age 3-6 months, and 30% of infants are "signalers" who cry and expect someone to respond. By 8 months of age, 60%-70% of infants self-soothe after waking during the night. Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, he said.

"Somewhere between 6 and 9 months of age, I may start to think of it as a disorder or impairment, not just for the child but [also] for the parent," said Dr. Zeanah, professor of clinical pediatrics and psychiatry and director of child and adolescent psychiatry at Tulane University, New Orleans.

First, take a good history of family structure and routines around bedtime, limit-setting behaviors, distress, what tactics the parents have tried, and whether the parents agree on what needs to be done.

"It’s amazing how many people don’t have a bedtime routine," he said. "The key question is, ‘Is the child put down while awake?’ " Learning how to fall asleep at bedtime on his or her own, without "signaling," allows the child to fall back asleep after waking during the night.

Before talking about the hardball or softball approach to teaching a child to fall asleep on his or her own, Dr. Zeanah plays a little "hard to get" with the parents, to assess their commitment to an intervention. He tells them that there’s no evidence that night wakings cause a mental illness or severely damage a child. "I know it’s annoying, but I’m not sure if you want to do something about this" night-waking problem, he says.

Tired parents usually do want to intervene.

The first steps are to create a set bedtime and establish a consistent bedtime routine (such as reading a story) that ends in the child’s room. Finish the routine before the child falls asleep.

Then he explains the hardball approach: If the child cries when you leave, wait 5 minutes, go back and soothe the child without using words (for instance, by patting or rubbing the child’s back), then leave again. If the child cries again, repeat until the child falls asleep. Over the ensuing days, gradually increase the 5-minute interval to longer stretches between soothings.

"The rigidity of this is the key," Dr. Zeanah said, and it works. In 30 years of practice, he has never seen a child last more than a week before learning to fall asleep on his or her own.

If a parent can’t handle letting the child cry because they fear the child is scared to be alone, he explains the softball approach: When the child cries, go in and sit in a chair next to the child’s bed without interacting with the child, which takes any fear out of the situation. Sit in the chair until the child falls asleep. The next night, move the chair a couple of feet toward the door. Move a little more toward the door each night until the chair is outside the door, but visible to the child when you sit in it. Then pull the chair back so just your knees are visible, and eventually so the parent can’t be seen.

"It’s not as effective" as the hardball approach, but helps in some cases, he said.

With either approach, he asks parents to call him early in the morning after the first night of the intervention to let him know how it went. Check in with parents frequently during the intervention to encourage them and make adjustments, he advised.

With the hardball approach, "by the third night, there’s usually no reason to call," he said.

Dr. Zeanah reported having no financial disclosures.

SAN DIEGO – The risk of venous thromboembolism in women using an etonogestrel-containing vaginal ring did not differ significantly from the risk in women on combined oral contraceptives over a 4-year period, a prospective cohort study of 33,704 women found.

There were 56 (less than 1%) venous thromboemboli during the study. The rate of venous thromboembolism (VTE) was approximately 9/10,000 woman-years in 16,884 women using the NuvaRing and in 16,820 women on combined oral contraceptives (OCs), Dr. Klaas Heinemann Jr. and his associates reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Photo courtesy Organon Inc

Subanalyses also found no significant difference in risk when comparing NuvaRing with combined OC regimens that did not contain desogestrel, gestodene, drospirenone, or combinations of those, said Dr. Heinemann, managing director of a private research institute, the Berlin Center for Epidemiology and Health Research.

There were 1,915 serious adverse events during the TASC (Transatlantic Active Surveillance on Cardiovascular Safety of NuvaRing) study. Rates of serious adverse events were less than 300 events/10,000 woman-years in women on NuvaRing or combined OCs and in women who had stopped treatment, but were not pregnant. The risk of serious adverse events did not differ significantly between those groups, but was significantly higher in women who became pregnant, who had 900 serious adverse events per 10,000 woman-years.

The study defined serious adverse events as any adverse event that results in death, a life-threatening experience, inpatient hospitalization, persistent or significant disability or incapacity, or the need for medical or surgical intervention to prevent one of these events. Most serious adverse events involved injury, the genitourinary system (ovarian cysts, kidney stones, salpingitis, UTI), or the digestive system (appendectomy).

From 2007 to 2012, the investigators followed patients recruited by ob.gyns. at more than 3,000 centers in the United States and five European countries, with 51% of the women enrolled at U.S. centers. Follow-up was by patient questionnaire at 6, 12, 24, 36, and 48 months, with all patient-reported outcomes verified with the attending physician. Three percent of patients were lost to follow-up in each of the NuvaRing and combined OC groups. The investigators controlled for the effects of previous hormonal contraceptive use, the patient’s medical history, and a family history of VTE.

Patients in the NuvaRing and combined OC groups did not differ significantly in age, although use of NuvaRing was slightly lower in women younger than 20 years, compared with use of OCs. In the NuvaRing group, 9% were younger than 20 years, 55% were aged 20-29 years, 27% were aged 30-39 years, and 9% were 40 years or older. In the combined OCs group, the distribution was 16%, 54%, 22%, and 8%, respectively.

The two groups also did not differ significantly in body mass index (BMI), smoking rates, regular use of medications, or history of VTE or arterial thromboembolism. Less than 2% in each group had a history of VTE or arterial thromboembolism, a nonsignificant difference.

Compared with patients in Europe, U.S. patients were more likely to have a BMI of 30 kg/m² or greater (25% vs. 13%), were half as likely to smoke (16% vs. 30%), and were more likely to be using medication regularly, mainly psychotropic medications (23% vs. 10%), Dr. Heinemann said.

The study won first prize from the ACOG’s committee on the scientific program among meeting papers on current clinical and basic investigations.

The findings are limited by the observational design of the study. Information on specific gene mutations were not available for many patients, but the predictive value of these mutations for VTE is low compared with the predictive value of family history, he said.

The study included women who were using contraceptives for the first time or switching from other contraceptives or previous users of NuvaRing who had at least a 4-week break since previous use. Long-term users of these contraceptive methods were excluded from the study because the risk for VTE is highest in the first few months of use.

The study was funded by Merck, which markets NuvaRing. Dr. Heinemann reported no other financial disclosures.

SAN DIEGO – The risk of venous thromboembolism in women using an etonogestrel-containing vaginal ring did not differ significantly from the risk in women on combined oral contraceptives over a 4-year period, a prospective cohort study of 33,704 women found.

There were 56 (less than 1%) venous thromboemboli during the study. The rate of venous thromboembolism (VTE) was approximately 9/10,000 woman-years in 16,884 women using the NuvaRing and in 16,820 women on combined oral contraceptives (OCs), Dr. Klaas Heinemann Jr. and his associates reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Photo courtesy Organon Inc

Subanalyses also found no significant difference in risk when comparing NuvaRing with combined OC regimens that did not contain desogestrel, gestodene, drospirenone, or combinations of those, said Dr. Heinemann, managing director of a private research institute, the Berlin Center for Epidemiology and Health Research.

There were 1,915 serious adverse events during the TASC (Transatlantic Active Surveillance on Cardiovascular Safety of NuvaRing) study. Rates of serious adverse events were less than 300 events/10,000 woman-years in women on NuvaRing or combined OCs and in women who had stopped treatment, but were not pregnant. The risk of serious adverse events did not differ significantly between those groups, but was significantly higher in women who became pregnant, who had 900 serious adverse events per 10,000 woman-years.

The study defined serious adverse events as any adverse event that results in death, a life-threatening experience, inpatient hospitalization, persistent or significant disability or incapacity, or the need for medical or surgical intervention to prevent one of these events. Most serious adverse events involved injury, the genitourinary system (ovarian cysts, kidney stones, salpingitis, UTI), or the digestive system (appendectomy).

From 2007 to 2012, the investigators followed patients recruited by ob.gyns. at more than 3,000 centers in the United States and five European countries, with 51% of the women enrolled at U.S. centers. Follow-up was by patient questionnaire at 6, 12, 24, 36, and 48 months, with all patient-reported outcomes verified with the attending physician. Three percent of patients were lost to follow-up in each of the NuvaRing and combined OC groups. The investigators controlled for the effects of previous hormonal contraceptive use, the patient’s medical history, and a family history of VTE.

Patients in the NuvaRing and combined OC groups did not differ significantly in age, although use of NuvaRing was slightly lower in women younger than 20 years, compared with use of OCs. In the NuvaRing group, 9% were younger than 20 years, 55% were aged 20-29 years, 27% were aged 30-39 years, and 9% were 40 years or older. In the combined OCs group, the distribution was 16%, 54%, 22%, and 8%, respectively.

The two groups also did not differ significantly in body mass index (BMI), smoking rates, regular use of medications, or history of VTE or arterial thromboembolism. Less than 2% in each group had a history of VTE or arterial thromboembolism, a nonsignificant difference.

Compared with patients in Europe, U.S. patients were more likely to have a BMI of 30 kg/m² or greater (25% vs. 13%), were half as likely to smoke (16% vs. 30%), and were more likely to be using medication regularly, mainly psychotropic medications (23% vs. 10%), Dr. Heinemann said.

The study won first prize from the ACOG’s committee on the scientific program among meeting papers on current clinical and basic investigations.

The findings are limited by the observational design of the study. Information on specific gene mutations were not available for many patients, but the predictive value of these mutations for VTE is low compared with the predictive value of family history, he said.

The study included women who were using contraceptives for the first time or switching from other contraceptives or previous users of NuvaRing who had at least a 4-week break since previous use. Long-term users of these contraceptive methods were excluded from the study because the risk for VTE is highest in the first few months of use.

The study was funded by Merck, which markets NuvaRing. Dr. Heinemann reported no other financial disclosures.

SAN DIEGO – The risk of venous thromboembolism in women using an etonogestrel-containing vaginal ring did not differ significantly from the risk in women on combined oral contraceptives over a 4-year period, a prospective cohort study of 33,704 women found.

There were 56 (less than 1%) venous thromboemboli during the study. The rate of venous thromboembolism (VTE) was approximately 9/10,000 woman-years in 16,884 women using the NuvaRing and in 16,820 women on combined oral contraceptives (OCs), Dr. Klaas Heinemann Jr. and his associates reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Photo courtesy Organon Inc

Subanalyses also found no significant difference in risk when comparing NuvaRing with combined OC regimens that did not contain desogestrel, gestodene, drospirenone, or combinations of those, said Dr. Heinemann, managing director of a private research institute, the Berlin Center for Epidemiology and Health Research.

There were 1,915 serious adverse events during the TASC (Transatlantic Active Surveillance on Cardiovascular Safety of NuvaRing) study. Rates of serious adverse events were less than 300 events/10,000 woman-years in women on NuvaRing or combined OCs and in women who had stopped treatment, but were not pregnant. The risk of serious adverse events did not differ significantly between those groups, but was significantly higher in women who became pregnant, who had 900 serious adverse events per 10,000 woman-years.

The study defined serious adverse events as any adverse event that results in death, a life-threatening experience, inpatient hospitalization, persistent or significant disability or incapacity, or the need for medical or surgical intervention to prevent one of these events. Most serious adverse events involved injury, the genitourinary system (ovarian cysts, kidney stones, salpingitis, UTI), or the digestive system (appendectomy).

From 2007 to 2012, the investigators followed patients recruited by ob.gyns. at more than 3,000 centers in the United States and five European countries, with 51% of the women enrolled at U.S. centers. Follow-up was by patient questionnaire at 6, 12, 24, 36, and 48 months, with all patient-reported outcomes verified with the attending physician. Three percent of patients were lost to follow-up in each of the NuvaRing and combined OC groups. The investigators controlled for the effects of previous hormonal contraceptive use, the patient’s medical history, and a family history of VTE.

Patients in the NuvaRing and combined OC groups did not differ significantly in age, although use of NuvaRing was slightly lower in women younger than 20 years, compared with use of OCs. In the NuvaRing group, 9% were younger than 20 years, 55% were aged 20-29 years, 27% were aged 30-39 years, and 9% were 40 years or older. In the combined OCs group, the distribution was 16%, 54%, 22%, and 8%, respectively.

The two groups also did not differ significantly in body mass index (BMI), smoking rates, regular use of medications, or history of VTE or arterial thromboembolism. Less than 2% in each group had a history of VTE or arterial thromboembolism, a nonsignificant difference.

Compared with patients in Europe, U.S. patients were more likely to have a BMI of 30 kg/m² or greater (25% vs. 13%), were half as likely to smoke (16% vs. 30%), and were more likely to be using medication regularly, mainly psychotropic medications (23% vs. 10%), Dr. Heinemann said.

The study won first prize from the ACOG’s committee on the scientific program among meeting papers on current clinical and basic investigations.

The findings are limited by the observational design of the study. Information on specific gene mutations were not available for many patients, but the predictive value of these mutations for VTE is low compared with the predictive value of family history, he said.

The study included women who were using contraceptives for the first time or switching from other contraceptives or previous users of NuvaRing who had at least a 4-week break since previous use. Long-term users of these contraceptive methods were excluded from the study because the risk for VTE is highest in the first few months of use.

The study was funded by Merck, which markets NuvaRing. Dr. Heinemann reported no other financial disclosures.

SAN DIEGO – Medical providers – especially physicians – underestimate how much pain a woman feels when an IUD is inserted, an analysis of data on 200 patients and their providers suggests.

The data came from a double-blind, randomized, placebo-controlled trial of intracervical lidocaine gel, compared with placebo, for relieving pain during IUD insertion; it found no advantage to lidocaine gel. This secondary analysis looked at patient and provider ratings for patient pain on a 100-mm visual analogue scale (VAS), with no pain at 0 mm and worst pain possible at 100 mm.

The point of maximum pain during the IUD insertion procedure rated a mean score of 64 from patients, compared with a mean rating of 35 from providers. That 29-mm difference was statistically significant, Dr. Karla E. Maguire and her associates reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Nineteen percent of providers rated patient pain within 10 mm of patients’ ratings. Twenty-three percent of providers gave ratings that were 50 mm or farther apart from patients’ pain ratings, said Dr. Maguire, an ob.gyn. at the University of Miami.

The results will be published in the journal Contraception, she said.

Patients rated pain at four points during the procedure: tenaculum placement; uterine sounding; IUD insertion; and speculum removal. Patients and providers agreed about the timing of maximum pain 41% of the time – a very poor level of agreement, she said.

Uterine sounding was rated the most painful point by 40% of patients and 45% of providers. IUD insertion was rated the most painful point by 36% of patients and 15% of providers. Tenaculum placement was rated the most painful point by 14% of patients and 25% of providers. Speculum removal was rated the most painful point by 10% of patients and 5% of providers. No patients and 8% of providers said patients felt no pain. Three percent of providers (and no patients) wrote in some other point of maximum pain for the procedure instead of answering the multiple-choice question.

Ratings by the midlevel providers were slightly but significantly closer to patient ratings, compared with physician ratings – 7 points closer, on average, Dr. Maguire said. The midlevel providers were no better than were attending physicians, however, in estimating the point of maximum patient pain during the procedure.

The mean age of the patients was 27 years. The cohort was 77% Latina/Hispanic, 13% white, and 10% other races/ethnicities. Thirty percent were nulliparous. Their mean pain score for past episodes of dysmenorrhea was 35. They anticipated a pain rating of 57 for the IUD insertion procedure.

Among the providers, 91 (46%) were physicians, 91 (46%) were nurse practitioners, certified nurse-midwives, or physician assistants, and 18 (9%) were residents. Most (52%) had 11-20 years of experience in IUD insertion, while 26% had 5-10 years of experience, and 22% had less than 5 years of experience.

The IUD insertion procedures were done in public clinics in 80% of cases and in private clinics in 20%.

The pain that accompanies IUD insertion may be a barrier to wider use of IUDs, she said. Previous studies suggest that pain is more likely in nulliparous women, those whose last pregnancy is remote from the time of IUD insertion, in women with dysmenorrhea, when pain is highly anticipated, or with the levonorgestrel IUD.

Previous studies have shown that medical providers underestimate patient pain in emergency departments, family medicine clinics, during cystoscopy, and in patients with coronary artery disease. Other studies suggest that differences in pain ratings by patients and physicians are predictive of inadequate pain management. Underestimating pain could result in less research on new methods of pain relief.

The current study’s large sample size and variety of providers were strengths, but it was a secondary analysis and may not be generalizable to other settings, Dr. Maguire said.

"More research needs to be done to provide patients with better anesthesia for IUD insertion," she said.

Approximately 6% of U.S. women who use contraceptives choose IUDs, she said. Both the copper IUD and levonorgestrel IUD have low failure rates (0.8% and 0.2% per year with typical use, respectively) and high percentages of users who choose to continue using the device (78% and 80%, respectively).

Dr. Maguire reported having no relevant financial disclosures.

SAN DIEGO – Medical providers – especially physicians – underestimate how much pain a woman feels when an IUD is inserted, an analysis of data on 200 patients and their providers suggests.

The data came from a double-blind, randomized, placebo-controlled trial of intracervical lidocaine gel, compared with placebo, for relieving pain during IUD insertion; it found no advantage to lidocaine gel. This secondary analysis looked at patient and provider ratings for patient pain on a 100-mm visual analogue scale (VAS), with no pain at 0 mm and worst pain possible at 100 mm.

The point of maximum pain during the IUD insertion procedure rated a mean score of 64 from patients, compared with a mean rating of 35 from providers. That 29-mm difference was statistically significant, Dr. Karla E. Maguire and her associates reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Nineteen percent of providers rated patient pain within 10 mm of patients’ ratings. Twenty-three percent of providers gave ratings that were 50 mm or farther apart from patients’ pain ratings, said Dr. Maguire, an ob.gyn. at the University of Miami.

The results will be published in the journal Contraception, she said.

Patients rated pain at four points during the procedure: tenaculum placement; uterine sounding; IUD insertion; and speculum removal. Patients and providers agreed about the timing of maximum pain 41% of the time – a very poor level of agreement, she said.

Uterine sounding was rated the most painful point by 40% of patients and 45% of providers. IUD insertion was rated the most painful point by 36% of patients and 15% of providers. Tenaculum placement was rated the most painful point by 14% of patients and 25% of providers. Speculum removal was rated the most painful point by 10% of patients and 5% of providers. No patients and 8% of providers said patients felt no pain. Three percent of providers (and no patients) wrote in some other point of maximum pain for the procedure instead of answering the multiple-choice question.

Ratings by the midlevel providers were slightly but significantly closer to patient ratings, compared with physician ratings – 7 points closer, on average, Dr. Maguire said. The midlevel providers were no better than were attending physicians, however, in estimating the point of maximum patient pain during the procedure.

The mean age of the patients was 27 years. The cohort was 77% Latina/Hispanic, 13% white, and 10% other races/ethnicities. Thirty percent were nulliparous. Their mean pain score for past episodes of dysmenorrhea was 35. They anticipated a pain rating of 57 for the IUD insertion procedure.

Among the providers, 91 (46%) were physicians, 91 (46%) were nurse practitioners, certified nurse-midwives, or physician assistants, and 18 (9%) were residents. Most (52%) had 11-20 years of experience in IUD insertion, while 26% had 5-10 years of experience, and 22% had less than 5 years of experience.

The IUD insertion procedures were done in public clinics in 80% of cases and in private clinics in 20%.

The pain that accompanies IUD insertion may be a barrier to wider use of IUDs, she said. Previous studies suggest that pain is more likely in nulliparous women, those whose last pregnancy is remote from the time of IUD insertion, in women with dysmenorrhea, when pain is highly anticipated, or with the levonorgestrel IUD.

Previous studies have shown that medical providers underestimate patient pain in emergency departments, family medicine clinics, during cystoscopy, and in patients with coronary artery disease. Other studies suggest that differences in pain ratings by patients and physicians are predictive of inadequate pain management. Underestimating pain could result in less research on new methods of pain relief.

The current study’s large sample size and variety of providers were strengths, but it was a secondary analysis and may not be generalizable to other settings, Dr. Maguire said.

"More research needs to be done to provide patients with better anesthesia for IUD insertion," she said.

Approximately 6% of U.S. women who use contraceptives choose IUDs, she said. Both the copper IUD and levonorgestrel IUD have low failure rates (0.8% and 0.2% per year with typical use, respectively) and high percentages of users who choose to continue using the device (78% and 80%, respectively).

Dr. Maguire reported having no relevant financial disclosures.

SAN DIEGO – Medical providers – especially physicians – underestimate how much pain a woman feels when an IUD is inserted, an analysis of data on 200 patients and their providers suggests.

The data came from a double-blind, randomized, placebo-controlled trial of intracervical lidocaine gel, compared with placebo, for relieving pain during IUD insertion; it found no advantage to lidocaine gel. This secondary analysis looked at patient and provider ratings for patient pain on a 100-mm visual analogue scale (VAS), with no pain at 0 mm and worst pain possible at 100 mm.

The point of maximum pain during the IUD insertion procedure rated a mean score of 64 from patients, compared with a mean rating of 35 from providers. That 29-mm difference was statistically significant, Dr. Karla E. Maguire and her associates reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Nineteen percent of providers rated patient pain within 10 mm of patients’ ratings. Twenty-three percent of providers gave ratings that were 50 mm or farther apart from patients’ pain ratings, said Dr. Maguire, an ob.gyn. at the University of Miami.

The results will be published in the journal Contraception, she said.

Patients rated pain at four points during the procedure: tenaculum placement; uterine sounding; IUD insertion; and speculum removal. Patients and providers agreed about the timing of maximum pain 41% of the time – a very poor level of agreement, she said.

Uterine sounding was rated the most painful point by 40% of patients and 45% of providers. IUD insertion was rated the most painful point by 36% of patients and 15% of providers. Tenaculum placement was rated the most painful point by 14% of patients and 25% of providers. Speculum removal was rated the most painful point by 10% of patients and 5% of providers. No patients and 8% of providers said patients felt no pain. Three percent of providers (and no patients) wrote in some other point of maximum pain for the procedure instead of answering the multiple-choice question.

Ratings by the midlevel providers were slightly but significantly closer to patient ratings, compared with physician ratings – 7 points closer, on average, Dr. Maguire said. The midlevel providers were no better than were attending physicians, however, in estimating the point of maximum patient pain during the procedure.

The mean age of the patients was 27 years. The cohort was 77% Latina/Hispanic, 13% white, and 10% other races/ethnicities. Thirty percent were nulliparous. Their mean pain score for past episodes of dysmenorrhea was 35. They anticipated a pain rating of 57 for the IUD insertion procedure.

Among the providers, 91 (46%) were physicians, 91 (46%) were nurse practitioners, certified nurse-midwives, or physician assistants, and 18 (9%) were residents. Most (52%) had 11-20 years of experience in IUD insertion, while 26% had 5-10 years of experience, and 22% had less than 5 years of experience.

The IUD insertion procedures were done in public clinics in 80% of cases and in private clinics in 20%.

The pain that accompanies IUD insertion may be a barrier to wider use of IUDs, she said. Previous studies suggest that pain is more likely in nulliparous women, those whose last pregnancy is remote from the time of IUD insertion, in women with dysmenorrhea, when pain is highly anticipated, or with the levonorgestrel IUD.

Previous studies have shown that medical providers underestimate patient pain in emergency departments, family medicine clinics, during cystoscopy, and in patients with coronary artery disease. Other studies suggest that differences in pain ratings by patients and physicians are predictive of inadequate pain management. Underestimating pain could result in less research on new methods of pain relief.

The current study’s large sample size and variety of providers were strengths, but it was a secondary analysis and may not be generalizable to other settings, Dr. Maguire said.

"More research needs to be done to provide patients with better anesthesia for IUD insertion," she said.

Approximately 6% of U.S. women who use contraceptives choose IUDs, she said. Both the copper IUD and levonorgestrel IUD have low failure rates (0.8% and 0.2% per year with typical use, respectively) and high percentages of users who choose to continue using the device (78% and 80%, respectively).

Dr. Maguire reported having no relevant financial disclosures.

BELLEVUE, WASH. – Start preparing parents during well-child visits at ages 8, 9, and 10 that eventually you’ll want to see the preteen or teenager alone, so they don’t resist when the time comes. Dr. Cora C. Breuner said.

She tells parents, "I really need to be your child’s physician, and it’s really important that I have a rapport with him or her. I need the child to trust me, and I need you to trust me," she said at a conference sponsored by the North Pacific Pediatric Society.

"I need you to trust that I’m going to tell you if there’s a serious medical problem that is uncovered when your child talks with me. I will bring you in on that. Sometimes kids tell me stuff as a provider that they might not necessarily share with you," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

The script seems to work, because parents always leave the room without a fuss when the time comes, even though some mothers try to assure her that there are no secrets between them and their daughters.

Dr. Breuner uses a different script to build trust and confidentiality between her and the patients: "Everything you say is between you and me unless you say you hurt yourself or someone else, or someone is hurting you physically or sexually."

She said it every time she sees them, even if it’s for something like strep throat. Some patients tease her for saying it repeatedly, but every once in a while it prompts a patient to reveal that this time they do feel sad, or someone is hurting them, or they’re cutting themselves, for example.

If you tell patients that everything they say is confidential, be explicit about what "confidential" means, because adolescents are concrete thinkers, she added. Dr. Breuner explains that what they say will be part of a dictated note in the chart, but behind a special tab so that only certain providers see it.

She uses yet another helpful script when a female patient reveals she’s sexually active and wants birth control, but doesn’t want her parents to know. One 14-year-old girl, for example, was brought in by her parents to discuss behavioral problems. The mother pulled Dr. Breuner aside to tell her that her daughter was hanging out with a "fast crowd" and that the parents wanted in the room at the end of the confidential part so all could talk about the situation.

The patient revealed that she is sexually active, asked for birth control, and begged her not to tell her parents. Her parents didn’t want her to be sexually active because "we’re not supposed to do this in our family," the girl said, adding, "but I love him."

"These kinds of situations are tough," Dr. Breuner said. She can’t provide contraception and bill for it without the parents finding out, but she wants to avoid a pregnancy, and she wants the parents to remain her allies and keep bringing the child back.

First she helps the patient calm down emotionally and step back from the flood of feelings, then she gives her three options: She can go down the street to Planned Parenthood for contraception and screenings without being billed. "Or, I can bring your mom and dad in, one at a time or together, and have a conversation as your advocate, because I’m your provider. Or, you can stop having sex. It’s your call, but you need one of those three things to happen," Dr. Breuner said.

Patients typically worry that their parents will get mad or upset.

"You have to trust me on that," Dr. Breuner said. "I’m pretty good at doing this, I think, and can advocate for you to keep you safe. Or, you can have a really terrible car ride home" if the parents aren’t let in. "Maybe I can help you."

Sometimes she does have to refer the patient somewhere else for confidential services, but in most cases, "It’s pretty easy to push families through to come up with something that’s more for her protection and their protection," she said.

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Start preparing parents during well-child visits at ages 8, 9, and 10 that eventually you’ll want to see the preteen or teenager alone, so they don’t resist when the time comes. Dr. Cora C. Breuner said.

She tells parents, "I really need to be your child’s physician, and it’s really important that I have a rapport with him or her. I need the child to trust me, and I need you to trust me," she said at a conference sponsored by the North Pacific Pediatric Society.

"I need you to trust that I’m going to tell you if there’s a serious medical problem that is uncovered when your child talks with me. I will bring you in on that. Sometimes kids tell me stuff as a provider that they might not necessarily share with you," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

The script seems to work, because parents always leave the room without a fuss when the time comes, even though some mothers try to assure her that there are no secrets between them and their daughters.

Dr. Breuner uses a different script to build trust and confidentiality between her and the patients: "Everything you say is between you and me unless you say you hurt yourself or someone else, or someone is hurting you physically or sexually."

She said it every time she sees them, even if it’s for something like strep throat. Some patients tease her for saying it repeatedly, but every once in a while it prompts a patient to reveal that this time they do feel sad, or someone is hurting them, or they’re cutting themselves, for example.

If you tell patients that everything they say is confidential, be explicit about what "confidential" means, because adolescents are concrete thinkers, she added. Dr. Breuner explains that what they say will be part of a dictated note in the chart, but behind a special tab so that only certain providers see it.

She uses yet another helpful script when a female patient reveals she’s sexually active and wants birth control, but doesn’t want her parents to know. One 14-year-old girl, for example, was brought in by her parents to discuss behavioral problems. The mother pulled Dr. Breuner aside to tell her that her daughter was hanging out with a "fast crowd" and that the parents wanted in the room at the end of the confidential part so all could talk about the situation.

The patient revealed that she is sexually active, asked for birth control, and begged her not to tell her parents. Her parents didn’t want her to be sexually active because "we’re not supposed to do this in our family," the girl said, adding, "but I love him."

"These kinds of situations are tough," Dr. Breuner said. She can’t provide contraception and bill for it without the parents finding out, but she wants to avoid a pregnancy, and she wants the parents to remain her allies and keep bringing the child back.

First she helps the patient calm down emotionally and step back from the flood of feelings, then she gives her three options: She can go down the street to Planned Parenthood for contraception and screenings without being billed. "Or, I can bring your mom and dad in, one at a time or together, and have a conversation as your advocate, because I’m your provider. Or, you can stop having sex. It’s your call, but you need one of those three things to happen," Dr. Breuner said.

Patients typically worry that their parents will get mad or upset.

"You have to trust me on that," Dr. Breuner said. "I’m pretty good at doing this, I think, and can advocate for you to keep you safe. Or, you can have a really terrible car ride home" if the parents aren’t let in. "Maybe I can help you."

Sometimes she does have to refer the patient somewhere else for confidential services, but in most cases, "It’s pretty easy to push families through to come up with something that’s more for her protection and their protection," she said.

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Start preparing parents during well-child visits at ages 8, 9, and 10 that eventually you’ll want to see the preteen or teenager alone, so they don’t resist when the time comes. Dr. Cora C. Breuner said.

She tells parents, "I really need to be your child’s physician, and it’s really important that I have a rapport with him or her. I need the child to trust me, and I need you to trust me," she said at a conference sponsored by the North Pacific Pediatric Society.

"I need you to trust that I’m going to tell you if there’s a serious medical problem that is uncovered when your child talks with me. I will bring you in on that. Sometimes kids tell me stuff as a provider that they might not necessarily share with you," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.

The script seems to work, because parents always leave the room without a fuss when the time comes, even though some mothers try to assure her that there are no secrets between them and their daughters.

Dr. Breuner uses a different script to build trust and confidentiality between her and the patients: "Everything you say is between you and me unless you say you hurt yourself or someone else, or someone is hurting you physically or sexually."

She said it every time she sees them, even if it’s for something like strep throat. Some patients tease her for saying it repeatedly, but every once in a while it prompts a patient to reveal that this time they do feel sad, or someone is hurting them, or they’re cutting themselves, for example.

If you tell patients that everything they say is confidential, be explicit about what "confidential" means, because adolescents are concrete thinkers, she added. Dr. Breuner explains that what they say will be part of a dictated note in the chart, but behind a special tab so that only certain providers see it.

She uses yet another helpful script when a female patient reveals she’s sexually active and wants birth control, but doesn’t want her parents to know. One 14-year-old girl, for example, was brought in by her parents to discuss behavioral problems. The mother pulled Dr. Breuner aside to tell her that her daughter was hanging out with a "fast crowd" and that the parents wanted in the room at the end of the confidential part so all could talk about the situation.

The patient revealed that she is sexually active, asked for birth control, and begged her not to tell her parents. Her parents didn’t want her to be sexually active because "we’re not supposed to do this in our family," the girl said, adding, "but I love him."

"These kinds of situations are tough," Dr. Breuner said. She can’t provide contraception and bill for it without the parents finding out, but she wants to avoid a pregnancy, and she wants the parents to remain her allies and keep bringing the child back.

First she helps the patient calm down emotionally and step back from the flood of feelings, then she gives her three options: She can go down the street to Planned Parenthood for contraception and screenings without being billed. "Or, I can bring your mom and dad in, one at a time or together, and have a conversation as your advocate, because I’m your provider. Or, you can stop having sex. It’s your call, but you need one of those three things to happen," Dr. Breuner said.

Patients typically worry that their parents will get mad or upset.

"You have to trust me on that," Dr. Breuner said. "I’m pretty good at doing this, I think, and can advocate for you to keep you safe. Or, you can have a really terrible car ride home" if the parents aren’t let in. "Maybe I can help you."

Sometimes she does have to refer the patient somewhere else for confidential services, but in most cases, "It’s pretty easy to push families through to come up with something that’s more for her protection and their protection," she said.

Dr. Breuner reported having no relevant financial disclosures.

SAN DIEGO – Less continuity of inpatient care by hospitalists significantly increased costs but didn’t increase readmissions in an analysis of 11,234 hospitalizations at one academic medical center.

In fact, lower continuity of care among hospitalists was associated with lower readmission rates, but this reduction was significant only in some models in the analysis, Jonathan Turner, Ph.D. and his associates reported at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

The total cost of a hospitalization increased by 7% for each hospitalist that cared for the patient. For each 10% decrease in a Usual Provider of Care index, based on the largest fraction of notes written by one provider, total costs increased by 12%, said Dr. Turner, a quality and innovation engineer at Northwestern Memorial Hospital, Chicago. Neither of those parameters significantly affected the likelihood of readmission.

The study was honored by the society as one of the three best presentations at the meeting.

The large non-teaching hospitalist service works blocks of 7 days on and 7 days off at the 900-bed academic hospital, with the schedule switch and case hand-offs on Mondays. The study included only patients whose primary service was provided exclusively by hospitalists, including no ICU days. Data were collected for June 2008 to May 2011.

The investigators used the authors of progress notes to calculate the number of providers. "We’re interested in changes in the driver of care – who is directing the plan of care? When that changes, does that affect costs and readmissions?" he said.

Because hospitalist shifts changed on Mondays, subanalyses in the study compared continuity of care for admissions on Mondays vs. Tuesdays through Sundays, or on weekdays instead of weekends, or on Mondays through Wednesdays rather than Thursdays through Sundays. Results were consistent, Dr. Turner said.

Higher costs with less continuity of care may be due to changes in the plan of care by the new provider and/or additional and possibly duplicate ordering of lab tests and imaging, he speculated. Lower readmission rates in some of the analytical models might be because additional orders turned out to be beneficial to the patient, or because the change in management was beneficial.

The findings may have implications for emerging efforts to improve patient handoff design and to reduce handoffs, perhaps by modifying work schedules to increase continuity of care, he suggested.

"We don’t talk much about handoff reduction," but interest in this is increasing, he said. "There are limited things we can do to decrease length of stay. Maybe we can focus on decreasing handoffs."

Previous studies have shown that continuity in outpatient care is associated with better control of hypertension, fewer hospitalizations or emergency department visits, and higher patient satisfaction, but little is known about continuity of inpatient care. Other research found that lower continuity of inpatient care was associated with significantly increased length of stay (J. Hosp. Med. 2010;5:335-338). From 1996 to 2006, the percentage of hospitalized patients who received care from one generalist physician declined from 71% to 59% (J. Hosp. Med. 2011;6:438-444).

In the current study, an average of 1.9 hospitalists managed each hospitalization. The average Usual Provider of Care index was 0.76. The readmission rate averaged 22% and the average length of stay was 3.5 days. Hospitalists averaged 33 years in age, and patients averaged 58 years of age. The patient cohort was 46% male, 53% white, 35% black, 8% Hispanic, and 4% other races/ethnicities. Medicaid or Medicare covered 58% of hospitalizations, private insurers covered 34%, and 8% were self-pay or other situations.

The investigators plan to conduct a similar study of nursing continuity of care.

The findings were limited by data collection from a single site, and only an academic institution, and exclusion of patients with ICU stays, who are the costliest, highest-risk patients. It’s possible that the continuity metrics were not optimal, and it’s unknown if patients were readmitted to other hospitals.

Dr. Turner reported having no financial disclosures.

SAN DIEGO – Less continuity of inpatient care by hospitalists significantly increased costs but didn’t increase readmissions in an analysis of 11,234 hospitalizations at one academic medical center.

In fact, lower continuity of care among hospitalists was associated with lower readmission rates, but this reduction was significant only in some models in the analysis, Jonathan Turner, Ph.D. and his associates reported at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

The total cost of a hospitalization increased by 7% for each hospitalist that cared for the patient. For each 10% decrease in a Usual Provider of Care index, based on the largest fraction of notes written by one provider, total costs increased by 12%, said Dr. Turner, a quality and innovation engineer at Northwestern Memorial Hospital, Chicago. Neither of those parameters significantly affected the likelihood of readmission.

The study was honored by the society as one of the three best presentations at the meeting.

The large non-teaching hospitalist service works blocks of 7 days on and 7 days off at the 900-bed academic hospital, with the schedule switch and case hand-offs on Mondays. The study included only patients whose primary service was provided exclusively by hospitalists, including no ICU days. Data were collected for June 2008 to May 2011.

The investigators used the authors of progress notes to calculate the number of providers. "We’re interested in changes in the driver of care – who is directing the plan of care? When that changes, does that affect costs and readmissions?" he said.

Because hospitalist shifts changed on Mondays, subanalyses in the study compared continuity of care for admissions on Mondays vs. Tuesdays through Sundays, or on weekdays instead of weekends, or on Mondays through Wednesdays rather than Thursdays through Sundays. Results were consistent, Dr. Turner said.

Higher costs with less continuity of care may be due to changes in the plan of care by the new provider and/or additional and possibly duplicate ordering of lab tests and imaging, he speculated. Lower readmission rates in some of the analytical models might be because additional orders turned out to be beneficial to the patient, or because the change in management was beneficial.

The findings may have implications for emerging efforts to improve patient handoff design and to reduce handoffs, perhaps by modifying work schedules to increase continuity of care, he suggested.

"We don’t talk much about handoff reduction," but interest in this is increasing, he said. "There are limited things we can do to decrease length of stay. Maybe we can focus on decreasing handoffs."

Previous studies have shown that continuity in outpatient care is associated with better control of hypertension, fewer hospitalizations or emergency department visits, and higher patient satisfaction, but little is known about continuity of inpatient care. Other research found that lower continuity of inpatient care was associated with significantly increased length of stay (J. Hosp. Med. 2010;5:335-338). From 1996 to 2006, the percentage of hospitalized patients who received care from one generalist physician declined from 71% to 59% (J. Hosp. Med. 2011;6:438-444).

In the current study, an average of 1.9 hospitalists managed each hospitalization. The average Usual Provider of Care index was 0.76. The readmission rate averaged 22% and the average length of stay was 3.5 days. Hospitalists averaged 33 years in age, and patients averaged 58 years of age. The patient cohort was 46% male, 53% white, 35% black, 8% Hispanic, and 4% other races/ethnicities. Medicaid or Medicare covered 58% of hospitalizations, private insurers covered 34%, and 8% were self-pay or other situations.

The investigators plan to conduct a similar study of nursing continuity of care.

The findings were limited by data collection from a single site, and only an academic institution, and exclusion of patients with ICU stays, who are the costliest, highest-risk patients. It’s possible that the continuity metrics were not optimal, and it’s unknown if patients were readmitted to other hospitals.

Dr. Turner reported having no financial disclosures.

SAN DIEGO – Less continuity of inpatient care by hospitalists significantly increased costs but didn’t increase readmissions in an analysis of 11,234 hospitalizations at one academic medical center.

In fact, lower continuity of care among hospitalists was associated with lower readmission rates, but this reduction was significant only in some models in the analysis, Jonathan Turner, Ph.D. and his associates reported at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

The total cost of a hospitalization increased by 7% for each hospitalist that cared for the patient. For each 10% decrease in a Usual Provider of Care index, based on the largest fraction of notes written by one provider, total costs increased by 12%, said Dr. Turner, a quality and innovation engineer at Northwestern Memorial Hospital, Chicago. Neither of those parameters significantly affected the likelihood of readmission.

The study was honored by the society as one of the three best presentations at the meeting.

The large non-teaching hospitalist service works blocks of 7 days on and 7 days off at the 900-bed academic hospital, with the schedule switch and case hand-offs on Mondays. The study included only patients whose primary service was provided exclusively by hospitalists, including no ICU days. Data were collected for June 2008 to May 2011.

The investigators used the authors of progress notes to calculate the number of providers. "We’re interested in changes in the driver of care – who is directing the plan of care? When that changes, does that affect costs and readmissions?" he said.

Because hospitalist shifts changed on Mondays, subanalyses in the study compared continuity of care for admissions on Mondays vs. Tuesdays through Sundays, or on weekdays instead of weekends, or on Mondays through Wednesdays rather than Thursdays through Sundays. Results were consistent, Dr. Turner said.

Higher costs with less continuity of care may be due to changes in the plan of care by the new provider and/or additional and possibly duplicate ordering of lab tests and imaging, he speculated. Lower readmission rates in some of the analytical models might be because additional orders turned out to be beneficial to the patient, or because the change in management was beneficial.

The findings may have implications for emerging efforts to improve patient handoff design and to reduce handoffs, perhaps by modifying work schedules to increase continuity of care, he suggested.

"We don’t talk much about handoff reduction," but interest in this is increasing, he said. "There are limited things we can do to decrease length of stay. Maybe we can focus on decreasing handoffs."

Previous studies have shown that continuity in outpatient care is associated with better control of hypertension, fewer hospitalizations or emergency department visits, and higher patient satisfaction, but little is known about continuity of inpatient care. Other research found that lower continuity of inpatient care was associated with significantly increased length of stay (J. Hosp. Med. 2010;5:335-338). From 1996 to 2006, the percentage of hospitalized patients who received care from one generalist physician declined from 71% to 59% (J. Hosp. Med. 2011;6:438-444).

In the current study, an average of 1.9 hospitalists managed each hospitalization. The average Usual Provider of Care index was 0.76. The readmission rate averaged 22% and the average length of stay was 3.5 days. Hospitalists averaged 33 years in age, and patients averaged 58 years of age. The patient cohort was 46% male, 53% white, 35% black, 8% Hispanic, and 4% other races/ethnicities. Medicaid or Medicare covered 58% of hospitalizations, private insurers covered 34%, and 8% were self-pay or other situations.

The investigators plan to conduct a similar study of nursing continuity of care.

The findings were limited by data collection from a single site, and only an academic institution, and exclusion of patients with ICU stays, who are the costliest, highest-risk patients. It’s possible that the continuity metrics were not optimal, and it’s unknown if patients were readmitted to other hospitals.

Dr. Turner reported having no financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Inpatients who most strongly preferred to leave medical decisions to their doctors were discharged a third of a day sooner with $970 lower mean costs per patient, compared with patients who strongly disagreed about leaving decisions to their physicians, a study of data on 20,213 patients found.

The findings throw a wrinkle into the idea that empowering patients for shared decision making is always the best approach, Hyo Jung Tak, Ph.D. said at the annual meeting of the Society of Hospital Medicine.

Administrative and patient interview data on patients in the general medicine service at the University of Chicago Medical Center from 2003-2011 included responses of to the statement, "I prefer to leave decisions about my medical care up to my doctor." Patients responded with "definitely agree" (37% of patients), "somewhat agree" (34%), "somewhat disagree" (15%), or "definitely disagree" (14%).

Although 96% of patients said that they prefer to be informed by their doctors about treatment options and to be asked their opinions, 71% of patients strongly or somewhat agreed that they prefer to leave decisions about medical care to their doctors.

Dr. Tak compared responses to data on patients’ health care utilization, length of stay, and mean total costs.

Length of stay averaged 5.3 days for the entire cohort, but patients who "definitely agreed" with letting doctors make decisions left the hospital 0.31 days sooner than did those who "definitely disagreed," reported Dr. Tak and her associate in the study, Dr. David Meltzer, both of the University.

Total costs averaged $14,500 for the entire cohort, but costs for patients who "definitely agreed" with leaving decision to doctors averaged $970 less than for patients who "definitely disagreed" with that approach.

The differences between groups in length of stay and cost were statistically significant, Dr. Tak said. The analysis controlled for the possible effects of age, gender, educational category, health status, 10 most frequent diagnoses, Charlson index, weekend admission, transfer from another institution, and attending physicians.

The results raise a provocative question, she said: "Will patient empowerment efforts in a shared-decision model increase costs" in an era in which cost-control is one of the most pressing health policy issues?

Patients who definitely agreed to leave medical decisions to their doctors were significantly more likely to have no more than a high school education and to have public or no insurance, compared with patients who definitely disagreed about leaving medical decisions to their doctors.

Shared decision making between doctors and patients has emerged as the preferred approach for medical decisions, but patient preference for this approach has not been well characterized, and the effects of this approach on medical resource utilization rarely have been studied, Dr. Tak said.

The study was limited by its reliance on data from a single institution and by a lack of information on physicians’ preferences for shared decision making and the decision-making mechanisms.

The investigators plan further studies on how preferences for shared decision making affect health outcomes and on associations between socioeconomic status and preferences about decision-making. "At least in our study, it was patients with higher education and with more generous health insurance who preferred to participate" in decision-making, she said.

Dr. Tak reported having no financial disclosures.

SAN DIEGO – Inpatients who most strongly preferred to leave medical decisions to their doctors were discharged a third of a day sooner with $970 lower mean costs per patient, compared with patients who strongly disagreed about leaving decisions to their physicians, a study of data on 20,213 patients found.

The findings throw a wrinkle into the idea that empowering patients for shared decision making is always the best approach, Hyo Jung Tak, Ph.D. said at the annual meeting of the Society of Hospital Medicine.

Administrative and patient interview data on patients in the general medicine service at the University of Chicago Medical Center from 2003-2011 included responses of to the statement, "I prefer to leave decisions about my medical care up to my doctor." Patients responded with "definitely agree" (37% of patients), "somewhat agree" (34%), "somewhat disagree" (15%), or "definitely disagree" (14%).

Although 96% of patients said that they prefer to be informed by their doctors about treatment options and to be asked their opinions, 71% of patients strongly or somewhat agreed that they prefer to leave decisions about medical care to their doctors.

Dr. Tak compared responses to data on patients’ health care utilization, length of stay, and mean total costs.

Length of stay averaged 5.3 days for the entire cohort, but patients who "definitely agreed" with letting doctors make decisions left the hospital 0.31 days sooner than did those who "definitely disagreed," reported Dr. Tak and her associate in the study, Dr. David Meltzer, both of the University.

Total costs averaged $14,500 for the entire cohort, but costs for patients who "definitely agreed" with leaving decision to doctors averaged $970 less than for patients who "definitely disagreed" with that approach.

The differences between groups in length of stay and cost were statistically significant, Dr. Tak said. The analysis controlled for the possible effects of age, gender, educational category, health status, 10 most frequent diagnoses, Charlson index, weekend admission, transfer from another institution, and attending physicians.

The results raise a provocative question, she said: "Will patient empowerment efforts in a shared-decision model increase costs" in an era in which cost-control is one of the most pressing health policy issues?

Patients who definitely agreed to leave medical decisions to their doctors were significantly more likely to have no more than a high school education and to have public or no insurance, compared with patients who definitely disagreed about leaving medical decisions to their doctors.

Shared decision making between doctors and patients has emerged as the preferred approach for medical decisions, but patient preference for this approach has not been well characterized, and the effects of this approach on medical resource utilization rarely have been studied, Dr. Tak said.

The study was limited by its reliance on data from a single institution and by a lack of information on physicians’ preferences for shared decision making and the decision-making mechanisms.

The investigators plan further studies on how preferences for shared decision making affect health outcomes and on associations between socioeconomic status and preferences about decision-making. "At least in our study, it was patients with higher education and with more generous health insurance who preferred to participate" in decision-making, she said.

Dr. Tak reported having no financial disclosures.

SAN DIEGO – Inpatients who most strongly preferred to leave medical decisions to their doctors were discharged a third of a day sooner with $970 lower mean costs per patient, compared with patients who strongly disagreed about leaving decisions to their physicians, a study of data on 20,213 patients found.

The findings throw a wrinkle into the idea that empowering patients for shared decision making is always the best approach, Hyo Jung Tak, Ph.D. said at the annual meeting of the Society of Hospital Medicine.

Administrative and patient interview data on patients in the general medicine service at the University of Chicago Medical Center from 2003-2011 included responses of to the statement, "I prefer to leave decisions about my medical care up to my doctor." Patients responded with "definitely agree" (37% of patients), "somewhat agree" (34%), "somewhat disagree" (15%), or "definitely disagree" (14%).

Although 96% of patients said that they prefer to be informed by their doctors about treatment options and to be asked their opinions, 71% of patients strongly or somewhat agreed that they prefer to leave decisions about medical care to their doctors.

Dr. Tak compared responses to data on patients’ health care utilization, length of stay, and mean total costs.

Length of stay averaged 5.3 days for the entire cohort, but patients who "definitely agreed" with letting doctors make decisions left the hospital 0.31 days sooner than did those who "definitely disagreed," reported Dr. Tak and her associate in the study, Dr. David Meltzer, both of the University.

Total costs averaged $14,500 for the entire cohort, but costs for patients who "definitely agreed" with leaving decision to doctors averaged $970 less than for patients who "definitely disagreed" with that approach.

The differences between groups in length of stay and cost were statistically significant, Dr. Tak said. The analysis controlled for the possible effects of age, gender, educational category, health status, 10 most frequent diagnoses, Charlson index, weekend admission, transfer from another institution, and attending physicians.

The results raise a provocative question, she said: "Will patient empowerment efforts in a shared-decision model increase costs" in an era in which cost-control is one of the most pressing health policy issues?

Patients who definitely agreed to leave medical decisions to their doctors were significantly more likely to have no more than a high school education and to have public or no insurance, compared with patients who definitely disagreed about leaving medical decisions to their doctors.

Shared decision making between doctors and patients has emerged as the preferred approach for medical decisions, but patient preference for this approach has not been well characterized, and the effects of this approach on medical resource utilization rarely have been studied, Dr. Tak said.

The study was limited by its reliance on data from a single institution and by a lack of information on physicians’ preferences for shared decision making and the decision-making mechanisms.

The investigators plan further studies on how preferences for shared decision making affect health outcomes and on associations between socioeconomic status and preferences about decision-making. "At least in our study, it was patients with higher education and with more generous health insurance who preferred to participate" in decision-making, she said.

Dr. Tak reported having no financial disclosures.

SAN DIEGO – Decreased availability of medical ICU beds was significantly associated with a 27% higher risk for cardiac arrest on general hospital wards in an observational cohort study of 68 ICU beds and 258 ward beds at one academic medical center.

The availability of nonmedical ICU beds did not affect the risk of cardiac arrests. While total ICU bed availability was associated with increased cardiac arrests, this did not reach statistical significance, Michael Huber and his associates reported at the annual meeting of the Society of Hospital Medicine.

Across the United States, the approximately 90,000 ICU beds account for less than 15% of all hospital beds and are distributed unevenly geographically. Demand for ICU beds is projected to increase 80% over the next 209 years as the population ages and comorbidities increase, said Mr. Huber, a fourth-year medical student at the University of Chicago.

The findings suggest a need to increase ICU bed availability by adding beds, adopting flexible surgery scheduling for planned surgical ICU admissions (which in turn may open up ICU beds for medical patients), or implementing practices to reduce ICU length of stay, he suggested. "Of course, some ICU beds are taken by patients awaiting discharge to wards, so prioritizing ward beds to ICU discharges may also free up ICU beds."

A second implication of the study is that ward patients may be triaged inappropriately when ICU beds are severely limited, he added. Improved ICU triage practices may be needed, particularly at times of limited medical ICU bed availability.

The study was honored as one of the best research presentations at the meeting. It defined cardiac arrest as loss of a palpable pulse with a resuscitation attempt.

Researchers analyzed 96 cardiac arrests on the general wards (81 arrests on medical wards and 15 on non-medical wards). During 1,716 work shifts, there were a median of 217 patients on the wards at the start of 12-hour shifts. A median of five total ICU beds were available at shift start. For medical ICU beds, a median of one was available at shift start, and for nonmedical ICU beds, a median of three were available at shift start.

The incidence rate of cardiac arrests on the general wards was 6% higher for each fewer ICU bed, but this was not a statistically significant difference. For each fewer medical ICU bed, a 27% increase in cardiac arrests on the general wards was seen, which was significant. No association appeared between non-medical ICU bed availability and cardiac arrests on the wards.

The investigators calculated a "ward cardiac arrest rate" (defined as the number of ward cardiac arrests divided by ward occupancy at shift start) and compared these by the number of ICU beds available. The mean cardiac arrest rate was 2.6 arrests per 10,000 ward patients per shift. The rate when no medical ICU beds were available was nearly double the rate when one or more medical ICU beds were available. The cardiac arrest rate stabilized at or below the mean when one, two, or three or more medical ICU beds were available, Mr. Huber said.

Previous studies focused mostly on the effects of bed availability on patients in the ICU. They found no association with mortality but showed increased severity of illness and readmission rates as ICU bed availability decreased. Previous studies of ward patients were limited to high-risk patients who were evaluated for ICU admission; these found higher mortality rates in patients who were refused admission to the ICU, he said.

Mr. Huber reported having no financial disclosures. One of his associates reported financial ties to Philips Healthcare and Sotera Wireless.

SAN DIEGO – Decreased availability of medical ICU beds was significantly associated with a 27% higher risk for cardiac arrest on general hospital wards in an observational cohort study of 68 ICU beds and 258 ward beds at one academic medical center.

The availability of nonmedical ICU beds did not affect the risk of cardiac arrests. While total ICU bed availability was associated with increased cardiac arrests, this did not reach statistical significance, Michael Huber and his associates reported at the annual meeting of the Society of Hospital Medicine.

Across the United States, the approximately 90,000 ICU beds account for less than 15% of all hospital beds and are distributed unevenly geographically. Demand for ICU beds is projected to increase 80% over the next 209 years as the population ages and comorbidities increase, said Mr. Huber, a fourth-year medical student at the University of Chicago.

The findings suggest a need to increase ICU bed availability by adding beds, adopting flexible surgery scheduling for planned surgical ICU admissions (which in turn may open up ICU beds for medical patients), or implementing practices to reduce ICU length of stay, he suggested. "Of course, some ICU beds are taken by patients awaiting discharge to wards, so prioritizing ward beds to ICU discharges may also free up ICU beds."

A second implication of the study is that ward patients may be triaged inappropriately when ICU beds are severely limited, he added. Improved ICU triage practices may be needed, particularly at times of limited medical ICU bed availability.

The study was honored as one of the best research presentations at the meeting. It defined cardiac arrest as loss of a palpable pulse with a resuscitation attempt.

Researchers analyzed 96 cardiac arrests on the general wards (81 arrests on medical wards and 15 on non-medical wards). During 1,716 work shifts, there were a median of 217 patients on the wards at the start of 12-hour shifts. A median of five total ICU beds were available at shift start. For medical ICU beds, a median of one was available at shift start, and for nonmedical ICU beds, a median of three were available at shift start.

The incidence rate of cardiac arrests on the general wards was 6% higher for each fewer ICU bed, but this was not a statistically significant difference. For each fewer medical ICU bed, a 27% increase in cardiac arrests on the general wards was seen, which was significant. No association appeared between non-medical ICU bed availability and cardiac arrests on the wards.

The investigators calculated a "ward cardiac arrest rate" (defined as the number of ward cardiac arrests divided by ward occupancy at shift start) and compared these by the number of ICU beds available. The mean cardiac arrest rate was 2.6 arrests per 10,000 ward patients per shift. The rate when no medical ICU beds were available was nearly double the rate when one or more medical ICU beds were available. The cardiac arrest rate stabilized at or below the mean when one, two, or three or more medical ICU beds were available, Mr. Huber said.

Previous studies focused mostly on the effects of bed availability on patients in the ICU. They found no association with mortality but showed increased severity of illness and readmission rates as ICU bed availability decreased. Previous studies of ward patients were limited to high-risk patients who were evaluated for ICU admission; these found higher mortality rates in patients who were refused admission to the ICU, he said.

Mr. Huber reported having no financial disclosures. One of his associates reported financial ties to Philips Healthcare and Sotera Wireless.

SAN DIEGO – Decreased availability of medical ICU beds was significantly associated with a 27% higher risk for cardiac arrest on general hospital wards in an observational cohort study of 68 ICU beds and 258 ward beds at one academic medical center.

The availability of nonmedical ICU beds did not affect the risk of cardiac arrests. While total ICU bed availability was associated with increased cardiac arrests, this did not reach statistical significance, Michael Huber and his associates reported at the annual meeting of the Society of Hospital Medicine.

Across the United States, the approximately 90,000 ICU beds account for less than 15% of all hospital beds and are distributed unevenly geographically. Demand for ICU beds is projected to increase 80% over the next 209 years as the population ages and comorbidities increase, said Mr. Huber, a fourth-year medical student at the University of Chicago.

The findings suggest a need to increase ICU bed availability by adding beds, adopting flexible surgery scheduling for planned surgical ICU admissions (which in turn may open up ICU beds for medical patients), or implementing practices to reduce ICU length of stay, he suggested. "Of course, some ICU beds are taken by patients awaiting discharge to wards, so prioritizing ward beds to ICU discharges may also free up ICU beds."

A second implication of the study is that ward patients may be triaged inappropriately when ICU beds are severely limited, he added. Improved ICU triage practices may be needed, particularly at times of limited medical ICU bed availability.

The study was honored as one of the best research presentations at the meeting. It defined cardiac arrest as loss of a palpable pulse with a resuscitation attempt.

Researchers analyzed 96 cardiac arrests on the general wards (81 arrests on medical wards and 15 on non-medical wards). During 1,716 work shifts, there were a median of 217 patients on the wards at the start of 12-hour shifts. A median of five total ICU beds were available at shift start. For medical ICU beds, a median of one was available at shift start, and for nonmedical ICU beds, a median of three were available at shift start.

The incidence rate of cardiac arrests on the general wards was 6% higher for each fewer ICU bed, but this was not a statistically significant difference. For each fewer medical ICU bed, a 27% increase in cardiac arrests on the general wards was seen, which was significant. No association appeared between non-medical ICU bed availability and cardiac arrests on the wards.

The investigators calculated a "ward cardiac arrest rate" (defined as the number of ward cardiac arrests divided by ward occupancy at shift start) and compared these by the number of ICU beds available. The mean cardiac arrest rate was 2.6 arrests per 10,000 ward patients per shift. The rate when no medical ICU beds were available was nearly double the rate when one or more medical ICU beds were available. The cardiac arrest rate stabilized at or below the mean when one, two, or three or more medical ICU beds were available, Mr. Huber said.

Previous studies focused mostly on the effects of bed availability on patients in the ICU. They found no association with mortality but showed increased severity of illness and readmission rates as ICU bed availability decreased. Previous studies of ward patients were limited to high-risk patients who were evaluated for ICU admission; these found higher mortality rates in patients who were refused admission to the ICU, he said.

Mr. Huber reported having no financial disclosures. One of his associates reported financial ties to Philips Healthcare and Sotera Wireless.

SAN DIEGO – Making specialized care plans for 28 high-risk patients easily accessible to physicians by computer decreased hospitalizations and emergency department visits by 65% over 2 months.

In the 2 months before implementation of the care plan system, the 28 patients visited EDs 122 times and had 59 admissions to the hospital. ED visits decreased to 53 and admissions dropped to 9 for these patients in the 2 months after implementation of the system, an overall reduction of about 65%, Dr. Richard J. Hilger and his associates reported at the annual meeting of the Society of Hospital Medicine.

The study was honored by the Society as one of the best three presentations at the meeting.

"Our financial department says that ideally, in a closed system, that would be a cost savings to society of over half a million dollars just for 28 patients over just a 2-month period," said Dr. Hilger, medical director of Care Management at Regions Hospital, St. Paul, Minn., a part of HealthPartners Medical Group.

Presently, there’s no way of knowing if patients circumvented the care plans by going to another hospital that’s not in the HealthPartners Medical Group, but records suggest that "only a handful of patients have left our system," he added.

The investigators next will try to integrate the care plans among health care systems in their geographic area, "so that care plans can be used from system to system," Dr. Hilger said.

The pilot study focused on three groups of patients with frequent ED visits and hospitalizations: narcotic-seeking patients, patients with mental health diagnoses (especially borderline traits), and patients with a long history of not complying with medical therapy.

A committee of hospital leaders created the specialized plans to restrict care in hopes of redirecting these patients to clinics and their primary care physicians, thus reducing medically unnecessary admissions and ED visits. The committee included specialists from hospital medicine, nursing, emergency medicine, primary care, risk management, quality control, care management, and electronic medical records.

When any physician in the medical group went to the computerized record of one of these patients, an orange bar across the bottom of the screen alerted the physician that a care plan was in place. Clicking on the bar opened a description of the plan, which could be read to the patient.

The "alpha case" that got the hospital team to start the care plan system was a 35-year-old patient named Ann who abused narcotics and had type 1 diabetes, borderline personality disorder, and severe anxiety disorder. Frequently, she would visit the ED in diabetic distress and would refuse insulin unless she was given narcotics. In the 6 weeks prior to institution of a care plan for her, she came to the ED 14 times and was admitted 6 times. In the 14 weeks after the plan started, she visited the ED twice and was admitted twice.

A Sample Plan

Dr. Hilger read an example of a care plan for narcotic-seeking patients, which said that care guidelines were being instituted in order to provide consistent and quality care that maintains the patient’s safety when seen by providers who may not know the patient well. The guidelines are as follows: The patient would not receive IV narcotics in the ED unless there is a medical condition unrelated to chronic pain. The ED should not be used for routine medical care or management of chronic pain, but the physician with the patient would help set up more frequent clinic visits. The ED or inpatient physicians would not fill orders for oral narcotics at discharge. The patient’s outpatient regimen should be used for chronic pain or exacerbations of chronic pain, and IV Benadryl or IV benzodiazepines should not be used for pain control.

The physician should offer substance-abuse treatment programs when appropriate, the care plan continued. Repeated imaging studies such as CT scans were discouraged unless new pathology was suggested by an exam, vital signs, and/or screening labs, because repeated imaging exposes the patient to radiation. The patient should not attempt to obtain narcotic prescriptions from anyone other than the designated primary care provider. If the patient does not follow the rules described in the care plan, the medical group "would have to consider releasing you from our care, since noncompliance leads us to being unable to care for you safely and appropriately."

Dr. Hilger cited a New Yorker magazine article by Dr. Atul Gawande of Harvard University describing the benefits of coordinating care for the most chronically expensive patients. The use of care plans promotes consistency in care; reinforces goals and expectations; empowers patients to take steps toward positive change; fosters patient trust; increases use of primary care; and decreases hospitalizations, readmissions, and total costs, the article suggests.

"We didn’t invent this" idea of care plans, Dr. Hilger said. Many hospitals are experimenting with elements of specialized care plans, but research so far has been limited mainly to EDs, he added. Specialized care plans are becoming popular for the less than 1% of patients with high rates of medically unnecessary emergency visits and admissions.

Dr. Hilger reported having no financial disclosures.

SAN DIEGO – Making specialized care plans for 28 high-risk patients easily accessible to physicians by computer decreased hospitalizations and emergency department visits by 65% over 2 months.

In the 2 months before implementation of the care plan system, the 28 patients visited EDs 122 times and had 59 admissions to the hospital. ED visits decreased to 53 and admissions dropped to 9 for these patients in the 2 months after implementation of the system, an overall reduction of about 65%, Dr. Richard J. Hilger and his associates reported at the annual meeting of the Society of Hospital Medicine.

The study was honored by the Society as one of the best three presentations at the meeting.

"Our financial department says that ideally, in a closed system, that would be a cost savings to society of over half a million dollars just for 28 patients over just a 2-month period," said Dr. Hilger, medical director of Care Management at Regions Hospital, St. Paul, Minn., a part of HealthPartners Medical Group.

Presently, there’s no way of knowing if patients circumvented the care plans by going to another hospital that’s not in the HealthPartners Medical Group, but records suggest that "only a handful of patients have left our system," he added.

The investigators next will try to integrate the care plans among health care systems in their geographic area, "so that care plans can be used from system to system," Dr. Hilger said.

The pilot study focused on three groups of patients with frequent ED visits and hospitalizations: narcotic-seeking patients, patients with mental health diagnoses (especially borderline traits), and patients with a long history of not complying with medical therapy.

A committee of hospital leaders created the specialized plans to restrict care in hopes of redirecting these patients to clinics and their primary care physicians, thus reducing medically unnecessary admissions and ED visits. The committee included specialists from hospital medicine, nursing, emergency medicine, primary care, risk management, quality control, care management, and electronic medical records.

When any physician in the medical group went to the computerized record of one of these patients, an orange bar across the bottom of the screen alerted the physician that a care plan was in place. Clicking on the bar opened a description of the plan, which could be read to the patient.

The "alpha case" that got the hospital team to start the care plan system was a 35-year-old patient named Ann who abused narcotics and had type 1 diabetes, borderline personality disorder, and severe anxiety disorder. Frequently, she would visit the ED in diabetic distress and would refuse insulin unless she was given narcotics. In the 6 weeks prior to institution of a care plan for her, she came to the ED 14 times and was admitted 6 times. In the 14 weeks after the plan started, she visited the ED twice and was admitted twice.

A Sample Plan

Dr. Hilger read an example of a care plan for narcotic-seeking patients, which said that care guidelines were being instituted in order to provide consistent and quality care that maintains the patient’s safety when seen by providers who may not know the patient well. The guidelines are as follows: The patient would not receive IV narcotics in the ED unless there is a medical condition unrelated to chronic pain. The ED should not be used for routine medical care or management of chronic pain, but the physician with the patient would help set up more frequent clinic visits. The ED or inpatient physicians would not fill orders for oral narcotics at discharge. The patient’s outpatient regimen should be used for chronic pain or exacerbations of chronic pain, and IV Benadryl or IV benzodiazepines should not be used for pain control.

The physician should offer substance-abuse treatment programs when appropriate, the care plan continued. Repeated imaging studies such as CT scans were discouraged unless new pathology was suggested by an exam, vital signs, and/or screening labs, because repeated imaging exposes the patient to radiation. The patient should not attempt to obtain narcotic prescriptions from anyone other than the designated primary care provider. If the patient does not follow the rules described in the care plan, the medical group "would have to consider releasing you from our care, since noncompliance leads us to being unable to care for you safely and appropriately."

Dr. Hilger cited a New Yorker magazine article by Dr. Atul Gawande of Harvard University describing the benefits of coordinating care for the most chronically expensive patients. The use of care plans promotes consistency in care; reinforces goals and expectations; empowers patients to take steps toward positive change; fosters patient trust; increases use of primary care; and decreases hospitalizations, readmissions, and total costs, the article suggests.

"We didn’t invent this" idea of care plans, Dr. Hilger said. Many hospitals are experimenting with elements of specialized care plans, but research so far has been limited mainly to EDs, he added. Specialized care plans are becoming popular for the less than 1% of patients with high rates of medically unnecessary emergency visits and admissions.

Dr. Hilger reported having no financial disclosures.

SAN DIEGO – Making specialized care plans for 28 high-risk patients easily accessible to physicians by computer decreased hospitalizations and emergency department visits by 65% over 2 months.

In the 2 months before implementation of the care plan system, the 28 patients visited EDs 122 times and had 59 admissions to the hospital. ED visits decreased to 53 and admissions dropped to 9 for these patients in the 2 months after implementation of the system, an overall reduction of about 65%, Dr. Richard J. Hilger and his associates reported at the annual meeting of the Society of Hospital Medicine.

The study was honored by the Society as one of the best three presentations at the meeting.

"Our financial department says that ideally, in a closed system, that would be a cost savings to society of over half a million dollars just for 28 patients over just a 2-month period," said Dr. Hilger, medical director of Care Management at Regions Hospital, St. Paul, Minn., a part of HealthPartners Medical Group.

Presently, there’s no way of knowing if patients circumvented the care plans by going to another hospital that’s not in the HealthPartners Medical Group, but records suggest that "only a handful of patients have left our system," he added.

The investigators next will try to integrate the care plans among health care systems in their geographic area, "so that care plans can be used from system to system," Dr. Hilger said.

The pilot study focused on three groups of patients with frequent ED visits and hospitalizations: narcotic-seeking patients, patients with mental health diagnoses (especially borderline traits), and patients with a long history of not complying with medical therapy.

A committee of hospital leaders created the specialized plans to restrict care in hopes of redirecting these patients to clinics and their primary care physicians, thus reducing medically unnecessary admissions and ED visits. The committee included specialists from hospital medicine, nursing, emergency medicine, primary care, risk management, quality control, care management, and electronic medical records.

When any physician in the medical group went to the computerized record of one of these patients, an orange bar across the bottom of the screen alerted the physician that a care plan was in place. Clicking on the bar opened a description of the plan, which could be read to the patient.

The "alpha case" that got the hospital team to start the care plan system was a 35-year-old patient named Ann who abused narcotics and had type 1 diabetes, borderline personality disorder, and severe anxiety disorder. Frequently, she would visit the ED in diabetic distress and would refuse insulin unless she was given narcotics. In the 6 weeks prior to institution of a care plan for her, she came to the ED 14 times and was admitted 6 times. In the 14 weeks after the plan started, she visited the ED twice and was admitted twice.

A Sample Plan

Dr. Hilger read an example of a care plan for narcotic-seeking patients, which said that care guidelines were being instituted in order to provide consistent and quality care that maintains the patient’s safety when seen by providers who may not know the patient well. The guidelines are as follows: The patient would not receive IV narcotics in the ED unless there is a medical condition unrelated to chronic pain. The ED should not be used for routine medical care or management of chronic pain, but the physician with the patient would help set up more frequent clinic visits. The ED or inpatient physicians would not fill orders for oral narcotics at discharge. The patient’s outpatient regimen should be used for chronic pain or exacerbations of chronic pain, and IV Benadryl or IV benzodiazepines should not be used for pain control.

The physician should offer substance-abuse treatment programs when appropriate, the care plan continued. Repeated imaging studies such as CT scans were discouraged unless new pathology was suggested by an exam, vital signs, and/or screening labs, because repeated imaging exposes the patient to radiation. The patient should not attempt to obtain narcotic prescriptions from anyone other than the designated primary care provider. If the patient does not follow the rules described in the care plan, the medical group "would have to consider releasing you from our care, since noncompliance leads us to being unable to care for you safely and appropriately."

Dr. Hilger cited a New Yorker magazine article by Dr. Atul Gawande of Harvard University describing the benefits of coordinating care for the most chronically expensive patients. The use of care plans promotes consistency in care; reinforces goals and expectations; empowers patients to take steps toward positive change; fosters patient trust; increases use of primary care; and decreases hospitalizations, readmissions, and total costs, the article suggests.

"We didn’t invent this" idea of care plans, Dr. Hilger said. Many hospitals are experimenting with elements of specialized care plans, but research so far has been limited mainly to EDs, he added. Specialized care plans are becoming popular for the less than 1% of patients with high rates of medically unnecessary emergency visits and admissions.

Dr. Hilger reported having no financial disclosures.

SAN DIEGO – Converting some conventional hospitalists to intensive care unit hospitalists reduced the average length of stay, duration on ventilators, and rate of catheter-related bloodstream infections, worth an estimated $1.45 million per year in savings at one community hospital.

After a year with the intensivist hospitalist team in action, the rate of catheter-related bloodstream infections decreased by 75%, the average length of ICU stay declined by 22%, ventilator days decreased by 35%, and the rate of ventilator-associated pneumonia was brought down to 0%. In addition, 30% more general ward patients were discharged before noon by non-ICU hospitalists, Dr. Min Hlaing and Dr. Rod Felber reported in a joint presentation at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

Surveys of other hospital staff suggested that having the intensivist hospitalist team improved communication between physician and nurses and between hospitalists and subspecialists. ICU nursing staff, respiratory technicians, and the sole pulmonologist reported being very satisfied with the ICU hospitalist care, said Dr. Hlaing and Dr. Felber of Lodi (Calif.) Memorial Hospital. The center has 270 beds.

The reductions in length of stay, ventilator days, and infections alone represent a savings to the hospital of $1.45 million per year, the speakers and their associates estimated.

Patient- and family-satisfaction scores increased after institution of the ICU hospitalist service. Job satisfaction among nurses improved, which increased retention of nurses in both the ICU and general ward. The hospital found it easier to recruit and retain specialists and easier to recruit general ward hospitalists because they no longer needed to have ICU skills. Satisfaction and retention among hospitalists as a whole improved at the hospital, said Dr. Felber, medical director of the hospitalist program.

To start the trial, Dr. Hlaing, who is an associate director of the hospitalist program, identified four of his hospitalists who were comfortable in caring for critically ill patients. He assigned them and himself to manage the 10-bed ICU and closed the ICU to other hospitalists. Team members became credentialed to perform procedures such as ultrasound-guided central venous catheter placement, arterial catheter insertion, lumbar puncture, paracentesis, endotracheal intubation, and ventilator management. They completed a course in the fundamentals of critical care support, and utilized evidence-based standardized order sets that were developed for common ICU conditions.

The ICU hospitalists had dedicated times for multidisciplinary rounds, family meetings, ICU-specific committees, and education of nurses. An emphasis on continuity of care enabled ICU patients to be admitted, rounded on daily in the ICU, followed after transfer to the medical/surgical floor, and discharged home by the same hospitalist.

After a year of the ICU hospitalist service in action, the investigators conducted a 360-degree evaluation and review of the major hospital stakeholders.

The workload of caring for an ICU patient was considered to be 1.5 times that of medical/surgical floor patients, so the intensivist hospitalists saw fewer patients than other hospitalists. The ICU hospitalists were paid $5 per hour more than other hospitalists. The Relative Value Units for ICU patient care and performance of procedures also led to higher compensation compared with medical/surgical hospitalists, Dr. Felber said.

Sherry Boschert/IMNG Medical Media

During the year, the hospital administration requested expansion of the ICU hospitalist model from 12 hours per day of coverage to 24 hours per day.

"If you have hospitalists who are capable of doing it, an ICU hospitalist model is one of the most sustainable and economically viable options to provide quality care to our most critically ill patients," Dr. Felber said.

Previous studies suggest that, in general, only 23% of critically ill patients are seen by intensivists, the speakers said. ICUs consume a quarter of hospital budgets on average. The aging U.S. population will increase demand for intensivist services by 38%. Strategies proposed for hospitals to cope with this evolution include hiring more intensivists, greater use of telemedicine, and partnering with hospitalists, as in the current study.

Dr. Hlaing and Dr. Felber did not report financial disclosures.

SAN DIEGO – Converting some conventional hospitalists to intensive care unit hospitalists reduced the average length of stay, duration on ventilators, and rate of catheter-related bloodstream infections, worth an estimated $1.45 million per year in savings at one community hospital.

After a year with the intensivist hospitalist team in action, the rate of catheter-related bloodstream infections decreased by 75%, the average length of ICU stay declined by 22%, ventilator days decreased by 35%, and the rate of ventilator-associated pneumonia was brought down to 0%. In addition, 30% more general ward patients were discharged before noon by non-ICU hospitalists, Dr. Min Hlaing and Dr. Rod Felber reported in a joint presentation at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

Surveys of other hospital staff suggested that having the intensivist hospitalist team improved communication between physician and nurses and between hospitalists and subspecialists. ICU nursing staff, respiratory technicians, and the sole pulmonologist reported being very satisfied with the ICU hospitalist care, said Dr. Hlaing and Dr. Felber of Lodi (Calif.) Memorial Hospital. The center has 270 beds.

The reductions in length of stay, ventilator days, and infections alone represent a savings to the hospital of $1.45 million per year, the speakers and their associates estimated.

Patient- and family-satisfaction scores increased after institution of the ICU hospitalist service. Job satisfaction among nurses improved, which increased retention of nurses in both the ICU and general ward. The hospital found it easier to recruit and retain specialists and easier to recruit general ward hospitalists because they no longer needed to have ICU skills. Satisfaction and retention among hospitalists as a whole improved at the hospital, said Dr. Felber, medical director of the hospitalist program.

To start the trial, Dr. Hlaing, who is an associate director of the hospitalist program, identified four of his hospitalists who were comfortable in caring for critically ill patients. He assigned them and himself to manage the 10-bed ICU and closed the ICU to other hospitalists. Team members became credentialed to perform procedures such as ultrasound-guided central venous catheter placement, arterial catheter insertion, lumbar puncture, paracentesis, endotracheal intubation, and ventilator management. They completed a course in the fundamentals of critical care support, and utilized evidence-based standardized order sets that were developed for common ICU conditions.

The ICU hospitalists had dedicated times for multidisciplinary rounds, family meetings, ICU-specific committees, and education of nurses. An emphasis on continuity of care enabled ICU patients to be admitted, rounded on daily in the ICU, followed after transfer to the medical/surgical floor, and discharged home by the same hospitalist.

After a year of the ICU hospitalist service in action, the investigators conducted a 360-degree evaluation and review of the major hospital stakeholders.

The workload of caring for an ICU patient was considered to be 1.5 times that of medical/surgical floor patients, so the intensivist hospitalists saw fewer patients than other hospitalists. The ICU hospitalists were paid $5 per hour more than other hospitalists. The Relative Value Units for ICU patient care and performance of procedures also led to higher compensation compared with medical/surgical hospitalists, Dr. Felber said.

Sherry Boschert/IMNG Medical Media

During the year, the hospital administration requested expansion of the ICU hospitalist model from 12 hours per day of coverage to 24 hours per day.

"If you have hospitalists who are capable of doing it, an ICU hospitalist model is one of the most sustainable and economically viable options to provide quality care to our most critically ill patients," Dr. Felber said.

Previous studies suggest that, in general, only 23% of critically ill patients are seen by intensivists, the speakers said. ICUs consume a quarter of hospital budgets on average. The aging U.S. population will increase demand for intensivist services by 38%. Strategies proposed for hospitals to cope with this evolution include hiring more intensivists, greater use of telemedicine, and partnering with hospitalists, as in the current study.

Dr. Hlaing and Dr. Felber did not report financial disclosures.

SAN DIEGO – Converting some conventional hospitalists to intensive care unit hospitalists reduced the average length of stay, duration on ventilators, and rate of catheter-related bloodstream infections, worth an estimated $1.45 million per year in savings at one community hospital.

After a year with the intensivist hospitalist team in action, the rate of catheter-related bloodstream infections decreased by 75%, the average length of ICU stay declined by 22%, ventilator days decreased by 35%, and the rate of ventilator-associated pneumonia was brought down to 0%. In addition, 30% more general ward patients were discharged before noon by non-ICU hospitalists, Dr. Min Hlaing and Dr. Rod Felber reported in a joint presentation at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

Surveys of other hospital staff suggested that having the intensivist hospitalist team improved communication between physician and nurses and between hospitalists and subspecialists. ICU nursing staff, respiratory technicians, and the sole pulmonologist reported being very satisfied with the ICU hospitalist care, said Dr. Hlaing and Dr. Felber of Lodi (Calif.) Memorial Hospital. The center has 270 beds.

The reductions in length of stay, ventilator days, and infections alone represent a savings to the hospital of $1.45 million per year, the speakers and their associates estimated.

Patient- and family-satisfaction scores increased after institution of the ICU hospitalist service. Job satisfaction among nurses improved, which increased retention of nurses in both the ICU and general ward. The hospital found it easier to recruit and retain specialists and easier to recruit general ward hospitalists because they no longer needed to have ICU skills. Satisfaction and retention among hospitalists as a whole improved at the hospital, said Dr. Felber, medical director of the hospitalist program.

To start the trial, Dr. Hlaing, who is an associate director of the hospitalist program, identified four of his hospitalists who were comfortable in caring for critically ill patients. He assigned them and himself to manage the 10-bed ICU and closed the ICU to other hospitalists. Team members became credentialed to perform procedures such as ultrasound-guided central venous catheter placement, arterial catheter insertion, lumbar puncture, paracentesis, endotracheal intubation, and ventilator management. They completed a course in the fundamentals of critical care support, and utilized evidence-based standardized order sets that were developed for common ICU conditions.

The ICU hospitalists had dedicated times for multidisciplinary rounds, family meetings, ICU-specific committees, and education of nurses. An emphasis on continuity of care enabled ICU patients to be admitted, rounded on daily in the ICU, followed after transfer to the medical/surgical floor, and discharged home by the same hospitalist.

After a year of the ICU hospitalist service in action, the investigators conducted a 360-degree evaluation and review of the major hospital stakeholders.

The workload of caring for an ICU patient was considered to be 1.5 times that of medical/surgical floor patients, so the intensivist hospitalists saw fewer patients than other hospitalists. The ICU hospitalists were paid $5 per hour more than other hospitalists. The Relative Value Units for ICU patient care and performance of procedures also led to higher compensation compared with medical/surgical hospitalists, Dr. Felber said.

Sherry Boschert/IMNG Medical Media

During the year, the hospital administration requested expansion of the ICU hospitalist model from 12 hours per day of coverage to 24 hours per day.

"If you have hospitalists who are capable of doing it, an ICU hospitalist model is one of the most sustainable and economically viable options to provide quality care to our most critically ill patients," Dr. Felber said.

Previous studies suggest that, in general, only 23% of critically ill patients are seen by intensivists, the speakers said. ICUs consume a quarter of hospital budgets on average. The aging U.S. population will increase demand for intensivist services by 38%. Strategies proposed for hospitals to cope with this evolution include hiring more intensivists, greater use of telemedicine, and partnering with hospitalists, as in the current study.

Dr. Hlaing and Dr. Felber did not report financial disclosures.