Evolving Practice of Hospital Medicine

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Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies
Author(s)
Smitha R. Chadaga, MD
Mary P. Maher, MD
Nancy Maller, MD
Diana Mancini, MD
Margherita Mascolo, MD
Shailendra Sharma, MD
Mel L. Anderson, MD
Eugene S. Chu, MD

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

Examples of Conditions Appropriate for Short Stay Unit
Evaluation of Diagnostic Syndromes Treatment of Emergent Conditions

  • NOTE: Adapted from SHM White Paper: Observation Unit White Paper.35

Chest pain Asthma
Abdominal pain Congestive heart failure
Fever Dehydration
Gastrointestinal bleed Hypoglycemia or hyperglycemia
Syncope Hypercalcemia
Dizziness Atrial fibrillation
Headache
Chest trauma
Abdominal trauma

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

Preoperative Clinics

In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59

Palliative Care

Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.

Geographic Rounding

In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69

Flexible Staffing Models

In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Acknowledgements

Disclosure: All authors disclose no relevant or financial conflicts of interest.

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References
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Article PDF
1951_ftp.pdf
Issue
Journal of Hospital Medicine - 7(8)
Page Number
649-654
Sections
Reviews
Author(s)
Smitha R. Chadaga, MD
Mary P. Maher, MD
Nancy Maller, MD
Diana Mancini, MD
Margherita Mascolo, MD
Shailendra Sharma, MD
Mel L. Anderson, MD
Eugene S. Chu, MD
Author(s)
Smitha R. Chadaga, MD
Mary P. Maher, MD
Nancy Maller, MD
Diana Mancini, MD
Margherita Mascolo, MD
Shailendra Sharma, MD
Mel L. Anderson, MD
Eugene S. Chu, MD
Files
Supporting Information (1)
Files
Supporting Information (1)
Article PDF
1951_ftp.pdf
Article PDF
1951_ftp.pdf

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

Examples of Conditions Appropriate for Short Stay Unit
Evaluation of Diagnostic Syndromes Treatment of Emergent Conditions

  • NOTE: Adapted from SHM White Paper: Observation Unit White Paper.35

Chest pain Asthma
Abdominal pain Congestive heart failure
Fever Dehydration
Gastrointestinal bleed Hypoglycemia or hyperglycemia
Syncope Hypercalcemia
Dizziness Atrial fibrillation
Headache
Chest trauma
Abdominal trauma

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

Preoperative Clinics

In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59

Palliative Care

Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.

Geographic Rounding

In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69

Flexible Staffing Models

In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Acknowledgements

Disclosure: All authors disclose no relevant or financial conflicts of interest.

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

Examples of Conditions Appropriate for Short Stay Unit
Evaluation of Diagnostic Syndromes Treatment of Emergent Conditions

  • NOTE: Adapted from SHM White Paper: Observation Unit White Paper.35

Chest pain Asthma
Abdominal pain Congestive heart failure
Fever Dehydration
Gastrointestinal bleed Hypoglycemia or hyperglycemia
Syncope Hypercalcemia
Dizziness Atrial fibrillation
Headache
Chest trauma
Abdominal trauma

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

Preoperative Clinics

In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59

Palliative Care

Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.

Geographic Rounding

In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69

Flexible Staffing Models

In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Acknowledgements

Disclosure: All authors disclose no relevant or financial conflicts of interest.

References
  1. SHM Benchmarks Committee. Maximizing throughput and improving patient flow. The Hospitalist, Supplement: How Hospitalists Add Value. Philadelphia, PA: Society of Hospital Medicine; 2005. Available online at http://www.the‐hospitalist.org/details/article/279433/Maximizing_Throughput_and_Improving_Patient_Flow.html. Accessed on July 2009.
  2. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital‐Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
  3. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1–5.
  4. Pines JM, Hollander JE, Baxt WG, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community‐acquired pneumonia. Ann Emerg Med. 2007;50:510–516.
  5. Chaflin DB, Trzeciak S, Likourezos A, Baumann DB, Dellinger RP; for the DELAYED‐ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477–1483.
  6. Litvak E. Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. In: Beurhaus P, Rudolph M, Prenney B, et al, eds. Joint Commission Resources, Joint Commission Resources, Inc., 2009.
  7. Vasilevskis E, Knebel M, Wachter RM, Auerback AD. California hospital leader's view of hospitalists: meeting needs of the present and the future. J Hosp Med. 2009;4(9):528–534.
  8. Wachter R, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514–517.
  9. Auerbach A, Chlouber R, Singler J, et al. Trends in market demand for internal medicine 1999–2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21:1079–1085.
  10. Lindenauer P, Pantilat S, Katz P, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
  11. Wachter R, Katz P, Showstack J, et al. Reorganizing an academic medical service impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:1560–1565.
  12. Wachter R, Katz P. The hospitalist movement 5 years later. JAMA. 2002;287:487–494.
  13. Auerback AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137(11):859–865.
  14. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10(8):561–568.
  15. Lindenauer PK, Rothberg MB, Pekow PS, et al. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med. 2007;357(25):2589–2600.
  16. Peterson MA. Systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84(3):248–254.
  17. Kuo Y, Goodwin J. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152–159.
  18. Lurie J, Miller D, Lindenauer P, et al. The potential size of the hospitalist workforce in the United States. Am Med. 1999;106(4):441–445.
  19. Whinney C, Michota F. Surgical co‐management: a natural evolution of hospitalist practice. J Hosp Med. 2008;3:394–397.
  20. Pistoria MH, Amin AN, Dressler DD, et al. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):1–30.
  21. Society of Hospital Medicine. Co‐Management Task Force Page. Available at: http://www.hospitalmedicine.org/AM/Template.cfm? Section=Home165(7):796–801.
  22. Roy A, Heckman MG, Roy V, et al. Associations between the hospitalist model of care and quality‐of‐care‐related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc. 2006;81(1):28–31.
  23. Batsis JA. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219–225.
  24. Huddleston JM, Long KH, Naessens JM, et al; for the Hospital‐Orthopedic Team Trial Investigators. Medical and surgical co‐management after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28–38.
  25. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist‐orthopedic co‐management of high‐risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.
  26. Simon TD, Eilert R, Dickinson LM, et al. Pediatric hospitalist co‐management of spinal fusion surgery patients. J Hosp Med. 2007;2:23–29.
  27. Siegal E. Just because you can, doesn't mean that you should: a call for the rational application of hospitalist co‐management. J Hosp Med. 2008;3:398–402.
  28. Society of Hospital Medicine. SHM White Paper: Co‐Management White Paper. Philadelphia, PA: 2010.
  29. American Medical Association, Council on Ethical and Judicial Affairs. CEJA Report 5–I‐99. Ethical Implications of Surgical Co‐Management. Available at: http://www.ama‐assn.org/resources/doc/code‐medical‐ethics/8043a.pdf. Accessed November 17, 2011.
  30. Southern WN, Berger MA, Bellin EY, et al. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007;167:1869–1874.
  31. Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247–254.
  32. Jaffer A, Michota E. Why perioperative medicine matters more than ever. Cleve Clin J Med. 2006;73(supp 1):S1.
  33. Mace SE, Graff L, Mikhail M, et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;12:529–533.
  34. Society of Hospital Medicine. SHM White Paper: Observation Unit White Paper. Philadelphia, PA: 2009.
  35. Lucas BP, Kumapley R, Mba B, et al. A hospitalist‐run short‐stay unit: features that predict length‐of‐stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276–284.
  36. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: a hospitalist‐run medical short‐stay unit in a teaching hospital. Can Med Assoc J. 2000:163(11):1477–1480.
  37. Scheinder M. Hospitalists can cut ED overcrowding. ACEP News. 2010.
  38. Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist‐run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med. 2010;5(9):E2–E5.
  39. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care survey: 2004 emergency department summary. Adv Data. 2006;23:1–29.
  40. Wilkinson K, Severance H. Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am. 2001;19:35–66.
  41. Chandra A, Rudraiah L, Zalenski RJ. Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001;19:87–103.
  42. Zalenski RJ, McCarren M, Roberts R, et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:1085–1091.
  43. Doherty RJ, Barish RA, Groleau G. The Chest Pain Evaluation Center at the University of Maryland Medical Center. Md Med J. 1994;43:1047–1052.
  44. Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM. Cost effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med. 1997;29:88–98.
  45. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med. 1995;25:1–8.
  46. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department‐based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:25–33.
  47. Goodacre S, Nicholl J, Dixon S, et al. Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ. 2004;328:254.
  48. Krantz MJ, Zwang O, Rowan SB, et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol. 2005;4(2):55–58.
  49. Myers JS, Bellini LM, Rohrback J, et al. Improving resource utilization in a teaching hospital: development of a nonteaching service for chest pain admissions. Acad Med. 2006;81(5):432–435.
  50. Bayley MD, Schwarts JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45(2):110–117.
  51. Somekh NN, Rachko M, Husk G, Friedmann P, Bergmann SR. Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008;15(2):186–192.
  52. Darves B. Taking charge of observation units. Today's Hospitalist. July 2007.
  53. Fatovich DM, Nagree Y, Spirvulis P. Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351–354.
  54. Nicholl J, West J, Goodacre S, Tuner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665–668.
  55. Hoot N, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126–136.
  56. Howell E, Bessman E, Kravat S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–810.
  57. Chadaga S, Mancini D, Mehler PS, et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):17–18.
  58. Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591–596.
  59. Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
  60. Magallanes M. The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:13–16.
  61. Darves B. A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
  62. Pistoria MJ, Amin AN, Dressler DD, McKean SCW, Budnitz TL. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:1–67.
  63. Cherlin E, Morris V, Morris J, Johnson‐Hurzeler R, Sullivan GM, Bradley EH. Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357–365.
  64. Auerbach A. End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669–675.
  65. Lindenauer PK, Pantilat SZ, Katz PP, Watcher RM. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
  66. Muir JC, Arnold RM. Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S–14S.
  67. Hertz B. Giving hospitalists their space. ACP Hospitalist. February 2008.
  68. Gesensway D. Having problems findings your patients? Today's Hospitalists. June 2010.
  69. O'Leary KJ, Wayne DB, Landler MP, et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):1223–1227.
  70. Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
  71. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.
  72. Bucheli B, Martina B. Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):29–34.
  73. Hinami K, Whelan CT, Konetzka RT, Meltzer DO. Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401–404.
References
  1. SHM Benchmarks Committee. Maximizing throughput and improving patient flow. The Hospitalist, Supplement: How Hospitalists Add Value. Philadelphia, PA: Society of Hospital Medicine; 2005. Available online at http://www.the‐hospitalist.org/details/article/279433/Maximizing_Throughput_and_Improving_Patient_Flow.html. Accessed on July 2009.
  2. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital‐Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
  3. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1–5.
  4. Pines JM, Hollander JE, Baxt WG, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community‐acquired pneumonia. Ann Emerg Med. 2007;50:510–516.
  5. Chaflin DB, Trzeciak S, Likourezos A, Baumann DB, Dellinger RP; for the DELAYED‐ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477–1483.
  6. Litvak E. Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. In: Beurhaus P, Rudolph M, Prenney B, et al, eds. Joint Commission Resources, Joint Commission Resources, Inc., 2009.
  7. Vasilevskis E, Knebel M, Wachter RM, Auerback AD. California hospital leader's view of hospitalists: meeting needs of the present and the future. J Hosp Med. 2009;4(9):528–534.
  8. Wachter R, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514–517.
  9. Auerbach A, Chlouber R, Singler J, et al. Trends in market demand for internal medicine 1999–2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21:1079–1085.
  10. Lindenauer P, Pantilat S, Katz P, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
  11. Wachter R, Katz P, Showstack J, et al. Reorganizing an academic medical service impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:1560–1565.
  12. Wachter R, Katz P. The hospitalist movement 5 years later. JAMA. 2002;287:487–494.
  13. Auerback AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137(11):859–865.
  14. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10(8):561–568.
  15. Lindenauer PK, Rothberg MB, Pekow PS, et al. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med. 2007;357(25):2589–2600.
  16. Peterson MA. Systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84(3):248–254.
  17. Kuo Y, Goodwin J. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152–159.
  18. Lurie J, Miller D, Lindenauer P, et al. The potential size of the hospitalist workforce in the United States. Am Med. 1999;106(4):441–445.
  19. Whinney C, Michota F. Surgical co‐management: a natural evolution of hospitalist practice. J Hosp Med. 2008;3:394–397.
  20. Pistoria MH, Amin AN, Dressler DD, et al. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):1–30.
  21. Society of Hospital Medicine. Co‐Management Task Force Page. Available at: http://www.hospitalmedicine.org/AM/Template.cfm? Section=Home165(7):796–801.
  22. Roy A, Heckman MG, Roy V, et al. Associations between the hospitalist model of care and quality‐of‐care‐related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc. 2006;81(1):28–31.
  23. Batsis JA. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219–225.
  24. Huddleston JM, Long KH, Naessens JM, et al; for the Hospital‐Orthopedic Team Trial Investigators. Medical and surgical co‐management after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28–38.
  25. Pinzur MS, Gurza E, Kristopaitis T, et al. Hospitalist‐orthopedic co‐management of high‐risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.
  26. Simon TD, Eilert R, Dickinson LM, et al. Pediatric hospitalist co‐management of spinal fusion surgery patients. J Hosp Med. 2007;2:23–29.
  27. Siegal E. Just because you can, doesn't mean that you should: a call for the rational application of hospitalist co‐management. J Hosp Med. 2008;3:398–402.
  28. Society of Hospital Medicine. SHM White Paper: Co‐Management White Paper. Philadelphia, PA: 2010.
  29. American Medical Association, Council on Ethical and Judicial Affairs. CEJA Report 5–I‐99. Ethical Implications of Surgical Co‐Management. Available at: http://www.ama‐assn.org/resources/doc/code‐medical‐ethics/8043a.pdf. Accessed November 17, 2011.
  30. Southern WN, Berger MA, Bellin EY, et al. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007;167:1869–1874.
  31. Plauth WH, Pantilat SZ, Wachter RM, et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247–254.
  32. Jaffer A, Michota E. Why perioperative medicine matters more than ever. Cleve Clin J Med. 2006;73(supp 1):S1.
  33. Mace SE, Graff L, Mikhail M, et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;12:529–533.
  34. Society of Hospital Medicine. SHM White Paper: Observation Unit White Paper. Philadelphia, PA: 2009.
  35. Lucas BP, Kumapley R, Mba B, et al. A hospitalist‐run short‐stay unit: features that predict length‐of‐stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276–284.
  36. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: a hospitalist‐run medical short‐stay unit in a teaching hospital. Can Med Assoc J. 2000:163(11):1477–1480.
  37. Scheinder M. Hospitalists can cut ED overcrowding. ACEP News. 2010.
  38. Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist‐run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med. 2010;5(9):E2–E5.
  39. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care survey: 2004 emergency department summary. Adv Data. 2006;23:1–29.
  40. Wilkinson K, Severance H. Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am. 2001;19:35–66.
  41. Chandra A, Rudraiah L, Zalenski RJ. Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001;19:87–103.
  42. Zalenski RJ, McCarren M, Roberts R, et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:1085–1091.
  43. Doherty RJ, Barish RA, Groleau G. The Chest Pain Evaluation Center at the University of Maryland Medical Center. Md Med J. 1994;43:1047–1052.
  44. Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM. Cost effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med. 1997;29:88–98.
  45. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med. 1995;25:1–8.
  46. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department‐based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:25–33.
  47. Goodacre S, Nicholl J, Dixon S, et al. Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ. 2004;328:254.
  48. Krantz MJ, Zwang O, Rowan SB, et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol. 2005;4(2):55–58.
  49. Myers JS, Bellini LM, Rohrback J, et al. Improving resource utilization in a teaching hospital: development of a nonteaching service for chest pain admissions. Acad Med. 2006;81(5):432–435.
  50. Bayley MD, Schwarts JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45(2):110–117.
  51. Somekh NN, Rachko M, Husk G, Friedmann P, Bergmann SR. Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008;15(2):186–192.
  52. Darves B. Taking charge of observation units. Today's Hospitalist. July 2007.
  53. Fatovich DM, Nagree Y, Spirvulis P. Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351–354.
  54. Nicholl J, West J, Goodacre S, Tuner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665–668.
  55. Hoot N, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126–136.
  56. Howell E, Bessman E, Kravat S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–810.
  57. Chadaga S, Mancini D, Mehler PS, et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):17–18.
  58. Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591–596.
  59. Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
  60. Magallanes M. The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:13–16.
  61. Darves B. A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
  62. Pistoria MJ, Amin AN, Dressler DD, McKean SCW, Budnitz TL. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:1–67.
  63. Cherlin E, Morris V, Morris J, Johnson‐Hurzeler R, Sullivan GM, Bradley EH. Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357–365.
  64. Auerbach A. End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669–675.
  65. Lindenauer PK, Pantilat SZ, Katz PP, Watcher RM. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
  66. Muir JC, Arnold RM. Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S–14S.
  67. Hertz B. Giving hospitalists their space. ACP Hospitalist. February 2008.
  68. Gesensway D. Having problems findings your patients? Today's Hospitalists. June 2010.
  69. O'Leary KJ, Wayne DB, Landler MP, et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):1223–1227.
  70. Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
  71. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.
  72. Bucheli B, Martina B. Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):29–34.
  73. Hinami K, Whelan CT, Konetzka RT, Meltzer DO. Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401–404.
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Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies
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Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies
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Smitha R. Chadaga, MD
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Hospitalist Physical Diagnosis Curricula

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Development of a hospitalist‐led‐and‐directed physical examination curriculum
Author(s)
Michael P. Janjigian, MD, FACP
Mitchell Charap, MD, FACP
Adina Kalet, MD

Deficiencies in physical examination skills among medical students, housestaff, and even faculty have been reported for decades. For example, cardiac examination skills have been shown to improve during the early years of medical school and then plateau by the third year, with no measurable improvement through residency or beyond without fellowship training.13

Despite efforts by residency programs to promote bedside teaching, many general medicine faculty shy away due to lack of confidence and comfort in teaching physical diagnosis.4 The presence of hospitalists increases satisfaction among trainees with inpatient teaching,5 and medical faculty's ability has been shown to positively impact medical students' test scores.6 This lack of bedside teaching is a missed opportunity, as general medicine faculty are assuming more teaching responsibility.

The Merrin Bedside Teaching Program was founded in 2004 at New York University (NYU) School of Medicine to improve the quality of bedside teaching in the Department of Medicine/Division of General Internal Medicine. In this article, we describe the development process and early outcomes of this program.

METHODS

The principal teaching institution of NYU is Bellevue Hospital, an 800‐bed tertiary care safety‐net facility located in New York City. Approximately 30 general medicine faculty members at Bellevue Hospital attend on the inpatient teaching service 12 weeks per year each, with the remaining time spent in the hospital‐based clinics and other inpatient services.

Prior to the initiation of this program, our faculty did not receive formal instruction in bedside teaching, in general, or in teaching physical diagnosis, in particular. Housestaff and students were reporting that bedside rounds were not being conducted consistently and were of variable educational quality. Among a number of our residency and fellowship programs, there were concerns about meeting Accreditation Counsel for Graduate Medical Education (ACGME) requirements for quantity and quality of bedside rounds and faculty development.

To inform program development, we conducted a literature review, a series of focus groups with residents and faculty, and a survey of 39 general medicine hospital and ambulatory‐based clinician teachers to determine the perceived bedside teaching faculty development needs of our department. Then, over the next 2 years, we recruited 32 hospitalists and fellowship faculty to participate in a videotaped bedside teaching simulation. Each attending reviewed the videotape one‐on‐one with an experienced facilitator (A.K.), who elicited the attending's goals and instructional models and methods used for clinical teaching. To address the wide variety in teaching approaches identified in the assessment, 4 to 6 attendings met weekly for 1 month to observe each other conducting rounds with their teams. The facilitator of these groups used materials derived from relevant medical education theory79 and related conceptual models to frame the debriefing. Participants enthusiastically supported the educational value of this learner‐centered, experiential teaching approach.

We integrated this needs assessment with an individualized approach, incorporating learner goal‐setting with interactive and highly experiential teaching strategies,7,9,10 to create the Merrin Bedside Teaching Program in 2004. This program recruits faculty, with reputations as excellent teachers, to design a program to develop their own bedside teaching skills and disseminate what they learn to their peers. Faculty fellows are recruited through an open call for applications, which includes a letter of support from a supervisor and a detailed independent learning plan, including an identified mentor. Fellows are selected by the program's executive committee based on the likelihood of the success of their proposed program. A stipend equivalent of between 5% and 10% of base salary is provided to each fellow for a period of 2 years. Selected faculty fellows are encouraged to focus on an aspect of the physical examination, work in groups of 2 or 3, and to identify and recruit a mentor who is considered a master clinician in the target specialty. Master clinicians are given an honorarium to acknowledge their selection and incentivize them to spend time with the faculty fellows. This is funded with philanthropic support from the Merrin Family Foundation.

Fellows are guided by program leadership in their independent study, development of clinical teaching skills, and curriculum development using the same theory‐driven, systematic approach that framed program inception.911 Bedside rounds are the core instructional method used by each group of fellows and are supplemented by lectures, interactive small‐group seminars, and Web‐based modules in certain cases. Bedside sessions are run by the master‐clinician mentor until the faculty fellows are deemed competent by the mentor and feel confident enough to lead independently.

Since 2004, there have been 14 fellows who have developed programs focused on the examination of the heart, skin, knee, and shoulder. Program development is underway in motivational interviewing, the pulmonary examination, and the examination of the critically ill patient. We describe the work of the first 4 fellows as an example of how this fellowship creates value for the individual fellows, our departmental teaching programs, and the medical school.

Our first cohort of fellows chose, out of personal interest, to concentrate on the cardiac examination. They spent the first year working with highly respected cardiologists to hone their own clinical skills, reviewing the literature on the evidence‐based cardiac physical examination and effective teaching methods,12,13 researching the use of electronic stethoscopes and related technology for teaching at the bedside, and piloting a variety of approaches to teaching their busy colleagues these skills.

Bedside rounds focus on pertinent physical findings with an emphasis on an evidence‐based approach. We find we are most effective when the patient's diagnosis is unknown by the group leader to avoid bias when formulating the differential diagnosis. Sessions include a discussion of how the exam correlates with the diagnosis, relevant pathophysiology, imaging, and treatment options.

Two, 1‐hour‐long lectures in cardiac examination are delivered: the first reviews basics of heart sounds, both normal and abnormal, and the second reviews the most common systolic and diastolic murmurs. These lectures, scheduled into routine faculty conference time, utilize a PowerPoint format, with an overview of basic physiology and pathophysiology, aided by phonocardiograms, frequency spectrographs, and audio recordings delivered via a loudspeaker. Interactive cases offered by Blaufuss Multimedia (Rolling Hills Estates, CA) are an excellent teaching tool that incorporate case presentations, videos of key physical findings, auscultatory recordings, and relevant pathophysiology. We initially used this resource because of its high quality and ease of use; we now use our own interactive case presentations, which allow for flexibility with content and style, and which reinforce the prevalence of interesting cases at our institution to the audience members.

Technology has proven to be an invaluable tool in teaching cardiac physical diagnosis, both at the bedside and in the classroom. Electronic stethoscopes provide the ability to record heart sounds for use in teaching venues on short notice, such as morning report, and for use in creating the interactive case presentations described above. The electronic stethoscopes we use can be wired to peripheral devices, such as camcorders, iPods, and speaker pads. Speaker pads are devices, approximately the size of a stethoscope head, that can be connected by wires in series, each attached to a stethoscope, allowing a group of people to listen to the same sounds simultaneously with excellent sound reproduction. This technology allows each person standing around the bedside to listen to a patient while the group leader auscultates and explains the findings in real time. There are distinct advantages of simultaneous auscultation both for describing auditory findings and minimizing discomfort to the patient.

Applications are available for the iPod (Stethoscope App, Thinklabs Technology, LLC, Centennial, CO) which can record and display real‐time phonocardiography when attached to an electronic stethoscope, even at the terminus of a speaker pad chain. This application also allows recorded sounds to be played directly through a speaker, or transferred to a computer with the corresponding phonocardiographic and spectrographic images, that can all be incorporated into an interactive case presentation. Frequency spectrographs allow visualization of differences between low‐ and high‐frequency sounds, which, in conjunction with the timing and amplitude displayed by phonocardiography, can aid in teaching subtle findings, such as shapes of murmurs, patterns of splitting, gallups, etc.14 Playback of heart sounds in a conference room setting can be challenging, given the often subtle and low‐frequency findings typical of cardiac pathology, and is effectively achieved by using a musician‐quality loudspeaker. We have found that speaker pads offer the best sound quality at the bedside, although they are inconvenient for larger groups.

DISCUSSION

A new framework has been proposed for considering faculty development programs that focuses on the participants, program, content, facilitator, and the context in which the program occurs.15 We have effectively addressed and synthesized these components in a rich, high impact, learner‐centered faculty development program that also responds to challenges raised by changes in the health delivery system, concerns about accreditation requirements, and targeted local needs assessment.

We have been fortunate to recruit specialty faculty who are outstanding teachers, have welcomed the fellows into their clinics, and have dedicated countless hours to supervision and education. An unintended, but important, outcome of the program is that we are able to highlight the exceptional skills of our senior, experienced clinicians. These are colleagues who all too often do not receive adequate recognition in the modern‐day academic medical center environment, but who are undoubtedly invaluable to the education mission of these centers.

The existence of the program has resulted in our general medicine faculty showing great enthusiasm, both to develop an area of expertise and to participate as learners in the programs developed by peers. The faculty fellows in each specialty have become a valuable resource to peer faculty, residents, and medical students alike, who are now less dependent on consultants to identify and explain physical findings. The faculty teaching the knee and shoulder exams started a Sports Medicine Clinic within primary care, and assist with joint injections throughout the clinic. In addition to providing clinical support, their educational curriculum is included in both the attending and housestaff conference schedules. The cardiac lectures, both didactic and interactive case presentations, are included in the attending conference schedule, intern and resident core curricula, and the third‐year medicine clerkship lecture series. The dermatology group has created a series of comprehensive online modules that provide content tailored to general medicine. All this durable material is available broadly to trainees of all professions in our medical center.

Given the ever‐growing burden of patient care and extra‐clinical responsibilities, the principal factor limiting the effectiveness of bedside rounds is faculty availability. Despite this, all of our hospitalists have attended at least 1 bedside cardiac session, and the majority have attended multiple times. Varying the time and day of the sessions, offering to join attending rounds, and being available for impromptu diagnostic consultations have maximized the fellows' contact with faculty, residents, and students.

Although funding for evaluation of the program has been limited, a research agenda is emerging. Both the pulmonary physical exam and critical care groups are in the process of evaluating the effectiveness of their programs on the quality of bedside rounds, student and resident learning, and, to the extent possible, on patient care.

CONCLUSION

We believe wholeheartedly that bedside instruction both in physical diagnosis and interview skills must not become a lost art. General medicine faculty are ideally situated to take on this challenge. An educational program targeting hospitalists and general medicine faculty energizes faculty and leverages local resources to fill in gaps in skills for faculty and then for trainees. Generalist faculty relish the opportunity to champion a particular element of the doctorpatient encounter, which has contributed to our ultimate goal of strengthening the core diagnostic skills of our faculty who are at the forefront of clinical care and medical education.

Acknowledgements

The authors thank the Merrin Family for their generous support of the program; Drs Gregory Mints, Tanping Wong, and Sabrina Felson for their initial work in developing the Merrin Faculty Development Program; and Dr Martin Kahn for his tireless dedication to mentorship and bedside teaching.

Disclosure: Drs Janjigian, Charap, and Kalet report receiving funding from the Merrin Family Foundation.

Files
Supporting Information (1)
References
  1. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA. 1997;278(9):717–722.
  2. Vukanovic‐Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med. 2006;166(6):610–616.
  3. Vukanovic‐Criley JM, Hovanesyan A, Criley SR, et al. Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study. Clin Cardiol. 2010;33(12):738–745.
  4. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus‐group study of clinical teachers. Acad Med. 2003;78(4):384–390.
  5. Natarajan P, Ranji SR, Auerbach AD, Hauer KE. Effect of hospitalist attending physicians on trainee educational experiences: a systematic review. J Hosp Med. 2009;4(8):490–498.
  6. Stern DT, Williams BC, Gill A, Gruppen LD, Woolliscroft JO, Grum CM. Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores? Acad Med. 2000;75(11):1144–1146.
  7. Neher JO, Gordon KC, Meyer B, Stevens N. A five‐step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419–424.
  8. Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending‐physician role models. N Engl J Med. 1998;339(27):1986–1993.
  9. Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach. 2003;25(2):127–130.
  10. Hewson MG. A theory‐based faculty development program for clinician‐educators. Acad Med. 2000;75(5):498–501.
  11. Kern D, Thomas P, Howard D, Bass E, ed. Curriculum Development for Medical Education: A Six‐Step Approach. Baltimore, MD: The Johns Hopkins University Press; 1998.
  12. Criley JM, Keiner J, Boker JR, Criley SR, Warde CM. Innovative web‐based multimedia curriculum improves cardiac examination competency of residents. J Hosp Med. 2008;3(2):124–133.
  13. Vukanovic‐Criley JM, Boker JR, Criley SR, Rajagopalan S, Criley JM. Using virtual patients to improve cardiac examination competency in medical students. Clin Cardiol. 2008;31(7):334–339.
  14. Tavel ME. Cardiac auscultation: a glorious past—and it does have a future! Circulation. 2006;113(9):1255–1259.
  15. O'Sullivan PS, Irby DM. Reframing research on faculty development. Acad Med. 2011;86(4):421–428.
Article PDF
1954_ftp.pdf
Issue
Journal of Hospital Medicine - 7(8)
Page Number
640-643
Sections
Brief Reports
Author(s)
Michael P. Janjigian, MD, FACP
Mitchell Charap, MD, FACP
Adina Kalet, MD
Author(s)
Michael P. Janjigian, MD, FACP
Mitchell Charap, MD, FACP
Adina Kalet, MD
Files
Supporting Information (1)
Files
Supporting Information (1)
Article PDF
1954_ftp.pdf
Article PDF
1954_ftp.pdf

Deficiencies in physical examination skills among medical students, housestaff, and even faculty have been reported for decades. For example, cardiac examination skills have been shown to improve during the early years of medical school and then plateau by the third year, with no measurable improvement through residency or beyond without fellowship training.13

Despite efforts by residency programs to promote bedside teaching, many general medicine faculty shy away due to lack of confidence and comfort in teaching physical diagnosis.4 The presence of hospitalists increases satisfaction among trainees with inpatient teaching,5 and medical faculty's ability has been shown to positively impact medical students' test scores.6 This lack of bedside teaching is a missed opportunity, as general medicine faculty are assuming more teaching responsibility.

The Merrin Bedside Teaching Program was founded in 2004 at New York University (NYU) School of Medicine to improve the quality of bedside teaching in the Department of Medicine/Division of General Internal Medicine. In this article, we describe the development process and early outcomes of this program.

METHODS

The principal teaching institution of NYU is Bellevue Hospital, an 800‐bed tertiary care safety‐net facility located in New York City. Approximately 30 general medicine faculty members at Bellevue Hospital attend on the inpatient teaching service 12 weeks per year each, with the remaining time spent in the hospital‐based clinics and other inpatient services.

Prior to the initiation of this program, our faculty did not receive formal instruction in bedside teaching, in general, or in teaching physical diagnosis, in particular. Housestaff and students were reporting that bedside rounds were not being conducted consistently and were of variable educational quality. Among a number of our residency and fellowship programs, there were concerns about meeting Accreditation Counsel for Graduate Medical Education (ACGME) requirements for quantity and quality of bedside rounds and faculty development.

To inform program development, we conducted a literature review, a series of focus groups with residents and faculty, and a survey of 39 general medicine hospital and ambulatory‐based clinician teachers to determine the perceived bedside teaching faculty development needs of our department. Then, over the next 2 years, we recruited 32 hospitalists and fellowship faculty to participate in a videotaped bedside teaching simulation. Each attending reviewed the videotape one‐on‐one with an experienced facilitator (A.K.), who elicited the attending's goals and instructional models and methods used for clinical teaching. To address the wide variety in teaching approaches identified in the assessment, 4 to 6 attendings met weekly for 1 month to observe each other conducting rounds with their teams. The facilitator of these groups used materials derived from relevant medical education theory79 and related conceptual models to frame the debriefing. Participants enthusiastically supported the educational value of this learner‐centered, experiential teaching approach.

We integrated this needs assessment with an individualized approach, incorporating learner goal‐setting with interactive and highly experiential teaching strategies,7,9,10 to create the Merrin Bedside Teaching Program in 2004. This program recruits faculty, with reputations as excellent teachers, to design a program to develop their own bedside teaching skills and disseminate what they learn to their peers. Faculty fellows are recruited through an open call for applications, which includes a letter of support from a supervisor and a detailed independent learning plan, including an identified mentor. Fellows are selected by the program's executive committee based on the likelihood of the success of their proposed program. A stipend equivalent of between 5% and 10% of base salary is provided to each fellow for a period of 2 years. Selected faculty fellows are encouraged to focus on an aspect of the physical examination, work in groups of 2 or 3, and to identify and recruit a mentor who is considered a master clinician in the target specialty. Master clinicians are given an honorarium to acknowledge their selection and incentivize them to spend time with the faculty fellows. This is funded with philanthropic support from the Merrin Family Foundation.

Fellows are guided by program leadership in their independent study, development of clinical teaching skills, and curriculum development using the same theory‐driven, systematic approach that framed program inception.911 Bedside rounds are the core instructional method used by each group of fellows and are supplemented by lectures, interactive small‐group seminars, and Web‐based modules in certain cases. Bedside sessions are run by the master‐clinician mentor until the faculty fellows are deemed competent by the mentor and feel confident enough to lead independently.

Since 2004, there have been 14 fellows who have developed programs focused on the examination of the heart, skin, knee, and shoulder. Program development is underway in motivational interviewing, the pulmonary examination, and the examination of the critically ill patient. We describe the work of the first 4 fellows as an example of how this fellowship creates value for the individual fellows, our departmental teaching programs, and the medical school.

Our first cohort of fellows chose, out of personal interest, to concentrate on the cardiac examination. They spent the first year working with highly respected cardiologists to hone their own clinical skills, reviewing the literature on the evidence‐based cardiac physical examination and effective teaching methods,12,13 researching the use of electronic stethoscopes and related technology for teaching at the bedside, and piloting a variety of approaches to teaching their busy colleagues these skills.

Bedside rounds focus on pertinent physical findings with an emphasis on an evidence‐based approach. We find we are most effective when the patient's diagnosis is unknown by the group leader to avoid bias when formulating the differential diagnosis. Sessions include a discussion of how the exam correlates with the diagnosis, relevant pathophysiology, imaging, and treatment options.

Two, 1‐hour‐long lectures in cardiac examination are delivered: the first reviews basics of heart sounds, both normal and abnormal, and the second reviews the most common systolic and diastolic murmurs. These lectures, scheduled into routine faculty conference time, utilize a PowerPoint format, with an overview of basic physiology and pathophysiology, aided by phonocardiograms, frequency spectrographs, and audio recordings delivered via a loudspeaker. Interactive cases offered by Blaufuss Multimedia (Rolling Hills Estates, CA) are an excellent teaching tool that incorporate case presentations, videos of key physical findings, auscultatory recordings, and relevant pathophysiology. We initially used this resource because of its high quality and ease of use; we now use our own interactive case presentations, which allow for flexibility with content and style, and which reinforce the prevalence of interesting cases at our institution to the audience members.

Technology has proven to be an invaluable tool in teaching cardiac physical diagnosis, both at the bedside and in the classroom. Electronic stethoscopes provide the ability to record heart sounds for use in teaching venues on short notice, such as morning report, and for use in creating the interactive case presentations described above. The electronic stethoscopes we use can be wired to peripheral devices, such as camcorders, iPods, and speaker pads. Speaker pads are devices, approximately the size of a stethoscope head, that can be connected by wires in series, each attached to a stethoscope, allowing a group of people to listen to the same sounds simultaneously with excellent sound reproduction. This technology allows each person standing around the bedside to listen to a patient while the group leader auscultates and explains the findings in real time. There are distinct advantages of simultaneous auscultation both for describing auditory findings and minimizing discomfort to the patient.

Applications are available for the iPod (Stethoscope App, Thinklabs Technology, LLC, Centennial, CO) which can record and display real‐time phonocardiography when attached to an electronic stethoscope, even at the terminus of a speaker pad chain. This application also allows recorded sounds to be played directly through a speaker, or transferred to a computer with the corresponding phonocardiographic and spectrographic images, that can all be incorporated into an interactive case presentation. Frequency spectrographs allow visualization of differences between low‐ and high‐frequency sounds, which, in conjunction with the timing and amplitude displayed by phonocardiography, can aid in teaching subtle findings, such as shapes of murmurs, patterns of splitting, gallups, etc.14 Playback of heart sounds in a conference room setting can be challenging, given the often subtle and low‐frequency findings typical of cardiac pathology, and is effectively achieved by using a musician‐quality loudspeaker. We have found that speaker pads offer the best sound quality at the bedside, although they are inconvenient for larger groups.

DISCUSSION

A new framework has been proposed for considering faculty development programs that focuses on the participants, program, content, facilitator, and the context in which the program occurs.15 We have effectively addressed and synthesized these components in a rich, high impact, learner‐centered faculty development program that also responds to challenges raised by changes in the health delivery system, concerns about accreditation requirements, and targeted local needs assessment.

We have been fortunate to recruit specialty faculty who are outstanding teachers, have welcomed the fellows into their clinics, and have dedicated countless hours to supervision and education. An unintended, but important, outcome of the program is that we are able to highlight the exceptional skills of our senior, experienced clinicians. These are colleagues who all too often do not receive adequate recognition in the modern‐day academic medical center environment, but who are undoubtedly invaluable to the education mission of these centers.

The existence of the program has resulted in our general medicine faculty showing great enthusiasm, both to develop an area of expertise and to participate as learners in the programs developed by peers. The faculty fellows in each specialty have become a valuable resource to peer faculty, residents, and medical students alike, who are now less dependent on consultants to identify and explain physical findings. The faculty teaching the knee and shoulder exams started a Sports Medicine Clinic within primary care, and assist with joint injections throughout the clinic. In addition to providing clinical support, their educational curriculum is included in both the attending and housestaff conference schedules. The cardiac lectures, both didactic and interactive case presentations, are included in the attending conference schedule, intern and resident core curricula, and the third‐year medicine clerkship lecture series. The dermatology group has created a series of comprehensive online modules that provide content tailored to general medicine. All this durable material is available broadly to trainees of all professions in our medical center.

Given the ever‐growing burden of patient care and extra‐clinical responsibilities, the principal factor limiting the effectiveness of bedside rounds is faculty availability. Despite this, all of our hospitalists have attended at least 1 bedside cardiac session, and the majority have attended multiple times. Varying the time and day of the sessions, offering to join attending rounds, and being available for impromptu diagnostic consultations have maximized the fellows' contact with faculty, residents, and students.

Although funding for evaluation of the program has been limited, a research agenda is emerging. Both the pulmonary physical exam and critical care groups are in the process of evaluating the effectiveness of their programs on the quality of bedside rounds, student and resident learning, and, to the extent possible, on patient care.

CONCLUSION

We believe wholeheartedly that bedside instruction both in physical diagnosis and interview skills must not become a lost art. General medicine faculty are ideally situated to take on this challenge. An educational program targeting hospitalists and general medicine faculty energizes faculty and leverages local resources to fill in gaps in skills for faculty and then for trainees. Generalist faculty relish the opportunity to champion a particular element of the doctorpatient encounter, which has contributed to our ultimate goal of strengthening the core diagnostic skills of our faculty who are at the forefront of clinical care and medical education.

Acknowledgements

The authors thank the Merrin Family for their generous support of the program; Drs Gregory Mints, Tanping Wong, and Sabrina Felson for their initial work in developing the Merrin Faculty Development Program; and Dr Martin Kahn for his tireless dedication to mentorship and bedside teaching.

Disclosure: Drs Janjigian, Charap, and Kalet report receiving funding from the Merrin Family Foundation.

Deficiencies in physical examination skills among medical students, housestaff, and even faculty have been reported for decades. For example, cardiac examination skills have been shown to improve during the early years of medical school and then plateau by the third year, with no measurable improvement through residency or beyond without fellowship training.13

Despite efforts by residency programs to promote bedside teaching, many general medicine faculty shy away due to lack of confidence and comfort in teaching physical diagnosis.4 The presence of hospitalists increases satisfaction among trainees with inpatient teaching,5 and medical faculty's ability has been shown to positively impact medical students' test scores.6 This lack of bedside teaching is a missed opportunity, as general medicine faculty are assuming more teaching responsibility.

The Merrin Bedside Teaching Program was founded in 2004 at New York University (NYU) School of Medicine to improve the quality of bedside teaching in the Department of Medicine/Division of General Internal Medicine. In this article, we describe the development process and early outcomes of this program.

METHODS

The principal teaching institution of NYU is Bellevue Hospital, an 800‐bed tertiary care safety‐net facility located in New York City. Approximately 30 general medicine faculty members at Bellevue Hospital attend on the inpatient teaching service 12 weeks per year each, with the remaining time spent in the hospital‐based clinics and other inpatient services.

Prior to the initiation of this program, our faculty did not receive formal instruction in bedside teaching, in general, or in teaching physical diagnosis, in particular. Housestaff and students were reporting that bedside rounds were not being conducted consistently and were of variable educational quality. Among a number of our residency and fellowship programs, there were concerns about meeting Accreditation Counsel for Graduate Medical Education (ACGME) requirements for quantity and quality of bedside rounds and faculty development.

To inform program development, we conducted a literature review, a series of focus groups with residents and faculty, and a survey of 39 general medicine hospital and ambulatory‐based clinician teachers to determine the perceived bedside teaching faculty development needs of our department. Then, over the next 2 years, we recruited 32 hospitalists and fellowship faculty to participate in a videotaped bedside teaching simulation. Each attending reviewed the videotape one‐on‐one with an experienced facilitator (A.K.), who elicited the attending's goals and instructional models and methods used for clinical teaching. To address the wide variety in teaching approaches identified in the assessment, 4 to 6 attendings met weekly for 1 month to observe each other conducting rounds with their teams. The facilitator of these groups used materials derived from relevant medical education theory79 and related conceptual models to frame the debriefing. Participants enthusiastically supported the educational value of this learner‐centered, experiential teaching approach.

We integrated this needs assessment with an individualized approach, incorporating learner goal‐setting with interactive and highly experiential teaching strategies,7,9,10 to create the Merrin Bedside Teaching Program in 2004. This program recruits faculty, with reputations as excellent teachers, to design a program to develop their own bedside teaching skills and disseminate what they learn to their peers. Faculty fellows are recruited through an open call for applications, which includes a letter of support from a supervisor and a detailed independent learning plan, including an identified mentor. Fellows are selected by the program's executive committee based on the likelihood of the success of their proposed program. A stipend equivalent of between 5% and 10% of base salary is provided to each fellow for a period of 2 years. Selected faculty fellows are encouraged to focus on an aspect of the physical examination, work in groups of 2 or 3, and to identify and recruit a mentor who is considered a master clinician in the target specialty. Master clinicians are given an honorarium to acknowledge their selection and incentivize them to spend time with the faculty fellows. This is funded with philanthropic support from the Merrin Family Foundation.

Fellows are guided by program leadership in their independent study, development of clinical teaching skills, and curriculum development using the same theory‐driven, systematic approach that framed program inception.911 Bedside rounds are the core instructional method used by each group of fellows and are supplemented by lectures, interactive small‐group seminars, and Web‐based modules in certain cases. Bedside sessions are run by the master‐clinician mentor until the faculty fellows are deemed competent by the mentor and feel confident enough to lead independently.

Since 2004, there have been 14 fellows who have developed programs focused on the examination of the heart, skin, knee, and shoulder. Program development is underway in motivational interviewing, the pulmonary examination, and the examination of the critically ill patient. We describe the work of the first 4 fellows as an example of how this fellowship creates value for the individual fellows, our departmental teaching programs, and the medical school.

Our first cohort of fellows chose, out of personal interest, to concentrate on the cardiac examination. They spent the first year working with highly respected cardiologists to hone their own clinical skills, reviewing the literature on the evidence‐based cardiac physical examination and effective teaching methods,12,13 researching the use of electronic stethoscopes and related technology for teaching at the bedside, and piloting a variety of approaches to teaching their busy colleagues these skills.

Bedside rounds focus on pertinent physical findings with an emphasis on an evidence‐based approach. We find we are most effective when the patient's diagnosis is unknown by the group leader to avoid bias when formulating the differential diagnosis. Sessions include a discussion of how the exam correlates with the diagnosis, relevant pathophysiology, imaging, and treatment options.

Two, 1‐hour‐long lectures in cardiac examination are delivered: the first reviews basics of heart sounds, both normal and abnormal, and the second reviews the most common systolic and diastolic murmurs. These lectures, scheduled into routine faculty conference time, utilize a PowerPoint format, with an overview of basic physiology and pathophysiology, aided by phonocardiograms, frequency spectrographs, and audio recordings delivered via a loudspeaker. Interactive cases offered by Blaufuss Multimedia (Rolling Hills Estates, CA) are an excellent teaching tool that incorporate case presentations, videos of key physical findings, auscultatory recordings, and relevant pathophysiology. We initially used this resource because of its high quality and ease of use; we now use our own interactive case presentations, which allow for flexibility with content and style, and which reinforce the prevalence of interesting cases at our institution to the audience members.

Technology has proven to be an invaluable tool in teaching cardiac physical diagnosis, both at the bedside and in the classroom. Electronic stethoscopes provide the ability to record heart sounds for use in teaching venues on short notice, such as morning report, and for use in creating the interactive case presentations described above. The electronic stethoscopes we use can be wired to peripheral devices, such as camcorders, iPods, and speaker pads. Speaker pads are devices, approximately the size of a stethoscope head, that can be connected by wires in series, each attached to a stethoscope, allowing a group of people to listen to the same sounds simultaneously with excellent sound reproduction. This technology allows each person standing around the bedside to listen to a patient while the group leader auscultates and explains the findings in real time. There are distinct advantages of simultaneous auscultation both for describing auditory findings and minimizing discomfort to the patient.

Applications are available for the iPod (Stethoscope App, Thinklabs Technology, LLC, Centennial, CO) which can record and display real‐time phonocardiography when attached to an electronic stethoscope, even at the terminus of a speaker pad chain. This application also allows recorded sounds to be played directly through a speaker, or transferred to a computer with the corresponding phonocardiographic and spectrographic images, that can all be incorporated into an interactive case presentation. Frequency spectrographs allow visualization of differences between low‐ and high‐frequency sounds, which, in conjunction with the timing and amplitude displayed by phonocardiography, can aid in teaching subtle findings, such as shapes of murmurs, patterns of splitting, gallups, etc.14 Playback of heart sounds in a conference room setting can be challenging, given the often subtle and low‐frequency findings typical of cardiac pathology, and is effectively achieved by using a musician‐quality loudspeaker. We have found that speaker pads offer the best sound quality at the bedside, although they are inconvenient for larger groups.

DISCUSSION

A new framework has been proposed for considering faculty development programs that focuses on the participants, program, content, facilitator, and the context in which the program occurs.15 We have effectively addressed and synthesized these components in a rich, high impact, learner‐centered faculty development program that also responds to challenges raised by changes in the health delivery system, concerns about accreditation requirements, and targeted local needs assessment.

We have been fortunate to recruit specialty faculty who are outstanding teachers, have welcomed the fellows into their clinics, and have dedicated countless hours to supervision and education. An unintended, but important, outcome of the program is that we are able to highlight the exceptional skills of our senior, experienced clinicians. These are colleagues who all too often do not receive adequate recognition in the modern‐day academic medical center environment, but who are undoubtedly invaluable to the education mission of these centers.

The existence of the program has resulted in our general medicine faculty showing great enthusiasm, both to develop an area of expertise and to participate as learners in the programs developed by peers. The faculty fellows in each specialty have become a valuable resource to peer faculty, residents, and medical students alike, who are now less dependent on consultants to identify and explain physical findings. The faculty teaching the knee and shoulder exams started a Sports Medicine Clinic within primary care, and assist with joint injections throughout the clinic. In addition to providing clinical support, their educational curriculum is included in both the attending and housestaff conference schedules. The cardiac lectures, both didactic and interactive case presentations, are included in the attending conference schedule, intern and resident core curricula, and the third‐year medicine clerkship lecture series. The dermatology group has created a series of comprehensive online modules that provide content tailored to general medicine. All this durable material is available broadly to trainees of all professions in our medical center.

Given the ever‐growing burden of patient care and extra‐clinical responsibilities, the principal factor limiting the effectiveness of bedside rounds is faculty availability. Despite this, all of our hospitalists have attended at least 1 bedside cardiac session, and the majority have attended multiple times. Varying the time and day of the sessions, offering to join attending rounds, and being available for impromptu diagnostic consultations have maximized the fellows' contact with faculty, residents, and students.

Although funding for evaluation of the program has been limited, a research agenda is emerging. Both the pulmonary physical exam and critical care groups are in the process of evaluating the effectiveness of their programs on the quality of bedside rounds, student and resident learning, and, to the extent possible, on patient care.

CONCLUSION

We believe wholeheartedly that bedside instruction both in physical diagnosis and interview skills must not become a lost art. General medicine faculty are ideally situated to take on this challenge. An educational program targeting hospitalists and general medicine faculty energizes faculty and leverages local resources to fill in gaps in skills for faculty and then for trainees. Generalist faculty relish the opportunity to champion a particular element of the doctorpatient encounter, which has contributed to our ultimate goal of strengthening the core diagnostic skills of our faculty who are at the forefront of clinical care and medical education.

Acknowledgements

The authors thank the Merrin Family for their generous support of the program; Drs Gregory Mints, Tanping Wong, and Sabrina Felson for their initial work in developing the Merrin Faculty Development Program; and Dr Martin Kahn for his tireless dedication to mentorship and bedside teaching.

Disclosure: Drs Janjigian, Charap, and Kalet report receiving funding from the Merrin Family Foundation.

References
  1. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA. 1997;278(9):717–722.
  2. Vukanovic‐Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med. 2006;166(6):610–616.
  3. Vukanovic‐Criley JM, Hovanesyan A, Criley SR, et al. Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study. Clin Cardiol. 2010;33(12):738–745.
  4. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus‐group study of clinical teachers. Acad Med. 2003;78(4):384–390.
  5. Natarajan P, Ranji SR, Auerbach AD, Hauer KE. Effect of hospitalist attending physicians on trainee educational experiences: a systematic review. J Hosp Med. 2009;4(8):490–498.
  6. Stern DT, Williams BC, Gill A, Gruppen LD, Woolliscroft JO, Grum CM. Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores? Acad Med. 2000;75(11):1144–1146.
  7. Neher JO, Gordon KC, Meyer B, Stevens N. A five‐step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419–424.
  8. Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending‐physician role models. N Engl J Med. 1998;339(27):1986–1993.
  9. Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach. 2003;25(2):127–130.
  10. Hewson MG. A theory‐based faculty development program for clinician‐educators. Acad Med. 2000;75(5):498–501.
  11. Kern D, Thomas P, Howard D, Bass E, ed. Curriculum Development for Medical Education: A Six‐Step Approach. Baltimore, MD: The Johns Hopkins University Press; 1998.
  12. Criley JM, Keiner J, Boker JR, Criley SR, Warde CM. Innovative web‐based multimedia curriculum improves cardiac examination competency of residents. J Hosp Med. 2008;3(2):124–133.
  13. Vukanovic‐Criley JM, Boker JR, Criley SR, Rajagopalan S, Criley JM. Using virtual patients to improve cardiac examination competency in medical students. Clin Cardiol. 2008;31(7):334–339.
  14. Tavel ME. Cardiac auscultation: a glorious past—and it does have a future! Circulation. 2006;113(9):1255–1259.
  15. O'Sullivan PS, Irby DM. Reframing research on faculty development. Acad Med. 2011;86(4):421–428.
References
  1. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA. 1997;278(9):717–722.
  2. Vukanovic‐Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study. Arch Intern Med. 2006;166(6):610–616.
  3. Vukanovic‐Criley JM, Hovanesyan A, Criley SR, et al. Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study. Clin Cardiol. 2010;33(12):738–745.
  4. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus‐group study of clinical teachers. Acad Med. 2003;78(4):384–390.
  5. Natarajan P, Ranji SR, Auerbach AD, Hauer KE. Effect of hospitalist attending physicians on trainee educational experiences: a systematic review. J Hosp Med. 2009;4(8):490–498.
  6. Stern DT, Williams BC, Gill A, Gruppen LD, Woolliscroft JO, Grum CM. Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores? Acad Med. 2000;75(11):1144–1146.
  7. Neher JO, Gordon KC, Meyer B, Stevens N. A five‐step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419–424.
  8. Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending‐physician role models. N Engl J Med. 1998;339(27):1986–1993.
  9. Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach. 2003;25(2):127–130.
  10. Hewson MG. A theory‐based faculty development program for clinician‐educators. Acad Med. 2000;75(5):498–501.
  11. Kern D, Thomas P, Howard D, Bass E, ed. Curriculum Development for Medical Education: A Six‐Step Approach. Baltimore, MD: The Johns Hopkins University Press; 1998.
  12. Criley JM, Keiner J, Boker JR, Criley SR, Warde CM. Innovative web‐based multimedia curriculum improves cardiac examination competency of residents. J Hosp Med. 2008;3(2):124–133.
  13. Vukanovic‐Criley JM, Boker JR, Criley SR, Rajagopalan S, Criley JM. Using virtual patients to improve cardiac examination competency in medical students. Clin Cardiol. 2008;31(7):334–339.
  14. Tavel ME. Cardiac auscultation: a glorious past—and it does have a future! Circulation. 2006;113(9):1255–1259.
  15. O'Sullivan PS, Irby DM. Reframing research on faculty development. Acad Med. 2011;86(4):421–428.
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Journal of Hospital Medicine - 7(8)
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Development of a hospitalist‐led‐and‐directed physical examination curriculum
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Michael P. Janjigian, MD, FACP
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FDA Clears First Test to ID Bacteria Associated with Bloodstream Infections

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Richard Quinn

Last month, the Food and Drug Administration cleared a test designed to quickly identify a dozen types of bacteria that can lead to bloodstream infections.

The Verigene GP Blood Culture Nucleic Acid Test, developed by molecular diagnostic firm Nanosphere Inc. of Northbrook, Ill., can identify Staphylococcus (including methicillin-resistant S. aureus, or MRSA), Streptococcus, Enterococcus (including vancomycin-resistant enterococci), and Listeria.

"The current standard of treatment is to provide broad-spectrum antibiotics, including some last-line therapies, such as vancomycin, in order to get coverage for everything," says Mike McGarrity, a Nanosphere executive. "With antibiotic stewardship programs in the majority of hospitals, there is an understanding of the overuse of these last-line therapies and the development of resistance."

Currently, blood cultures can take two to four days to identify certain types of bacteria and determine whether any present are resistant to certain therapies. Once a blood culture is positive, the Nanosphere test can identify bacteria and antimicrobial resistance genes in roughly two and half hours. In a pitch that McGarrity believes will resonate with HM groups, he positions the product as a cost-saver that can reduce length of stay (LOS) for hospitalized patients, as physicians don’t have to wait two days for test results. Quicker identification can also lead to lower mortality rates, he says.

McGarrity, who says Nanosphere will submit an application to the FDA this year for a similar rapid-results test for Clostridium difficile and a broad enteric panel, adds that the test is $75 per use. With LOS reduction and cost savings for targeted de-escalated therapies, he says, there is clear value in the test.

"This gets the attention of stakeholders," he says.

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Richard Quinn
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Richard Quinn

Last month, the Food and Drug Administration cleared a test designed to quickly identify a dozen types of bacteria that can lead to bloodstream infections.

The Verigene GP Blood Culture Nucleic Acid Test, developed by molecular diagnostic firm Nanosphere Inc. of Northbrook, Ill., can identify Staphylococcus (including methicillin-resistant S. aureus, or MRSA), Streptococcus, Enterococcus (including vancomycin-resistant enterococci), and Listeria.

"The current standard of treatment is to provide broad-spectrum antibiotics, including some last-line therapies, such as vancomycin, in order to get coverage for everything," says Mike McGarrity, a Nanosphere executive. "With antibiotic stewardship programs in the majority of hospitals, there is an understanding of the overuse of these last-line therapies and the development of resistance."

Currently, blood cultures can take two to four days to identify certain types of bacteria and determine whether any present are resistant to certain therapies. Once a blood culture is positive, the Nanosphere test can identify bacteria and antimicrobial resistance genes in roughly two and half hours. In a pitch that McGarrity believes will resonate with HM groups, he positions the product as a cost-saver that can reduce length of stay (LOS) for hospitalized patients, as physicians don’t have to wait two days for test results. Quicker identification can also lead to lower mortality rates, he says.

McGarrity, who says Nanosphere will submit an application to the FDA this year for a similar rapid-results test for Clostridium difficile and a broad enteric panel, adds that the test is $75 per use. With LOS reduction and cost savings for targeted de-escalated therapies, he says, there is clear value in the test.

"This gets the attention of stakeholders," he says.

Last month, the Food and Drug Administration cleared a test designed to quickly identify a dozen types of bacteria that can lead to bloodstream infections.

The Verigene GP Blood Culture Nucleic Acid Test, developed by molecular diagnostic firm Nanosphere Inc. of Northbrook, Ill., can identify Staphylococcus (including methicillin-resistant S. aureus, or MRSA), Streptococcus, Enterococcus (including vancomycin-resistant enterococci), and Listeria.

"The current standard of treatment is to provide broad-spectrum antibiotics, including some last-line therapies, such as vancomycin, in order to get coverage for everything," says Mike McGarrity, a Nanosphere executive. "With antibiotic stewardship programs in the majority of hospitals, there is an understanding of the overuse of these last-line therapies and the development of resistance."

Currently, blood cultures can take two to four days to identify certain types of bacteria and determine whether any present are resistant to certain therapies. Once a blood culture is positive, the Nanosphere test can identify bacteria and antimicrobial resistance genes in roughly two and half hours. In a pitch that McGarrity believes will resonate with HM groups, he positions the product as a cost-saver that can reduce length of stay (LOS) for hospitalized patients, as physicians don’t have to wait two days for test results. Quicker identification can also lead to lower mortality rates, he says.

McGarrity, who says Nanosphere will submit an application to the FDA this year for a similar rapid-results test for Clostridium difficile and a broad enteric panel, adds that the test is $75 per use. With LOS reduction and cost savings for targeted de-escalated therapies, he says, there is clear value in the test.

"This gets the attention of stakeholders," he says.

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ITL: Physician Reviews of HM-Relevant Research

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ITL: Physician Reviews of HM-Relevant Research
Author(s)
Alexander R. Carbo, MD, SFHM
Jonathan T. Crocker, MD
Lauren Doctoroff, MD, FHM
Elizabeth Farrell, MD
Rebecca Newlin Hutchinson, MD, MPH

Clinical question: Do oral fluoroquinolones increase the risk of retinal detachment?

Background: Fluoroquinolones are increasingly used in both inpatient and outpatient settings, given their broad antimicrobial coverage. However, adverse effects, including those related to connective tissue and the eye, are increasingly reported. Whether that also includes retinal detachment is not yet known.

Study design: Nested case control study.

Setting: Canadian province.

Synopsis: Using data from administrative databases to identify patients who visited ophthalmologists in British Columbia between 2000 and 2007, the investigators identified 4,384 cases of retinal detachment, and matched those cases to controls at a rate of 10:1. Current, recent, and past fluoroquinolone usage was the exposure of interest.

Patients actively taking a fluoroquinolone had a higher risk of retinal detachment compared with those not taking the drug (adjusted RR of 4.5, 95% CI of 3.56-5.70). Prior or recent use of a fluoroquinolone did not increase the rate of retinal detachment. The patients were more likely to be male, myopic, diabetic, and have a prior history of cataract surgery. Ciprofloxacin was the drug most frequently involved, but this is not adjusted by frequency of prescription. Despite this association, the actual outcome is quite rare (approximately 1,440 cases per year in the U.S.).

This study has the benefit of a large amount of data and captures prescription data well. It relied on coding to identify the cases and might have missed or inappropriately categorized some cases. Despite these caveats, this study adds to the concerning adverse events due to the increasing use of fluoroquinolone therapy, and hospitalists should use appropriate clinical judgment when prescribing and educating patients about the risks and benefits.

Bottom line: Fluoroquinolone use might increase the rate of retinal detachment in patients, but the absolute risk of the event is low.

Citation: Etminan M, Forooghian F, Brophy JM, Bird ST, Maberley D. Oral fluoroquinolones and the risk of retinal detachment. JAMA. 2012;307:1414-1419.

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Alexander R. Carbo, MD, SFHM
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Lauren Doctoroff, MD, FHM
Elizabeth Farrell, MD
Rebecca Newlin Hutchinson, MD, MPH
Author(s)
Alexander R. Carbo, MD, SFHM
Jonathan T. Crocker, MD
Lauren Doctoroff, MD, FHM
Elizabeth Farrell, MD
Rebecca Newlin Hutchinson, MD, MPH

Clinical question: Do oral fluoroquinolones increase the risk of retinal detachment?

Background: Fluoroquinolones are increasingly used in both inpatient and outpatient settings, given their broad antimicrobial coverage. However, adverse effects, including those related to connective tissue and the eye, are increasingly reported. Whether that also includes retinal detachment is not yet known.

Study design: Nested case control study.

Setting: Canadian province.

Synopsis: Using data from administrative databases to identify patients who visited ophthalmologists in British Columbia between 2000 and 2007, the investigators identified 4,384 cases of retinal detachment, and matched those cases to controls at a rate of 10:1. Current, recent, and past fluoroquinolone usage was the exposure of interest.

Patients actively taking a fluoroquinolone had a higher risk of retinal detachment compared with those not taking the drug (adjusted RR of 4.5, 95% CI of 3.56-5.70). Prior or recent use of a fluoroquinolone did not increase the rate of retinal detachment. The patients were more likely to be male, myopic, diabetic, and have a prior history of cataract surgery. Ciprofloxacin was the drug most frequently involved, but this is not adjusted by frequency of prescription. Despite this association, the actual outcome is quite rare (approximately 1,440 cases per year in the U.S.).

This study has the benefit of a large amount of data and captures prescription data well. It relied on coding to identify the cases and might have missed or inappropriately categorized some cases. Despite these caveats, this study adds to the concerning adverse events due to the increasing use of fluoroquinolone therapy, and hospitalists should use appropriate clinical judgment when prescribing and educating patients about the risks and benefits.

Bottom line: Fluoroquinolone use might increase the rate of retinal detachment in patients, but the absolute risk of the event is low.

Citation: Etminan M, Forooghian F, Brophy JM, Bird ST, Maberley D. Oral fluoroquinolones and the risk of retinal detachment. JAMA. 2012;307:1414-1419.

Clinical question: Do oral fluoroquinolones increase the risk of retinal detachment?

Background: Fluoroquinolones are increasingly used in both inpatient and outpatient settings, given their broad antimicrobial coverage. However, adverse effects, including those related to connective tissue and the eye, are increasingly reported. Whether that also includes retinal detachment is not yet known.

Study design: Nested case control study.

Setting: Canadian province.

Synopsis: Using data from administrative databases to identify patients who visited ophthalmologists in British Columbia between 2000 and 2007, the investigators identified 4,384 cases of retinal detachment, and matched those cases to controls at a rate of 10:1. Current, recent, and past fluoroquinolone usage was the exposure of interest.

Patients actively taking a fluoroquinolone had a higher risk of retinal detachment compared with those not taking the drug (adjusted RR of 4.5, 95% CI of 3.56-5.70). Prior or recent use of a fluoroquinolone did not increase the rate of retinal detachment. The patients were more likely to be male, myopic, diabetic, and have a prior history of cataract surgery. Ciprofloxacin was the drug most frequently involved, but this is not adjusted by frequency of prescription. Despite this association, the actual outcome is quite rare (approximately 1,440 cases per year in the U.S.).

This study has the benefit of a large amount of data and captures prescription data well. It relied on coding to identify the cases and might have missed or inappropriately categorized some cases. Despite these caveats, this study adds to the concerning adverse events due to the increasing use of fluoroquinolone therapy, and hospitalists should use appropriate clinical judgment when prescribing and educating patients about the risks and benefits.

Bottom line: Fluoroquinolone use might increase the rate of retinal detachment in patients, but the absolute risk of the event is low.

Citation: Etminan M, Forooghian F, Brophy JM, Bird ST, Maberley D. Oral fluoroquinolones and the risk of retinal detachment. JAMA. 2012;307:1414-1419.

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Hemophilia patients plagued by professional challenges

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Hemophilia patients plagued by professional challenges
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HT Staff

PARIS—Results of a large study suggest that 8 in 10 hemophilia patients feel

their disorder has had a negative impact on their career.

In fact, 1 in 5

patients said they have lost a job because of their condition. However, only 8% said they were unable to find employment because of it.

These findings were presented at the World Federation of Hemophilia 2012 World Congress. The data are part of the HERO study, which

evaluated the psychosocial aspects of living with hemophilia. The study

was sponsored by Novo Nordisk.

“Treatment of hemophilia has advanced greatly over the past decades, but psychosocial issues can still be a challenge for people with hemophilia . . . ,” said Alfonso Iorio, MD, PhD, a member of the HERO International Advisory Board and a professor at McMaster University in Canada.

With this in mind, HERO researchers examined hemophilia’s effects on relationships, sexual health, and quality of life. The investigators also assessed treatment and management of the disorder, patients’ knowledge and education levels, and how hemophilia has impacted their professional life.

For the career analysis, researchers interviewed 605 patients with hemophilia. Forty percent of patients said their hemophilia played a major role in their choice of profession or job training, but 21% of patients said their disorder had no impact on their job choice.

Thirty percent of patients said their current treatment allows them to work in most situations. But 21% of patients said they have to restrict their hours due to their hemophilia, and 17% said they must work flexible hours.

Twenty-four percent of patients said they have voluntarily left a job because of their hemophilia, and 22% thought they lost a job because of their disorder.

Twenty-two percent of patients believed they were not hired for a job because of their hemophilia, and 14% felt they had not received a promotion because of it. But 10% of patients said their disorder actually helped them land a job.

These results were presented at the World Federation of Hemophilia 2012 World Congress on Monday as poster 199. Other results from the HERO study will also be presented at the meeting, which is taking place July 8-12.

“The insights from the HERO study will provide much-needed evidence to support advocating for better comprehensive hemophilia care,” Dr Iorio said.

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PARIS—Results of a large study suggest that 8 in 10 hemophilia patients feel

their disorder has had a negative impact on their career.

In fact, 1 in 5

patients said they have lost a job because of their condition. However, only 8% said they were unable to find employment because of it.

These findings were presented at the World Federation of Hemophilia 2012 World Congress. The data are part of the HERO study, which

evaluated the psychosocial aspects of living with hemophilia. The study

was sponsored by Novo Nordisk.

“Treatment of hemophilia has advanced greatly over the past decades, but psychosocial issues can still be a challenge for people with hemophilia . . . ,” said Alfonso Iorio, MD, PhD, a member of the HERO International Advisory Board and a professor at McMaster University in Canada.

With this in mind, HERO researchers examined hemophilia’s effects on relationships, sexual health, and quality of life. The investigators also assessed treatment and management of the disorder, patients’ knowledge and education levels, and how hemophilia has impacted their professional life.

For the career analysis, researchers interviewed 605 patients with hemophilia. Forty percent of patients said their hemophilia played a major role in their choice of profession or job training, but 21% of patients said their disorder had no impact on their job choice.

Thirty percent of patients said their current treatment allows them to work in most situations. But 21% of patients said they have to restrict their hours due to their hemophilia, and 17% said they must work flexible hours.

Twenty-four percent of patients said they have voluntarily left a job because of their hemophilia, and 22% thought they lost a job because of their disorder.

Twenty-two percent of patients believed they were not hired for a job because of their hemophilia, and 14% felt they had not received a promotion because of it. But 10% of patients said their disorder actually helped them land a job.

These results were presented at the World Federation of Hemophilia 2012 World Congress on Monday as poster 199. Other results from the HERO study will also be presented at the meeting, which is taking place July 8-12.

“The insights from the HERO study will provide much-needed evidence to support advocating for better comprehensive hemophilia care,” Dr Iorio said.

PARIS—Results of a large study suggest that 8 in 10 hemophilia patients feel

their disorder has had a negative impact on their career.

In fact, 1 in 5

patients said they have lost a job because of their condition. However, only 8% said they were unable to find employment because of it.

These findings were presented at the World Federation of Hemophilia 2012 World Congress. The data are part of the HERO study, which

evaluated the psychosocial aspects of living with hemophilia. The study

was sponsored by Novo Nordisk.

“Treatment of hemophilia has advanced greatly over the past decades, but psychosocial issues can still be a challenge for people with hemophilia . . . ,” said Alfonso Iorio, MD, PhD, a member of the HERO International Advisory Board and a professor at McMaster University in Canada.

With this in mind, HERO researchers examined hemophilia’s effects on relationships, sexual health, and quality of life. The investigators also assessed treatment and management of the disorder, patients’ knowledge and education levels, and how hemophilia has impacted their professional life.

For the career analysis, researchers interviewed 605 patients with hemophilia. Forty percent of patients said their hemophilia played a major role in their choice of profession or job training, but 21% of patients said their disorder had no impact on their job choice.

Thirty percent of patients said their current treatment allows them to work in most situations. But 21% of patients said they have to restrict their hours due to their hemophilia, and 17% said they must work flexible hours.

Twenty-four percent of patients said they have voluntarily left a job because of their hemophilia, and 22% thought they lost a job because of their disorder.

Twenty-two percent of patients believed they were not hired for a job because of their hemophilia, and 14% felt they had not received a promotion because of it. But 10% of patients said their disorder actually helped them land a job.

These results were presented at the World Federation of Hemophilia 2012 World Congress on Monday as poster 199. Other results from the HERO study will also be presented at the meeting, which is taking place July 8-12.

“The insights from the HERO study will provide much-needed evidence to support advocating for better comprehensive hemophilia care,” Dr Iorio said.

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Tech Takes Off: Videoconferences in medical settings is more acceptable and affordable, but hurdles remain

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Tech Takes Off: Videoconferences in medical settings is more acceptable and affordable, but hurdles remain
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Susan Kreimer

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

than D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

As the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.


—Matthew Harbison, MD, medical director, Sound Physicians hospitalist services, Memorial Hermann-Texas Medical Center

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

 

 

Telemedicine isn’t always appropriate for patient care. All of this depends on the circumstances and needs of the patient.


—Jonathan D. Linkous, CEO, American Telemedicine Association

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

 

 

 

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Author(s)
Susan Kreimer
Author(s)
Susan Kreimer

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

than D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

As the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.


—Matthew Harbison, MD, medical director, Sound Physicians hospitalist services, Memorial Hermann-Texas Medical Center

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

 

 

Telemedicine isn’t always appropriate for patient care. All of this depends on the circumstances and needs of the patient.


—Jonathan D. Linkous, CEO, American Telemedicine Association

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

 

 

 

Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.

Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.

Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona

than D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.

Advantages and Challenges

Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1

In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.

Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.

As the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.


—Matthew Harbison, MD, medical director, Sound Physicians hospitalist services, Memorial Hermann-Texas Medical Center

Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.

When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”

Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.

“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.

Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.

 

 

Telemedicine isn’t always appropriate for patient care. All of this depends on the circumstances and needs of the patient.


—Jonathan D. Linkous, CEO, American Telemedicine Association

Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.

“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”

Moving Ahead

As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.

The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.

IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”

Susan Kreimer is a freelance medical writer based in New York.

Reference

1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.

 

 

 

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Physicians struggle every day to pick the right drug dosage for the treatment and prevention of disease. For the acute illnesses, efficacy is evident within hours or days. For the prevention of chronic disease, however, the outcome is uncertain at best. Therefore, we rely on randomized clinical trials to provide evidence that a specific drug and dosage are safe and effective.

Unfortunately, because of the limited average follow-up of 3-5 years, randomized clinical trials (RCTs) do not provide efficacy and safety information for lifetime therapy that is often advocated for the prevention of chronic disease.

For both the patient and physician, the side effects become the deciding factor. The physician usually chooses the smallest dose in order to avoid toxicity and presumably to achieve some benefit. The patient takes the drug irregularly at best.

As an example, consider the appropriate dosage for statin therapy for the prevention of atherosclerotic cardiovascular disease. Although numerous RCTs have defined the effective dose of a number of statins, recent trends in therapeutics have advocated that rather than using the dose that was used in RCTs, clinicians should increase the dose in order to reach a specific LDL cholesterol blood level.

Choosing the dosage of a drug in an RCT is a less-than-perfect exercise. Here’s how it usually goes:

Phase I trials – often based on pharmacokinetic data derived from animal studies – examine the physiological characteristics of the drug in healthy human volunteers in order to determine an effective and safe dosage prior to a phase II trial.

Phase II trials are larger; they usually examine the effect of several different dosages on a target population, and are focused not on physiological effects but on clinical outcomes and safety, in order to choose the best dosage for a phase III study. Because of their small size, these phase II studies are underpowered and prone to providing misleading dose choices.

Nevertheless, one or two doses are chosen to be used in the definitive phase III RCT, which includes enough patients to provide proof of benefit and safety of the drug based solely on its effect on mortality and morbidity.

Information is often collected in regard to the physiological effects of the drug on, for example, LDL cholesterol (in the case of statins) or heart rate (in the case of beta-blocking drugs). The proof of benefit, however, is determined by clinical outcomes, not on the physiological or "surrogate" measurements.

In the process of designing an RCT, we often make presumptions about mechanisms and will identify certain parameters that theoretically provide insight into the presumed benefit. However, many of the drugs we use have physiological effects that extend beyond the specific therapeutic target. We often remain ignorant about the mechanism by which drugs express their benefit long after their proof of benefit is demonstrated.

Statins, for instance, have a variety of pleiotropic effects. One of the most interesting is their ability to modulate inflammation, a process that is thought to be central to the progression of atherosclerotic disease. Although we presume that their effect is on LDL cholesterol, that presumption may be incorrect. Similarly, beta-blockers have well-known effects on heart rate and blood pressure, but their effect on modulating the up-regulated sympathetic nervous system in heart failure has presumed importance well beyond their effect on heart rate and blood pressure.

It is tempting to make presumptions about the effect of a drug intervention on the basis of surrogate measures like heart rate or LDL cholesterol effects, but their mechanisms of action on mortality and morbidity of disease may be unrelated to that measure.

RCTs have come a long way from relying on "surrogate" end points as the basis for making therapeutic decisions. More than 20 years ago, the CAST (Cardiac Arrhythmia Suppression Trial) was the watershed RCT that excluded the surrogate as a measure of therapeutic efficacy (J. Am. Coll. Cardiol. 1991;18:14-9). At a time when ventricular premature contraction (VPC) suppression was the "mantra" to prevent sudden death, CAST examined the pharmacologic suppression of VPCs in post–MI patients and found that, as the drugs decreased ventricular ectopy, mortality increased.

The use of the seemingly appropriate and obvious "surrogate" of LDL cholesterol lowering as a measure of therapeutic efficacy may be just as illusory. As enticing as surrogates are, the contemporary drive to lower LDL cholesterol may be as misdirected as the target to decrease the frequency of VPCs to prevent sudden death.

Like many things in life and science, things may not be what they seem.

Dr. Goldstein, the medical editor of Cardiology News, is a professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

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Physicians struggle every day to pick the right drug dosage for the treatment and prevention of disease. For the acute illnesses, efficacy is evident within hours or days. For the prevention of chronic disease, however, the outcome is uncertain at best. Therefore, we rely on randomized clinical trials to provide evidence that a specific drug and dosage are safe and effective.

Unfortunately, because of the limited average follow-up of 3-5 years, randomized clinical trials (RCTs) do not provide efficacy and safety information for lifetime therapy that is often advocated for the prevention of chronic disease.

For both the patient and physician, the side effects become the deciding factor. The physician usually chooses the smallest dose in order to avoid toxicity and presumably to achieve some benefit. The patient takes the drug irregularly at best.

As an example, consider the appropriate dosage for statin therapy for the prevention of atherosclerotic cardiovascular disease. Although numerous RCTs have defined the effective dose of a number of statins, recent trends in therapeutics have advocated that rather than using the dose that was used in RCTs, clinicians should increase the dose in order to reach a specific LDL cholesterol blood level.

Choosing the dosage of a drug in an RCT is a less-than-perfect exercise. Here’s how it usually goes:

Phase I trials – often based on pharmacokinetic data derived from animal studies – examine the physiological characteristics of the drug in healthy human volunteers in order to determine an effective and safe dosage prior to a phase II trial.

Phase II trials are larger; they usually examine the effect of several different dosages on a target population, and are focused not on physiological effects but on clinical outcomes and safety, in order to choose the best dosage for a phase III study. Because of their small size, these phase II studies are underpowered and prone to providing misleading dose choices.

Nevertheless, one or two doses are chosen to be used in the definitive phase III RCT, which includes enough patients to provide proof of benefit and safety of the drug based solely on its effect on mortality and morbidity.

Information is often collected in regard to the physiological effects of the drug on, for example, LDL cholesterol (in the case of statins) or heart rate (in the case of beta-blocking drugs). The proof of benefit, however, is determined by clinical outcomes, not on the physiological or "surrogate" measurements.

In the process of designing an RCT, we often make presumptions about mechanisms and will identify certain parameters that theoretically provide insight into the presumed benefit. However, many of the drugs we use have physiological effects that extend beyond the specific therapeutic target. We often remain ignorant about the mechanism by which drugs express their benefit long after their proof of benefit is demonstrated.

Statins, for instance, have a variety of pleiotropic effects. One of the most interesting is their ability to modulate inflammation, a process that is thought to be central to the progression of atherosclerotic disease. Although we presume that their effect is on LDL cholesterol, that presumption may be incorrect. Similarly, beta-blockers have well-known effects on heart rate and blood pressure, but their effect on modulating the up-regulated sympathetic nervous system in heart failure has presumed importance well beyond their effect on heart rate and blood pressure.

It is tempting to make presumptions about the effect of a drug intervention on the basis of surrogate measures like heart rate or LDL cholesterol effects, but their mechanisms of action on mortality and morbidity of disease may be unrelated to that measure.

RCTs have come a long way from relying on "surrogate" end points as the basis for making therapeutic decisions. More than 20 years ago, the CAST (Cardiac Arrhythmia Suppression Trial) was the watershed RCT that excluded the surrogate as a measure of therapeutic efficacy (J. Am. Coll. Cardiol. 1991;18:14-9). At a time when ventricular premature contraction (VPC) suppression was the "mantra" to prevent sudden death, CAST examined the pharmacologic suppression of VPCs in post–MI patients and found that, as the drugs decreased ventricular ectopy, mortality increased.

The use of the seemingly appropriate and obvious "surrogate" of LDL cholesterol lowering as a measure of therapeutic efficacy may be just as illusory. As enticing as surrogates are, the contemporary drive to lower LDL cholesterol may be as misdirected as the target to decrease the frequency of VPCs to prevent sudden death.

Like many things in life and science, things may not be what they seem.

Dr. Goldstein, the medical editor of Cardiology News, is a professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Physicians struggle every day to pick the right drug dosage for the treatment and prevention of disease. For the acute illnesses, efficacy is evident within hours or days. For the prevention of chronic disease, however, the outcome is uncertain at best. Therefore, we rely on randomized clinical trials to provide evidence that a specific drug and dosage are safe and effective.

Unfortunately, because of the limited average follow-up of 3-5 years, randomized clinical trials (RCTs) do not provide efficacy and safety information for lifetime therapy that is often advocated for the prevention of chronic disease.

For both the patient and physician, the side effects become the deciding factor. The physician usually chooses the smallest dose in order to avoid toxicity and presumably to achieve some benefit. The patient takes the drug irregularly at best.

As an example, consider the appropriate dosage for statin therapy for the prevention of atherosclerotic cardiovascular disease. Although numerous RCTs have defined the effective dose of a number of statins, recent trends in therapeutics have advocated that rather than using the dose that was used in RCTs, clinicians should increase the dose in order to reach a specific LDL cholesterol blood level.

Choosing the dosage of a drug in an RCT is a less-than-perfect exercise. Here’s how it usually goes:

Phase I trials – often based on pharmacokinetic data derived from animal studies – examine the physiological characteristics of the drug in healthy human volunteers in order to determine an effective and safe dosage prior to a phase II trial.

Phase II trials are larger; they usually examine the effect of several different dosages on a target population, and are focused not on physiological effects but on clinical outcomes and safety, in order to choose the best dosage for a phase III study. Because of their small size, these phase II studies are underpowered and prone to providing misleading dose choices.

Nevertheless, one or two doses are chosen to be used in the definitive phase III RCT, which includes enough patients to provide proof of benefit and safety of the drug based solely on its effect on mortality and morbidity.

Information is often collected in regard to the physiological effects of the drug on, for example, LDL cholesterol (in the case of statins) or heart rate (in the case of beta-blocking drugs). The proof of benefit, however, is determined by clinical outcomes, not on the physiological or "surrogate" measurements.

In the process of designing an RCT, we often make presumptions about mechanisms and will identify certain parameters that theoretically provide insight into the presumed benefit. However, many of the drugs we use have physiological effects that extend beyond the specific therapeutic target. We often remain ignorant about the mechanism by which drugs express their benefit long after their proof of benefit is demonstrated.

Statins, for instance, have a variety of pleiotropic effects. One of the most interesting is their ability to modulate inflammation, a process that is thought to be central to the progression of atherosclerotic disease. Although we presume that their effect is on LDL cholesterol, that presumption may be incorrect. Similarly, beta-blockers have well-known effects on heart rate and blood pressure, but their effect on modulating the up-regulated sympathetic nervous system in heart failure has presumed importance well beyond their effect on heart rate and blood pressure.

It is tempting to make presumptions about the effect of a drug intervention on the basis of surrogate measures like heart rate or LDL cholesterol effects, but their mechanisms of action on mortality and morbidity of disease may be unrelated to that measure.

RCTs have come a long way from relying on "surrogate" end points as the basis for making therapeutic decisions. More than 20 years ago, the CAST (Cardiac Arrhythmia Suppression Trial) was the watershed RCT that excluded the surrogate as a measure of therapeutic efficacy (J. Am. Coll. Cardiol. 1991;18:14-9). At a time when ventricular premature contraction (VPC) suppression was the "mantra" to prevent sudden death, CAST examined the pharmacologic suppression of VPCs in post–MI patients and found that, as the drugs decreased ventricular ectopy, mortality increased.

The use of the seemingly appropriate and obvious "surrogate" of LDL cholesterol lowering as a measure of therapeutic efficacy may be just as illusory. As enticing as surrogates are, the contemporary drive to lower LDL cholesterol may be as misdirected as the target to decrease the frequency of VPCs to prevent sudden death.

Like many things in life and science, things may not be what they seem.

Dr. Goldstein, the medical editor of Cardiology News, is a professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

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Early Data Find No Adalimumab Teratogenicity

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Elizabeth Mechcatie

BALTIMORE – Exposure to adalimumab was not associated with any specific pattern of minor or major birth defects in women with rheumatoid arthritis taking the biologic drug during pregnancy, according to preliminary data from an ongoing prospective cohort study.

Between November 2004 and January 2012, 312 pregnant women in the United States and Canada – 69 women with RA exposed to adalimumab, 80 women with RA who had not taken adalimumab, and 163 healthy controls – were enrolled before 20 weeks’ gestation. Their mean age was 32-33 years, and about two-thirds were white.

Dr. Christina Chambers

Major birth defects among the live births were identified in 5% of the babies born to women exposed to adalimumab, compared with about 4% among disease-matched controls who did not take adalimumab, and about 7% among healthy controls, Christina Chambers, Ph.D., of the University of California, San Diego, reported at the annual meeting of the Teratology Society.

The rate of minor structural abnormalities was similar in the three groups, at about 22%-24%, and there was no pattern of major or minor structural defects noted among the adalimumab-exposed group. (The three major malformations in the adalimumab-exposed group were one ventricular septal defect, one unilateral cryptorchidism, and one case of microcephaly.)

There were no stillbirths. The rate of spontaneous abortions was not significantly different between the three groups, nor were the rates of preterm delivery or birth weights, said Dr. Chambers, director of the California Teratogen Information Service and Clinical Research Program.

Through 1-year of follow-up, there were no malignancies among the infants and the rates of serious infections in the three groups were similar (about 3% in the two RA groups and 2% in the healthy comparison group).

The teratogenic effects of adalimumab, a tumor necrosis factor blocker, are being evaluated in the pregnancy registry, which is part of the Organization of Teratology Information Specialists (OTIS) Autoimmune Diseases in Pregnancy Project.

Adalimumab, marketed as Humira by Abbott Laboratories, was first approved in the United States in 2002 as a treatment for people with moderately to severely active RA, and has since been approved for other autoimmune diseases, including psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, and psoriasis.

The registry study is comparing outcomes in women with RA who are treated with adalimumab during pregnancy, in women with RA not treated with adalimumab during pregnancy, and in women who do not have an autoimmune disease and have not been exposed to adalimumab or any known teratogenic drug during pregnancy. The study includes medical record reviews, examination of infants for major and minor structural abnormalities, and follow-up for 1 year post partum. It is expected to continue through 2017; the pregnant women are recruited from OTIS member services and from rheumatologists, and other clinicians who care for these patients.

Although little to no placental transfer of adalimumab is expected during early pregnancy, limited information on the safety of adalimumab during pregnancy has been published, Dr. Chambers said.

Abbott Laboratories is among the sponsors of the OTIS Autoimmune Diseases in Pregnancy Project, which is also evaluating safety of medications in women with ankylosing spondylitis, psoriasis and psoriatic arthritis, and Crohn’s disease. Dr. Chambers and her coauthors have received or receive grant funding for research on medications for autoimmune diseases from Abbott and other manufacturers: Amgen, Bristol Myers Squibb, Roche Genentech, Sanofi, Teva, Par, Sandoz, and Apotex.

Information for women and clinicians interested in enrolling in the OTIS Autoimmune Diseases in Pregnancy Project is available at www.otispregnancy.org/autoimmune-studies-s13049.

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BALTIMORE – Exposure to adalimumab was not associated with any specific pattern of minor or major birth defects in women with rheumatoid arthritis taking the biologic drug during pregnancy, according to preliminary data from an ongoing prospective cohort study.

Between November 2004 and January 2012, 312 pregnant women in the United States and Canada – 69 women with RA exposed to adalimumab, 80 women with RA who had not taken adalimumab, and 163 healthy controls – were enrolled before 20 weeks’ gestation. Their mean age was 32-33 years, and about two-thirds were white.

Dr. Christina Chambers

Major birth defects among the live births were identified in 5% of the babies born to women exposed to adalimumab, compared with about 4% among disease-matched controls who did not take adalimumab, and about 7% among healthy controls, Christina Chambers, Ph.D., of the University of California, San Diego, reported at the annual meeting of the Teratology Society.

The rate of minor structural abnormalities was similar in the three groups, at about 22%-24%, and there was no pattern of major or minor structural defects noted among the adalimumab-exposed group. (The three major malformations in the adalimumab-exposed group were one ventricular septal defect, one unilateral cryptorchidism, and one case of microcephaly.)

There were no stillbirths. The rate of spontaneous abortions was not significantly different between the three groups, nor were the rates of preterm delivery or birth weights, said Dr. Chambers, director of the California Teratogen Information Service and Clinical Research Program.

Through 1-year of follow-up, there were no malignancies among the infants and the rates of serious infections in the three groups were similar (about 3% in the two RA groups and 2% in the healthy comparison group).

The teratogenic effects of adalimumab, a tumor necrosis factor blocker, are being evaluated in the pregnancy registry, which is part of the Organization of Teratology Information Specialists (OTIS) Autoimmune Diseases in Pregnancy Project.

Adalimumab, marketed as Humira by Abbott Laboratories, was first approved in the United States in 2002 as a treatment for people with moderately to severely active RA, and has since been approved for other autoimmune diseases, including psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, and psoriasis.

The registry study is comparing outcomes in women with RA who are treated with adalimumab during pregnancy, in women with RA not treated with adalimumab during pregnancy, and in women who do not have an autoimmune disease and have not been exposed to adalimumab or any known teratogenic drug during pregnancy. The study includes medical record reviews, examination of infants for major and minor structural abnormalities, and follow-up for 1 year post partum. It is expected to continue through 2017; the pregnant women are recruited from OTIS member services and from rheumatologists, and other clinicians who care for these patients.

Although little to no placental transfer of adalimumab is expected during early pregnancy, limited information on the safety of adalimumab during pregnancy has been published, Dr. Chambers said.

Abbott Laboratories is among the sponsors of the OTIS Autoimmune Diseases in Pregnancy Project, which is also evaluating safety of medications in women with ankylosing spondylitis, psoriasis and psoriatic arthritis, and Crohn’s disease. Dr. Chambers and her coauthors have received or receive grant funding for research on medications for autoimmune diseases from Abbott and other manufacturers: Amgen, Bristol Myers Squibb, Roche Genentech, Sanofi, Teva, Par, Sandoz, and Apotex.

Information for women and clinicians interested in enrolling in the OTIS Autoimmune Diseases in Pregnancy Project is available at www.otispregnancy.org/autoimmune-studies-s13049.

BALTIMORE – Exposure to adalimumab was not associated with any specific pattern of minor or major birth defects in women with rheumatoid arthritis taking the biologic drug during pregnancy, according to preliminary data from an ongoing prospective cohort study.

Between November 2004 and January 2012, 312 pregnant women in the United States and Canada – 69 women with RA exposed to adalimumab, 80 women with RA who had not taken adalimumab, and 163 healthy controls – were enrolled before 20 weeks’ gestation. Their mean age was 32-33 years, and about two-thirds were white.

Dr. Christina Chambers

Major birth defects among the live births were identified in 5% of the babies born to women exposed to adalimumab, compared with about 4% among disease-matched controls who did not take adalimumab, and about 7% among healthy controls, Christina Chambers, Ph.D., of the University of California, San Diego, reported at the annual meeting of the Teratology Society.

The rate of minor structural abnormalities was similar in the three groups, at about 22%-24%, and there was no pattern of major or minor structural defects noted among the adalimumab-exposed group. (The three major malformations in the adalimumab-exposed group were one ventricular septal defect, one unilateral cryptorchidism, and one case of microcephaly.)

There were no stillbirths. The rate of spontaneous abortions was not significantly different between the three groups, nor were the rates of preterm delivery or birth weights, said Dr. Chambers, director of the California Teratogen Information Service and Clinical Research Program.

Through 1-year of follow-up, there were no malignancies among the infants and the rates of serious infections in the three groups were similar (about 3% in the two RA groups and 2% in the healthy comparison group).

The teratogenic effects of adalimumab, a tumor necrosis factor blocker, are being evaluated in the pregnancy registry, which is part of the Organization of Teratology Information Specialists (OTIS) Autoimmune Diseases in Pregnancy Project.

Adalimumab, marketed as Humira by Abbott Laboratories, was first approved in the United States in 2002 as a treatment for people with moderately to severely active RA, and has since been approved for other autoimmune diseases, including psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, and psoriasis.

The registry study is comparing outcomes in women with RA who are treated with adalimumab during pregnancy, in women with RA not treated with adalimumab during pregnancy, and in women who do not have an autoimmune disease and have not been exposed to adalimumab or any known teratogenic drug during pregnancy. The study includes medical record reviews, examination of infants for major and minor structural abnormalities, and follow-up for 1 year post partum. It is expected to continue through 2017; the pregnant women are recruited from OTIS member services and from rheumatologists, and other clinicians who care for these patients.

Although little to no placental transfer of adalimumab is expected during early pregnancy, limited information on the safety of adalimumab during pregnancy has been published, Dr. Chambers said.

Abbott Laboratories is among the sponsors of the OTIS Autoimmune Diseases in Pregnancy Project, which is also evaluating safety of medications in women with ankylosing spondylitis, psoriasis and psoriatic arthritis, and Crohn’s disease. Dr. Chambers and her coauthors have received or receive grant funding for research on medications for autoimmune diseases from Abbott and other manufacturers: Amgen, Bristol Myers Squibb, Roche Genentech, Sanofi, Teva, Par, Sandoz, and Apotex.

Information for women and clinicians interested in enrolling in the OTIS Autoimmune Diseases in Pregnancy Project is available at www.otispregnancy.org/autoimmune-studies-s13049.

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Treating Kids' Sleep Apnea Can Improve Brain Function

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BOSTON – Neuronal abnormalities in the brains of children with obstructive sleep apnea are reversible with treatment, a prospective study has shown.

The findings are the first to show that the altered brain metabolites of the frontal cortex – the neuronal network responsible for attention and executive function – normalize with treatment of pediatric obstructive sleep apnea, Dr. Ann C. Halbower reported at the annual meeting of the Associated Professional Sleep Societies.

Previous studies have demonstrated an association between obstructive sleep apnea (OSA) and deficits in attention, cognition, and executive function, "but ours is the first to look at the effect of [OSA] treatment on the neuronal brain injury and to show a relationship between treatment and improvements in attention and verbal memory in these patients," said Dr. Halbower of the Children’s Hospital Colorado Sleep Center and the University of Colorado at Denver.

The study included 28 children aged 8-11 years; 17 had moderate or severe OSA and 11 were healthy controls matched by age, sex, race, and socioeconomic status. At study baseline, all participants underwent neuropsychological testing, and 22 of the children (15 with OSA and 7 healthy controls) also underwent magnetic resonance spectroscopy imaging. Six months post treatment, 11 of the OSA patients underwent repeat brain imaging and neuropsychological testing, Dr. Halbower said. Treatment for OSA consisted of adenotonsillectomy followed by monitored continuous positive airway pressure (CPAP) for children whose apnea-hypopnea index (AHI) score was higher than 3, or nasal treatments for those with an AHI score of 2-3, she explained.

Among the OSA patients, the mean AHI score at baseline was 13.6, compared with 0.3 for the healthy controls – a discrepancy mirrored by differences observed in both the brain imaging and the function tests. Specifically, Dr. Halbower reported, "the N-acetyl aspartate to choline (NAA/Cho) ratios in the left hippocampus and left frontal cortex were significantly decreased in [OSA] patients, compared with healthy controls, and the [OSA] patients had significant decreases in the executive function of working memory, attention, and verbal memory."

After treatment, "the neuronal metabolites of the right and left frontal cortex normalized, and the hippocampal metabolites improved with a medium effect size," Dr. Halbower said. The follow-up neuropsychological testing showed significant improvements in verbal memory and attention, "which correlated with the normalization of the [NAA/Cho] ratios in the frontal lobes," she said. A further analysis of the data linked improvement on the AHI with a more complete reversal of the hippocampal abnormalities in children with mild OSA, she said, noting, however, that this finding "is very preliminary."

Based on the study results, "we speculate that early diagnosis and treatment of obstructive sleep apnea in children could have profound effects on the trajectory of their development," Dr. Halbower said. In particular, she suggested, earlier treatment may lead to a "more brisk improvement" in the hippocampus, which is the "relay station" for executive function, learning, and memory.

Dr. Halbower said she had no relevant financial disclosures.

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BOSTON – Neuronal abnormalities in the brains of children with obstructive sleep apnea are reversible with treatment, a prospective study has shown.

The findings are the first to show that the altered brain metabolites of the frontal cortex – the neuronal network responsible for attention and executive function – normalize with treatment of pediatric obstructive sleep apnea, Dr. Ann C. Halbower reported at the annual meeting of the Associated Professional Sleep Societies.

Previous studies have demonstrated an association between obstructive sleep apnea (OSA) and deficits in attention, cognition, and executive function, "but ours is the first to look at the effect of [OSA] treatment on the neuronal brain injury and to show a relationship between treatment and improvements in attention and verbal memory in these patients," said Dr. Halbower of the Children’s Hospital Colorado Sleep Center and the University of Colorado at Denver.

The study included 28 children aged 8-11 years; 17 had moderate or severe OSA and 11 were healthy controls matched by age, sex, race, and socioeconomic status. At study baseline, all participants underwent neuropsychological testing, and 22 of the children (15 with OSA and 7 healthy controls) also underwent magnetic resonance spectroscopy imaging. Six months post treatment, 11 of the OSA patients underwent repeat brain imaging and neuropsychological testing, Dr. Halbower said. Treatment for OSA consisted of adenotonsillectomy followed by monitored continuous positive airway pressure (CPAP) for children whose apnea-hypopnea index (AHI) score was higher than 3, or nasal treatments for those with an AHI score of 2-3, she explained.

Among the OSA patients, the mean AHI score at baseline was 13.6, compared with 0.3 for the healthy controls – a discrepancy mirrored by differences observed in both the brain imaging and the function tests. Specifically, Dr. Halbower reported, "the N-acetyl aspartate to choline (NAA/Cho) ratios in the left hippocampus and left frontal cortex were significantly decreased in [OSA] patients, compared with healthy controls, and the [OSA] patients had significant decreases in the executive function of working memory, attention, and verbal memory."

After treatment, "the neuronal metabolites of the right and left frontal cortex normalized, and the hippocampal metabolites improved with a medium effect size," Dr. Halbower said. The follow-up neuropsychological testing showed significant improvements in verbal memory and attention, "which correlated with the normalization of the [NAA/Cho] ratios in the frontal lobes," she said. A further analysis of the data linked improvement on the AHI with a more complete reversal of the hippocampal abnormalities in children with mild OSA, she said, noting, however, that this finding "is very preliminary."

Based on the study results, "we speculate that early diagnosis and treatment of obstructive sleep apnea in children could have profound effects on the trajectory of their development," Dr. Halbower said. In particular, she suggested, earlier treatment may lead to a "more brisk improvement" in the hippocampus, which is the "relay station" for executive function, learning, and memory.

Dr. Halbower said she had no relevant financial disclosures.

BOSTON – Neuronal abnormalities in the brains of children with obstructive sleep apnea are reversible with treatment, a prospective study has shown.

The findings are the first to show that the altered brain metabolites of the frontal cortex – the neuronal network responsible for attention and executive function – normalize with treatment of pediatric obstructive sleep apnea, Dr. Ann C. Halbower reported at the annual meeting of the Associated Professional Sleep Societies.

Previous studies have demonstrated an association between obstructive sleep apnea (OSA) and deficits in attention, cognition, and executive function, "but ours is the first to look at the effect of [OSA] treatment on the neuronal brain injury and to show a relationship between treatment and improvements in attention and verbal memory in these patients," said Dr. Halbower of the Children’s Hospital Colorado Sleep Center and the University of Colorado at Denver.

The study included 28 children aged 8-11 years; 17 had moderate or severe OSA and 11 were healthy controls matched by age, sex, race, and socioeconomic status. At study baseline, all participants underwent neuropsychological testing, and 22 of the children (15 with OSA and 7 healthy controls) also underwent magnetic resonance spectroscopy imaging. Six months post treatment, 11 of the OSA patients underwent repeat brain imaging and neuropsychological testing, Dr. Halbower said. Treatment for OSA consisted of adenotonsillectomy followed by monitored continuous positive airway pressure (CPAP) for children whose apnea-hypopnea index (AHI) score was higher than 3, or nasal treatments for those with an AHI score of 2-3, she explained.

Among the OSA patients, the mean AHI score at baseline was 13.6, compared with 0.3 for the healthy controls – a discrepancy mirrored by differences observed in both the brain imaging and the function tests. Specifically, Dr. Halbower reported, "the N-acetyl aspartate to choline (NAA/Cho) ratios in the left hippocampus and left frontal cortex were significantly decreased in [OSA] patients, compared with healthy controls, and the [OSA] patients had significant decreases in the executive function of working memory, attention, and verbal memory."

After treatment, "the neuronal metabolites of the right and left frontal cortex normalized, and the hippocampal metabolites improved with a medium effect size," Dr. Halbower said. The follow-up neuropsychological testing showed significant improvements in verbal memory and attention, "which correlated with the normalization of the [NAA/Cho] ratios in the frontal lobes," she said. A further analysis of the data linked improvement on the AHI with a more complete reversal of the hippocampal abnormalities in children with mild OSA, she said, noting, however, that this finding "is very preliminary."

Based on the study results, "we speculate that early diagnosis and treatment of obstructive sleep apnea in children could have profound effects on the trajectory of their development," Dr. Halbower said. In particular, she suggested, earlier treatment may lead to a "more brisk improvement" in the hippocampus, which is the "relay station" for executive function, learning, and memory.

Dr. Halbower said she had no relevant financial disclosures.

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AT THE ANNUAL MEETING OF THE ASSOCIATED PROFESSIONAL SLEEP SOCIETIES

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Major Finding: Ratios of N-acetyl aspartate to choline in the frontal cortex of children with obstructive sleep apnea normalized after treatment, correlating to improvements in verbal memory and attention.

Data Source: The prospective study compared the pre- and posttreatment neuroimaging and neuropsychological test results of children with OSA to those of matched controls.

Disclosures: Dr. Halbower said she had no relevant financial disclosures.

Outcomes Data Used to Assess Residents' Surgical Skills

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SAN FRANCISCO – Resident involvement in surgical procedures does not clinically affect surgical outcomes, according to a retrospective study of more than 60,000 cases from the National Surgical Quality Improvement Program database.

"There is a small – although questionable as clinically relevant – overall increase in mild and surgical complications. This is mostly caused by superficial wound infections when residents participate in surgical procedures," said Dr. P. Ravi Kiran, staff surgeon and head of the research section in the department of colorectal surgery at the Cleveland Clinic.

Using data from the National Surgical Quality Improvement Program database from 2005 to 2007, Dr. Kiran and his colleagues compared outcomes for patients who underwent surgery with and without resident participation.

The database, which includes data from pre-, intra-, and postoperative phases, uses clearly defined parameters and specialist nurse reviewers. It also includes resident participation and a morbidity probability, which offers an opportunity to use preoperative factors to stratify risk within subgroups, Dr. Kiran said at the annual meeting of the American Surgical Association.

Resident cases were matched with nonresident cases on the basis of age, sex, specialty, surgical procedure, morbidity probability, and important comorbidities and risk factors. Primary outcomes included 30-day mortality and postoperative complications (mild vs. severe, and surgical vs. medical). Secondary outcomes included the duration of surgery and length of hospital stay.

Mild complications included superficial surgical site infections (SSIs), peripheral nerve injury, urinary tract infection, deep venous thrombosis, and thrombophlebitis. Severe complications included deep (organ) SSI, wound disruption, bleeding requiring transfusion, failure of graft or prosthesis, reoperation, pneumonia, pulmonary embolism, acute renal failure, stroke, myocardial infarction, and sepsis.

Surgical complications included superficial SSI, deep (organ) SSI, wound disruption, bleeding requiring transfusion, failure of graft or prosthesis, peripheral nerve injury, and reoperation. Medical complications included pneumonia, pulmonary embolism, acute renal failure, stroke, myocardial infarction, sepsis, urinary tract infection, deep vein thrombosis, and thrombophlebitis.

For cases with resident vs. nonresident participation, the surgical complication rates were 7% and 6.2%, respectively – a significant difference – and mild complications rates were 4.4% and 3.5%, respectively. In addition, the mean operative time was significantly greater for cases involving residents – 122 vs. 97 minutes. The length of postoperative hospital stay was not significantly longer in the resident group.

The researchers identified 40,474 patients in the resident group and 20,237 patients in the nonresident group. The two groups were similar in terms of median age (50 years), sex (67% female), mean morbidity probability (0.09), American Society of Anesthesiologists classification, and presence of diabetes (6.4%) and hypertension (35%).

The groups were also similar in terms of presence of chronic obstructive pulmonary disease (0.27%), congestive heart failure or myocardial infarction in the past 6 months (0%), dialysis (0.044%), and preoperative sepsis (0.035%). Surgeons’ speciality areas were likewise similar for the two groups (general, 93%; vascular, 6%; and other, 1.36%).

Postgraduate year (PGY) 1-2 residents participated in 31% of operations, PGY 3-5 residents participated in 56%, and residents in PGY 6 or higher participated in 13% of cases.

The 10 most common surgical procedures were laparoscopic appendectomy, laparoscopic gastric bypass, laparoscopic cholecystectomy with and without operative cholangiogram, open appendectomy (nonruptured), thromboendarterectomy, colectomy (partial with anastomosis), laparoscopic colectomy (partial with anastomosis), ventral hernia repair, and placement of gastric band. These procedures were similar in terms of the percentages of resident and nonresident participation.

"We found that there was no difference in the [overall] 30-day mortality between the groups – 0.18% in the resident group and 0.20% in the no-resident group," said Dr. Kiran. However, any 30-day complications were 7.5% in the resident group and 6.7% in the nonresident group, a significant difference.

"When we further looked at the surgical complications, we noted that the cause of the difference in surgical complications between the two groups was the higher rate of SSIs in the resident group, when compared with the no-resident group ... the other surgical complications were similar," he said. The SSI rate was 3.0% for the resident group, compared with 2.2% for the nonresident group.

Interestingly, the researchers also found that overall 30-day complication rates increased with PGY – the rates were 6% for PGY 1-2, 8% for PGY 3-5, and 9% for PGY of 6 or more.

When they examined specific outcomes and complications between different PGY groups and matched cases without the involvement of residents, they found a similar pattern for the overall cohort.

"The reason for the difference in 30-day complications in the groups was because of differences in complications that were classified as mild, and primarily because the superficial surgical site infections were higher in the PGY 1-2 years, with an increased operative time," they said. The same was true for PGY 3-5 and PGY 6 and greater.

 

 

Also, as PGY increased, so did operative time – in both resident and nonresident groups. "This suggests that the reason for the increasing complications with increasing PGY years may have been related to increasing complexity of surgery," said Dr. Kiran.

"One overarching issue seems to be how we might achieve high-quality patient care and delivery of the clinical outcomes in the context of training," said Dr. Clifford Ko, a discussant.

However, he also acknowledged that teaching residents takes time. Dr. Ko, a colorectal surgeon and the director of the Center for Surgical Outcomes and Quality at the University of California, Los Angeles, questioned whether the longer operating time associated with resident involvement should be reduced.

"Although we would not perhaps be able to minimize time differences, I think that we have already achieved some mark of control by the gradation of responsibility over time, as residents continue with their training," Dr. Kiran said.

Although the surgical and mild complication rates were slightly greater, it’s unclear whether these differences are clinically relevant.

"The reasons for [these differences] are likely multifactorial and may be related to prolonged operative time. Considering that more complex cases may be performed in teaching hospitals and require resident participation, ‘resident’ could be a surrogate of severity of disease and intensity of operation – factors that may not be clearly discernible in a retrospective study – and this may explain the differences seen.

"Also, quality measures currently underway to reduce surgical site infections across the board may further minimize any of these differences that may exist," Dr. Kiran concluded.

The authors reported that they had no relevant disclosures.

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SAN FRANCISCO – Resident involvement in surgical procedures does not clinically affect surgical outcomes, according to a retrospective study of more than 60,000 cases from the National Surgical Quality Improvement Program database.

"There is a small – although questionable as clinically relevant – overall increase in mild and surgical complications. This is mostly caused by superficial wound infections when residents participate in surgical procedures," said Dr. P. Ravi Kiran, staff surgeon and head of the research section in the department of colorectal surgery at the Cleveland Clinic.

Using data from the National Surgical Quality Improvement Program database from 2005 to 2007, Dr. Kiran and his colleagues compared outcomes for patients who underwent surgery with and without resident participation.

The database, which includes data from pre-, intra-, and postoperative phases, uses clearly defined parameters and specialist nurse reviewers. It also includes resident participation and a morbidity probability, which offers an opportunity to use preoperative factors to stratify risk within subgroups, Dr. Kiran said at the annual meeting of the American Surgical Association.

Resident cases were matched with nonresident cases on the basis of age, sex, specialty, surgical procedure, morbidity probability, and important comorbidities and risk factors. Primary outcomes included 30-day mortality and postoperative complications (mild vs. severe, and surgical vs. medical). Secondary outcomes included the duration of surgery and length of hospital stay.

Mild complications included superficial surgical site infections (SSIs), peripheral nerve injury, urinary tract infection, deep venous thrombosis, and thrombophlebitis. Severe complications included deep (organ) SSI, wound disruption, bleeding requiring transfusion, failure of graft or prosthesis, reoperation, pneumonia, pulmonary embolism, acute renal failure, stroke, myocardial infarction, and sepsis.

Surgical complications included superficial SSI, deep (organ) SSI, wound disruption, bleeding requiring transfusion, failure of graft or prosthesis, peripheral nerve injury, and reoperation. Medical complications included pneumonia, pulmonary embolism, acute renal failure, stroke, myocardial infarction, sepsis, urinary tract infection, deep vein thrombosis, and thrombophlebitis.

For cases with resident vs. nonresident participation, the surgical complication rates were 7% and 6.2%, respectively – a significant difference – and mild complications rates were 4.4% and 3.5%, respectively. In addition, the mean operative time was significantly greater for cases involving residents – 122 vs. 97 minutes. The length of postoperative hospital stay was not significantly longer in the resident group.

The researchers identified 40,474 patients in the resident group and 20,237 patients in the nonresident group. The two groups were similar in terms of median age (50 years), sex (67% female), mean morbidity probability (0.09), American Society of Anesthesiologists classification, and presence of diabetes (6.4%) and hypertension (35%).

The groups were also similar in terms of presence of chronic obstructive pulmonary disease (0.27%), congestive heart failure or myocardial infarction in the past 6 months (0%), dialysis (0.044%), and preoperative sepsis (0.035%). Surgeons’ speciality areas were likewise similar for the two groups (general, 93%; vascular, 6%; and other, 1.36%).

Postgraduate year (PGY) 1-2 residents participated in 31% of operations, PGY 3-5 residents participated in 56%, and residents in PGY 6 or higher participated in 13% of cases.

The 10 most common surgical procedures were laparoscopic appendectomy, laparoscopic gastric bypass, laparoscopic cholecystectomy with and without operative cholangiogram, open appendectomy (nonruptured), thromboendarterectomy, colectomy (partial with anastomosis), laparoscopic colectomy (partial with anastomosis), ventral hernia repair, and placement of gastric band. These procedures were similar in terms of the percentages of resident and nonresident participation.

"We found that there was no difference in the [overall] 30-day mortality between the groups – 0.18% in the resident group and 0.20% in the no-resident group," said Dr. Kiran. However, any 30-day complications were 7.5% in the resident group and 6.7% in the nonresident group, a significant difference.

"When we further looked at the surgical complications, we noted that the cause of the difference in surgical complications between the two groups was the higher rate of SSIs in the resident group, when compared with the no-resident group ... the other surgical complications were similar," he said. The SSI rate was 3.0% for the resident group, compared with 2.2% for the nonresident group.

Interestingly, the researchers also found that overall 30-day complication rates increased with PGY – the rates were 6% for PGY 1-2, 8% for PGY 3-5, and 9% for PGY of 6 or more.

When they examined specific outcomes and complications between different PGY groups and matched cases without the involvement of residents, they found a similar pattern for the overall cohort.

"The reason for the difference in 30-day complications in the groups was because of differences in complications that were classified as mild, and primarily because the superficial surgical site infections were higher in the PGY 1-2 years, with an increased operative time," they said. The same was true for PGY 3-5 and PGY 6 and greater.

 

 

Also, as PGY increased, so did operative time – in both resident and nonresident groups. "This suggests that the reason for the increasing complications with increasing PGY years may have been related to increasing complexity of surgery," said Dr. Kiran.

"One overarching issue seems to be how we might achieve high-quality patient care and delivery of the clinical outcomes in the context of training," said Dr. Clifford Ko, a discussant.

However, he also acknowledged that teaching residents takes time. Dr. Ko, a colorectal surgeon and the director of the Center for Surgical Outcomes and Quality at the University of California, Los Angeles, questioned whether the longer operating time associated with resident involvement should be reduced.

"Although we would not perhaps be able to minimize time differences, I think that we have already achieved some mark of control by the gradation of responsibility over time, as residents continue with their training," Dr. Kiran said.

Although the surgical and mild complication rates were slightly greater, it’s unclear whether these differences are clinically relevant.

"The reasons for [these differences] are likely multifactorial and may be related to prolonged operative time. Considering that more complex cases may be performed in teaching hospitals and require resident participation, ‘resident’ could be a surrogate of severity of disease and intensity of operation – factors that may not be clearly discernible in a retrospective study – and this may explain the differences seen.

"Also, quality measures currently underway to reduce surgical site infections across the board may further minimize any of these differences that may exist," Dr. Kiran concluded.

The authors reported that they had no relevant disclosures.

SAN FRANCISCO – Resident involvement in surgical procedures does not clinically affect surgical outcomes, according to a retrospective study of more than 60,000 cases from the National Surgical Quality Improvement Program database.

"There is a small – although questionable as clinically relevant – overall increase in mild and surgical complications. This is mostly caused by superficial wound infections when residents participate in surgical procedures," said Dr. P. Ravi Kiran, staff surgeon and head of the research section in the department of colorectal surgery at the Cleveland Clinic.

Using data from the National Surgical Quality Improvement Program database from 2005 to 2007, Dr. Kiran and his colleagues compared outcomes for patients who underwent surgery with and without resident participation.

The database, which includes data from pre-, intra-, and postoperative phases, uses clearly defined parameters and specialist nurse reviewers. It also includes resident participation and a morbidity probability, which offers an opportunity to use preoperative factors to stratify risk within subgroups, Dr. Kiran said at the annual meeting of the American Surgical Association.

Resident cases were matched with nonresident cases on the basis of age, sex, specialty, surgical procedure, morbidity probability, and important comorbidities and risk factors. Primary outcomes included 30-day mortality and postoperative complications (mild vs. severe, and surgical vs. medical). Secondary outcomes included the duration of surgery and length of hospital stay.

Mild complications included superficial surgical site infections (SSIs), peripheral nerve injury, urinary tract infection, deep venous thrombosis, and thrombophlebitis. Severe complications included deep (organ) SSI, wound disruption, bleeding requiring transfusion, failure of graft or prosthesis, reoperation, pneumonia, pulmonary embolism, acute renal failure, stroke, myocardial infarction, and sepsis.

Surgical complications included superficial SSI, deep (organ) SSI, wound disruption, bleeding requiring transfusion, failure of graft or prosthesis, peripheral nerve injury, and reoperation. Medical complications included pneumonia, pulmonary embolism, acute renal failure, stroke, myocardial infarction, sepsis, urinary tract infection, deep vein thrombosis, and thrombophlebitis.

For cases with resident vs. nonresident participation, the surgical complication rates were 7% and 6.2%, respectively – a significant difference – and mild complications rates were 4.4% and 3.5%, respectively. In addition, the mean operative time was significantly greater for cases involving residents – 122 vs. 97 minutes. The length of postoperative hospital stay was not significantly longer in the resident group.

The researchers identified 40,474 patients in the resident group and 20,237 patients in the nonresident group. The two groups were similar in terms of median age (50 years), sex (67% female), mean morbidity probability (0.09), American Society of Anesthesiologists classification, and presence of diabetes (6.4%) and hypertension (35%).

The groups were also similar in terms of presence of chronic obstructive pulmonary disease (0.27%), congestive heart failure or myocardial infarction in the past 6 months (0%), dialysis (0.044%), and preoperative sepsis (0.035%). Surgeons’ speciality areas were likewise similar for the two groups (general, 93%; vascular, 6%; and other, 1.36%).

Postgraduate year (PGY) 1-2 residents participated in 31% of operations, PGY 3-5 residents participated in 56%, and residents in PGY 6 or higher participated in 13% of cases.

The 10 most common surgical procedures were laparoscopic appendectomy, laparoscopic gastric bypass, laparoscopic cholecystectomy with and without operative cholangiogram, open appendectomy (nonruptured), thromboendarterectomy, colectomy (partial with anastomosis), laparoscopic colectomy (partial with anastomosis), ventral hernia repair, and placement of gastric band. These procedures were similar in terms of the percentages of resident and nonresident participation.

"We found that there was no difference in the [overall] 30-day mortality between the groups – 0.18% in the resident group and 0.20% in the no-resident group," said Dr. Kiran. However, any 30-day complications were 7.5% in the resident group and 6.7% in the nonresident group, a significant difference.

"When we further looked at the surgical complications, we noted that the cause of the difference in surgical complications between the two groups was the higher rate of SSIs in the resident group, when compared with the no-resident group ... the other surgical complications were similar," he said. The SSI rate was 3.0% for the resident group, compared with 2.2% for the nonresident group.

Interestingly, the researchers also found that overall 30-day complication rates increased with PGY – the rates were 6% for PGY 1-2, 8% for PGY 3-5, and 9% for PGY of 6 or more.

When they examined specific outcomes and complications between different PGY groups and matched cases without the involvement of residents, they found a similar pattern for the overall cohort.

"The reason for the difference in 30-day complications in the groups was because of differences in complications that were classified as mild, and primarily because the superficial surgical site infections were higher in the PGY 1-2 years, with an increased operative time," they said. The same was true for PGY 3-5 and PGY 6 and greater.

 

 

Also, as PGY increased, so did operative time – in both resident and nonresident groups. "This suggests that the reason for the increasing complications with increasing PGY years may have been related to increasing complexity of surgery," said Dr. Kiran.

"One overarching issue seems to be how we might achieve high-quality patient care and delivery of the clinical outcomes in the context of training," said Dr. Clifford Ko, a discussant.

However, he also acknowledged that teaching residents takes time. Dr. Ko, a colorectal surgeon and the director of the Center for Surgical Outcomes and Quality at the University of California, Los Angeles, questioned whether the longer operating time associated with resident involvement should be reduced.

"Although we would not perhaps be able to minimize time differences, I think that we have already achieved some mark of control by the gradation of responsibility over time, as residents continue with their training," Dr. Kiran said.

Although the surgical and mild complication rates were slightly greater, it’s unclear whether these differences are clinically relevant.

"The reasons for [these differences] are likely multifactorial and may be related to prolonged operative time. Considering that more complex cases may be performed in teaching hospitals and require resident participation, ‘resident’ could be a surrogate of severity of disease and intensity of operation – factors that may not be clearly discernible in a retrospective study – and this may explain the differences seen.

"Also, quality measures currently underway to reduce surgical site infections across the board may further minimize any of these differences that may exist," Dr. Kiran concluded.

The authors reported that they had no relevant disclosures.

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References

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Outcomes Data Used to Assess Residents' Surgical Skills
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Outcomes Data Used to Assess Residents' Surgical Skills
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Major Finding: There was no difference in the overall 30-day mortality between the surgery patient groups with (0.18%) and without (0.20%) resident involvement.

Data Source: Data from the National Surgical Quality Improvement Program database from 2005 to 2007 were used to compare outcomes for patients who underwent surgery with and without resident participation.

Disclosures: The authors reported that they had no relevant disclosures.

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