Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?

Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.

Study design: Observational study of Medicare admissions before and after duty hour reforms.

Setting: Short-term, acute-care hospitals.

Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.

No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.

When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).

Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.

Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.

Citation: Patel MS, Volpp KG, Small DS, et al. Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients. JAMA. 2014;312(22):2364-2373.

Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?

Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.

Study design: Observational study of Medicare admissions before and after duty hour reforms.

Setting: Short-term, acute-care hospitals.

Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.

No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.

When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).

Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.

Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.

Citation: Patel MS, Volpp KG, Small DS, et al. Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients. JAMA. 2014;312(22):2364-2373.

Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?

Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.

Study design: Observational study of Medicare admissions before and after duty hour reforms.

Setting: Short-term, acute-care hospitals.

Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.

No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.

When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).

Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.

Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.

Citation: Patel MS, Volpp KG, Small DS, et al. Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients. JAMA. 2014;312(22):2364-2373.

Clinical question: After hospitalization for acute hematogenous osteomyelitis (AHOM), do children discharged with oral antibiotics have similar clinical outcomes compared to those discharged with home IV antibiotics?

Background: AHOM occurs in one in 5,000 children yearly and makes up approximately 1% of pediatric hospitalizations in the U.S.¹ The incidence of AHOM might be increasing in some communities, concurrent with the increasing prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA).² Uncomplicated AHOM typically is defined as osteomyelitis not associated with trauma, with less than 14 days of symptoms and not requiring surgical intervention beyond diagnostic sampling.¹ Most recent published studies support a seven-day inpatient course of IV antibiotics for uncomplicated AHOM, followed by 21 to 28 days of oral therapy for patients who continue to improve clinically.¹ Significant variability exists in practice, with a recent study of free-standing children’s hospitals showing rates of transition to oral antibiotics after hospitalization for AHOM ranging from approximately 10% to more than 90%.³

Study design: Multi-center, retrospective, cohort study.

Setting: Thirty-eight U.S. children’s hospitals.

Synopsis: Researchers used clinical and billing data from the Pediatric Health Information System (PHIS) to identify children between the ages of two months and 18 years over a 48-month period who were discharged with a diagnosis of acute or unspecified osteomyelitis based on ICD-9-CM coding.

PHIS is a database of administrative, billing, and clinical details derived from hospitalizations at 44 U.S. children’s hospitals.

Exclusions from the study were numerous, and included:

• Hospitalization in the six months prior with acute, unspecified, or chronic osteomyelitis;
• Chronic cardiac, hematologic, immunologic, oncologic, or respiratory conditions that would increase the risk of treatment failure;
• Transfer either to or from the hospital at any point during hospitalization;
• More than one site of osteomyelitis;
• Length of stay of less than two or more than 14 days;
• Inability to take antibiotics orally or enterally;
• Malabsorption disorders;
• Primary diagnosis of cellulitis or septic arthritis;
• Orthopedic hardware or bone fractures;
• Prolonged immobilization or developed pressure ulcers; and
• Osteomyelitis of the head, face, and orbits.

Local physicians and research assistants at each hospital site reviewed medical records to confirm the validity of the ICD-9-CM diagnosis, determine the post-discharge antibiotic details, review for return ED visits or readmission within six months, and extract culture results. Primary outcome was treatment failure, defined as revisit to the ED or readmission for a change in antibiotic treatment (type, dosage, or prolongation), drainage of abscess, debridement, bone biopsy, or conversion to PICC route. Secondary outcomes included a return to ED or rehospitalization for adverse drug reactions (vomiting/diarrhea, dehydration, C. difficile infection, allergic reactions, drug-induced neutropenia, acute kidney injury) or PICC complication (fever evaluation, PICC site infection, blood stream infection, sepsis, thrombosis, breakage, repair, adjustment, manipulation, or PICC removal).

Of 8,555 patients from 38 hospitals who satisfied inclusion criteria, 2,060 patients from 36 hospitals remained after application of exclusion criteria, with 1,005 receiving antibiotics orally and 1,055 via a peripherally inserted central catheter (PICC) upon discharge. Median length of stay was six days, and the percentage of patients discharged on oral antibiotics ranged widely at the hospital level, from zero to 100%. Patients were most commonly discharged on clindamycin (50%) and cephalexin (37%) in the oral cohort, and clindamycin (36%) and cefazolin (33%) in the PICC cohort.

The rate of treatment failure was similar in unmatched analyses of the oral cohort (5%) versus the PICC cohort (6%). This similarity persisted in across-hospital and within-hospital matched analyses. Rates of adverse drug reactions were low (<4%) in both groups, but 15% of the PICC cohort returned to the ED or were readmitted for a PICC complication.

Bottom line: Previously healthy children hospitalized with a single focus of AHOM have similarly low rates of treatment failure whether discharged on oral- or PICC-administered antibiotics. Patients discharged with PICC-administered antibiotics suffer from a higher rate of return ED visit or readmission due to PICC-related complications.

 

Citation: Keren R, Shah SS, Srivastava R. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120-128.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

References

1. Majewski J, Del Vecchio M, Aronoff S. Route and length of therapy of acute uncomplicated hematogenous osteomyelitis: do we have the answers yet? Hosp Pediatr. 2014;4(1):44-47.
2. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26(6):703-708.
3. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus eraly transtion to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics. 2009;123(2):636-642.

Clinical question: After hospitalization for acute hematogenous osteomyelitis (AHOM), do children discharged with oral antibiotics have similar clinical outcomes compared to those discharged with home IV antibiotics?

Background: AHOM occurs in one in 5,000 children yearly and makes up approximately 1% of pediatric hospitalizations in the U.S.¹ The incidence of AHOM might be increasing in some communities, concurrent with the increasing prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA).² Uncomplicated AHOM typically is defined as osteomyelitis not associated with trauma, with less than 14 days of symptoms and not requiring surgical intervention beyond diagnostic sampling.¹ Most recent published studies support a seven-day inpatient course of IV antibiotics for uncomplicated AHOM, followed by 21 to 28 days of oral therapy for patients who continue to improve clinically.¹ Significant variability exists in practice, with a recent study of free-standing children’s hospitals showing rates of transition to oral antibiotics after hospitalization for AHOM ranging from approximately 10% to more than 90%.³

Study design: Multi-center, retrospective, cohort study.

Setting: Thirty-eight U.S. children’s hospitals.

Synopsis: Researchers used clinical and billing data from the Pediatric Health Information System (PHIS) to identify children between the ages of two months and 18 years over a 48-month period who were discharged with a diagnosis of acute or unspecified osteomyelitis based on ICD-9-CM coding.

PHIS is a database of administrative, billing, and clinical details derived from hospitalizations at 44 U.S. children’s hospitals.

Exclusions from the study were numerous, and included:

• Hospitalization in the six months prior with acute, unspecified, or chronic osteomyelitis;
• Chronic cardiac, hematologic, immunologic, oncologic, or respiratory conditions that would increase the risk of treatment failure;
• Transfer either to or from the hospital at any point during hospitalization;
• More than one site of osteomyelitis;
• Length of stay of less than two or more than 14 days;
• Inability to take antibiotics orally or enterally;
• Malabsorption disorders;
• Primary diagnosis of cellulitis or septic arthritis;
• Orthopedic hardware or bone fractures;
• Prolonged immobilization or developed pressure ulcers; and
• Osteomyelitis of the head, face, and orbits.

Local physicians and research assistants at each hospital site reviewed medical records to confirm the validity of the ICD-9-CM diagnosis, determine the post-discharge antibiotic details, review for return ED visits or readmission within six months, and extract culture results. Primary outcome was treatment failure, defined as revisit to the ED or readmission for a change in antibiotic treatment (type, dosage, or prolongation), drainage of abscess, debridement, bone biopsy, or conversion to PICC route. Secondary outcomes included a return to ED or rehospitalization for adverse drug reactions (vomiting/diarrhea, dehydration, C. difficile infection, allergic reactions, drug-induced neutropenia, acute kidney injury) or PICC complication (fever evaluation, PICC site infection, blood stream infection, sepsis, thrombosis, breakage, repair, adjustment, manipulation, or PICC removal).

Of 8,555 patients from 38 hospitals who satisfied inclusion criteria, 2,060 patients from 36 hospitals remained after application of exclusion criteria, with 1,005 receiving antibiotics orally and 1,055 via a peripherally inserted central catheter (PICC) upon discharge. Median length of stay was six days, and the percentage of patients discharged on oral antibiotics ranged widely at the hospital level, from zero to 100%. Patients were most commonly discharged on clindamycin (50%) and cephalexin (37%) in the oral cohort, and clindamycin (36%) and cefazolin (33%) in the PICC cohort.

The rate of treatment failure was similar in unmatched analyses of the oral cohort (5%) versus the PICC cohort (6%). This similarity persisted in across-hospital and within-hospital matched analyses. Rates of adverse drug reactions were low (<4%) in both groups, but 15% of the PICC cohort returned to the ED or were readmitted for a PICC complication.

Bottom line: Previously healthy children hospitalized with a single focus of AHOM have similarly low rates of treatment failure whether discharged on oral- or PICC-administered antibiotics. Patients discharged with PICC-administered antibiotics suffer from a higher rate of return ED visit or readmission due to PICC-related complications.

 

Citation: Keren R, Shah SS, Srivastava R. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120-128.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

References

1. Majewski J, Del Vecchio M, Aronoff S. Route and length of therapy of acute uncomplicated hematogenous osteomyelitis: do we have the answers yet? Hosp Pediatr. 2014;4(1):44-47.
2. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26(6):703-708.
3. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus eraly transtion to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics. 2009;123(2):636-642.

Clinical question: After hospitalization for acute hematogenous osteomyelitis (AHOM), do children discharged with oral antibiotics have similar clinical outcomes compared to those discharged with home IV antibiotics?

Background: AHOM occurs in one in 5,000 children yearly and makes up approximately 1% of pediatric hospitalizations in the U.S.¹ The incidence of AHOM might be increasing in some communities, concurrent with the increasing prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA).² Uncomplicated AHOM typically is defined as osteomyelitis not associated with trauma, with less than 14 days of symptoms and not requiring surgical intervention beyond diagnostic sampling.¹ Most recent published studies support a seven-day inpatient course of IV antibiotics for uncomplicated AHOM, followed by 21 to 28 days of oral therapy for patients who continue to improve clinically.¹ Significant variability exists in practice, with a recent study of free-standing children’s hospitals showing rates of transition to oral antibiotics after hospitalization for AHOM ranging from approximately 10% to more than 90%.³

Study design: Multi-center, retrospective, cohort study.

Setting: Thirty-eight U.S. children’s hospitals.

Synopsis: Researchers used clinical and billing data from the Pediatric Health Information System (PHIS) to identify children between the ages of two months and 18 years over a 48-month period who were discharged with a diagnosis of acute or unspecified osteomyelitis based on ICD-9-CM coding.

PHIS is a database of administrative, billing, and clinical details derived from hospitalizations at 44 U.S. children’s hospitals.

Exclusions from the study were numerous, and included:

• Hospitalization in the six months prior with acute, unspecified, or chronic osteomyelitis;
• Chronic cardiac, hematologic, immunologic, oncologic, or respiratory conditions that would increase the risk of treatment failure;
• Transfer either to or from the hospital at any point during hospitalization;
• More than one site of osteomyelitis;
• Length of stay of less than two or more than 14 days;
• Inability to take antibiotics orally or enterally;
• Malabsorption disorders;
• Primary diagnosis of cellulitis or septic arthritis;
• Orthopedic hardware or bone fractures;
• Prolonged immobilization or developed pressure ulcers; and
• Osteomyelitis of the head, face, and orbits.

Local physicians and research assistants at each hospital site reviewed medical records to confirm the validity of the ICD-9-CM diagnosis, determine the post-discharge antibiotic details, review for return ED visits or readmission within six months, and extract culture results. Primary outcome was treatment failure, defined as revisit to the ED or readmission for a change in antibiotic treatment (type, dosage, or prolongation), drainage of abscess, debridement, bone biopsy, or conversion to PICC route. Secondary outcomes included a return to ED or rehospitalization for adverse drug reactions (vomiting/diarrhea, dehydration, C. difficile infection, allergic reactions, drug-induced neutropenia, acute kidney injury) or PICC complication (fever evaluation, PICC site infection, blood stream infection, sepsis, thrombosis, breakage, repair, adjustment, manipulation, or PICC removal).

Of 8,555 patients from 38 hospitals who satisfied inclusion criteria, 2,060 patients from 36 hospitals remained after application of exclusion criteria, with 1,005 receiving antibiotics orally and 1,055 via a peripherally inserted central catheter (PICC) upon discharge. Median length of stay was six days, and the percentage of patients discharged on oral antibiotics ranged widely at the hospital level, from zero to 100%. Patients were most commonly discharged on clindamycin (50%) and cephalexin (37%) in the oral cohort, and clindamycin (36%) and cefazolin (33%) in the PICC cohort.

The rate of treatment failure was similar in unmatched analyses of the oral cohort (5%) versus the PICC cohort (6%). This similarity persisted in across-hospital and within-hospital matched analyses. Rates of adverse drug reactions were low (<4%) in both groups, but 15% of the PICC cohort returned to the ED or were readmitted for a PICC complication.

Bottom line: Previously healthy children hospitalized with a single focus of AHOM have similarly low rates of treatment failure whether discharged on oral- or PICC-administered antibiotics. Patients discharged with PICC-administered antibiotics suffer from a higher rate of return ED visit or readmission due to PICC-related complications.

 

Citation: Keren R, Shah SS, Srivastava R. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120-128.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

References

1. Majewski J, Del Vecchio M, Aronoff S. Route and length of therapy of acute uncomplicated hematogenous osteomyelitis: do we have the answers yet? Hosp Pediatr. 2014;4(1):44-47.
2. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26(6):703-708.
3. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus eraly transtion to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics. 2009;123(2):636-642.

Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?

Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.

Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.

Setting: Probability sample of American EDs and ED visits.

Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.

Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.

Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.

Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.

Citation: Pitts SR, Morgan SR, Schrager JD, Berger TJ. Emergency department resource use by supervised residents vs attending physicians alone. JAMA. 2014;312(22):2394-2400.

Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?

Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.

Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.

Setting: Probability sample of American EDs and ED visits.

Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.

Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.

Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.

Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.

Citation: Pitts SR, Morgan SR, Schrager JD, Berger TJ. Emergency department resource use by supervised residents vs attending physicians alone. JAMA. 2014;312(22):2394-2400.

Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?

Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.

Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.

Setting: Probability sample of American EDs and ED visits.

Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.

Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.

Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.

Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.

Citation: Pitts SR, Morgan SR, Schrager JD, Berger TJ. Emergency department resource use by supervised residents vs attending physicians alone. JAMA. 2014;312(22):2394-2400.

Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?

Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.

Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.

Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.

Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.

Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.

This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.

Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.

Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.

Citation: Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393.

Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?

Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.

Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.

Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.

Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.

Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.

This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.

Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.

Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.

Citation: Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393.

Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?

Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.

Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.

Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.

Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.

Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.

This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.

Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.

Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.

Citation: Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393.

Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?

Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.

Study design: Case-control.

Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.

Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.

Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.

Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.

Citaton: Waxman DA, Greenberg MD, Ridgely MS, Kellermann AL, Heaton P. The effect of malpractice reform on emergency department care. N Engl J Med. 2014;371(16):1518-1525.

Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?

Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.

Study design: Case-control.

Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.

Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.

Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.

Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.

Citaton: Waxman DA, Greenberg MD, Ridgely MS, Kellermann AL, Heaton P. The effect of malpractice reform on emergency department care. N Engl J Med. 2014;371(16):1518-1525.

Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?

Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.

Study design: Case-control.

Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.

Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.

Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.

Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.

Citaton: Waxman DA, Greenberg MD, Ridgely MS, Kellermann AL, Heaton P. The effect of malpractice reform on emergency department care. N Engl J Med. 2014;371(16):1518-1525.

Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?

Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.

Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.

Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.

Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.

An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).

“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.

Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.

All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.

Citation: Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64(24):e139-228.

Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?

Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.

Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.

Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.

Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.

An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).

“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.

Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.

All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.

Citation: Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64(24):e139-228.

Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?

Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.

Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.

Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.

Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.

An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).

“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.

Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.

All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.

Citation: Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64(24):e139-228.

Clinical question: What is the recommended approach to platelet transfusion in several common clinical scenarios?

Background: The AABB (formerly American Association of Blood Banks) developed these guidelines from a recent systematic review on platelet transfusion.

Synopsis: One strong recommendation was made based on moderate-quality evidence. Four weak or uncertain recommendations were made based on low- or very low-quality evidence.

For hospitalized patients with therapy-induced hypoproliferative thrombocytopenia, transfusion of up to a single unit of platelets is recommended for a platelet count of 10x109 cells/L or less to reduce the risk of spontaneous bleeding (strong recommendation, moderate-quality evidence).

For patients undergoing elective central venous catheter placement, platelet transfusion is recommended for a platelet count of less than 20x109 cells/L (weak recommendation, low-quality evidence).

For patients undergoing elective diagnostic lumbar puncture, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).

For patients undergoing major elective non-neuraxial surgery, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).

For patients undergoing cardiopulmonary bypass surgery, it is recommended that surgeons not perform routine transfusion of platelets in non-thrombocytopenic patients. For patients who have peri-operative bleeding with thrombocytopenia and/or evidence of platelet dysfunction, platelet transfusion is recommended (weak recommendation, very low-quality evidence).

There is insufficient evidence to recommend for or against platelet transfusion in patients with intracranial hemorrhage who are taking antiplatelet medications (uncertain recommendation, very low-quality evidence).

Citation: Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: A clinical practice guideline from the AABB. Ann Intern Med. 2015;162(3):205-213.

Clinical question: What is the recommended approach to platelet transfusion in several common clinical scenarios?

Background: The AABB (formerly American Association of Blood Banks) developed these guidelines from a recent systematic review on platelet transfusion.

Synopsis: One strong recommendation was made based on moderate-quality evidence. Four weak or uncertain recommendations were made based on low- or very low-quality evidence.

For hospitalized patients with therapy-induced hypoproliferative thrombocytopenia, transfusion of up to a single unit of platelets is recommended for a platelet count of 10x109 cells/L or less to reduce the risk of spontaneous bleeding (strong recommendation, moderate-quality evidence).

For patients undergoing elective central venous catheter placement, platelet transfusion is recommended for a platelet count of less than 20x109 cells/L (weak recommendation, low-quality evidence).

For patients undergoing elective diagnostic lumbar puncture, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).

For patients undergoing major elective non-neuraxial surgery, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).

For patients undergoing cardiopulmonary bypass surgery, it is recommended that surgeons not perform routine transfusion of platelets in non-thrombocytopenic patients. For patients who have peri-operative bleeding with thrombocytopenia and/or evidence of platelet dysfunction, platelet transfusion is recommended (weak recommendation, very low-quality evidence).

There is insufficient evidence to recommend for or against platelet transfusion in patients with intracranial hemorrhage who are taking antiplatelet medications (uncertain recommendation, very low-quality evidence).

Citation: Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: A clinical practice guideline from the AABB. Ann Intern Med. 2015;162(3):205-213.

Clinical question: What is the recommended approach to platelet transfusion in several common clinical scenarios?

Background: The AABB (formerly American Association of Blood Banks) developed these guidelines from a recent systematic review on platelet transfusion.

Synopsis: One strong recommendation was made based on moderate-quality evidence. Four weak or uncertain recommendations were made based on low- or very low-quality evidence.

For hospitalized patients with therapy-induced hypoproliferative thrombocytopenia, transfusion of up to a single unit of platelets is recommended for a platelet count of 10x109 cells/L or less to reduce the risk of spontaneous bleeding (strong recommendation, moderate-quality evidence).

For patients undergoing elective central venous catheter placement, platelet transfusion is recommended for a platelet count of less than 20x109 cells/L (weak recommendation, low-quality evidence).

For patients undergoing elective diagnostic lumbar puncture, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).

For patients undergoing major elective non-neuraxial surgery, platelet transfusion is recommended for a platelet count of less than 50x109 cells/L (weak recommendation, very low-quality evidence).

For patients undergoing cardiopulmonary bypass surgery, it is recommended that surgeons not perform routine transfusion of platelets in non-thrombocytopenic patients. For patients who have peri-operative bleeding with thrombocytopenia and/or evidence of platelet dysfunction, platelet transfusion is recommended (weak recommendation, very low-quality evidence).

There is insufficient evidence to recommend for or against platelet transfusion in patients with intracranial hemorrhage who are taking antiplatelet medications (uncertain recommendation, very low-quality evidence).

Citation: Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: A clinical practice guideline from the AABB. Ann Intern Med. 2015;162(3):205-213.

Clinical question: Is a six-week regimen of antibiotics as effective as a 12-week regimen in the treatment of vertebral osteomyelitis?

Background: The optimal duration of antibiotic treatment for vertebral osteomyelitis is unknown. Previous guidelines recommending six to 12 weeks of therapy have been based on expert opinion rather than clinical trial data.

Study design: Multi-center, open-label, randomized controlled trial.

Setting: Seventy-one medical care centers in France.

Synopsis: Three hundred fifty-six adult patients with culture-proven bacterial vertebral osteomyelitis were randomized to six- or 12- week antibiotic treatment regimens. The primary outcome was confirmed cure of infection at 12 months, as defined by absence of pain, fever, and CRP <10 mg/L. Outcomes were determined by a blinded panel of physicians.

Results showed 90.9% of the patients in the six-week group, and 90.8% of the patients in the 12-week group, met criteria for clinical cure. The lower bound of the 95% confidence interval for the difference in percentages of cure between groups was -6.2%, satisfying the predetermined noninferiority margin of 10%.

Antibiotic therapy in this trial was governed by French guidelines, which recommend oral fluoroquinolones and rifampin as first-line agents for vertebral osteomyelitis. Median duration of IV antibiotic therapy was less than 14 days. Relatively few patients had abscesses, and only eight of the 145 patients with Staphylococcus aureus (SA) infections had methicillin-resistant SA (MRSA).

Bottom line: A six-week regimen of antibiotics was shown to be noninferior to a 12-week regimen for treatment of vertebral osteomyelitis. Treatment for longer than six weeks may be indicated in the setting of drug-resistant organisms, extensive bone destruction, or abscesses.

Citation: Bernard L, Dinh A, Ghout I, et al; on behalf of the Duration of Treatment for Spondylodiscitis (DTS) study group. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomized, controlled trial [published online ahead of print November 5, 2014]. Lancet. doi: 10.1016/S0140-6736(14)61233-2.

Clinical question: Is a six-week regimen of antibiotics as effective as a 12-week regimen in the treatment of vertebral osteomyelitis?

Background: The optimal duration of antibiotic treatment for vertebral osteomyelitis is unknown. Previous guidelines recommending six to 12 weeks of therapy have been based on expert opinion rather than clinical trial data.

Study design: Multi-center, open-label, randomized controlled trial.

Setting: Seventy-one medical care centers in France.

Synopsis: Three hundred fifty-six adult patients with culture-proven bacterial vertebral osteomyelitis were randomized to six- or 12- week antibiotic treatment regimens. The primary outcome was confirmed cure of infection at 12 months, as defined by absence of pain, fever, and CRP <10 mg/L. Outcomes were determined by a blinded panel of physicians.

Results showed 90.9% of the patients in the six-week group, and 90.8% of the patients in the 12-week group, met criteria for clinical cure. The lower bound of the 95% confidence interval for the difference in percentages of cure between groups was -6.2%, satisfying the predetermined noninferiority margin of 10%.

Antibiotic therapy in this trial was governed by French guidelines, which recommend oral fluoroquinolones and rifampin as first-line agents for vertebral osteomyelitis. Median duration of IV antibiotic therapy was less than 14 days. Relatively few patients had abscesses, and only eight of the 145 patients with Staphylococcus aureus (SA) infections had methicillin-resistant SA (MRSA).

Bottom line: A six-week regimen of antibiotics was shown to be noninferior to a 12-week regimen for treatment of vertebral osteomyelitis. Treatment for longer than six weeks may be indicated in the setting of drug-resistant organisms, extensive bone destruction, or abscesses.

Citation: Bernard L, Dinh A, Ghout I, et al; on behalf of the Duration of Treatment for Spondylodiscitis (DTS) study group. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomized, controlled trial [published online ahead of print November 5, 2014]. Lancet. doi: 10.1016/S0140-6736(14)61233-2.

Clinical question: Is a six-week regimen of antibiotics as effective as a 12-week regimen in the treatment of vertebral osteomyelitis?

Background: The optimal duration of antibiotic treatment for vertebral osteomyelitis is unknown. Previous guidelines recommending six to 12 weeks of therapy have been based on expert opinion rather than clinical trial data.

Study design: Multi-center, open-label, randomized controlled trial.

Setting: Seventy-one medical care centers in France.

Synopsis: Three hundred fifty-six adult patients with culture-proven bacterial vertebral osteomyelitis were randomized to six- or 12- week antibiotic treatment regimens. The primary outcome was confirmed cure of infection at 12 months, as defined by absence of pain, fever, and CRP <10 mg/L. Outcomes were determined by a blinded panel of physicians.

Results showed 90.9% of the patients in the six-week group, and 90.8% of the patients in the 12-week group, met criteria for clinical cure. The lower bound of the 95% confidence interval for the difference in percentages of cure between groups was -6.2%, satisfying the predetermined noninferiority margin of 10%.

Antibiotic therapy in this trial was governed by French guidelines, which recommend oral fluoroquinolones and rifampin as first-line agents for vertebral osteomyelitis. Median duration of IV antibiotic therapy was less than 14 days. Relatively few patients had abscesses, and only eight of the 145 patients with Staphylococcus aureus (SA) infections had methicillin-resistant SA (MRSA).

Bottom line: A six-week regimen of antibiotics was shown to be noninferior to a 12-week regimen for treatment of vertebral osteomyelitis. Treatment for longer than six weeks may be indicated in the setting of drug-resistant organisms, extensive bone destruction, or abscesses.

Citation: Bernard L, Dinh A, Ghout I, et al; on behalf of the Duration of Treatment for Spondylodiscitis (DTS) study group. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomized, controlled trial [published online ahead of print November 5, 2014]. Lancet. doi: 10.1016/S0140-6736(14)61233-2.

Sam Bagchi, MD,

is the new senior vice president/chief medical officer for Methodist Health System in Dallas, Texas. Dr. Bagchi comes to Methodist from Vanguard Health Systems’ New England region, where he served as chief medical informatics officer and medical director of utilization management. Before Vanguard, he served as director of hospital medicine and associate vice president of utilization management for Emerson Hospital in Concord, Mass.

George Bailey, MD, has been named 2014 Physician of the Year by the Ob Hospitalist Group (OBHG), based in Mauldin, S.C. Dr. Bailey has been a practicing OB/GYN hospitalist at Yakima Valley Memorial Hospital in Yakima, Wash., since the OB hospitalist program began there in July 2013. Dr. Bailey’s colleagues cite his emphasis on safety, communication, and mentorship as a few of the characteristics that define him as a leader at their hospital.

Martha Buckley, MD, is the new chief quality officer at Fairfield Medical Center in Lancaster, Ohio. Dr. Buckley joined FMC as a hospitalist in 2010 before serving as a part-time chief medical quality officer. FMC is a 222-bed, nonprofit, acute care center serving Athens, Fairfield, Hocking, and Perry counties in central Ohio.

Marina Farah, MD, MHA, has been promoted to vice president of clinical innovation at Sound Physicians, based in Tacoma, Wash. Prior to her new role, Dr. Farah served as senior medical director of performance management at Sound. Dr. Farah has been with Sound since 2002, and, in 2011, she received the Milliman Care Guidelines Richard L. Doyle Award for Innovation and Leadership in Healthcare.

Robert Holloway, MD, SFHM, is the new executive vice president of management services and consulting for Hospitalists Now, Inc., based in Austin, Texas. Dr. Holloway comes to HNI from his role as CEO and chief medical officer for InCompass Health, an Atlanta-based national hospitalist service provider that he founded in 1999. Dr. Holloway will continue his work as a clinical faculty member at Emory University School of Medicine in Atlanta.

Salima Oukachbi, MD, received the Physician Assistant Educator Award from the Canadian Physician Assistant Education Association and the Canadian Association of Physician Assistants in recognition for her performance as an educator of physician assistants in Northwestern Ontario. Dr. Oukachbi is a hospitalist at Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario, Canada.

 

Olevia Pitts, MD, SFHM, has been appointed executive director of IPC Healthcare’s Kansas City Region. Prior to her new role, Dr. Pitts served as regional medical director of IPC’s Kansas City Region. She is also a member of IPC’s Practice Group Leadership Council, where she serves as a mentor for future physician leaders.

 

Syed A. Raza, MD, is the new chief medical officer at CHI St. Luke’s Health—The Woodlands Hospital in The Woodlands, Texas. Most recently, Dr. Raza worked as associate chief of medicine and chief hospitalist for The Woodlands Hospital’s primary hospitalist group. In 2006, he helped establish the original hospitalist group at CHI St. Luke’s The Woodlands and Memorial Hermann The Woodlands hospitals.

Thomas Whalen, DO, received the Hal Belknap Heart of Gold award from Norman Regional Health System in Norman, Okla., for outstanding service to his community. Dr. Whalen is the hospitalist service medical director at Norman Regional Hospital. Before Norman, he served as an Air Force major and chief of medicine at Tinker Air Force Base in Oklahoma City. Dr. Whalen is also recognized as a respected Angel Flight pilot and frequent blood donor.

 

Business Moves

The hospitalist program at MountainView Regional Medical Center in Las Cruces, N.M., was awarded with the Program of the Year Award by its parent provider, Apogee Physicians, based in Phoenix, Ariz. The award is presented to the program with the highest performance in achieving measurable outcomes, according to the company. Apogee has been providing hospitalist services since 2002.

The North Hollywood, Calif.-based IPC The Hospitalist Company recently announced that its name has changed to IPC Healthcare, Inc. Adam Singer, MD, CEO, and chair of IPC, cited “a natural progression for our company” as the impetus for the change. Since unveiling its new name, IPC announced its acquisition of selected assets of Hospitalists Now, Inc. (HNI), in the Jacksonville, Fla. area. According to company officials from IPC and HNI, “a collaborative approach would be of greatest benefit to the community,” since both companies share many of the same clients in the Jacksonville area.

The Ob Hospitalist Group (OBHG) recently announced new hospitalist program partnerships at six different hospitals. OBHG will now provide OB hospitalist services at Atlanta Medical Center in Atlanta, Ga.; El Camino Hospital Los Gatos in Los Gatos, Calif.; El Camino Hospital Mountain View in Mountain View, Calif.; Memorial Medical Center in Springfield, Ill.; Swedish Covenant Hospital in Chicago, Ill.; and Union Hospital in Terre Haute, Ind. OBHG has been staffing OB/GYN hospitalists since 2006.

Jameson Hospital North Campus, a 254-bed, not-for-profit, acute care facility in New Castle, Penn., has partnered with Emergency Resource Management Inc. (ERMI) in Pittsburgh to provide hospitalist services at Jameson, the flagship hospital of Jameson Health System. ERMI provides hospitalist and emergency medicine physician staffing services across Western Pennsylvania and the greater Pittsburgh area, serving over 600,000 patients per year.

---

Michael O’Neal is a freelance writer in New York City.

Sam Bagchi, MD,

is the new senior vice president/chief medical officer for Methodist Health System in Dallas, Texas. Dr. Bagchi comes to Methodist from Vanguard Health Systems’ New England region, where he served as chief medical informatics officer and medical director of utilization management. Before Vanguard, he served as director of hospital medicine and associate vice president of utilization management for Emerson Hospital in Concord, Mass.

George Bailey, MD, has been named 2014 Physician of the Year by the Ob Hospitalist Group (OBHG), based in Mauldin, S.C. Dr. Bailey has been a practicing OB/GYN hospitalist at Yakima Valley Memorial Hospital in Yakima, Wash., since the OB hospitalist program began there in July 2013. Dr. Bailey’s colleagues cite his emphasis on safety, communication, and mentorship as a few of the characteristics that define him as a leader at their hospital.

Martha Buckley, MD, is the new chief quality officer at Fairfield Medical Center in Lancaster, Ohio. Dr. Buckley joined FMC as a hospitalist in 2010 before serving as a part-time chief medical quality officer. FMC is a 222-bed, nonprofit, acute care center serving Athens, Fairfield, Hocking, and Perry counties in central Ohio.

Marina Farah, MD, MHA, has been promoted to vice president of clinical innovation at Sound Physicians, based in Tacoma, Wash. Prior to her new role, Dr. Farah served as senior medical director of performance management at Sound. Dr. Farah has been with Sound since 2002, and, in 2011, she received the Milliman Care Guidelines Richard L. Doyle Award for Innovation and Leadership in Healthcare.

Robert Holloway, MD, SFHM, is the new executive vice president of management services and consulting for Hospitalists Now, Inc., based in Austin, Texas. Dr. Holloway comes to HNI from his role as CEO and chief medical officer for InCompass Health, an Atlanta-based national hospitalist service provider that he founded in 1999. Dr. Holloway will continue his work as a clinical faculty member at Emory University School of Medicine in Atlanta.

Salima Oukachbi, MD, received the Physician Assistant Educator Award from the Canadian Physician Assistant Education Association and the Canadian Association of Physician Assistants in recognition for her performance as an educator of physician assistants in Northwestern Ontario. Dr. Oukachbi is a hospitalist at Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario, Canada.

 

Olevia Pitts, MD, SFHM, has been appointed executive director of IPC Healthcare’s Kansas City Region. Prior to her new role, Dr. Pitts served as regional medical director of IPC’s Kansas City Region. She is also a member of IPC’s Practice Group Leadership Council, where she serves as a mentor for future physician leaders.

 

Syed A. Raza, MD, is the new chief medical officer at CHI St. Luke’s Health—The Woodlands Hospital in The Woodlands, Texas. Most recently, Dr. Raza worked as associate chief of medicine and chief hospitalist for The Woodlands Hospital’s primary hospitalist group. In 2006, he helped establish the original hospitalist group at CHI St. Luke’s The Woodlands and Memorial Hermann The Woodlands hospitals.

Thomas Whalen, DO, received the Hal Belknap Heart of Gold award from Norman Regional Health System in Norman, Okla., for outstanding service to his community. Dr. Whalen is the hospitalist service medical director at Norman Regional Hospital. Before Norman, he served as an Air Force major and chief of medicine at Tinker Air Force Base in Oklahoma City. Dr. Whalen is also recognized as a respected Angel Flight pilot and frequent blood donor.

 

Business Moves

The hospitalist program at MountainView Regional Medical Center in Las Cruces, N.M., was awarded with the Program of the Year Award by its parent provider, Apogee Physicians, based in Phoenix, Ariz. The award is presented to the program with the highest performance in achieving measurable outcomes, according to the company. Apogee has been providing hospitalist services since 2002.

The North Hollywood, Calif.-based IPC The Hospitalist Company recently announced that its name has changed to IPC Healthcare, Inc. Adam Singer, MD, CEO, and chair of IPC, cited “a natural progression for our company” as the impetus for the change. Since unveiling its new name, IPC announced its acquisition of selected assets of Hospitalists Now, Inc. (HNI), in the Jacksonville, Fla. area. According to company officials from IPC and HNI, “a collaborative approach would be of greatest benefit to the community,” since both companies share many of the same clients in the Jacksonville area.

The Ob Hospitalist Group (OBHG) recently announced new hospitalist program partnerships at six different hospitals. OBHG will now provide OB hospitalist services at Atlanta Medical Center in Atlanta, Ga.; El Camino Hospital Los Gatos in Los Gatos, Calif.; El Camino Hospital Mountain View in Mountain View, Calif.; Memorial Medical Center in Springfield, Ill.; Swedish Covenant Hospital in Chicago, Ill.; and Union Hospital in Terre Haute, Ind. OBHG has been staffing OB/GYN hospitalists since 2006.

Jameson Hospital North Campus, a 254-bed, not-for-profit, acute care facility in New Castle, Penn., has partnered with Emergency Resource Management Inc. (ERMI) in Pittsburgh to provide hospitalist services at Jameson, the flagship hospital of Jameson Health System. ERMI provides hospitalist and emergency medicine physician staffing services across Western Pennsylvania and the greater Pittsburgh area, serving over 600,000 patients per year.

---

Michael O’Neal is a freelance writer in New York City.

Sam Bagchi, MD,

is the new senior vice president/chief medical officer for Methodist Health System in Dallas, Texas. Dr. Bagchi comes to Methodist from Vanguard Health Systems’ New England region, where he served as chief medical informatics officer and medical director of utilization management. Before Vanguard, he served as director of hospital medicine and associate vice president of utilization management for Emerson Hospital in Concord, Mass.

George Bailey, MD, has been named 2014 Physician of the Year by the Ob Hospitalist Group (OBHG), based in Mauldin, S.C. Dr. Bailey has been a practicing OB/GYN hospitalist at Yakima Valley Memorial Hospital in Yakima, Wash., since the OB hospitalist program began there in July 2013. Dr. Bailey’s colleagues cite his emphasis on safety, communication, and mentorship as a few of the characteristics that define him as a leader at their hospital.

Martha Buckley, MD, is the new chief quality officer at Fairfield Medical Center in Lancaster, Ohio. Dr. Buckley joined FMC as a hospitalist in 2010 before serving as a part-time chief medical quality officer. FMC is a 222-bed, nonprofit, acute care center serving Athens, Fairfield, Hocking, and Perry counties in central Ohio.

Marina Farah, MD, MHA, has been promoted to vice president of clinical innovation at Sound Physicians, based in Tacoma, Wash. Prior to her new role, Dr. Farah served as senior medical director of performance management at Sound. Dr. Farah has been with Sound since 2002, and, in 2011, she received the Milliman Care Guidelines Richard L. Doyle Award for Innovation and Leadership in Healthcare.

Robert Holloway, MD, SFHM, is the new executive vice president of management services and consulting for Hospitalists Now, Inc., based in Austin, Texas. Dr. Holloway comes to HNI from his role as CEO and chief medical officer for InCompass Health, an Atlanta-based national hospitalist service provider that he founded in 1999. Dr. Holloway will continue his work as a clinical faculty member at Emory University School of Medicine in Atlanta.

Salima Oukachbi, MD, received the Physician Assistant Educator Award from the Canadian Physician Assistant Education Association and the Canadian Association of Physician Assistants in recognition for her performance as an educator of physician assistants in Northwestern Ontario. Dr. Oukachbi is a hospitalist at Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario, Canada.

 

Olevia Pitts, MD, SFHM, has been appointed executive director of IPC Healthcare’s Kansas City Region. Prior to her new role, Dr. Pitts served as regional medical director of IPC’s Kansas City Region. She is also a member of IPC’s Practice Group Leadership Council, where she serves as a mentor for future physician leaders.

 

Syed A. Raza, MD, is the new chief medical officer at CHI St. Luke’s Health—The Woodlands Hospital in The Woodlands, Texas. Most recently, Dr. Raza worked as associate chief of medicine and chief hospitalist for The Woodlands Hospital’s primary hospitalist group. In 2006, he helped establish the original hospitalist group at CHI St. Luke’s The Woodlands and Memorial Hermann The Woodlands hospitals.

Thomas Whalen, DO, received the Hal Belknap Heart of Gold award from Norman Regional Health System in Norman, Okla., for outstanding service to his community. Dr. Whalen is the hospitalist service medical director at Norman Regional Hospital. Before Norman, he served as an Air Force major and chief of medicine at Tinker Air Force Base in Oklahoma City. Dr. Whalen is also recognized as a respected Angel Flight pilot and frequent blood donor.

 

Business Moves

The hospitalist program at MountainView Regional Medical Center in Las Cruces, N.M., was awarded with the Program of the Year Award by its parent provider, Apogee Physicians, based in Phoenix, Ariz. The award is presented to the program with the highest performance in achieving measurable outcomes, according to the company. Apogee has been providing hospitalist services since 2002.

The North Hollywood, Calif.-based IPC The Hospitalist Company recently announced that its name has changed to IPC Healthcare, Inc. Adam Singer, MD, CEO, and chair of IPC, cited “a natural progression for our company” as the impetus for the change. Since unveiling its new name, IPC announced its acquisition of selected assets of Hospitalists Now, Inc. (HNI), in the Jacksonville, Fla. area. According to company officials from IPC and HNI, “a collaborative approach would be of greatest benefit to the community,” since both companies share many of the same clients in the Jacksonville area.

The Ob Hospitalist Group (OBHG) recently announced new hospitalist program partnerships at six different hospitals. OBHG will now provide OB hospitalist services at Atlanta Medical Center in Atlanta, Ga.; El Camino Hospital Los Gatos in Los Gatos, Calif.; El Camino Hospital Mountain View in Mountain View, Calif.; Memorial Medical Center in Springfield, Ill.; Swedish Covenant Hospital in Chicago, Ill.; and Union Hospital in Terre Haute, Ind. OBHG has been staffing OB/GYN hospitalists since 2006.

Jameson Hospital North Campus, a 254-bed, not-for-profit, acute care facility in New Castle, Penn., has partnered with Emergency Resource Management Inc. (ERMI) in Pittsburgh to provide hospitalist services at Jameson, the flagship hospital of Jameson Health System. ERMI provides hospitalist and emergency medicine physician staffing services across Western Pennsylvania and the greater Pittsburgh area, serving over 600,000 patients per year.

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Michael O’Neal is a freelance writer in New York City.

A dedicated procedure team or service can give hospitals needed expertise without requiring a one-size-fits-all approach. In many cases, hospitalists run procedure services, but interventional radiologists and pulmonary critical care specialists also oversee some of them.

At The Johns Hopkins Hospital, the bedside procedure service began in the department of medicine and has since expanded throughout the hospital.

“I think a proceduralist service is as important as the hospitalist service,” says David Lichtman, PA, director of the service. He calls it “essential” for good patient care because it can allow experienced providers to be consistently involved in the process, whether proceduralists, medical students, or new interns perform the procedure.

“Patients have the benefit of expert care, and the trainees have the ability to learn and do without having to worry about working without a safety net,” he says. As a result, the service keeps patients safe while maximizing medical education.

At many institutions, a service or team can also meet a pressing need. In its seven years of existence, for example, the hospitalist-led procedures team at the University of Miami Jackson Memorial Hospital Medical Campus has been called upon to do more than 7,500 procedures.

“The idea behind procedure services is that you consolidate the expertise and training within a few people, be it a few hospitalists or a few proceduralists,” says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California

San Francisco (UCSF). But a successful service can require significant investments in infrastructure and other resources. When they run the numbers, many hospitalist groups are forced to conclude that they simply don’t have sufficient demand to justify the expense of maintaining provider competency.

“People are really struggling with this,” she says.

The few studies conducted on procedure services, however, suggest that hospitals can benefit from improved patient satisfaction and a potential reduction in some complications.

“We were worried that that use of trainees and the teaching that went on at the bedside might be a concern for patients,” Dr. Mourad says of the UCSF procedures program. “We found that, instead, patients were reassured by having a designated expert in the room and recognized that it hadn’t always been the case in the past.” Accordingly, she says, a survey of satisfaction recorded “exceptionally high” rates.³

Initial research also suggests a reduction in such complications as thoracentesis-related pneumothorax.

“We have some inkling that perhaps the rigor with which we approach procedures, the high level of experience that we bring to procedures, and the presence of an expert in the room for every procedure may have decreased the complication rate for thoracentesis at our institution,” Dr. Mourad says.

At Boston University, the procedure service is based in the department of pulmonary critical care, and the department’s attending physicians supervise internal medicine residents. It was developed after “identifying some potential patient safety concerns with unsupervised resident procedures,” says Melissa Tukey, MD, MSc, now a pulmonology critical care physician at Lahey Clinic in Burlington, Mass. A major aim of the procedure service, she says, is to provide supervision and teaching to medical house staff performing the procedures.

 

To test whether the service was delivering on those goals, Dr. Tukey and colleagues studied thoracentesis, paracentesis, central line, and lumbar puncture procedures.⁴ The study, an 18-month comparison of the procedures performed by the dedicated procedure service versus those done by other providers, found no significant difference in what were already quite low complication rates.

Unexpectedly, the researchers didn’t see higher levels of resident engagement in procedures performed by the procedure team, but they did find improvement in “best practice safety process measures,” such as whether ultrasound use followed established recommendations.

“I think that whenever you’re looking at quality improvement initiatives, you have to have an understanding of what might be the potential benefits,”

Dr. Tukey says. Her study, at least, suggests that launching a procedure service primarily to reduce the number of severe complications may not be the most appropriate goal. On the other hand, she says, the data do support the “very realistic goals” of improving residency education and maintaining procedure quality.

A dedicated service may not be a cure-all, in other words. And it’s certainly not for everyone. But given enough resources and buy-in, experts say, it could at least help put a hospital’s ailing bedside procedure strategy on the road to recovery without overextending its providers.

A dedicated procedure team or service can give hospitals needed expertise without requiring a one-size-fits-all approach. In many cases, hospitalists run procedure services, but interventional radiologists and pulmonary critical care specialists also oversee some of them.

At The Johns Hopkins Hospital, the bedside procedure service began in the department of medicine and has since expanded throughout the hospital.

“I think a proceduralist service is as important as the hospitalist service,” says David Lichtman, PA, director of the service. He calls it “essential” for good patient care because it can allow experienced providers to be consistently involved in the process, whether proceduralists, medical students, or new interns perform the procedure.

“Patients have the benefit of expert care, and the trainees have the ability to learn and do without having to worry about working without a safety net,” he says. As a result, the service keeps patients safe while maximizing medical education.

At many institutions, a service or team can also meet a pressing need. In its seven years of existence, for example, the hospitalist-led procedures team at the University of Miami Jackson Memorial Hospital Medical Campus has been called upon to do more than 7,500 procedures.

“The idea behind procedure services is that you consolidate the expertise and training within a few people, be it a few hospitalists or a few proceduralists,” says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California

San Francisco (UCSF). But a successful service can require significant investments in infrastructure and other resources. When they run the numbers, many hospitalist groups are forced to conclude that they simply don’t have sufficient demand to justify the expense of maintaining provider competency.

“People are really struggling with this,” she says.

The few studies conducted on procedure services, however, suggest that hospitals can benefit from improved patient satisfaction and a potential reduction in some complications.

“We were worried that that use of trainees and the teaching that went on at the bedside might be a concern for patients,” Dr. Mourad says of the UCSF procedures program. “We found that, instead, patients were reassured by having a designated expert in the room and recognized that it hadn’t always been the case in the past.” Accordingly, she says, a survey of satisfaction recorded “exceptionally high” rates.³

Initial research also suggests a reduction in such complications as thoracentesis-related pneumothorax.

“We have some inkling that perhaps the rigor with which we approach procedures, the high level of experience that we bring to procedures, and the presence of an expert in the room for every procedure may have decreased the complication rate for thoracentesis at our institution,” Dr. Mourad says.

At Boston University, the procedure service is based in the department of pulmonary critical care, and the department’s attending physicians supervise internal medicine residents. It was developed after “identifying some potential patient safety concerns with unsupervised resident procedures,” says Melissa Tukey, MD, MSc, now a pulmonology critical care physician at Lahey Clinic in Burlington, Mass. A major aim of the procedure service, she says, is to provide supervision and teaching to medical house staff performing the procedures.

 

To test whether the service was delivering on those goals, Dr. Tukey and colleagues studied thoracentesis, paracentesis, central line, and lumbar puncture procedures.⁴ The study, an 18-month comparison of the procedures performed by the dedicated procedure service versus those done by other providers, found no significant difference in what were already quite low complication rates.

Unexpectedly, the researchers didn’t see higher levels of resident engagement in procedures performed by the procedure team, but they did find improvement in “best practice safety process measures,” such as whether ultrasound use followed established recommendations.

“I think that whenever you’re looking at quality improvement initiatives, you have to have an understanding of what might be the potential benefits,”

Dr. Tukey says. Her study, at least, suggests that launching a procedure service primarily to reduce the number of severe complications may not be the most appropriate goal. On the other hand, she says, the data do support the “very realistic goals” of improving residency education and maintaining procedure quality.

A dedicated service may not be a cure-all, in other words. And it’s certainly not for everyone. But given enough resources and buy-in, experts say, it could at least help put a hospital’s ailing bedside procedure strategy on the road to recovery without overextending its providers.

A dedicated procedure team or service can give hospitals needed expertise without requiring a one-size-fits-all approach. In many cases, hospitalists run procedure services, but interventional radiologists and pulmonary critical care specialists also oversee some of them.

At The Johns Hopkins Hospital, the bedside procedure service began in the department of medicine and has since expanded throughout the hospital.

“I think a proceduralist service is as important as the hospitalist service,” says David Lichtman, PA, director of the service. He calls it “essential” for good patient care because it can allow experienced providers to be consistently involved in the process, whether proceduralists, medical students, or new interns perform the procedure.

“Patients have the benefit of expert care, and the trainees have the ability to learn and do without having to worry about working without a safety net,” he says. As a result, the service keeps patients safe while maximizing medical education.

At many institutions, a service or team can also meet a pressing need. In its seven years of existence, for example, the hospitalist-led procedures team at the University of Miami Jackson Memorial Hospital Medical Campus has been called upon to do more than 7,500 procedures.

“The idea behind procedure services is that you consolidate the expertise and training within a few people, be it a few hospitalists or a few proceduralists,” says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California

San Francisco (UCSF). But a successful service can require significant investments in infrastructure and other resources. When they run the numbers, many hospitalist groups are forced to conclude that they simply don’t have sufficient demand to justify the expense of maintaining provider competency.

“People are really struggling with this,” she says.

The few studies conducted on procedure services, however, suggest that hospitals can benefit from improved patient satisfaction and a potential reduction in some complications.

“We were worried that that use of trainees and the teaching that went on at the bedside might be a concern for patients,” Dr. Mourad says of the UCSF procedures program. “We found that, instead, patients were reassured by having a designated expert in the room and recognized that it hadn’t always been the case in the past.” Accordingly, she says, a survey of satisfaction recorded “exceptionally high” rates.³

Initial research also suggests a reduction in such complications as thoracentesis-related pneumothorax.

“We have some inkling that perhaps the rigor with which we approach procedures, the high level of experience that we bring to procedures, and the presence of an expert in the room for every procedure may have decreased the complication rate for thoracentesis at our institution,” Dr. Mourad says.

At Boston University, the procedure service is based in the department of pulmonary critical care, and the department’s attending physicians supervise internal medicine residents. It was developed after “identifying some potential patient safety concerns with unsupervised resident procedures,” says Melissa Tukey, MD, MSc, now a pulmonology critical care physician at Lahey Clinic in Burlington, Mass. A major aim of the procedure service, she says, is to provide supervision and teaching to medical house staff performing the procedures.

 

To test whether the service was delivering on those goals, Dr. Tukey and colleagues studied thoracentesis, paracentesis, central line, and lumbar puncture procedures.⁴ The study, an 18-month comparison of the procedures performed by the dedicated procedure service versus those done by other providers, found no significant difference in what were already quite low complication rates.

Unexpectedly, the researchers didn’t see higher levels of resident engagement in procedures performed by the procedure team, but they did find improvement in “best practice safety process measures,” such as whether ultrasound use followed established recommendations.

“I think that whenever you’re looking at quality improvement initiatives, you have to have an understanding of what might be the potential benefits,”

Dr. Tukey says. Her study, at least, suggests that launching a procedure service primarily to reduce the number of severe complications may not be the most appropriate goal. On the other hand, she says, the data do support the “very realistic goals” of improving residency education and maintaining procedure quality.

A dedicated service may not be a cure-all, in other words. And it’s certainly not for everyone. But given enough resources and buy-in, experts say, it could at least help put a hospital’s ailing bedside procedure strategy on the road to recovery without overextending its providers.