Eduard Vasilevskis, MD, is a member of SHM’s Research Committee and was a judge for the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition at HM11 outside Dallas. But when the committee members discussed who would judge the HM12 contest, Dr. Vasilevskis passed. He had a poster he wanted to enter instead.

Smart move.

His poster took the top prize in the Research portion of the annual contest, as judged by a panel of hospitalist leaders and visiting professor Pamela Lipsett, MD, MHPE, FACS, FCCM, a professor in the department of surgery, anesthesiology, and critical-care medicine at Johns Hopkins University Schools of Medicine and Nursing in Baltimore.

“When you work in a specific research area and you’re really passionate about the subject you’re studying, you sometimes lose sight of how other people might care about it,” says Dr. Vasilevskis, a hospitalist and assistant professor of medicine in the section of hospital medicine at Vanderbilt University School of Medicine and Tennessee Valley-Nashville VA Hospital in Nashville. “It’s nice to have an audience to validate that.”

HM has “a really outstanding core of researchers,” he adds. “The people who are walking around in that group, I really look up to.”

The feeling was mutual, as a team of judges led by SHM Education Committee Chair Daniel Brotman, MD, FACP, FHM, set out to pick a winner in a contest that has grown so large, the Clinical Vignettes portion was broken into a separate session.

First, SHM selects which abstracts to accept. Then, 186 hospitalists or HM-led teams were invited to give poster presentations at the San Diego Convention Center. Then, 23 finalists were chosen for judging rounds. All of that happened before anyone got to the annual meeting. Once in the exhibit hall, two-clinician judging teams worked their way through two dozen research posters deemed the best of the best. Each team recommended a finalist except for one, which Dr. Brotman dubbed “the Russian judges.”

But from the get-go, it was clear that the work completed by Dr. Vasilevskis and his colleagues would be the winner. As the two-member teams went around naming the posters they wanted the full judging panel to visit, one of those who visited Dr. Vasilevskis was brief but enthusiastic in the description: “I really liked this one.”

So the judges went back to poster No. 63, “Veterans Administration Acute Care 30-Day Mortality Model: Development, Validation, and Performance Variation.” Dr. Brotman was impressed by the breadth of the study, which aimed to develop a hybrid administrative/clinical risk model to address the shortcomings of risk models that rely on only administrative data or clinical data.

The first number that caught the judges’ attention was 1,114,327. That’s how many patients were used in retrospective cohort study of 131 VA hospitals. Then it was the results, which were impressively accurate given the size of the sample.

“It was a strong survey with incredible methodological rigor, addressing an incredibly important issue,” Dr. Brotman says. Dr. Vasilevskis notes that few hospitals or health systems currently have access to the level of data available to his research team. But as electronic health records (EHR) capture more clinical and administrative data, the ability to build models like the one he presented will only increase. “The better your model, the more you can believe your results,” he adds. “And we want our clinicians and CEOs and hospital boards to believe those numbers.”

Eduard Vasilevskis, MD, is a member of SHM’s Research Committee and was a judge for the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition at HM11 outside Dallas. But when the committee members discussed who would judge the HM12 contest, Dr. Vasilevskis passed. He had a poster he wanted to enter instead.

Smart move.

His poster took the top prize in the Research portion of the annual contest, as judged by a panel of hospitalist leaders and visiting professor Pamela Lipsett, MD, MHPE, FACS, FCCM, a professor in the department of surgery, anesthesiology, and critical-care medicine at Johns Hopkins University Schools of Medicine and Nursing in Baltimore.

“When you work in a specific research area and you’re really passionate about the subject you’re studying, you sometimes lose sight of how other people might care about it,” says Dr. Vasilevskis, a hospitalist and assistant professor of medicine in the section of hospital medicine at Vanderbilt University School of Medicine and Tennessee Valley-Nashville VA Hospital in Nashville. “It’s nice to have an audience to validate that.”

HM has “a really outstanding core of researchers,” he adds. “The people who are walking around in that group, I really look up to.”

The feeling was mutual, as a team of judges led by SHM Education Committee Chair Daniel Brotman, MD, FACP, FHM, set out to pick a winner in a contest that has grown so large, the Clinical Vignettes portion was broken into a separate session.

First, SHM selects which abstracts to accept. Then, 186 hospitalists or HM-led teams were invited to give poster presentations at the San Diego Convention Center. Then, 23 finalists were chosen for judging rounds. All of that happened before anyone got to the annual meeting. Once in the exhibit hall, two-clinician judging teams worked their way through two dozen research posters deemed the best of the best. Each team recommended a finalist except for one, which Dr. Brotman dubbed “the Russian judges.”

But from the get-go, it was clear that the work completed by Dr. Vasilevskis and his colleagues would be the winner. As the two-member teams went around naming the posters they wanted the full judging panel to visit, one of those who visited Dr. Vasilevskis was brief but enthusiastic in the description: “I really liked this one.”

So the judges went back to poster No. 63, “Veterans Administration Acute Care 30-Day Mortality Model: Development, Validation, and Performance Variation.” Dr. Brotman was impressed by the breadth of the study, which aimed to develop a hybrid administrative/clinical risk model to address the shortcomings of risk models that rely on only administrative data or clinical data.

The first number that caught the judges’ attention was 1,114,327. That’s how many patients were used in retrospective cohort study of 131 VA hospitals. Then it was the results, which were impressively accurate given the size of the sample.

“It was a strong survey with incredible methodological rigor, addressing an incredibly important issue,” Dr. Brotman says. Dr. Vasilevskis notes that few hospitals or health systems currently have access to the level of data available to his research team. But as electronic health records (EHR) capture more clinical and administrative data, the ability to build models like the one he presented will only increase. “The better your model, the more you can believe your results,” he adds. “And we want our clinicians and CEOs and hospital boards to believe those numbers.”

Eduard Vasilevskis, MD, is a member of SHM’s Research Committee and was a judge for the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition at HM11 outside Dallas. But when the committee members discussed who would judge the HM12 contest, Dr. Vasilevskis passed. He had a poster he wanted to enter instead.

Smart move.

His poster took the top prize in the Research portion of the annual contest, as judged by a panel of hospitalist leaders and visiting professor Pamela Lipsett, MD, MHPE, FACS, FCCM, a professor in the department of surgery, anesthesiology, and critical-care medicine at Johns Hopkins University Schools of Medicine and Nursing in Baltimore.

“When you work in a specific research area and you’re really passionate about the subject you’re studying, you sometimes lose sight of how other people might care about it,” says Dr. Vasilevskis, a hospitalist and assistant professor of medicine in the section of hospital medicine at Vanderbilt University School of Medicine and Tennessee Valley-Nashville VA Hospital in Nashville. “It’s nice to have an audience to validate that.”

HM has “a really outstanding core of researchers,” he adds. “The people who are walking around in that group, I really look up to.”

The feeling was mutual, as a team of judges led by SHM Education Committee Chair Daniel Brotman, MD, FACP, FHM, set out to pick a winner in a contest that has grown so large, the Clinical Vignettes portion was broken into a separate session.

First, SHM selects which abstracts to accept. Then, 186 hospitalists or HM-led teams were invited to give poster presentations at the San Diego Convention Center. Then, 23 finalists were chosen for judging rounds. All of that happened before anyone got to the annual meeting. Once in the exhibit hall, two-clinician judging teams worked their way through two dozen research posters deemed the best of the best. Each team recommended a finalist except for one, which Dr. Brotman dubbed “the Russian judges.”

But from the get-go, it was clear that the work completed by Dr. Vasilevskis and his colleagues would be the winner. As the two-member teams went around naming the posters they wanted the full judging panel to visit, one of those who visited Dr. Vasilevskis was brief but enthusiastic in the description: “I really liked this one.”

So the judges went back to poster No. 63, “Veterans Administration Acute Care 30-Day Mortality Model: Development, Validation, and Performance Variation.” Dr. Brotman was impressed by the breadth of the study, which aimed to develop a hybrid administrative/clinical risk model to address the shortcomings of risk models that rely on only administrative data or clinical data.

The first number that caught the judges’ attention was 1,114,327. That’s how many patients were used in retrospective cohort study of 131 VA hospitals. Then it was the results, which were impressively accurate given the size of the sample.

“It was a strong survey with incredible methodological rigor, addressing an incredibly important issue,” Dr. Brotman says. Dr. Vasilevskis notes that few hospitals or health systems currently have access to the level of data available to his research team. But as electronic health records (EHR) capture more clinical and administrative data, the ability to build models like the one he presented will only increase. “The better your model, the more you can believe your results,” he adds. “And we want our clinicians and CEOs and hospital boards to believe those numbers.”

Sometimes the first impression really is the right one.

Nearly 150 HM-focused innovations abstracts were submitted for the 2012 Research, Innovations, and Clinical Vignettes poster competition at HM12, and more than 60 of the submitters were invited to display posters in San Diego. A judging committee reviewed 24 poster finalists, and the consensus was that one poster stood out from the start: “Structured Interdisciplinary Bedside Rounds at Emory University School of Medicine in Atlanta, Ga.,” presented by Emory hospitalist Christina Payne, MD.

One of the Innovations judges noted the 73% reduction in mortality rates realized via Emory’s Accountable Care Unit, along with a one-day reduction in length of stay and a 90% reduction in catheter-related bloodstream infections. “My God, what’s going on there?” one judge exclaimed.

Added a second judge: “We tried something like this and didn’t succeed—but we didn’t have a champion like [Dr. Payne].”

SHM’s Innovations co-chair, Andrew Modest, MD, assistant clinical professor of medicine at Harvard Medical School and Mount Auburn Hospital in Cambridge, Mass., explained that the poster contests are a real stepping-stone opportunity for young clinicians—particularly junior faculty and residents. “You can go on to do more elaborate work and, with some statistical analysis, all of a sudden, you have a research paper,” Dr. Modest said, “or else turn it into a true quality-improvement project for your hospital. And if you’re a poster finalist at SHM, that goes on your resume.”

Innovation implies either something new or a new and effective application of existing methods for addressing an issue that all hospitalists deal with, Dr. Modest said. At HM12, posters featured innovative approaches to such issues as scheduling, readmissions, care transitions, and team communication.

“What I like to see is a buzz in the room,” Dr. Modest said. “Something that people recognize they can just take home and start using.”

In addition to Dr. Payne’s winning poster, the judges also chose five abstracts for oral presentations on Day Two of the annual meeting; one abstract was chosen and orally presented to start the Day Two plenary session before all HM12 attendees.

The Innovations judges, in teams of two, each met with four or five poster finalists in front of their panels; each principal investigator was asked to briefly summarize the innovation.

For example, at the University of Texas Health Sciences Center at San Antonio, financial support to add a fourth chief resident dedicated to quality led to the launch of a procedural service, explained by principal investigator David Schmit, MD. Medical interns now are taught in a one-month rotation to perform a number of medical procedures, aided by ultrasound, using a standardized curriculum, checklists, video training, and practice on a simulator. In Month Two, they perform the procedures on actual patients. Trained interns have performed 342 procedures, with 100% success rates for paracentesis and thoracentesis, Dr. Schmit said.

“This has to be incorporated into physicians’ training,” noted judge James Yturri, MD, a hospitalist from Great Falls, Mont. “How many programs are actually doing this?”

The service, Dr. Schmit said, has required a lot of coordination, infrastructure, and investment from the hospitalist group, residency program, and three participating hospitals.

“How did you get them all to buy in?” Dr. Yturri asked.

“I think the data on patient safety was persuasive,” Dr. Schmit said. “If you look at our low rate of pneumothorax, we saved money.”

When the 10 judges reconvened, discussion focused on innovative telemedicine and real-time reporting of VTE. A statewide collaborative to improve care transitions in Michigan was singled out for its active participation by the state’s health payors.

“I’m partial to the procedural project,” said Michael Pistoria, DO, SFHM, a hospitalist at Lehigh Valley Health Network in Allentown, Pa., and HM13 course director.

Kimberly Tartaglia, MD, was complimented for a succinct presentation of her poster about improving the inpatient management of neonatal jaundice. “Nicely done,” Dr. Modest told the hospitalist from Ohio State University Medical Center in Columbus.

But the judges eventually circled back to the Emory poster about rounds done on a nonteaching, medical accountable-care unit, defined as a unit that is consistently responsible for the outcomes it produces. On the unit, interns are trained to lead team-based, patient-centered rounds.

“They really have learned to love it,” Dr. Payne said.

Rounds start punctually each morning, with five minutes spent in each room for updates from the intern, nurse, social worker, patient and family, leading to a plan for the day with a safety checklist and discharge planning checklist, all entered in real time into the medical record by a second intern.

“How hard is it to get through all that in five minutes?” Dr. Modest queried.

“Every month, I get a new set of learners,” Dr. Payne replied. “At the beginning of the month, it doesn’t work as well. But by Week Two, we’re a well-oiled machine.”

The judges huddled again, but quickly agreed to award the poster prize to Dr. Payne.

Sometimes the first impression really is the right one.

Nearly 150 HM-focused innovations abstracts were submitted for the 2012 Research, Innovations, and Clinical Vignettes poster competition at HM12, and more than 60 of the submitters were invited to display posters in San Diego. A judging committee reviewed 24 poster finalists, and the consensus was that one poster stood out from the start: “Structured Interdisciplinary Bedside Rounds at Emory University School of Medicine in Atlanta, Ga.,” presented by Emory hospitalist Christina Payne, MD.

One of the Innovations judges noted the 73% reduction in mortality rates realized via Emory’s Accountable Care Unit, along with a one-day reduction in length of stay and a 90% reduction in catheter-related bloodstream infections. “My God, what’s going on there?” one judge exclaimed.

Added a second judge: “We tried something like this and didn’t succeed—but we didn’t have a champion like [Dr. Payne].”

SHM’s Innovations co-chair, Andrew Modest, MD, assistant clinical professor of medicine at Harvard Medical School and Mount Auburn Hospital in Cambridge, Mass., explained that the poster contests are a real stepping-stone opportunity for young clinicians—particularly junior faculty and residents. “You can go on to do more elaborate work and, with some statistical analysis, all of a sudden, you have a research paper,” Dr. Modest said, “or else turn it into a true quality-improvement project for your hospital. And if you’re a poster finalist at SHM, that goes on your resume.”

Innovation implies either something new or a new and effective application of existing methods for addressing an issue that all hospitalists deal with, Dr. Modest said. At HM12, posters featured innovative approaches to such issues as scheduling, readmissions, care transitions, and team communication.

“What I like to see is a buzz in the room,” Dr. Modest said. “Something that people recognize they can just take home and start using.”

In addition to Dr. Payne’s winning poster, the judges also chose five abstracts for oral presentations on Day Two of the annual meeting; one abstract was chosen and orally presented to start the Day Two plenary session before all HM12 attendees.

The Innovations judges, in teams of two, each met with four or five poster finalists in front of their panels; each principal investigator was asked to briefly summarize the innovation.

For example, at the University of Texas Health Sciences Center at San Antonio, financial support to add a fourth chief resident dedicated to quality led to the launch of a procedural service, explained by principal investigator David Schmit, MD. Medical interns now are taught in a one-month rotation to perform a number of medical procedures, aided by ultrasound, using a standardized curriculum, checklists, video training, and practice on a simulator. In Month Two, they perform the procedures on actual patients. Trained interns have performed 342 procedures, with 100% success rates for paracentesis and thoracentesis, Dr. Schmit said.

“This has to be incorporated into physicians’ training,” noted judge James Yturri, MD, a hospitalist from Great Falls, Mont. “How many programs are actually doing this?”

The service, Dr. Schmit said, has required a lot of coordination, infrastructure, and investment from the hospitalist group, residency program, and three participating hospitals.

“How did you get them all to buy in?” Dr. Yturri asked.

“I think the data on patient safety was persuasive,” Dr. Schmit said. “If you look at our low rate of pneumothorax, we saved money.”

When the 10 judges reconvened, discussion focused on innovative telemedicine and real-time reporting of VTE. A statewide collaborative to improve care transitions in Michigan was singled out for its active participation by the state’s health payors.

“I’m partial to the procedural project,” said Michael Pistoria, DO, SFHM, a hospitalist at Lehigh Valley Health Network in Allentown, Pa., and HM13 course director.

Kimberly Tartaglia, MD, was complimented for a succinct presentation of her poster about improving the inpatient management of neonatal jaundice. “Nicely done,” Dr. Modest told the hospitalist from Ohio State University Medical Center in Columbus.

But the judges eventually circled back to the Emory poster about rounds done on a nonteaching, medical accountable-care unit, defined as a unit that is consistently responsible for the outcomes it produces. On the unit, interns are trained to lead team-based, patient-centered rounds.

“They really have learned to love it,” Dr. Payne said.

Rounds start punctually each morning, with five minutes spent in each room for updates from the intern, nurse, social worker, patient and family, leading to a plan for the day with a safety checklist and discharge planning checklist, all entered in real time into the medical record by a second intern.

“How hard is it to get through all that in five minutes?” Dr. Modest queried.

“Every month, I get a new set of learners,” Dr. Payne replied. “At the beginning of the month, it doesn’t work as well. But by Week Two, we’re a well-oiled machine.”

The judges huddled again, but quickly agreed to award the poster prize to Dr. Payne.

Sometimes the first impression really is the right one.

Nearly 150 HM-focused innovations abstracts were submitted for the 2012 Research, Innovations, and Clinical Vignettes poster competition at HM12, and more than 60 of the submitters were invited to display posters in San Diego. A judging committee reviewed 24 poster finalists, and the consensus was that one poster stood out from the start: “Structured Interdisciplinary Bedside Rounds at Emory University School of Medicine in Atlanta, Ga.,” presented by Emory hospitalist Christina Payne, MD.

One of the Innovations judges noted the 73% reduction in mortality rates realized via Emory’s Accountable Care Unit, along with a one-day reduction in length of stay and a 90% reduction in catheter-related bloodstream infections. “My God, what’s going on there?” one judge exclaimed.

Added a second judge: “We tried something like this and didn’t succeed—but we didn’t have a champion like [Dr. Payne].”

SHM’s Innovations co-chair, Andrew Modest, MD, assistant clinical professor of medicine at Harvard Medical School and Mount Auburn Hospital in Cambridge, Mass., explained that the poster contests are a real stepping-stone opportunity for young clinicians—particularly junior faculty and residents. “You can go on to do more elaborate work and, with some statistical analysis, all of a sudden, you have a research paper,” Dr. Modest said, “or else turn it into a true quality-improvement project for your hospital. And if you’re a poster finalist at SHM, that goes on your resume.”

Innovation implies either something new or a new and effective application of existing methods for addressing an issue that all hospitalists deal with, Dr. Modest said. At HM12, posters featured innovative approaches to such issues as scheduling, readmissions, care transitions, and team communication.

“What I like to see is a buzz in the room,” Dr. Modest said. “Something that people recognize they can just take home and start using.”

In addition to Dr. Payne’s winning poster, the judges also chose five abstracts for oral presentations on Day Two of the annual meeting; one abstract was chosen and orally presented to start the Day Two plenary session before all HM12 attendees.

The Innovations judges, in teams of two, each met with four or five poster finalists in front of their panels; each principal investigator was asked to briefly summarize the innovation.

For example, at the University of Texas Health Sciences Center at San Antonio, financial support to add a fourth chief resident dedicated to quality led to the launch of a procedural service, explained by principal investigator David Schmit, MD. Medical interns now are taught in a one-month rotation to perform a number of medical procedures, aided by ultrasound, using a standardized curriculum, checklists, video training, and practice on a simulator. In Month Two, they perform the procedures on actual patients. Trained interns have performed 342 procedures, with 100% success rates for paracentesis and thoracentesis, Dr. Schmit said.

“This has to be incorporated into physicians’ training,” noted judge James Yturri, MD, a hospitalist from Great Falls, Mont. “How many programs are actually doing this?”

The service, Dr. Schmit said, has required a lot of coordination, infrastructure, and investment from the hospitalist group, residency program, and three participating hospitals.

“How did you get them all to buy in?” Dr. Yturri asked.

“I think the data on patient safety was persuasive,” Dr. Schmit said. “If you look at our low rate of pneumothorax, we saved money.”

When the 10 judges reconvened, discussion focused on innovative telemedicine and real-time reporting of VTE. A statewide collaborative to improve care transitions in Michigan was singled out for its active participation by the state’s health payors.

“I’m partial to the procedural project,” said Michael Pistoria, DO, SFHM, a hospitalist at Lehigh Valley Health Network in Allentown, Pa., and HM13 course director.

Kimberly Tartaglia, MD, was complimented for a succinct presentation of her poster about improving the inpatient management of neonatal jaundice. “Nicely done,” Dr. Modest told the hospitalist from Ohio State University Medical Center in Columbus.

But the judges eventually circled back to the Emory poster about rounds done on a nonteaching, medical accountable-care unit, defined as a unit that is consistently responsible for the outcomes it produces. On the unit, interns are trained to lead team-based, patient-centered rounds.

“They really have learned to love it,” Dr. Payne said.

Rounds start punctually each morning, with five minutes spent in each room for updates from the intern, nurse, social worker, patient and family, leading to a plan for the day with a safety checklist and discharge planning checklist, all entered in real time into the medical record by a second intern.

“How hard is it to get through all that in five minutes?” Dr. Modest queried.

“Every month, I get a new set of learners,” Dr. Payne replied. “At the beginning of the month, it doesn’t work as well. But by Week Two, we’re a well-oiled machine.”

The judges huddled again, but quickly agreed to award the poster prize to Dr. Payne.

Informatics specialist David Knoepfler, MD, sat in the back row of a daylong HM12 pre-course that aimed to prepare hospitalists for the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) examination. The question-and-answer session was intended to help the longtime clinician pass his second certification renewal.

But it was utterly unnecessary.

Dr. Knoepfler is the chief medical information officer at Overlake Hospital Medical Center (http://www.overlakehospital.org/about-us/) in the Seattle suburb of Bellevue, Wash. As much as 90% of his time is spent on information technology (IT) duties, and since he is grandfathered, he does not need to get recertified. So why did he spend seven hours scribbling notes as though he was preparing for his first boards?

Pride in his career development, plain and simple.

“Despite my heavily administrative role, I want to stay in touch with the clinical side,” says Dr. Knoepfler, a practicing hospitalist for 20 years who hadn’t attended an SHM annual meeting in more than 10 years before participating in HM12 last month at the San Diego Convention Center. “I feel like I have to for my patients’ sake. Even if I’m doing 10 percent or 15 percent [of my time in clinical], I absolutely have to be practicing quality medicine.”

SHM’s annual meeting is a hotbed of lifelong learning. A majority of attendees each year say that the continuing medical education (CME) credits are a major draw. This year’s pre-course lineup included the MOC test preparation, hands-on classes in medical procedures and ultrasound usage, and a debut class on “How to Improve Performance in CMS’s Value-Based Purchasing Program,” which was led by SHM senior vice president Joseph Miller and

Patrick Torcson, MD, MMM, FAACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee.

Dr. Torcson

Career development, of course, means different things to different people. Dr. Knoepfler might have been focused on updating his clinical knowledge, but he is a technology expert whose main duties are to integrate health IT into the daily routine of his 349-bed hospital. So whether listening in a pre-course, attending a workshop, or meeting old or new colleagues for a drink, he spent the four-day conference constantly looking for ways to improve his job performance.

“My ears are constantly listening for how can I tie this into our electronic health record,” Dr. Knoepfler adds. “Whether it’s a clinical topic, an administrative topic, an insurance topic, a governmental topic, for me, I’m going to take all those back and see how I can make our electronic record work with the practitioners rather than fight them.”

A Learning Process

Former SHM president Jeff Weise, MD, professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, feels so strongly about the value of professional development and the ABIM’s MOC process for hospital medicine that he and several society staffers held an impromptu session between plenary addresses to tackle perceived confusion with the Focused Practice in Hospital Medicine (FPHM) MOC pathway.

Dr. Weise

Dr. Weise says that the FPHM pathway does not mean doctors give up board certification in internal medicine, nor does it apply only to academic or community physicians.

Dr. Torcson, who works at St. Tammany Parish Hospital in Covington, La., says that the certification should be viewed as a “meaningful affirmation” of HM’s solidified place in the healthcare system.

“It’s really the right thing to do for our developing specialty,” he says. “We really have to distinguish ourselves, and there’s really no better brand distinction than a professional designation based on board certification and maintenance of certification.”

Ethan Cumbler, MD, FACP, of the University of Colorado Denver, led a portion of the MOC pre-course at HM12. He says that those who attend SHM’s annual meeting are able to take advantage of communal learning, which provides benefits that those who study alone can’t absorb. Taking a pre-test just teaches whether participants answered correctly or not. Questioning why the answer is what it is, with interactive feedback, is “a learning process,” he says.

“There’s a very different feel to learning in a group setting with your peers than to sitting down with a journal or a magazine or a textbook or an online module,” Dr. Cumbler says. “Part of what makes this conference engaging is not just content, it’s the milieu. It’s a social milieu of our peers, and we’re learning together and we’re exploring these difficult issues together.

“My sense is that the people who come to this are probably a cut above,” adds Dr. Cumbler, whose University of Colorado In-Hospital Stroke QI Team was the 2012 recipient of SHM’s Award for Excellence in Teamwork in Quality Improvement. “They are people who are really committed to being more evidence-based and understanding what the evidence is and how they apply that to their patients.”

Career Decisions

They are physicians like James Eppinette, MD, who became a hospitalist three years ago after 20 years in private practice as a primary-care physician (PCP). He joined a hospital-owned group at St. Francis Medical Center in Monroe, La., and HM12 was his first annual meeting—he attended because the meeting’s clinical focus provided him with professional development opportunities. He began with the pre-operative-care pre-course, an area in which he felt he wanted more exposure. From there, he bounced around clinical workshops.

“[HM12] has an incredible variety of tracks that you can pursue, so there’s something here for everybody,” Dr. Eppinette says, later adding that “my primary responsibility is clinical. That’s all I do is take care of people. I don’t manage people, I don’t run a practice, nor do I want to. That’s why I left 20 years of private practice to be a hospitalist. I just think it’s well set up structurally for an educational event.”

Dr. Eppinette, who took his notes back to the 12 hospitalists and nine pulmonologists in his hospitalist group, says that the decision to attend HM12 came from his increasing satisfaction with his late-career job change.

“I didn’t know how I would like going from an independent practitioner to being employed, hospital-owned. But I’ve done it three years,” he says, and “[I think this is] how I will finish my career. After three years, I’m kind of liking this road I’m on, so I’ve started looking into more about it.”

That level of personal accountability is a next step for hospitalists nationwide, according to new SHM president Shaun Frost, MD, SFHM, FACP, chief medical officer for the Northeast region of Brentwood, Tenn.-based Cogent HMG. Dr. Frost says that personal and professional accountability will be the drivers for HM’s continued growth and success, and that without individual physicians pushing their career development goals to new heights, the fastest-growing medical specialty in history could stall.

“We must all strive to consistently hold each other and hold ourselves personally accountable for embracing the work that is necessary to realize the potential of hospital medicine to be a true healthcare reform effector,” Dr. Frost says. “It’s time, I think, for each of us to put our money where our mouths have been.”

Informatics specialist David Knoepfler, MD, sat in the back row of a daylong HM12 pre-course that aimed to prepare hospitalists for the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) examination. The question-and-answer session was intended to help the longtime clinician pass his second certification renewal.

But it was utterly unnecessary.

Dr. Knoepfler is the chief medical information officer at Overlake Hospital Medical Center (http://www.overlakehospital.org/about-us/) in the Seattle suburb of Bellevue, Wash. As much as 90% of his time is spent on information technology (IT) duties, and since he is grandfathered, he does not need to get recertified. So why did he spend seven hours scribbling notes as though he was preparing for his first boards?

Pride in his career development, plain and simple.

“Despite my heavily administrative role, I want to stay in touch with the clinical side,” says Dr. Knoepfler, a practicing hospitalist for 20 years who hadn’t attended an SHM annual meeting in more than 10 years before participating in HM12 last month at the San Diego Convention Center. “I feel like I have to for my patients’ sake. Even if I’m doing 10 percent or 15 percent [of my time in clinical], I absolutely have to be practicing quality medicine.”

SHM’s annual meeting is a hotbed of lifelong learning. A majority of attendees each year say that the continuing medical education (CME) credits are a major draw. This year’s pre-course lineup included the MOC test preparation, hands-on classes in medical procedures and ultrasound usage, and a debut class on “How to Improve Performance in CMS’s Value-Based Purchasing Program,” which was led by SHM senior vice president Joseph Miller and

Patrick Torcson, MD, MMM, FAACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee.

Dr. Torcson

Career development, of course, means different things to different people. Dr. Knoepfler might have been focused on updating his clinical knowledge, but he is a technology expert whose main duties are to integrate health IT into the daily routine of his 349-bed hospital. So whether listening in a pre-course, attending a workshop, or meeting old or new colleagues for a drink, he spent the four-day conference constantly looking for ways to improve his job performance.

“My ears are constantly listening for how can I tie this into our electronic health record,” Dr. Knoepfler adds. “Whether it’s a clinical topic, an administrative topic, an insurance topic, a governmental topic, for me, I’m going to take all those back and see how I can make our electronic record work with the practitioners rather than fight them.”

A Learning Process

Former SHM president Jeff Weise, MD, professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, feels so strongly about the value of professional development and the ABIM’s MOC process for hospital medicine that he and several society staffers held an impromptu session between plenary addresses to tackle perceived confusion with the Focused Practice in Hospital Medicine (FPHM) MOC pathway.

Dr. Weise

Dr. Weise says that the FPHM pathway does not mean doctors give up board certification in internal medicine, nor does it apply only to academic or community physicians.

Dr. Torcson, who works at St. Tammany Parish Hospital in Covington, La., says that the certification should be viewed as a “meaningful affirmation” of HM’s solidified place in the healthcare system.

“It’s really the right thing to do for our developing specialty,” he says. “We really have to distinguish ourselves, and there’s really no better brand distinction than a professional designation based on board certification and maintenance of certification.”

Ethan Cumbler, MD, FACP, of the University of Colorado Denver, led a portion of the MOC pre-course at HM12. He says that those who attend SHM’s annual meeting are able to take advantage of communal learning, which provides benefits that those who study alone can’t absorb. Taking a pre-test just teaches whether participants answered correctly or not. Questioning why the answer is what it is, with interactive feedback, is “a learning process,” he says.

“There’s a very different feel to learning in a group setting with your peers than to sitting down with a journal or a magazine or a textbook or an online module,” Dr. Cumbler says. “Part of what makes this conference engaging is not just content, it’s the milieu. It’s a social milieu of our peers, and we’re learning together and we’re exploring these difficult issues together.

“My sense is that the people who come to this are probably a cut above,” adds Dr. Cumbler, whose University of Colorado In-Hospital Stroke QI Team was the 2012 recipient of SHM’s Award for Excellence in Teamwork in Quality Improvement. “They are people who are really committed to being more evidence-based and understanding what the evidence is and how they apply that to their patients.”

Career Decisions

They are physicians like James Eppinette, MD, who became a hospitalist three years ago after 20 years in private practice as a primary-care physician (PCP). He joined a hospital-owned group at St. Francis Medical Center in Monroe, La., and HM12 was his first annual meeting—he attended because the meeting’s clinical focus provided him with professional development opportunities. He began with the pre-operative-care pre-course, an area in which he felt he wanted more exposure. From there, he bounced around clinical workshops.

“[HM12] has an incredible variety of tracks that you can pursue, so there’s something here for everybody,” Dr. Eppinette says, later adding that “my primary responsibility is clinical. That’s all I do is take care of people. I don’t manage people, I don’t run a practice, nor do I want to. That’s why I left 20 years of private practice to be a hospitalist. I just think it’s well set up structurally for an educational event.”

Dr. Eppinette, who took his notes back to the 12 hospitalists and nine pulmonologists in his hospitalist group, says that the decision to attend HM12 came from his increasing satisfaction with his late-career job change.

“I didn’t know how I would like going from an independent practitioner to being employed, hospital-owned. But I’ve done it three years,” he says, and “[I think this is] how I will finish my career. After three years, I’m kind of liking this road I’m on, so I’ve started looking into more about it.”

That level of personal accountability is a next step for hospitalists nationwide, according to new SHM president Shaun Frost, MD, SFHM, FACP, chief medical officer for the Northeast region of Brentwood, Tenn.-based Cogent HMG. Dr. Frost says that personal and professional accountability will be the drivers for HM’s continued growth and success, and that without individual physicians pushing their career development goals to new heights, the fastest-growing medical specialty in history could stall.

“We must all strive to consistently hold each other and hold ourselves personally accountable for embracing the work that is necessary to realize the potential of hospital medicine to be a true healthcare reform effector,” Dr. Frost says. “It’s time, I think, for each of us to put our money where our mouths have been.”

Informatics specialist David Knoepfler, MD, sat in the back row of a daylong HM12 pre-course that aimed to prepare hospitalists for the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) examination. The question-and-answer session was intended to help the longtime clinician pass his second certification renewal.

But it was utterly unnecessary.

Dr. Knoepfler is the chief medical information officer at Overlake Hospital Medical Center (http://www.overlakehospital.org/about-us/) in the Seattle suburb of Bellevue, Wash. As much as 90% of his time is spent on information technology (IT) duties, and since he is grandfathered, he does not need to get recertified. So why did he spend seven hours scribbling notes as though he was preparing for his first boards?

Pride in his career development, plain and simple.

“Despite my heavily administrative role, I want to stay in touch with the clinical side,” says Dr. Knoepfler, a practicing hospitalist for 20 years who hadn’t attended an SHM annual meeting in more than 10 years before participating in HM12 last month at the San Diego Convention Center. “I feel like I have to for my patients’ sake. Even if I’m doing 10 percent or 15 percent [of my time in clinical], I absolutely have to be practicing quality medicine.”

SHM’s annual meeting is a hotbed of lifelong learning. A majority of attendees each year say that the continuing medical education (CME) credits are a major draw. This year’s pre-course lineup included the MOC test preparation, hands-on classes in medical procedures and ultrasound usage, and a debut class on “How to Improve Performance in CMS’s Value-Based Purchasing Program,” which was led by SHM senior vice president Joseph Miller and

Patrick Torcson, MD, MMM, FAACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee.

Dr. Torcson

Career development, of course, means different things to different people. Dr. Knoepfler might have been focused on updating his clinical knowledge, but he is a technology expert whose main duties are to integrate health IT into the daily routine of his 349-bed hospital. So whether listening in a pre-course, attending a workshop, or meeting old or new colleagues for a drink, he spent the four-day conference constantly looking for ways to improve his job performance.

“My ears are constantly listening for how can I tie this into our electronic health record,” Dr. Knoepfler adds. “Whether it’s a clinical topic, an administrative topic, an insurance topic, a governmental topic, for me, I’m going to take all those back and see how I can make our electronic record work with the practitioners rather than fight them.”

A Learning Process

Former SHM president Jeff Weise, MD, professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, feels so strongly about the value of professional development and the ABIM’s MOC process for hospital medicine that he and several society staffers held an impromptu session between plenary addresses to tackle perceived confusion with the Focused Practice in Hospital Medicine (FPHM) MOC pathway.

Dr. Weise

Dr. Weise says that the FPHM pathway does not mean doctors give up board certification in internal medicine, nor does it apply only to academic or community physicians.

Dr. Torcson, who works at St. Tammany Parish Hospital in Covington, La., says that the certification should be viewed as a “meaningful affirmation” of HM’s solidified place in the healthcare system.

“It’s really the right thing to do for our developing specialty,” he says. “We really have to distinguish ourselves, and there’s really no better brand distinction than a professional designation based on board certification and maintenance of certification.”

Ethan Cumbler, MD, FACP, of the University of Colorado Denver, led a portion of the MOC pre-course at HM12. He says that those who attend SHM’s annual meeting are able to take advantage of communal learning, which provides benefits that those who study alone can’t absorb. Taking a pre-test just teaches whether participants answered correctly or not. Questioning why the answer is what it is, with interactive feedback, is “a learning process,” he says.

“There’s a very different feel to learning in a group setting with your peers than to sitting down with a journal or a magazine or a textbook or an online module,” Dr. Cumbler says. “Part of what makes this conference engaging is not just content, it’s the milieu. It’s a social milieu of our peers, and we’re learning together and we’re exploring these difficult issues together.

“My sense is that the people who come to this are probably a cut above,” adds Dr. Cumbler, whose University of Colorado In-Hospital Stroke QI Team was the 2012 recipient of SHM’s Award for Excellence in Teamwork in Quality Improvement. “They are people who are really committed to being more evidence-based and understanding what the evidence is and how they apply that to their patients.”

Career Decisions

They are physicians like James Eppinette, MD, who became a hospitalist three years ago after 20 years in private practice as a primary-care physician (PCP). He joined a hospital-owned group at St. Francis Medical Center in Monroe, La., and HM12 was his first annual meeting—he attended because the meeting’s clinical focus provided him with professional development opportunities. He began with the pre-operative-care pre-course, an area in which he felt he wanted more exposure. From there, he bounced around clinical workshops.

“[HM12] has an incredible variety of tracks that you can pursue, so there’s something here for everybody,” Dr. Eppinette says, later adding that “my primary responsibility is clinical. That’s all I do is take care of people. I don’t manage people, I don’t run a practice, nor do I want to. That’s why I left 20 years of private practice to be a hospitalist. I just think it’s well set up structurally for an educational event.”

Dr. Eppinette, who took his notes back to the 12 hospitalists and nine pulmonologists in his hospitalist group, says that the decision to attend HM12 came from his increasing satisfaction with his late-career job change.

“I didn’t know how I would like going from an independent practitioner to being employed, hospital-owned. But I’ve done it three years,” he says, and “[I think this is] how I will finish my career. After three years, I’m kind of liking this road I’m on, so I’ve started looking into more about it.”

That level of personal accountability is a next step for hospitalists nationwide, according to new SHM president Shaun Frost, MD, SFHM, FACP, chief medical officer for the Northeast region of Brentwood, Tenn.-based Cogent HMG. Dr. Frost says that personal and professional accountability will be the drivers for HM’s continued growth and success, and that without individual physicians pushing their career development goals to new heights, the fastest-growing medical specialty in history could stall.

“We must all strive to consistently hold each other and hold ourselves personally accountable for embracing the work that is necessary to realize the potential of hospital medicine to be a true healthcare reform effector,” Dr. Frost says. “It’s time, I think, for each of us to put our money where our mouths have been.”

In a Venn diagram, patient handoffs would fall at the intersection of quality improvement (QI), patient safety, and technology.

Vineet Arora, MD, MPP, FACP, FHM, associate professor of medicine at the University of Chicago, wants hospitalists to understand that best practices in transitional care only work efficiently if they incorporate pieces from all three spheres. Hospitalists who focus too much on the outcome of an individual case might fail to utilize technology that could create a systemic protocol that would improve outcomes across multiple cases, she says. Similarly, hospitalists who leave notes in an electronic health record (EHR) can mistakenly believe that the next physician will interpret that information perfectly despite a lack of verbal and physical cues that guide verbal communication.

Dr. Arora

“People may fall into the fallacy that electronic health records actually equal good handoffs,” says Dr. Arora, a faculty member at HM12 last month in San Diego who led a breakout session that focused on the obstacles of handoffs. “The challenge is that handoffs actually are about a verbal exchange of informationa conversation and a dialogue, in conjunction with and supplemented with written communication. Technology certainly has the ability to revolutionize the way we review information and access information, but it will not change the way we speak about the information.”

The crossroads of patient safety, QI, and the use of technology from medical devices to iPhones was a major theme at SHM’s annual meeting, April 1-4 at the San Diego Convention Center. Hospitalist leaders agree that clinicians must focus on all three tenets to improve healthcare delivery, particularly in the face of generational healthcare reform. But they also acknowledge that finding a balance between best practices, budget and staffing constraints, and the rigors of daily practice is difficult.

Hospitalist Mark Lyons, MD, who works on residency programs and a patient-handoff initiative at Methodist Health System of Dallas, says that sessions on QI and patient safety provide new ideas from industry leaders who are in the trenches. To wit, he was impressed by the suggestions from Dr. Arora’s handoffs session as she described cases in which she was involved.

“They understand the limitations and the other things that go along with doing the actual act itself,” Dr. Lyons says. “They understand those things and take them into consideration. And you appreciate that.”

He and other hospitalists at HM12 agree that when leading practices are promoted at national forums, they take on the imprimatur of evidence-based procedures that physicians want to bring back to their respective HM groups. And QI suggestions promoted by physicians, not management, often tend to be more readily accepted.

“When you force change upon people, then it really leads to resistance,” Dr. Lyons says. “These are good opportunities to learn different strategies, to learn easier ways to present new ideas to people, to encourage them to do better, and to make it easier for them to do those things.”

Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston, says technology can range from global EHRs across a multiple-institutional health system to microblogs to practice-centered wikis that promote communication between physicians. But integrating those technologies into care delivery that improves outcomes hinges not on technical hurdles, but on physicians accepting their validity and utility, he says. Once clinicians start digitally codifying the informal communication tools they currently use, patient-specific communication can improve.

And while Dr. Dalal, who co-led a session on the use of wikis as a communication-management strategy, adds that despite the little research linking those technological tacks to patient outcomes, he believes they are related.

“We’re using our devices, our iPads, our iPhones, our Android devices, to send information to other providers, but that information may not be transparent to other people,” says Dr. Dalal, who heads an SHM technology subcommittee. “But if you have it on a blog, a patient-specific Facebook, or a patient-specific Twitter, than everyone who subscribes to that will have access to the whole discussion.”

Dr. Dalal cautions that the details of legal compliance are important to ensure private patient information is safely transmitted. He anticipates vendors will market products that will balance the need for that privacy with a wider dissemination of information to ensure all involved physicians know what they need to know. One example: He expects the internal-messaging components of EHRs to improve in the next few years.

“It wouldn’t surprise me if these companies start realizing we need to support patient-specific communication in informal dialogues using microblogs and mobile devices,” he adds. “If they don’t do that, they’re probably going to miss the boat.”

The power of technology, large and small, must be balanced with what hospitalist pioneer Robert Wachter, MD, MHM, calls “foundational knowledge.” Dr. Wachter, who counts chair-elect of the American Board of Internal Medicine (ABIM) among his myriad titles, says that hospitalists can’t be slaves to technology. He relates it to a well-known adage in the aviation industry in which planes have become so advanced that some pilots would be incapable of flying them should the technology fail. In one quip, it is said that two people will soon populate cockpits: a pilot and a dog. The pilot’s job is to feed the dog, while the dog’s job is to bite the pilot’s hand if he tries to touch the controls.

Dr. Wachter

“As we move quickly, briskly, appropriately into this new world of computerization, if we aren’t constantly asking ourselves what have we lost in terms of our relationship with patients, we will really screw things up,” Dr. Wachter says. “This is not an argument to be Luddites, it’s not an argument to send back your meaningful use and get rid of the computers. We need them, but we have to be very thoughtful about how we maintain this balance.”

Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), says that to tie quality, safety, and technology together, government has to be willing to back therapies, then determine whether their efficacy deserves financial coverage.

One example Dr. Conway cites is the use of intravascular shunts. After backing their use initially for Medicare patients, it was determined that compared with medical management, the therapy had greater risks for death and stroke—and cost about 100 times more. Still, Dr. Conway says, determining how well the shunt works is exactly the process medicine should go through.

“When we have these new technologies that made a promise, we want to get them to market where they might help patients, but we also want to make sure evidence is developed to make sure they truly benefit patients,” he says, later adding, “I think this catalyst for health system transformation is important, and it’s teaching vision coupled with that execution.”

A well-planned blending of quality and technology can lead to improved patient safety, Dr. Arora says. But physicians and HM group leaders have to be proactive. Those with a clinical focus must seek out their IT counterparts and provide guidance on what information users need to access from electronic interfaces. Chief medical information officers and their staffs must seek feedback from providers before creating templates that don’t serve the clinical functions of end users.

Put simply: The fight to improve outcomes requires all parties to be properly armed. “You can choose a weapon,” she adds, “but you still have to choose it wisely and customize it to fit the needs of your organization.”

In a Venn diagram, patient handoffs would fall at the intersection of quality improvement (QI), patient safety, and technology.

Vineet Arora, MD, MPP, FACP, FHM, associate professor of medicine at the University of Chicago, wants hospitalists to understand that best practices in transitional care only work efficiently if they incorporate pieces from all three spheres. Hospitalists who focus too much on the outcome of an individual case might fail to utilize technology that could create a systemic protocol that would improve outcomes across multiple cases, she says. Similarly, hospitalists who leave notes in an electronic health record (EHR) can mistakenly believe that the next physician will interpret that information perfectly despite a lack of verbal and physical cues that guide verbal communication.

Dr. Arora

“People may fall into the fallacy that electronic health records actually equal good handoffs,” says Dr. Arora, a faculty member at HM12 last month in San Diego who led a breakout session that focused on the obstacles of handoffs. “The challenge is that handoffs actually are about a verbal exchange of informationa conversation and a dialogue, in conjunction with and supplemented with written communication. Technology certainly has the ability to revolutionize the way we review information and access information, but it will not change the way we speak about the information.”

The crossroads of patient safety, QI, and the use of technology from medical devices to iPhones was a major theme at SHM’s annual meeting, April 1-4 at the San Diego Convention Center. Hospitalist leaders agree that clinicians must focus on all three tenets to improve healthcare delivery, particularly in the face of generational healthcare reform. But they also acknowledge that finding a balance between best practices, budget and staffing constraints, and the rigors of daily practice is difficult.

Hospitalist Mark Lyons, MD, who works on residency programs and a patient-handoff initiative at Methodist Health System of Dallas, says that sessions on QI and patient safety provide new ideas from industry leaders who are in the trenches. To wit, he was impressed by the suggestions from Dr. Arora’s handoffs session as she described cases in which she was involved.

“They understand the limitations and the other things that go along with doing the actual act itself,” Dr. Lyons says. “They understand those things and take them into consideration. And you appreciate that.”

He and other hospitalists at HM12 agree that when leading practices are promoted at national forums, they take on the imprimatur of evidence-based procedures that physicians want to bring back to their respective HM groups. And QI suggestions promoted by physicians, not management, often tend to be more readily accepted.

“When you force change upon people, then it really leads to resistance,” Dr. Lyons says. “These are good opportunities to learn different strategies, to learn easier ways to present new ideas to people, to encourage them to do better, and to make it easier for them to do those things.”

Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston, says technology can range from global EHRs across a multiple-institutional health system to microblogs to practice-centered wikis that promote communication between physicians. But integrating those technologies into care delivery that improves outcomes hinges not on technical hurdles, but on physicians accepting their validity and utility, he says. Once clinicians start digitally codifying the informal communication tools they currently use, patient-specific communication can improve.

And while Dr. Dalal, who co-led a session on the use of wikis as a communication-management strategy, adds that despite the little research linking those technological tacks to patient outcomes, he believes they are related.

“We’re using our devices, our iPads, our iPhones, our Android devices, to send information to other providers, but that information may not be transparent to other people,” says Dr. Dalal, who heads an SHM technology subcommittee. “But if you have it on a blog, a patient-specific Facebook, or a patient-specific Twitter, than everyone who subscribes to that will have access to the whole discussion.”

Dr. Dalal cautions that the details of legal compliance are important to ensure private patient information is safely transmitted. He anticipates vendors will market products that will balance the need for that privacy with a wider dissemination of information to ensure all involved physicians know what they need to know. One example: He expects the internal-messaging components of EHRs to improve in the next few years.

“It wouldn’t surprise me if these companies start realizing we need to support patient-specific communication in informal dialogues using microblogs and mobile devices,” he adds. “If they don’t do that, they’re probably going to miss the boat.”

The power of technology, large and small, must be balanced with what hospitalist pioneer Robert Wachter, MD, MHM, calls “foundational knowledge.” Dr. Wachter, who counts chair-elect of the American Board of Internal Medicine (ABIM) among his myriad titles, says that hospitalists can’t be slaves to technology. He relates it to a well-known adage in the aviation industry in which planes have become so advanced that some pilots would be incapable of flying them should the technology fail. In one quip, it is said that two people will soon populate cockpits: a pilot and a dog. The pilot’s job is to feed the dog, while the dog’s job is to bite the pilot’s hand if he tries to touch the controls.

Dr. Wachter

“As we move quickly, briskly, appropriately into this new world of computerization, if we aren’t constantly asking ourselves what have we lost in terms of our relationship with patients, we will really screw things up,” Dr. Wachter says. “This is not an argument to be Luddites, it’s not an argument to send back your meaningful use and get rid of the computers. We need them, but we have to be very thoughtful about how we maintain this balance.”

Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), says that to tie quality, safety, and technology together, government has to be willing to back therapies, then determine whether their efficacy deserves financial coverage.

One example Dr. Conway cites is the use of intravascular shunts. After backing their use initially for Medicare patients, it was determined that compared with medical management, the therapy had greater risks for death and stroke—and cost about 100 times more. Still, Dr. Conway says, determining how well the shunt works is exactly the process medicine should go through.

“When we have these new technologies that made a promise, we want to get them to market where they might help patients, but we also want to make sure evidence is developed to make sure they truly benefit patients,” he says, later adding, “I think this catalyst for health system transformation is important, and it’s teaching vision coupled with that execution.”

A well-planned blending of quality and technology can lead to improved patient safety, Dr. Arora says. But physicians and HM group leaders have to be proactive. Those with a clinical focus must seek out their IT counterparts and provide guidance on what information users need to access from electronic interfaces. Chief medical information officers and their staffs must seek feedback from providers before creating templates that don’t serve the clinical functions of end users.

Put simply: The fight to improve outcomes requires all parties to be properly armed. “You can choose a weapon,” she adds, “but you still have to choose it wisely and customize it to fit the needs of your organization.”

In a Venn diagram, patient handoffs would fall at the intersection of quality improvement (QI), patient safety, and technology.

Vineet Arora, MD, MPP, FACP, FHM, associate professor of medicine at the University of Chicago, wants hospitalists to understand that best practices in transitional care only work efficiently if they incorporate pieces from all three spheres. Hospitalists who focus too much on the outcome of an individual case might fail to utilize technology that could create a systemic protocol that would improve outcomes across multiple cases, she says. Similarly, hospitalists who leave notes in an electronic health record (EHR) can mistakenly believe that the next physician will interpret that information perfectly despite a lack of verbal and physical cues that guide verbal communication.

Dr. Arora

“People may fall into the fallacy that electronic health records actually equal good handoffs,” says Dr. Arora, a faculty member at HM12 last month in San Diego who led a breakout session that focused on the obstacles of handoffs. “The challenge is that handoffs actually are about a verbal exchange of informationa conversation and a dialogue, in conjunction with and supplemented with written communication. Technology certainly has the ability to revolutionize the way we review information and access information, but it will not change the way we speak about the information.”

The crossroads of patient safety, QI, and the use of technology from medical devices to iPhones was a major theme at SHM’s annual meeting, April 1-4 at the San Diego Convention Center. Hospitalist leaders agree that clinicians must focus on all three tenets to improve healthcare delivery, particularly in the face of generational healthcare reform. But they also acknowledge that finding a balance between best practices, budget and staffing constraints, and the rigors of daily practice is difficult.

Hospitalist Mark Lyons, MD, who works on residency programs and a patient-handoff initiative at Methodist Health System of Dallas, says that sessions on QI and patient safety provide new ideas from industry leaders who are in the trenches. To wit, he was impressed by the suggestions from Dr. Arora’s handoffs session as she described cases in which she was involved.

“They understand the limitations and the other things that go along with doing the actual act itself,” Dr. Lyons says. “They understand those things and take them into consideration. And you appreciate that.”

He and other hospitalists at HM12 agree that when leading practices are promoted at national forums, they take on the imprimatur of evidence-based procedures that physicians want to bring back to their respective HM groups. And QI suggestions promoted by physicians, not management, often tend to be more readily accepted.

“When you force change upon people, then it really leads to resistance,” Dr. Lyons says. “These are good opportunities to learn different strategies, to learn easier ways to present new ideas to people, to encourage them to do better, and to make it easier for them to do those things.”

Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston, says technology can range from global EHRs across a multiple-institutional health system to microblogs to practice-centered wikis that promote communication between physicians. But integrating those technologies into care delivery that improves outcomes hinges not on technical hurdles, but on physicians accepting their validity and utility, he says. Once clinicians start digitally codifying the informal communication tools they currently use, patient-specific communication can improve.

And while Dr. Dalal, who co-led a session on the use of wikis as a communication-management strategy, adds that despite the little research linking those technological tacks to patient outcomes, he believes they are related.

“We’re using our devices, our iPads, our iPhones, our Android devices, to send information to other providers, but that information may not be transparent to other people,” says Dr. Dalal, who heads an SHM technology subcommittee. “But if you have it on a blog, a patient-specific Facebook, or a patient-specific Twitter, than everyone who subscribes to that will have access to the whole discussion.”

Dr. Dalal cautions that the details of legal compliance are important to ensure private patient information is safely transmitted. He anticipates vendors will market products that will balance the need for that privacy with a wider dissemination of information to ensure all involved physicians know what they need to know. One example: He expects the internal-messaging components of EHRs to improve in the next few years.

“It wouldn’t surprise me if these companies start realizing we need to support patient-specific communication in informal dialogues using microblogs and mobile devices,” he adds. “If they don’t do that, they’re probably going to miss the boat.”

The power of technology, large and small, must be balanced with what hospitalist pioneer Robert Wachter, MD, MHM, calls “foundational knowledge.” Dr. Wachter, who counts chair-elect of the American Board of Internal Medicine (ABIM) among his myriad titles, says that hospitalists can’t be slaves to technology. He relates it to a well-known adage in the aviation industry in which planes have become so advanced that some pilots would be incapable of flying them should the technology fail. In one quip, it is said that two people will soon populate cockpits: a pilot and a dog. The pilot’s job is to feed the dog, while the dog’s job is to bite the pilot’s hand if he tries to touch the controls.

Dr. Wachter

“As we move quickly, briskly, appropriately into this new world of computerization, if we aren’t constantly asking ourselves what have we lost in terms of our relationship with patients, we will really screw things up,” Dr. Wachter says. “This is not an argument to be Luddites, it’s not an argument to send back your meaningful use and get rid of the computers. We need them, but we have to be very thoughtful about how we maintain this balance.”

Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), says that to tie quality, safety, and technology together, government has to be willing to back therapies, then determine whether their efficacy deserves financial coverage.

One example Dr. Conway cites is the use of intravascular shunts. After backing their use initially for Medicare patients, it was determined that compared with medical management, the therapy had greater risks for death and stroke—and cost about 100 times more. Still, Dr. Conway says, determining how well the shunt works is exactly the process medicine should go through.

“When we have these new technologies that made a promise, we want to get them to market where they might help patients, but we also want to make sure evidence is developed to make sure they truly benefit patients,” he says, later adding, “I think this catalyst for health system transformation is important, and it’s teaching vision coupled with that execution.”

A well-planned blending of quality and technology can lead to improved patient safety, Dr. Arora says. But physicians and HM group leaders have to be proactive. Those with a clinical focus must seek out their IT counterparts and provide guidance on what information users need to access from electronic interfaces. Chief medical information officers and their staffs must seek feedback from providers before creating templates that don’t serve the clinical functions of end users.

Put simply: The fight to improve outcomes requires all parties to be properly armed. “You can choose a weapon,” she adds, “but you still have to choose it wisely and customize it to fit the needs of your organization.”

Jin Park, MD, is worried. She worries about the health of her patients, her hospital, and her HM group. She frets that the U.S. healthcare system will be too slow to implement must-needed change—the kind of national transformation that will improve care, contain costs, and eliminate political jousting.

“I’m a doctor with more than a decade of experience; I don’t have a personal concern. I have a community concern, a societal concern,” says Dr. Park, one of 17 hospitalists at Adventist Health in Portland, Ore. “I think adversity is good, and given the magnetism of the change, I feel like only the monsters are going to be able to survive. But you can’t just have the Kaiser [Permanentes] and the Monarch [Healthcares] and all these other examples take over the entire country. I mean, that’s not going to happen, right?”

Dr. Park wasn’t the only anxious hospitalist at HM12, held last month at the San Diego Convention Center. She and more than 150 others listened to SHM Public Policy Committee Chair Ron Greeno, MD, MHM, explain in detail the Accountable Care Organization (ACO) program being ramped up by the Centers for Medicare & Medicaid Services (CMS). Dr. Greeno, chief medical officer for Brentwood, Tenn.-based Cogent HMG, outlined how ACOs are designed to change the healthcare payment paradigm.

“They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers,” Dr. Greeno said. “Right now, we’re profit centers. We do something, we get paid; we don’t do it, we don’t get paid. You see a patient, you get paid for that; your hospital admits a patient, you get paid for that. They’re a profit center. Under a [capitation] methodology, everything’s flipped on its head. If we admit a patient, we have to pay for that. We use those dollars; we’re now a cost center.”

For hospitalists, he added, that means making themselves more valuable by providing cost-effective care that translates into a healthier population.

On the Horizon: Systematic Change

While payment reform was a central theme of the annual meeting, another main takeaway was the shift of Medicare from a payor for quantity (fee-for-service) to a payor for quality (value-based purchasing).

It’s “systematically linking quality to payment,” said Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist, chief medical officer of CMS, and director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C. “We are transitioning to a more value-based purchaser, an active purchaser, and a catalyst for health system change. Our aims: better care for individuals, better health for populations, and lower cost for improvement.”

One in 3 Americans uses Medicare or Medicaid, the nation’s largest provider of healthcare coverage. And that number could rise when health exchanges launch in 2014 as part of the Affordable Care Act (ACA), Dr. Conway said. Combined, the two agencies spend about $800 billion annually. Medicare alone spends more than $1.5 billion per day.

Dr. Conway acknowledged the difficulty in changing the system, especially at the “ground level.” In addition to outlining key CMS’ initiatives, he indicated one of the main goals of his position is to “learn how to scale and spread successful interventions.”

They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers.

—Ron Greeno, MD, MHM

“Quality can be measured and improved at multiple levels,” he told more than 2,000 hospitalists at the opening keynote address. “We’ve got the individual physician level, the group level, and then the community level. So we’re thinking about these three levels of measurement and how we align across those three levels.”

Dr. Conway, who volunteers for pediatric HM shifts on weekends, said CMS is especially excited about the Center for Medicare and Medicaid Innovation, an ACA creation that is gaining momentum with its Petri-dish-like efforts to improve quality and contain costs.

“We haven’t scaled any of these yet. We’re in testing mode,” Dr. Conway said. “I think the important point is that we have to figure out pre-testing mode, agree on evaluation models, without actuaries, that if these things work, we’re actually able to scale them to the program. This has so much robust support and applications, one could argue that we’re going to have so much interest that, one, it will be difficult to evaluate, but also, depending on how much interest you have, it could almost be at scale out of the gate.”

The Perfect Storm

National elections, Supreme Court activism, and public outrage at an “utterly dysfunctional” Congress: That’s how Norm Ornstein, PhD, MA, resident scholar at the American Enterprise Institute for Public Policy Research and a policy analyst for CBS News, views the day-to-day workings inside the Beltway.

Ornstein explained that “tribalism” is worse now than during any of his 40-plus years in Washington. He doesn’t see it getting any better, either, and wouldn’t be surprised if another wave of voter dissent tips the scales of power this November.

“We are a fairly evenly divided country,” Ornstein said, using a football analogy to describe the major political parties. “The basic reality is the Democratic Party has gravitated over to its own 20- or 25-yard line from its normal place, which was around its 40-yard line. The Republican Party, however, has moved behind its goalpost right now.”

Ornstein said he doesn’t think the U.S. Supreme Court will declare the ACA unconstitutional. Even though he’s skeptical of the conservative-leaning court’s motives, he said, “overturning even the individual mandate doesn’t make a lot of sense.”

Even so, he told hospitalists that the ever-increasing cost of healthcare, combined with America’s aging population, translates into a hostile political climate.

“All of that makes your challenge that much greater,” he said.

No matter what happens in the 2012 elections, Ornstein explained that at the end of December, a political “perfect storm” is brewing.

“Barack Obama will still be the president until Jan. 20, 2013. All of the Bush tax cuts expire the last day of December. The agreement that extended the payroll tax cut, unemployment insurance, and the doc-pay fix also expire at the end of December,” he explained. “Jan. 1, 2013, the Draconian sequesters—mindless, across-the-board cuts in defense and discretionary spending, not sparing any programs, designed to try and force them to the table to reach a broader budget deal but they couldn’t reach—all begin. And that’s $50 billion taken from what is already a pretty tight discretionary domestic budget.

“So fasten your seat belts for what’s going to be an extremely bumpy ride over the next several months, and a very murky picture for what will follow.”

Don’t Give Up

Many hospitalists think advocacy is beyond their pay grade, assuming their voice or idea will get lost in the bureaucracy that is the nation’s capital. Dr. Conway exhorted hospitalists to stay in the fight, partner with hospital administration, and champion quality initiatives.

“We’re all in this together,” he said. “You can understand your hospital’s performance statement, share data within and outside your hospital, be actively engaged in your hospital value-based purchasing programs and inpatient quality reporting. Physician leadership and professionalism, I think, is incredibly important.”

Jin Park, MD, is worried. She worries about the health of her patients, her hospital, and her HM group. She frets that the U.S. healthcare system will be too slow to implement must-needed change—the kind of national transformation that will improve care, contain costs, and eliminate political jousting.

“I’m a doctor with more than a decade of experience; I don’t have a personal concern. I have a community concern, a societal concern,” says Dr. Park, one of 17 hospitalists at Adventist Health in Portland, Ore. “I think adversity is good, and given the magnetism of the change, I feel like only the monsters are going to be able to survive. But you can’t just have the Kaiser [Permanentes] and the Monarch [Healthcares] and all these other examples take over the entire country. I mean, that’s not going to happen, right?”

Dr. Park wasn’t the only anxious hospitalist at HM12, held last month at the San Diego Convention Center. She and more than 150 others listened to SHM Public Policy Committee Chair Ron Greeno, MD, MHM, explain in detail the Accountable Care Organization (ACO) program being ramped up by the Centers for Medicare & Medicaid Services (CMS). Dr. Greeno, chief medical officer for Brentwood, Tenn.-based Cogent HMG, outlined how ACOs are designed to change the healthcare payment paradigm.

“They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers,” Dr. Greeno said. “Right now, we’re profit centers. We do something, we get paid; we don’t do it, we don’t get paid. You see a patient, you get paid for that; your hospital admits a patient, you get paid for that. They’re a profit center. Under a [capitation] methodology, everything’s flipped on its head. If we admit a patient, we have to pay for that. We use those dollars; we’re now a cost center.”

For hospitalists, he added, that means making themselves more valuable by providing cost-effective care that translates into a healthier population.

On the Horizon: Systematic Change

While payment reform was a central theme of the annual meeting, another main takeaway was the shift of Medicare from a payor for quantity (fee-for-service) to a payor for quality (value-based purchasing).

It’s “systematically linking quality to payment,” said Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist, chief medical officer of CMS, and director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C. “We are transitioning to a more value-based purchaser, an active purchaser, and a catalyst for health system change. Our aims: better care for individuals, better health for populations, and lower cost for improvement.”

One in 3 Americans uses Medicare or Medicaid, the nation’s largest provider of healthcare coverage. And that number could rise when health exchanges launch in 2014 as part of the Affordable Care Act (ACA), Dr. Conway said. Combined, the two agencies spend about $800 billion annually. Medicare alone spends more than $1.5 billion per day.

Dr. Conway acknowledged the difficulty in changing the system, especially at the “ground level.” In addition to outlining key CMS’ initiatives, he indicated one of the main goals of his position is to “learn how to scale and spread successful interventions.”

They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers.

—Ron Greeno, MD, MHM

“Quality can be measured and improved at multiple levels,” he told more than 2,000 hospitalists at the opening keynote address. “We’ve got the individual physician level, the group level, and then the community level. So we’re thinking about these three levels of measurement and how we align across those three levels.”

Dr. Conway, who volunteers for pediatric HM shifts on weekends, said CMS is especially excited about the Center for Medicare and Medicaid Innovation, an ACA creation that is gaining momentum with its Petri-dish-like efforts to improve quality and contain costs.

“We haven’t scaled any of these yet. We’re in testing mode,” Dr. Conway said. “I think the important point is that we have to figure out pre-testing mode, agree on evaluation models, without actuaries, that if these things work, we’re actually able to scale them to the program. This has so much robust support and applications, one could argue that we’re going to have so much interest that, one, it will be difficult to evaluate, but also, depending on how much interest you have, it could almost be at scale out of the gate.”

The Perfect Storm

National elections, Supreme Court activism, and public outrage at an “utterly dysfunctional” Congress: That’s how Norm Ornstein, PhD, MA, resident scholar at the American Enterprise Institute for Public Policy Research and a policy analyst for CBS News, views the day-to-day workings inside the Beltway.

Ornstein explained that “tribalism” is worse now than during any of his 40-plus years in Washington. He doesn’t see it getting any better, either, and wouldn’t be surprised if another wave of voter dissent tips the scales of power this November.

“We are a fairly evenly divided country,” Ornstein said, using a football analogy to describe the major political parties. “The basic reality is the Democratic Party has gravitated over to its own 20- or 25-yard line from its normal place, which was around its 40-yard line. The Republican Party, however, has moved behind its goalpost right now.”

Ornstein said he doesn’t think the U.S. Supreme Court will declare the ACA unconstitutional. Even though he’s skeptical of the conservative-leaning court’s motives, he said, “overturning even the individual mandate doesn’t make a lot of sense.”

Even so, he told hospitalists that the ever-increasing cost of healthcare, combined with America’s aging population, translates into a hostile political climate.

“All of that makes your challenge that much greater,” he said.

No matter what happens in the 2012 elections, Ornstein explained that at the end of December, a political “perfect storm” is brewing.

“Barack Obama will still be the president until Jan. 20, 2013. All of the Bush tax cuts expire the last day of December. The agreement that extended the payroll tax cut, unemployment insurance, and the doc-pay fix also expire at the end of December,” he explained. “Jan. 1, 2013, the Draconian sequesters—mindless, across-the-board cuts in defense and discretionary spending, not sparing any programs, designed to try and force them to the table to reach a broader budget deal but they couldn’t reach—all begin. And that’s $50 billion taken from what is already a pretty tight discretionary domestic budget.

“So fasten your seat belts for what’s going to be an extremely bumpy ride over the next several months, and a very murky picture for what will follow.”

Don’t Give Up

Many hospitalists think advocacy is beyond their pay grade, assuming their voice or idea will get lost in the bureaucracy that is the nation’s capital. Dr. Conway exhorted hospitalists to stay in the fight, partner with hospital administration, and champion quality initiatives.

“We’re all in this together,” he said. “You can understand your hospital’s performance statement, share data within and outside your hospital, be actively engaged in your hospital value-based purchasing programs and inpatient quality reporting. Physician leadership and professionalism, I think, is incredibly important.”

Jin Park, MD, is worried. She worries about the health of her patients, her hospital, and her HM group. She frets that the U.S. healthcare system will be too slow to implement must-needed change—the kind of national transformation that will improve care, contain costs, and eliminate political jousting.

“I’m a doctor with more than a decade of experience; I don’t have a personal concern. I have a community concern, a societal concern,” says Dr. Park, one of 17 hospitalists at Adventist Health in Portland, Ore. “I think adversity is good, and given the magnetism of the change, I feel like only the monsters are going to be able to survive. But you can’t just have the Kaiser [Permanentes] and the Monarch [Healthcares] and all these other examples take over the entire country. I mean, that’s not going to happen, right?”

Dr. Park wasn’t the only anxious hospitalist at HM12, held last month at the San Diego Convention Center. She and more than 150 others listened to SHM Public Policy Committee Chair Ron Greeno, MD, MHM, explain in detail the Accountable Care Organization (ACO) program being ramped up by the Centers for Medicare & Medicaid Services (CMS). Dr. Greeno, chief medical officer for Brentwood, Tenn.-based Cogent HMG, outlined how ACOs are designed to change the healthcare payment paradigm.

“They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers,” Dr. Greeno said. “Right now, we’re profit centers. We do something, we get paid; we don’t do it, we don’t get paid. You see a patient, you get paid for that; your hospital admits a patient, you get paid for that. They’re a profit center. Under a [capitation] methodology, everything’s flipped on its head. If we admit a patient, we have to pay for that. We use those dollars; we’re now a cost center.”

For hospitalists, he added, that means making themselves more valuable by providing cost-effective care that translates into a healthier population.

On the Horizon: Systematic Change

While payment reform was a central theme of the annual meeting, another main takeaway was the shift of Medicare from a payor for quantity (fee-for-service) to a payor for quality (value-based purchasing).

It’s “systematically linking quality to payment,” said Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist, chief medical officer of CMS, and director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C. “We are transitioning to a more value-based purchaser, an active purchaser, and a catalyst for health system change. Our aims: better care for individuals, better health for populations, and lower cost for improvement.”

One in 3 Americans uses Medicare or Medicaid, the nation’s largest provider of healthcare coverage. And that number could rise when health exchanges launch in 2014 as part of the Affordable Care Act (ACA), Dr. Conway said. Combined, the two agencies spend about $800 billion annually. Medicare alone spends more than $1.5 billion per day.

Dr. Conway acknowledged the difficulty in changing the system, especially at the “ground level.” In addition to outlining key CMS’ initiatives, he indicated one of the main goals of his position is to “learn how to scale and spread successful interventions.”

They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers.

—Ron Greeno, MD, MHM

“Quality can be measured and improved at multiple levels,” he told more than 2,000 hospitalists at the opening keynote address. “We’ve got the individual physician level, the group level, and then the community level. So we’re thinking about these three levels of measurement and how we align across those three levels.”

Dr. Conway, who volunteers for pediatric HM shifts on weekends, said CMS is especially excited about the Center for Medicare and Medicaid Innovation, an ACA creation that is gaining momentum with its Petri-dish-like efforts to improve quality and contain costs.

“We haven’t scaled any of these yet. We’re in testing mode,” Dr. Conway said. “I think the important point is that we have to figure out pre-testing mode, agree on evaluation models, without actuaries, that if these things work, we’re actually able to scale them to the program. This has so much robust support and applications, one could argue that we’re going to have so much interest that, one, it will be difficult to evaluate, but also, depending on how much interest you have, it could almost be at scale out of the gate.”

The Perfect Storm

National elections, Supreme Court activism, and public outrage at an “utterly dysfunctional” Congress: That’s how Norm Ornstein, PhD, MA, resident scholar at the American Enterprise Institute for Public Policy Research and a policy analyst for CBS News, views the day-to-day workings inside the Beltway.

Ornstein explained that “tribalism” is worse now than during any of his 40-plus years in Washington. He doesn’t see it getting any better, either, and wouldn’t be surprised if another wave of voter dissent tips the scales of power this November.

“We are a fairly evenly divided country,” Ornstein said, using a football analogy to describe the major political parties. “The basic reality is the Democratic Party has gravitated over to its own 20- or 25-yard line from its normal place, which was around its 40-yard line. The Republican Party, however, has moved behind its goalpost right now.”

Ornstein said he doesn’t think the U.S. Supreme Court will declare the ACA unconstitutional. Even though he’s skeptical of the conservative-leaning court’s motives, he said, “overturning even the individual mandate doesn’t make a lot of sense.”

Even so, he told hospitalists that the ever-increasing cost of healthcare, combined with America’s aging population, translates into a hostile political climate.

“All of that makes your challenge that much greater,” he said.

No matter what happens in the 2012 elections, Ornstein explained that at the end of December, a political “perfect storm” is brewing.

“Barack Obama will still be the president until Jan. 20, 2013. All of the Bush tax cuts expire the last day of December. The agreement that extended the payroll tax cut, unemployment insurance, and the doc-pay fix also expire at the end of December,” he explained. “Jan. 1, 2013, the Draconian sequesters—mindless, across-the-board cuts in defense and discretionary spending, not sparing any programs, designed to try and force them to the table to reach a broader budget deal but they couldn’t reach—all begin. And that’s $50 billion taken from what is already a pretty tight discretionary domestic budget.

“So fasten your seat belts for what’s going to be an extremely bumpy ride over the next several months, and a very murky picture for what will follow.”

Don’t Give Up

Many hospitalists think advocacy is beyond their pay grade, assuming their voice or idea will get lost in the bureaucracy that is the nation’s capital. Dr. Conway exhorted hospitalists to stay in the fight, partner with hospital administration, and champion quality initiatives.

“We’re all in this together,” he said. “You can understand your hospital’s performance statement, share data within and outside your hospital, be actively engaged in your hospital value-based purchasing programs and inpatient quality reporting. Physician leadership and professionalism, I think, is incredibly important.”

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Online calculator helps prevent post-op respiratory failure
2. New drug for long-term treatment of PE
3. Benefits of triple therapy for COPD
4. Knee-length compression stockings as good as thigh-length for PTS
5. Video monitoring improves hand hygiene
6. Asymptomatic bacteriuria often misdiagnosed as UTI
7. CT accurate for lower GI bleeding diagnosis
8. Switch from albuterol to lavalbuterol to reduce tachycardia not recommended

Preoperative Risk Calculator Can Help Predict Postoperative Respiratory Failure

Clinical question: Can preoperative factors identify patients at risk for postoperative respiratory failure (PRF)?

Background: PRF—when a patient requires mechanical ventilation >48 hours after surgery or needs unplanned intubation within 30 days of surgery—is associated with high mortality, with 30-day mortality rates of 26%.

Study design: Analysis of multicenter, prospective databases of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Setting: Analysis of NSQIP data from 2007 (training set) and 2008 (validation set).

Synopsis: PRF was seen in 3.1% of patients in the 2007 data set and 2.6% in the 2008 data set. Those with PRF had significantly higher mortality rates than those without PRF (25.62% vs. 0.98%; P<0.0001). Preoperative risk factors associated with significantly increased risk of PRF were American Society of Anesthesiologists’ class, functional status, emergent nature of procedure, type of surgery, and preoperative sepsis.

The 2007 data set was used to develop the model, and the 2008 data set was used as a validation set. The selected risk model showed similar results in both sets with a c-statistic of 0.91 in the training set and 0.90 in the validation set. This selected model was then used to develop an interactive calculator predicting PRF (available at www.surgicalriskcalculator.com/prf-risk-calculator).

Bottom line: The PRF risk calculator can identify patients at high risk for PRF, which can aid in tailoring preventive strategies for patients prior to surgery.

Citation: Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140:1207-1215.

New Drug for Treatment of Acute Symptomatic Pulmonary Embolism

Clinical question: Is the incidence of recurrent venous thromboembolism (VTE) or bleeding with use of idrabiotaparinux comparable to warfarin for treatment of acute symptomatic pulmonary embolism (PE)?

Background: Warfarin is an effective treatment for PE; however, maintenance of effective and safe levels of anticoagulation is difficult to achieve. A straightforward treatment option would be an attractive alternative. Idrabiotaparinux, a factor Xa inhibitor bound with a biotin moiety, is a weekly subcutaneous injection proposed as an alternative to warfarin for treatment of PE.

Study design: Industry-sponsored double-blind, randomized controlled trial.

Setting: 291 centers in 37 countries.

Synopsis: A group of 3,202 patients aged 18 to 96 years were randomly assigned to receive enoxaparin, followed by idrabiotaparinux or enoxaparin, then overlapped and followed by warfarin for three or six months. The incidence of recurrent VTE (including fatal and nonfatal PE or deep vein thrombosis) did not differ between the two treatment arms.

Of the 1,599 patients treated with idrabiotaparinux, 48 (3%) had a recurrence; of the 1,603 treated with warfarin, 97 (6%) had a recurrence (odds ratio, 0.49). The rate of clinically relevant bleeding was also similar, with 72 (5%) in the idrabiotaparinux group versus 106 (7%) in the warfarin group. Much like warfarin, idrabiotaparinux requires bridging therapy with initial low-molecular-weight heparin.

Bottom line: Use of enoxaparin followed by weekly subcutaneous injection of idrabiotaparinux was as effective as enoxaparin followed by warfarin for preventing recurrent VTE, and may provide a suitable option for treatment of acute symptomatic PE.

Citation: Buller HR, Gallus AS, Pillion G, Prins MH, Raskob GE. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet. 2012;379:123-129.

Triple Therapy Better than Double for COPD

Clinical question: Does addition of tiotropium to inhaled corticosteroids and long-acting beta-agonists (LABA) have an additive benefit in reducing mortality, hospital admissions, and exacerbations in COPD?

Background: Triple therapy in COPD involves adding LABA and long-acting antimuscarinics (LAMA), such as tiotropium, to inhaled corticosteroids (ICS). Despite the guidelines recommending triple therapy for severe COPD, most studies have evaluated either LAMA or LABA plus ICS, but not all three together.

Study design: Retrospective cohort.

Setting: Tayside, Scotland’s National Health Services database.

Synopsis: Patients with severe COPD were divided into two groups: 1,857 patients had received ICS+LABA (double therapy) and 996 had received ICS+LABA+tiotropium (triple therapy), with follow-up of 4.65 years.

All-cause mortality was 35% lower in the triple therapy group (HR 0.65, 95% CI 0.57-0.75). Corticosteroid use was 29% lower (HR 0.71, 95% CI 0.63-0.80), and hospital admissions were 15% lower (HR 0.85, 95% CI 0.73-0.99) in the triple-therapy group. These results were adjusted for smoking, age, sex, socioeconomic status, and history of diabetes, cardiovascular, and respiratory disease.

This study is limited by its observational retrospective design but provides good evidence of the need for randomized controlled trials to validate the clinical benefits of triple therapy.

Bottom line: Adding tiotropium to ICS plus LABA is associated with lower all-cause mortality, hospitalizations, and corticosteroid use when compared with ICS plus LABA, validating its current use in management of severe COPD.

Citation: Short PM, Williamson PA, Elder DHJ, Lipworth SIW, Schembi S, Lipworth BJ. The impact of tiotropium on mortality and exacerbations when added to inhaled corticosteroids and long-acting β-agonist therapy in COPD. Chest. 2012;141:81-86.

Above-Knee Compression Stockings Not Better than Below-Knee Stockings for Protection Against Post-Thrombotic Syndrome

Clinical question: Do above-knee compression elastic stockings prevent post-thrombotic syndrome (PTS) better than below-knee stockings?

Background: PTS—characterized by leg pain, cramps, edema, and hyperpigmentation—occurs in 25% to 50% of patients after an episode of deep venous thrombosis (DVT). Previous studies demonstrated a 50% reduction in the incidence of PTS when patients used below-knee stockings.

Study design: Open-label, randomized clinical trial.

Setting: Eight hospitals in Italy.

Synopsis: A total of 267 patients with their first episode of DVT were randomized to thigh-length or below-knee compression elastic stockings, as well as therapeutic anticoagulation, with a primary endpoint of three-year incidence of PTS. Assessment was done by study personnel who were blinded to the type of stocking the patients had been prescribed. Severity of PTS was graded by a scoring system incorporating objective and subjective criteria with an independent adjudicator.

The intention-to-treat analysis showed no significant difference in the three-year incidence of PTS between thigh- and knee-length stockings (32.6% vs. 35.6%, respectively). Compliance was better in the knee-length (82.6%) than in the thigh-length (66.7%) group due to the significantly lower rate of stockings-related side effects.

The study is limited by a lack of blinding in the study participants.

Bottom line: Knee-length stockings offer equal similar protection against PTS with better compliance when compared with thigh-length stockings.

Citation: Prandoni P, Noventa F, Quintavalla R, et al. Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial. Blood. 2012;119:1561-1565.

Video Auditing With Near- Real-Time Feedback Improves Hand Hygiene Practices

Clinical question: Does the use of direct video monitoring with continuous, multi-modal feedback promote improvement in healthcare workers’ compliance with hand hygiene?

Background: Appropriate hand hygiene is an effective means of infection control. Direct human observation of hand hygiene compliance does little more than provide a biased, temporary, and often overestimated assessment of compliance. The use of video-based monitoring technology in other aspects of society (e.g. traffic signal cameras) has been well demonstrated to modify behavior.

Study design: Prospective cohort study.

Setting: Tertiary-care hospital’s 17-bed medical ICU in the northeastern U.S.

Synopsis: Through the use of 21 motion-activated video cameras with continuous third-party auditing, the provision of near real-time feedback improved hand hygiene rates of healthcare workers from 6.5% to 81.6%. In the four months preceding feedback, only 3,933 hand-washing events out of 60,542 (6.5%) were considered “passing.” During the active feedback period, 59,627 events out of 73,080 (81.6%) passed.

The improvement was sustained in the maintenance period of the study with an average rate of hand hygiene compliance of 87.9%. The improvement in hand hygiene compliance required active provision of feedback as well as the presence of monitoring equipment, making the applicability of this study limited, based on the cost of the technology and the manpower to provide feedback.

Bottom line: Hand hygiene practices improve when healthcare workers are given immediate feedback on their compliance.

Citation: Rebellion D, Husain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012:54(1):1-7.

Mismanagement of Enterococcal Bacteriuria

Clinical question: Are clinical providers following appropriate guidelines to identify and manage enterococcal bacteriuria?

Background: There are specific evidence-based guidelines for the diagnosis and treatment of urinary tract infections (UTI) and asymptomatic bacteriuria (ABU). ABU is often mistaken for a UTI, and incorrectly treated as one.

Study design: Retrospective cohort.

Setting: Two academic teaching hospitals in Houston, Texas.

Synopsis: Using the current Infectious Disease Society of America (IDSA) guidelines, 375 Enterococcus urine cultures were reviewed and determined to be either UTI or ABU. The cultures were initially reviewed for appropriate treatment and again 30 days later for complications. UTI was defined as bacteriuria with one or more sign or symptom (urgency, frequency, dysuria, suprapubic tenderness, flank pain, rigors, visible hematuria, delirium, or fevers) without another identifiable cause. ABU was defined as bacteriuria without any of the signs or symptoms, or a clear nonurinary source.

Of the 339 cultures matching inclusion criteria, 156 were classified as UTI and 183 classified as ABU. Sixty of the 183 ABU (32.8%) were inappropriately treated with antibiotics, while antibiotics were withheld in 23 of the 156 UTI (14.7%). Eighty-three of 339 cultures (24.5%) were incorrectly treated. The most common reason for ABU being inappropriately treated was the presence of pyuria, associated with a threefold higher use of antibiotics.

There was no significant difference in subsequent infections or infectious complications between UTI and ABU.

Bottom line: Enterococcal ABU is frequently treated with antibiotics, even though guidelines recommend against it; providers should resist overtreating enterococcal ABU.

Citation: Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococcal bacteriuria. Arch Intern Med. 2012;172:33-38.

CT Angiography for the Diagnosis of Acute Lower GI Bleeding in an Emergency Setting

Clinical question: Is CT angiography a reliable initial diagnostic procedure to identify the presence and location of an acute lower gastrointestinal (GI) bleed in the ED setting?

Background: CT angiography has been identified as a potentially useful procedure to identify acute GI bleeds; however, the specific role and timing of the procedure has not been clearly identified.

Study design: Prospective study.

Setting: ED of a university-based hospital in Madrid.

Synopsis: CT angiography was performed on 47 ED patients (27 men, 20 women, with a mean age of 68 years) with an acute lower GI bleed. Study protocol included a preliminary unenhanced CT scan followed by CT angiogram prior to the standard clinical protocol, which included colonoscopy, angiography, or laparotomy.

Images were reviewed by two different ED radiologists, who were blinded to the diagnosis, and compared with the standard protocol findings. CT angiography correctly identified active acute or recent GI bleeding in 46 of the 47 patients, with a sensitivity of 100% (19 of 19), NPV of 100% (27 of 27), specificity of 96% (27 of 28), and PPV of 95% (19 of 20). CT angiography also was 93% accurate in identifying the cause of the GI bleed when compared with the standard reference.

Limitations of the study include its small size and the lack of a control group.

Bottom line: CT angiography is an accurate and more readily available modality for the diagnosis of acute lower GI bleeding, though it does not provide a therapeutic option.

Citation: Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262:109-116.

Substitution of Levalbuterol to Avoid Tachyarrhythmia Not Supported

Clinical question: Does substitution of levalbuterol for albuterol in critically ill adult patients result in decreased incidence of tachyarrhythmias?

Background: Studies have indicated an increased risk of mortality from tachycardia and tachyarrhythmias in ICU patients. Levalbuterol is the R-isomer of albuterol, and it has been proposed that it may mitigate cardiac side effects seen with beta-2 agonists. For this reason, some clinicians have advocated using nebulized levalbuterol in critically ill patients.

Study design: Prospective randomized controlled trial with patient crossover.

Setting: Single academic medical center.

Synopsis: All ICU patients in a single teaching hospital were screened, and 70 patients were included. Patients were randomly crossed over between albuterol and levalbuterol every four to six hours. This resulted in a total of 836 measurements of heart rate, the primary outcome measurement. The study showed no clinically significant differences in average heart rate when using levalbuterol versus albuterol. This was a small study of ICU patients, using a surrogate endpoint of heart rate rather than mortality. Furthermore, the assessment of tachyarrhythmias was limited given the study size and relative rarity of these events. Despite these limitations, the study casts significant doubt on the theory and practice of switching from albuterol to levalbuterol solely for the purpose of reducing or avoiding tachycardia or tachyarrhythmias.

Bottom line: Substitution of levalbuterol for albuterol to avert tachycardia in critically ill patients is not warranted.

Citation: Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;140:1466-1472.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Online calculator helps prevent post-op respiratory failure
2. New drug for long-term treatment of PE
3. Benefits of triple therapy for COPD
4. Knee-length compression stockings as good as thigh-length for PTS
5. Video monitoring improves hand hygiene
6. Asymptomatic bacteriuria often misdiagnosed as UTI
7. CT accurate for lower GI bleeding diagnosis
8. Switch from albuterol to lavalbuterol to reduce tachycardia not recommended

Preoperative Risk Calculator Can Help Predict Postoperative Respiratory Failure

Clinical question: Can preoperative factors identify patients at risk for postoperative respiratory failure (PRF)?

Background: PRF—when a patient requires mechanical ventilation >48 hours after surgery or needs unplanned intubation within 30 days of surgery—is associated with high mortality, with 30-day mortality rates of 26%.

Study design: Analysis of multicenter, prospective databases of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Setting: Analysis of NSQIP data from 2007 (training set) and 2008 (validation set).

Synopsis: PRF was seen in 3.1% of patients in the 2007 data set and 2.6% in the 2008 data set. Those with PRF had significantly higher mortality rates than those without PRF (25.62% vs. 0.98%; P<0.0001). Preoperative risk factors associated with significantly increased risk of PRF were American Society of Anesthesiologists’ class, functional status, emergent nature of procedure, type of surgery, and preoperative sepsis.

The 2007 data set was used to develop the model, and the 2008 data set was used as a validation set. The selected risk model showed similar results in both sets with a c-statistic of 0.91 in the training set and 0.90 in the validation set. This selected model was then used to develop an interactive calculator predicting PRF (available at www.surgicalriskcalculator.com/prf-risk-calculator).

Bottom line: The PRF risk calculator can identify patients at high risk for PRF, which can aid in tailoring preventive strategies for patients prior to surgery.

Citation: Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140:1207-1215.

New Drug for Treatment of Acute Symptomatic Pulmonary Embolism

Clinical question: Is the incidence of recurrent venous thromboembolism (VTE) or bleeding with use of idrabiotaparinux comparable to warfarin for treatment of acute symptomatic pulmonary embolism (PE)?

Background: Warfarin is an effective treatment for PE; however, maintenance of effective and safe levels of anticoagulation is difficult to achieve. A straightforward treatment option would be an attractive alternative. Idrabiotaparinux, a factor Xa inhibitor bound with a biotin moiety, is a weekly subcutaneous injection proposed as an alternative to warfarin for treatment of PE.

Study design: Industry-sponsored double-blind, randomized controlled trial.

Setting: 291 centers in 37 countries.

Synopsis: A group of 3,202 patients aged 18 to 96 years were randomly assigned to receive enoxaparin, followed by idrabiotaparinux or enoxaparin, then overlapped and followed by warfarin for three or six months. The incidence of recurrent VTE (including fatal and nonfatal PE or deep vein thrombosis) did not differ between the two treatment arms.

Of the 1,599 patients treated with idrabiotaparinux, 48 (3%) had a recurrence; of the 1,603 treated with warfarin, 97 (6%) had a recurrence (odds ratio, 0.49). The rate of clinically relevant bleeding was also similar, with 72 (5%) in the idrabiotaparinux group versus 106 (7%) in the warfarin group. Much like warfarin, idrabiotaparinux requires bridging therapy with initial low-molecular-weight heparin.

Bottom line: Use of enoxaparin followed by weekly subcutaneous injection of idrabiotaparinux was as effective as enoxaparin followed by warfarin for preventing recurrent VTE, and may provide a suitable option for treatment of acute symptomatic PE.

Citation: Buller HR, Gallus AS, Pillion G, Prins MH, Raskob GE. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet. 2012;379:123-129.

Triple Therapy Better than Double for COPD

Clinical question: Does addition of tiotropium to inhaled corticosteroids and long-acting beta-agonists (LABA) have an additive benefit in reducing mortality, hospital admissions, and exacerbations in COPD?

Background: Triple therapy in COPD involves adding LABA and long-acting antimuscarinics (LAMA), such as tiotropium, to inhaled corticosteroids (ICS). Despite the guidelines recommending triple therapy for severe COPD, most studies have evaluated either LAMA or LABA plus ICS, but not all three together.

Study design: Retrospective cohort.

Setting: Tayside, Scotland’s National Health Services database.

Synopsis: Patients with severe COPD were divided into two groups: 1,857 patients had received ICS+LABA (double therapy) and 996 had received ICS+LABA+tiotropium (triple therapy), with follow-up of 4.65 years.

All-cause mortality was 35% lower in the triple therapy group (HR 0.65, 95% CI 0.57-0.75). Corticosteroid use was 29% lower (HR 0.71, 95% CI 0.63-0.80), and hospital admissions were 15% lower (HR 0.85, 95% CI 0.73-0.99) in the triple-therapy group. These results were adjusted for smoking, age, sex, socioeconomic status, and history of diabetes, cardiovascular, and respiratory disease.

This study is limited by its observational retrospective design but provides good evidence of the need for randomized controlled trials to validate the clinical benefits of triple therapy.

Bottom line: Adding tiotropium to ICS plus LABA is associated with lower all-cause mortality, hospitalizations, and corticosteroid use when compared with ICS plus LABA, validating its current use in management of severe COPD.

Citation: Short PM, Williamson PA, Elder DHJ, Lipworth SIW, Schembi S, Lipworth BJ. The impact of tiotropium on mortality and exacerbations when added to inhaled corticosteroids and long-acting β-agonist therapy in COPD. Chest. 2012;141:81-86.

Above-Knee Compression Stockings Not Better than Below-Knee Stockings for Protection Against Post-Thrombotic Syndrome

Clinical question: Do above-knee compression elastic stockings prevent post-thrombotic syndrome (PTS) better than below-knee stockings?

Background: PTS—characterized by leg pain, cramps, edema, and hyperpigmentation—occurs in 25% to 50% of patients after an episode of deep venous thrombosis (DVT). Previous studies demonstrated a 50% reduction in the incidence of PTS when patients used below-knee stockings.

Study design: Open-label, randomized clinical trial.

Setting: Eight hospitals in Italy.

Synopsis: A total of 267 patients with their first episode of DVT were randomized to thigh-length or below-knee compression elastic stockings, as well as therapeutic anticoagulation, with a primary endpoint of three-year incidence of PTS. Assessment was done by study personnel who were blinded to the type of stocking the patients had been prescribed. Severity of PTS was graded by a scoring system incorporating objective and subjective criteria with an independent adjudicator.

The intention-to-treat analysis showed no significant difference in the three-year incidence of PTS between thigh- and knee-length stockings (32.6% vs. 35.6%, respectively). Compliance was better in the knee-length (82.6%) than in the thigh-length (66.7%) group due to the significantly lower rate of stockings-related side effects.

The study is limited by a lack of blinding in the study participants.

Bottom line: Knee-length stockings offer equal similar protection against PTS with better compliance when compared with thigh-length stockings.

Citation: Prandoni P, Noventa F, Quintavalla R, et al. Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial. Blood. 2012;119:1561-1565.

Video Auditing With Near- Real-Time Feedback Improves Hand Hygiene Practices

Clinical question: Does the use of direct video monitoring with continuous, multi-modal feedback promote improvement in healthcare workers’ compliance with hand hygiene?

Background: Appropriate hand hygiene is an effective means of infection control. Direct human observation of hand hygiene compliance does little more than provide a biased, temporary, and often overestimated assessment of compliance. The use of video-based monitoring technology in other aspects of society (e.g. traffic signal cameras) has been well demonstrated to modify behavior.

Study design: Prospective cohort study.

Setting: Tertiary-care hospital’s 17-bed medical ICU in the northeastern U.S.

Synopsis: Through the use of 21 motion-activated video cameras with continuous third-party auditing, the provision of near real-time feedback improved hand hygiene rates of healthcare workers from 6.5% to 81.6%. In the four months preceding feedback, only 3,933 hand-washing events out of 60,542 (6.5%) were considered “passing.” During the active feedback period, 59,627 events out of 73,080 (81.6%) passed.

The improvement was sustained in the maintenance period of the study with an average rate of hand hygiene compliance of 87.9%. The improvement in hand hygiene compliance required active provision of feedback as well as the presence of monitoring equipment, making the applicability of this study limited, based on the cost of the technology and the manpower to provide feedback.

Bottom line: Hand hygiene practices improve when healthcare workers are given immediate feedback on their compliance.

Citation: Rebellion D, Husain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012:54(1):1-7.

Mismanagement of Enterococcal Bacteriuria

Clinical question: Are clinical providers following appropriate guidelines to identify and manage enterococcal bacteriuria?

Background: There are specific evidence-based guidelines for the diagnosis and treatment of urinary tract infections (UTI) and asymptomatic bacteriuria (ABU). ABU is often mistaken for a UTI, and incorrectly treated as one.

Study design: Retrospective cohort.

Setting: Two academic teaching hospitals in Houston, Texas.

Synopsis: Using the current Infectious Disease Society of America (IDSA) guidelines, 375 Enterococcus urine cultures were reviewed and determined to be either UTI or ABU. The cultures were initially reviewed for appropriate treatment and again 30 days later for complications. UTI was defined as bacteriuria with one or more sign or symptom (urgency, frequency, dysuria, suprapubic tenderness, flank pain, rigors, visible hematuria, delirium, or fevers) without another identifiable cause. ABU was defined as bacteriuria without any of the signs or symptoms, or a clear nonurinary source.

Of the 339 cultures matching inclusion criteria, 156 were classified as UTI and 183 classified as ABU. Sixty of the 183 ABU (32.8%) were inappropriately treated with antibiotics, while antibiotics were withheld in 23 of the 156 UTI (14.7%). Eighty-three of 339 cultures (24.5%) were incorrectly treated. The most common reason for ABU being inappropriately treated was the presence of pyuria, associated with a threefold higher use of antibiotics.

There was no significant difference in subsequent infections or infectious complications between UTI and ABU.

Bottom line: Enterococcal ABU is frequently treated with antibiotics, even though guidelines recommend against it; providers should resist overtreating enterococcal ABU.

Citation: Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococcal bacteriuria. Arch Intern Med. 2012;172:33-38.

CT Angiography for the Diagnosis of Acute Lower GI Bleeding in an Emergency Setting

Clinical question: Is CT angiography a reliable initial diagnostic procedure to identify the presence and location of an acute lower gastrointestinal (GI) bleed in the ED setting?

Background: CT angiography has been identified as a potentially useful procedure to identify acute GI bleeds; however, the specific role and timing of the procedure has not been clearly identified.

Study design: Prospective study.

Setting: ED of a university-based hospital in Madrid.

Synopsis: CT angiography was performed on 47 ED patients (27 men, 20 women, with a mean age of 68 years) with an acute lower GI bleed. Study protocol included a preliminary unenhanced CT scan followed by CT angiogram prior to the standard clinical protocol, which included colonoscopy, angiography, or laparotomy.

Images were reviewed by two different ED radiologists, who were blinded to the diagnosis, and compared with the standard protocol findings. CT angiography correctly identified active acute or recent GI bleeding in 46 of the 47 patients, with a sensitivity of 100% (19 of 19), NPV of 100% (27 of 27), specificity of 96% (27 of 28), and PPV of 95% (19 of 20). CT angiography also was 93% accurate in identifying the cause of the GI bleed when compared with the standard reference.

Limitations of the study include its small size and the lack of a control group.

Bottom line: CT angiography is an accurate and more readily available modality for the diagnosis of acute lower GI bleeding, though it does not provide a therapeutic option.

Citation: Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262:109-116.

Substitution of Levalbuterol to Avoid Tachyarrhythmia Not Supported

Clinical question: Does substitution of levalbuterol for albuterol in critically ill adult patients result in decreased incidence of tachyarrhythmias?

Background: Studies have indicated an increased risk of mortality from tachycardia and tachyarrhythmias in ICU patients. Levalbuterol is the R-isomer of albuterol, and it has been proposed that it may mitigate cardiac side effects seen with beta-2 agonists. For this reason, some clinicians have advocated using nebulized levalbuterol in critically ill patients.

Study design: Prospective randomized controlled trial with patient crossover.

Setting: Single academic medical center.

Synopsis: All ICU patients in a single teaching hospital were screened, and 70 patients were included. Patients were randomly crossed over between albuterol and levalbuterol every four to six hours. This resulted in a total of 836 measurements of heart rate, the primary outcome measurement. The study showed no clinically significant differences in average heart rate when using levalbuterol versus albuterol. This was a small study of ICU patients, using a surrogate endpoint of heart rate rather than mortality. Furthermore, the assessment of tachyarrhythmias was limited given the study size and relative rarity of these events. Despite these limitations, the study casts significant doubt on the theory and practice of switching from albuterol to levalbuterol solely for the purpose of reducing or avoiding tachycardia or tachyarrhythmias.

Bottom line: Substitution of levalbuterol for albuterol to avert tachycardia in critically ill patients is not warranted.

Citation: Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;140:1466-1472.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Online calculator helps prevent post-op respiratory failure
2. New drug for long-term treatment of PE
3. Benefits of triple therapy for COPD
4. Knee-length compression stockings as good as thigh-length for PTS
5. Video monitoring improves hand hygiene
6. Asymptomatic bacteriuria often misdiagnosed as UTI
7. CT accurate for lower GI bleeding diagnosis
8. Switch from albuterol to lavalbuterol to reduce tachycardia not recommended

Preoperative Risk Calculator Can Help Predict Postoperative Respiratory Failure

Clinical question: Can preoperative factors identify patients at risk for postoperative respiratory failure (PRF)?

Background: PRF—when a patient requires mechanical ventilation >48 hours after surgery or needs unplanned intubation within 30 days of surgery—is associated with high mortality, with 30-day mortality rates of 26%.

Study design: Analysis of multicenter, prospective databases of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Setting: Analysis of NSQIP data from 2007 (training set) and 2008 (validation set).

Synopsis: PRF was seen in 3.1% of patients in the 2007 data set and 2.6% in the 2008 data set. Those with PRF had significantly higher mortality rates than those without PRF (25.62% vs. 0.98%; P<0.0001). Preoperative risk factors associated with significantly increased risk of PRF were American Society of Anesthesiologists’ class, functional status, emergent nature of procedure, type of surgery, and preoperative sepsis.

The 2007 data set was used to develop the model, and the 2008 data set was used as a validation set. The selected risk model showed similar results in both sets with a c-statistic of 0.91 in the training set and 0.90 in the validation set. This selected model was then used to develop an interactive calculator predicting PRF (available at www.surgicalriskcalculator.com/prf-risk-calculator).

Bottom line: The PRF risk calculator can identify patients at high risk for PRF, which can aid in tailoring preventive strategies for patients prior to surgery.

Citation: Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140:1207-1215.

New Drug for Treatment of Acute Symptomatic Pulmonary Embolism

Clinical question: Is the incidence of recurrent venous thromboembolism (VTE) or bleeding with use of idrabiotaparinux comparable to warfarin for treatment of acute symptomatic pulmonary embolism (PE)?

Background: Warfarin is an effective treatment for PE; however, maintenance of effective and safe levels of anticoagulation is difficult to achieve. A straightforward treatment option would be an attractive alternative. Idrabiotaparinux, a factor Xa inhibitor bound with a biotin moiety, is a weekly subcutaneous injection proposed as an alternative to warfarin for treatment of PE.

Study design: Industry-sponsored double-blind, randomized controlled trial.

Setting: 291 centers in 37 countries.

Synopsis: A group of 3,202 patients aged 18 to 96 years were randomly assigned to receive enoxaparin, followed by idrabiotaparinux or enoxaparin, then overlapped and followed by warfarin for three or six months. The incidence of recurrent VTE (including fatal and nonfatal PE or deep vein thrombosis) did not differ between the two treatment arms.

Of the 1,599 patients treated with idrabiotaparinux, 48 (3%) had a recurrence; of the 1,603 treated with warfarin, 97 (6%) had a recurrence (odds ratio, 0.49). The rate of clinically relevant bleeding was also similar, with 72 (5%) in the idrabiotaparinux group versus 106 (7%) in the warfarin group. Much like warfarin, idrabiotaparinux requires bridging therapy with initial low-molecular-weight heparin.

Bottom line: Use of enoxaparin followed by weekly subcutaneous injection of idrabiotaparinux was as effective as enoxaparin followed by warfarin for preventing recurrent VTE, and may provide a suitable option for treatment of acute symptomatic PE.

Citation: Buller HR, Gallus AS, Pillion G, Prins MH, Raskob GE. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet. 2012;379:123-129.

Triple Therapy Better than Double for COPD

Clinical question: Does addition of tiotropium to inhaled corticosteroids and long-acting beta-agonists (LABA) have an additive benefit in reducing mortality, hospital admissions, and exacerbations in COPD?

Background: Triple therapy in COPD involves adding LABA and long-acting antimuscarinics (LAMA), such as tiotropium, to inhaled corticosteroids (ICS). Despite the guidelines recommending triple therapy for severe COPD, most studies have evaluated either LAMA or LABA plus ICS, but not all three together.

Study design: Retrospective cohort.

Setting: Tayside, Scotland’s National Health Services database.

Synopsis: Patients with severe COPD were divided into two groups: 1,857 patients had received ICS+LABA (double therapy) and 996 had received ICS+LABA+tiotropium (triple therapy), with follow-up of 4.65 years.

All-cause mortality was 35% lower in the triple therapy group (HR 0.65, 95% CI 0.57-0.75). Corticosteroid use was 29% lower (HR 0.71, 95% CI 0.63-0.80), and hospital admissions were 15% lower (HR 0.85, 95% CI 0.73-0.99) in the triple-therapy group. These results were adjusted for smoking, age, sex, socioeconomic status, and history of diabetes, cardiovascular, and respiratory disease.

This study is limited by its observational retrospective design but provides good evidence of the need for randomized controlled trials to validate the clinical benefits of triple therapy.

Bottom line: Adding tiotropium to ICS plus LABA is associated with lower all-cause mortality, hospitalizations, and corticosteroid use when compared with ICS plus LABA, validating its current use in management of severe COPD.

Citation: Short PM, Williamson PA, Elder DHJ, Lipworth SIW, Schembi S, Lipworth BJ. The impact of tiotropium on mortality and exacerbations when added to inhaled corticosteroids and long-acting β-agonist therapy in COPD. Chest. 2012;141:81-86.

Above-Knee Compression Stockings Not Better than Below-Knee Stockings for Protection Against Post-Thrombotic Syndrome

Clinical question: Do above-knee compression elastic stockings prevent post-thrombotic syndrome (PTS) better than below-knee stockings?

Background: PTS—characterized by leg pain, cramps, edema, and hyperpigmentation—occurs in 25% to 50% of patients after an episode of deep venous thrombosis (DVT). Previous studies demonstrated a 50% reduction in the incidence of PTS when patients used below-knee stockings.

Study design: Open-label, randomized clinical trial.

Setting: Eight hospitals in Italy.

Synopsis: A total of 267 patients with their first episode of DVT were randomized to thigh-length or below-knee compression elastic stockings, as well as therapeutic anticoagulation, with a primary endpoint of three-year incidence of PTS. Assessment was done by study personnel who were blinded to the type of stocking the patients had been prescribed. Severity of PTS was graded by a scoring system incorporating objective and subjective criteria with an independent adjudicator.

The intention-to-treat analysis showed no significant difference in the three-year incidence of PTS between thigh- and knee-length stockings (32.6% vs. 35.6%, respectively). Compliance was better in the knee-length (82.6%) than in the thigh-length (66.7%) group due to the significantly lower rate of stockings-related side effects.

The study is limited by a lack of blinding in the study participants.

Bottom line: Knee-length stockings offer equal similar protection against PTS with better compliance when compared with thigh-length stockings.

Citation: Prandoni P, Noventa F, Quintavalla R, et al. Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial. Blood. 2012;119:1561-1565.

Video Auditing With Near- Real-Time Feedback Improves Hand Hygiene Practices

Clinical question: Does the use of direct video monitoring with continuous, multi-modal feedback promote improvement in healthcare workers’ compliance with hand hygiene?

Background: Appropriate hand hygiene is an effective means of infection control. Direct human observation of hand hygiene compliance does little more than provide a biased, temporary, and often overestimated assessment of compliance. The use of video-based monitoring technology in other aspects of society (e.g. traffic signal cameras) has been well demonstrated to modify behavior.

Study design: Prospective cohort study.

Setting: Tertiary-care hospital’s 17-bed medical ICU in the northeastern U.S.

Synopsis: Through the use of 21 motion-activated video cameras with continuous third-party auditing, the provision of near real-time feedback improved hand hygiene rates of healthcare workers from 6.5% to 81.6%. In the four months preceding feedback, only 3,933 hand-washing events out of 60,542 (6.5%) were considered “passing.” During the active feedback period, 59,627 events out of 73,080 (81.6%) passed.

The improvement was sustained in the maintenance period of the study with an average rate of hand hygiene compliance of 87.9%. The improvement in hand hygiene compliance required active provision of feedback as well as the presence of monitoring equipment, making the applicability of this study limited, based on the cost of the technology and the manpower to provide feedback.

Bottom line: Hand hygiene practices improve when healthcare workers are given immediate feedback on their compliance.

Citation: Rebellion D, Husain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012:54(1):1-7.

Mismanagement of Enterococcal Bacteriuria

Clinical question: Are clinical providers following appropriate guidelines to identify and manage enterococcal bacteriuria?

Background: There are specific evidence-based guidelines for the diagnosis and treatment of urinary tract infections (UTI) and asymptomatic bacteriuria (ABU). ABU is often mistaken for a UTI, and incorrectly treated as one.

Study design: Retrospective cohort.

Setting: Two academic teaching hospitals in Houston, Texas.

Synopsis: Using the current Infectious Disease Society of America (IDSA) guidelines, 375 Enterococcus urine cultures were reviewed and determined to be either UTI or ABU. The cultures were initially reviewed for appropriate treatment and again 30 days later for complications. UTI was defined as bacteriuria with one or more sign or symptom (urgency, frequency, dysuria, suprapubic tenderness, flank pain, rigors, visible hematuria, delirium, or fevers) without another identifiable cause. ABU was defined as bacteriuria without any of the signs or symptoms, or a clear nonurinary source.

Of the 339 cultures matching inclusion criteria, 156 were classified as UTI and 183 classified as ABU. Sixty of the 183 ABU (32.8%) were inappropriately treated with antibiotics, while antibiotics were withheld in 23 of the 156 UTI (14.7%). Eighty-three of 339 cultures (24.5%) were incorrectly treated. The most common reason for ABU being inappropriately treated was the presence of pyuria, associated with a threefold higher use of antibiotics.

There was no significant difference in subsequent infections or infectious complications between UTI and ABU.

Bottom line: Enterococcal ABU is frequently treated with antibiotics, even though guidelines recommend against it; providers should resist overtreating enterococcal ABU.

Citation: Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococcal bacteriuria. Arch Intern Med. 2012;172:33-38.

CT Angiography for the Diagnosis of Acute Lower GI Bleeding in an Emergency Setting

Clinical question: Is CT angiography a reliable initial diagnostic procedure to identify the presence and location of an acute lower gastrointestinal (GI) bleed in the ED setting?

Background: CT angiography has been identified as a potentially useful procedure to identify acute GI bleeds; however, the specific role and timing of the procedure has not been clearly identified.

Study design: Prospective study.

Setting: ED of a university-based hospital in Madrid.

Synopsis: CT angiography was performed on 47 ED patients (27 men, 20 women, with a mean age of 68 years) with an acute lower GI bleed. Study protocol included a preliminary unenhanced CT scan followed by CT angiogram prior to the standard clinical protocol, which included colonoscopy, angiography, or laparotomy.

Images were reviewed by two different ED radiologists, who were blinded to the diagnosis, and compared with the standard protocol findings. CT angiography correctly identified active acute or recent GI bleeding in 46 of the 47 patients, with a sensitivity of 100% (19 of 19), NPV of 100% (27 of 27), specificity of 96% (27 of 28), and PPV of 95% (19 of 20). CT angiography also was 93% accurate in identifying the cause of the GI bleed when compared with the standard reference.

Limitations of the study include its small size and the lack of a control group.

Bottom line: CT angiography is an accurate and more readily available modality for the diagnosis of acute lower GI bleeding, though it does not provide a therapeutic option.

Citation: Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262:109-116.

Substitution of Levalbuterol to Avoid Tachyarrhythmia Not Supported

Clinical question: Does substitution of levalbuterol for albuterol in critically ill adult patients result in decreased incidence of tachyarrhythmias?

Background: Studies have indicated an increased risk of mortality from tachycardia and tachyarrhythmias in ICU patients. Levalbuterol is the R-isomer of albuterol, and it has been proposed that it may mitigate cardiac side effects seen with beta-2 agonists. For this reason, some clinicians have advocated using nebulized levalbuterol in critically ill patients.

Study design: Prospective randomized controlled trial with patient crossover.

Setting: Single academic medical center.

Synopsis: All ICU patients in a single teaching hospital were screened, and 70 patients were included. Patients were randomly crossed over between albuterol and levalbuterol every four to six hours. This resulted in a total of 836 measurements of heart rate, the primary outcome measurement. The study showed no clinically significant differences in average heart rate when using levalbuterol versus albuterol. This was a small study of ICU patients, using a surrogate endpoint of heart rate rather than mortality. Furthermore, the assessment of tachyarrhythmias was limited given the study size and relative rarity of these events. Despite these limitations, the study casts significant doubt on the theory and practice of switching from albuterol to levalbuterol solely for the purpose of reducing or avoiding tachycardia or tachyarrhythmias.

Bottom line: Substitution of levalbuterol for albuterol to avert tachycardia in critically ill patients is not warranted.

Citation: Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;140:1466-1472.

Clinical question: What is the association between childhood urinary tract infections (UTIs) and chronic kidney disease (CKD)?

Background: A traditional paradigm in pediatrics is that CKD might be caused by renal scarring as a result of recurrent UTIs, particularly in the presence of vesicoureteral reflux (VUR). Increasingly, this has been called into question as nonintervention for low-grade VUR has not impacted clinical outcomes.

Study design: Retrospective cohort and systematic literature review.

Setting: Tertiary-care hospital in Finland and PubMed database.

Synopsis: A search of the PubMed database for articles published from 1966 to 2009 relating to a potential association between CKD and UTIs yielded 10 studies reporting on 1,576 patients with UTIs and long-term evaluation for CKD. Only three of the 1,576 patients had childhood UTIs without structural kidney abnormalities as a potential cause of the CKD. VUR was not considered a structural abnormality. The authors note that no data on kidney morphology prior to UTI recurrence were available in these cases.

At the same time, the study authors reviewed the records of 366 patients with CKD at a tertiary-care hospital in Finland. They excluded 308 patients with defined noninfectious causes of CKD. Of the 58 remaining patients, three potentially had recurrent UTIs as a contributing cause to eventual CKD. All three patients had structurally abnormal kidneys on first radiologic examination, possibly suggesting pre-existing renal anomalies. The potential association between recurrent childhood UTIs without structural abnormalities and CKD appears to be less than 1%.

Limitations of this study include its retrospective design and incomplete characterization systematic review. Nevertheless, the study appears to support recent work that childhood UTIs without underlying kidney abnormalities are unlikely to result in permanent renal damage.

Bottom line: Childhood UTIs, without structural kidney abnormality, are not a significant cause of chronic kidney disease in adults.

Citation: Salo J, Ilkäheimo R, Tapiainen T, Uhari M. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128:840-847.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the association between childhood urinary tract infections (UTIs) and chronic kidney disease (CKD)?

Background: A traditional paradigm in pediatrics is that CKD might be caused by renal scarring as a result of recurrent UTIs, particularly in the presence of vesicoureteral reflux (VUR). Increasingly, this has been called into question as nonintervention for low-grade VUR has not impacted clinical outcomes.

Study design: Retrospective cohort and systematic literature review.

Setting: Tertiary-care hospital in Finland and PubMed database.

Synopsis: A search of the PubMed database for articles published from 1966 to 2009 relating to a potential association between CKD and UTIs yielded 10 studies reporting on 1,576 patients with UTIs and long-term evaluation for CKD. Only three of the 1,576 patients had childhood UTIs without structural kidney abnormalities as a potential cause of the CKD. VUR was not considered a structural abnormality. The authors note that no data on kidney morphology prior to UTI recurrence were available in these cases.

At the same time, the study authors reviewed the records of 366 patients with CKD at a tertiary-care hospital in Finland. They excluded 308 patients with defined noninfectious causes of CKD. Of the 58 remaining patients, three potentially had recurrent UTIs as a contributing cause to eventual CKD. All three patients had structurally abnormal kidneys on first radiologic examination, possibly suggesting pre-existing renal anomalies. The potential association between recurrent childhood UTIs without structural abnormalities and CKD appears to be less than 1%.

Limitations of this study include its retrospective design and incomplete characterization systematic review. Nevertheless, the study appears to support recent work that childhood UTIs without underlying kidney abnormalities are unlikely to result in permanent renal damage.

Bottom line: Childhood UTIs, without structural kidney abnormality, are not a significant cause of chronic kidney disease in adults.

Citation: Salo J, Ilkäheimo R, Tapiainen T, Uhari M. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128:840-847.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the association between childhood urinary tract infections (UTIs) and chronic kidney disease (CKD)?

Background: A traditional paradigm in pediatrics is that CKD might be caused by renal scarring as a result of recurrent UTIs, particularly in the presence of vesicoureteral reflux (VUR). Increasingly, this has been called into question as nonintervention for low-grade VUR has not impacted clinical outcomes.

Study design: Retrospective cohort and systematic literature review.

Setting: Tertiary-care hospital in Finland and PubMed database.

Synopsis: A search of the PubMed database for articles published from 1966 to 2009 relating to a potential association between CKD and UTIs yielded 10 studies reporting on 1,576 patients with UTIs and long-term evaluation for CKD. Only three of the 1,576 patients had childhood UTIs without structural kidney abnormalities as a potential cause of the CKD. VUR was not considered a structural abnormality. The authors note that no data on kidney morphology prior to UTI recurrence were available in these cases.

At the same time, the study authors reviewed the records of 366 patients with CKD at a tertiary-care hospital in Finland. They excluded 308 patients with defined noninfectious causes of CKD. Of the 58 remaining patients, three potentially had recurrent UTIs as a contributing cause to eventual CKD. All three patients had structurally abnormal kidneys on first radiologic examination, possibly suggesting pre-existing renal anomalies. The potential association between recurrent childhood UTIs without structural abnormalities and CKD appears to be less than 1%.

Limitations of this study include its retrospective design and incomplete characterization systematic review. Nevertheless, the study appears to support recent work that childhood UTIs without underlying kidney abnormalities are unlikely to result in permanent renal damage.

Bottom line: Childhood UTIs, without structural kidney abnormality, are not a significant cause of chronic kidney disease in adults.

Citation: Salo J, Ilkäheimo R, Tapiainen T, Uhari M. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128:840-847.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Background

Uncomplicated cystitis is one of the most common indications for prescribing antimicrobial therapy to otherwise healthy women, but wide variation in prescribing practices has been described.^1-2 This has prompted the need for guidelines to help providers in their selection of empiric antimicrobial regimens. Antibiotic selection should take into consideration the efficacy of individual agents, as well as their propensity for inducing resistance, altering gut flora, and increasing the risk of colonization or infection with multi-drug resistant organisms.

Guideline Update

In March 2010, the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESCMID) published new guidelines for the treatment of uncomplicated cystitis and pyelonephritis in healthy, community-dwelling women.³

First-line recommended agents for empiric treatment of uncomplicated cystitis are:

• nitrofurantoin for five days;
• trimethoprim-sulfamethoxazole for three days;
• fosfomycin in a single dose; or
• pivmecillinam (where available) for three to seven days.

Although highly efficacious, fluoroquinolones are not recommended as first-line treatment for acute cystitis because of their propensity for causing “collateral damage,” especially alteration of gut flora and increased risk of multi-drug resistant infection or colonization, including methicillin-resistant Staphylococcus aureus. Oral beta-lactams (other than pivmecillinam) have generally demonstrated inferior efficacy and more adverse effects when compared with the above agents, and should be used only if none of the preferred agents can be used. Specifically, amoxicillin and ampicillin are not recommended as empiric therapy due to their low efficacy in unselected patients, though may be appropriate when culture data is available to guide therapy. Narrow spectrum cephalosporins are also a potential agent for use in certain clinical situations, although the guidelines do not make any recommendation for or against their use, given a lack of studies.

For the treatment of acute pyelonephritis, the guidelines emphasize that all patients should have urine culture and susceptibility testing in order to tailor empiric therapy to the specific uropathogen. A 5-7 day course of an oral fluoroquinolone is appropriate when the prevalence of resistance in community uropathogens is ≤10%. Where resistance is more common, an initial intravenous dose of ceftriaxone or an aminoglycoside can be administered prior to starting oral therapy. Other alternatives include a 14-day course of trimethoprim-sulfamethoxazole or an oral beta-lactam.

Women requiring hospitalization for pyelonephritis should initially be treated with an intravenous antimicrobial regimen, the choice of which should be based on local resistance patterns. Recommended intravenous agents include fluoroquinolones, aminoglycosides (with or without ampicillin), extended-spectrum cephalosporins / penicillins, or carbapenems.

Analysis

Previous guidelines for the treatment of uncomplicated cystitis and pyelonephritis were published by the IDSA in 1999.⁴ The guidelines were updated based on the following factors:

• continued variability in prescribing practices;1-2
• increase in antimicrobial resistance among uropathogens;
• awareness of the unintended consequences of antimicrobial therapy, such as selection of drug-resistant organisms and colonization or infection with multi-drug resistant organisms; and
• study of newer agents and different durations of therapy.

Two important differences exist between the 1999 and 2010 guidelines:

• Nitrofurantoin has taken on more prominence in the 2010 guidelines for uncomplicated cystitis. The 1999 guidelines recommended trimethoprim-sulfamethoxazole as a first-line agent and mentioned nitrofurantoin and fosfomycin as potential alternative agents, but had few studies available to inform comparative efficacy or duration of therapy.
• For the outpatient treatment of mildly-ill patients with acute pyelonephritis, the 1999 guidelines recommended 14 days of therapy regardless of the agent used; in contrast, the 2010 guidelines recommend a five- to seven-day course for oral fluoroquinolones.

The American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine have endorsed the 2010 IDSA-ESCMID guidelines. The IDSA and ESCMID plan to evaluate the need for revisions to the 2010 guidelines based on an annual review of the current literature.

HM Takeaways

The 2010 IDSA-ESCMID guidelines are a resource available to hospitalists treating acute uncomplicated cystitis and pyelonephritis. As important differences exist between the target population and the hospitalist’s patient population, there are some key points to consider for clinicians treating cystitis or pyelonephritis in hospitalized patients.

Importantly, while nitrofurantoin is favored as a first-line antimicrobial agent for cystitis in the 2010 IDSA-ESCMID guidelines, it might be problematic in hospitalized patients for several reasons:

• it is not approved or recommended for the treatment of pyelonephritis;
• it is contraindicated in patients with creatinine clearance <60 ml/min; and
• it is generally not recommended for use in patients >65 years old because of the risk of renal impairment (Beers Criteria).⁵

Additionally, the treatment of acute cystitis in men requires special consideration. Notably, nitrofurantoin is not recommended in men because of poor prostatic tissue penetration, and although studies are limited, some sources recommend a longer treatment duration of at least 7 days.⁶ Finally, hospitalized patients commonly have other conditions, such as urological abnormalities, indwelling Foley catheters, recent urinary tract instrumentation, recent use of antibiotics, risk for multi-drug resistant organisms, potential interactions with other medications, and immunosuppression. The presence of any of these factors will influence the choice of empiric therapy and may warrant treatment for complicated cystitis or pyelonephritis, which are not addressed by these guidelines.

Drs. Tarvin and Sponsler are academic hospitalists at Vanderbilt University School of Medicine in Nashville, Tenn.

References

1. Huang ES, Stafford RS. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med. 2006;166:635-639.
2. Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Therap. 2004;29:59-63.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Inf Dis. 2011;52(5):e103-20.
4. Warren JW, Abrutyn E, Hebel JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America. Clin Inf Dis. 1999;29(4):745-58.
5. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
6. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. A Fam Phys. 2005;72(3):451-456.

Background

Uncomplicated cystitis is one of the most common indications for prescribing antimicrobial therapy to otherwise healthy women, but wide variation in prescribing practices has been described.^1-2 This has prompted the need for guidelines to help providers in their selection of empiric antimicrobial regimens. Antibiotic selection should take into consideration the efficacy of individual agents, as well as their propensity for inducing resistance, altering gut flora, and increasing the risk of colonization or infection with multi-drug resistant organisms.

Guideline Update

In March 2010, the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESCMID) published new guidelines for the treatment of uncomplicated cystitis and pyelonephritis in healthy, community-dwelling women.³

First-line recommended agents for empiric treatment of uncomplicated cystitis are:

• nitrofurantoin for five days;
• trimethoprim-sulfamethoxazole for three days;
• fosfomycin in a single dose; or
• pivmecillinam (where available) for three to seven days.

Although highly efficacious, fluoroquinolones are not recommended as first-line treatment for acute cystitis because of their propensity for causing “collateral damage,” especially alteration of gut flora and increased risk of multi-drug resistant infection or colonization, including methicillin-resistant Staphylococcus aureus. Oral beta-lactams (other than pivmecillinam) have generally demonstrated inferior efficacy and more adverse effects when compared with the above agents, and should be used only if none of the preferred agents can be used. Specifically, amoxicillin and ampicillin are not recommended as empiric therapy due to their low efficacy in unselected patients, though may be appropriate when culture data is available to guide therapy. Narrow spectrum cephalosporins are also a potential agent for use in certain clinical situations, although the guidelines do not make any recommendation for or against their use, given a lack of studies.

For the treatment of acute pyelonephritis, the guidelines emphasize that all patients should have urine culture and susceptibility testing in order to tailor empiric therapy to the specific uropathogen. A 5-7 day course of an oral fluoroquinolone is appropriate when the prevalence of resistance in community uropathogens is ≤10%. Where resistance is more common, an initial intravenous dose of ceftriaxone or an aminoglycoside can be administered prior to starting oral therapy. Other alternatives include a 14-day course of trimethoprim-sulfamethoxazole or an oral beta-lactam.

Women requiring hospitalization for pyelonephritis should initially be treated with an intravenous antimicrobial regimen, the choice of which should be based on local resistance patterns. Recommended intravenous agents include fluoroquinolones, aminoglycosides (with or without ampicillin), extended-spectrum cephalosporins / penicillins, or carbapenems.

Analysis

Previous guidelines for the treatment of uncomplicated cystitis and pyelonephritis were published by the IDSA in 1999.⁴ The guidelines were updated based on the following factors:

• continued variability in prescribing practices;1-2
• increase in antimicrobial resistance among uropathogens;
• awareness of the unintended consequences of antimicrobial therapy, such as selection of drug-resistant organisms and colonization or infection with multi-drug resistant organisms; and
• study of newer agents and different durations of therapy.

Two important differences exist between the 1999 and 2010 guidelines:

• Nitrofurantoin has taken on more prominence in the 2010 guidelines for uncomplicated cystitis. The 1999 guidelines recommended trimethoprim-sulfamethoxazole as a first-line agent and mentioned nitrofurantoin and fosfomycin as potential alternative agents, but had few studies available to inform comparative efficacy or duration of therapy.
• For the outpatient treatment of mildly-ill patients with acute pyelonephritis, the 1999 guidelines recommended 14 days of therapy regardless of the agent used; in contrast, the 2010 guidelines recommend a five- to seven-day course for oral fluoroquinolones.

The American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine have endorsed the 2010 IDSA-ESCMID guidelines. The IDSA and ESCMID plan to evaluate the need for revisions to the 2010 guidelines based on an annual review of the current literature.

HM Takeaways

The 2010 IDSA-ESCMID guidelines are a resource available to hospitalists treating acute uncomplicated cystitis and pyelonephritis. As important differences exist between the target population and the hospitalist’s patient population, there are some key points to consider for clinicians treating cystitis or pyelonephritis in hospitalized patients.

Importantly, while nitrofurantoin is favored as a first-line antimicrobial agent for cystitis in the 2010 IDSA-ESCMID guidelines, it might be problematic in hospitalized patients for several reasons:

• it is not approved or recommended for the treatment of pyelonephritis;
• it is contraindicated in patients with creatinine clearance <60 ml/min; and
• it is generally not recommended for use in patients >65 years old because of the risk of renal impairment (Beers Criteria).⁵

Additionally, the treatment of acute cystitis in men requires special consideration. Notably, nitrofurantoin is not recommended in men because of poor prostatic tissue penetration, and although studies are limited, some sources recommend a longer treatment duration of at least 7 days.⁶ Finally, hospitalized patients commonly have other conditions, such as urological abnormalities, indwelling Foley catheters, recent urinary tract instrumentation, recent use of antibiotics, risk for multi-drug resistant organisms, potential interactions with other medications, and immunosuppression. The presence of any of these factors will influence the choice of empiric therapy and may warrant treatment for complicated cystitis or pyelonephritis, which are not addressed by these guidelines.

Drs. Tarvin and Sponsler are academic hospitalists at Vanderbilt University School of Medicine in Nashville, Tenn.

References

1. Huang ES, Stafford RS. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med. 2006;166:635-639.
2. Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Therap. 2004;29:59-63.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Inf Dis. 2011;52(5):e103-20.
4. Warren JW, Abrutyn E, Hebel JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America. Clin Inf Dis. 1999;29(4):745-58.
5. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
6. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. A Fam Phys. 2005;72(3):451-456.

Background

Uncomplicated cystitis is one of the most common indications for prescribing antimicrobial therapy to otherwise healthy women, but wide variation in prescribing practices has been described.^1-2 This has prompted the need for guidelines to help providers in their selection of empiric antimicrobial regimens. Antibiotic selection should take into consideration the efficacy of individual agents, as well as their propensity for inducing resistance, altering gut flora, and increasing the risk of colonization or infection with multi-drug resistant organisms.

Guideline Update

In March 2010, the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESCMID) published new guidelines for the treatment of uncomplicated cystitis and pyelonephritis in healthy, community-dwelling women.³

First-line recommended agents for empiric treatment of uncomplicated cystitis are:

• nitrofurantoin for five days;
• trimethoprim-sulfamethoxazole for three days;
• fosfomycin in a single dose; or
• pivmecillinam (where available) for three to seven days.

Although highly efficacious, fluoroquinolones are not recommended as first-line treatment for acute cystitis because of their propensity for causing “collateral damage,” especially alteration of gut flora and increased risk of multi-drug resistant infection or colonization, including methicillin-resistant Staphylococcus aureus. Oral beta-lactams (other than pivmecillinam) have generally demonstrated inferior efficacy and more adverse effects when compared with the above agents, and should be used only if none of the preferred agents can be used. Specifically, amoxicillin and ampicillin are not recommended as empiric therapy due to their low efficacy in unselected patients, though may be appropriate when culture data is available to guide therapy. Narrow spectrum cephalosporins are also a potential agent for use in certain clinical situations, although the guidelines do not make any recommendation for or against their use, given a lack of studies.

For the treatment of acute pyelonephritis, the guidelines emphasize that all patients should have urine culture and susceptibility testing in order to tailor empiric therapy to the specific uropathogen. A 5-7 day course of an oral fluoroquinolone is appropriate when the prevalence of resistance in community uropathogens is ≤10%. Where resistance is more common, an initial intravenous dose of ceftriaxone or an aminoglycoside can be administered prior to starting oral therapy. Other alternatives include a 14-day course of trimethoprim-sulfamethoxazole or an oral beta-lactam.

Women requiring hospitalization for pyelonephritis should initially be treated with an intravenous antimicrobial regimen, the choice of which should be based on local resistance patterns. Recommended intravenous agents include fluoroquinolones, aminoglycosides (with or without ampicillin), extended-spectrum cephalosporins / penicillins, or carbapenems.

Analysis

Previous guidelines for the treatment of uncomplicated cystitis and pyelonephritis were published by the IDSA in 1999.⁴ The guidelines were updated based on the following factors:

• continued variability in prescribing practices;1-2
• increase in antimicrobial resistance among uropathogens;
• awareness of the unintended consequences of antimicrobial therapy, such as selection of drug-resistant organisms and colonization or infection with multi-drug resistant organisms; and
• study of newer agents and different durations of therapy.

Two important differences exist between the 1999 and 2010 guidelines:

• Nitrofurantoin has taken on more prominence in the 2010 guidelines for uncomplicated cystitis. The 1999 guidelines recommended trimethoprim-sulfamethoxazole as a first-line agent and mentioned nitrofurantoin and fosfomycin as potential alternative agents, but had few studies available to inform comparative efficacy or duration of therapy.
• For the outpatient treatment of mildly-ill patients with acute pyelonephritis, the 1999 guidelines recommended 14 days of therapy regardless of the agent used; in contrast, the 2010 guidelines recommend a five- to seven-day course for oral fluoroquinolones.

The American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine have endorsed the 2010 IDSA-ESCMID guidelines. The IDSA and ESCMID plan to evaluate the need for revisions to the 2010 guidelines based on an annual review of the current literature.

HM Takeaways

The 2010 IDSA-ESCMID guidelines are a resource available to hospitalists treating acute uncomplicated cystitis and pyelonephritis. As important differences exist between the target population and the hospitalist’s patient population, there are some key points to consider for clinicians treating cystitis or pyelonephritis in hospitalized patients.

Importantly, while nitrofurantoin is favored as a first-line antimicrobial agent for cystitis in the 2010 IDSA-ESCMID guidelines, it might be problematic in hospitalized patients for several reasons:

• it is not approved or recommended for the treatment of pyelonephritis;
• it is contraindicated in patients with creatinine clearance <60 ml/min; and
• it is generally not recommended for use in patients >65 years old because of the risk of renal impairment (Beers Criteria).⁵

Additionally, the treatment of acute cystitis in men requires special consideration. Notably, nitrofurantoin is not recommended in men because of poor prostatic tissue penetration, and although studies are limited, some sources recommend a longer treatment duration of at least 7 days.⁶ Finally, hospitalized patients commonly have other conditions, such as urological abnormalities, indwelling Foley catheters, recent urinary tract instrumentation, recent use of antibiotics, risk for multi-drug resistant organisms, potential interactions with other medications, and immunosuppression. The presence of any of these factors will influence the choice of empiric therapy and may warrant treatment for complicated cystitis or pyelonephritis, which are not addressed by these guidelines.

Drs. Tarvin and Sponsler are academic hospitalists at Vanderbilt University School of Medicine in Nashville, Tenn.

References

1. Huang ES, Stafford RS. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med. 2006;166:635-639.
2. Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Therap. 2004;29:59-63.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Inf Dis. 2011;52(5):e103-20.
4. Warren JW, Abrutyn E, Hebel JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America. Clin Inf Dis. 1999;29(4):745-58.
5. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
6. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. A Fam Phys. 2005;72(3):451-456.

Four hospitalists have joined Team Hospitalist, the only readerinvolvement group of its kind in HM. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Rajan Gurunathan, MD

Chief, section of hospital medicine, Division of General Medicine, associate attending, Department of Medicine, St. Luke’s-Roosevelt Hospital Center, New York, N.Y.

Nick Fitterman, MD, FACp, SFHM

Chief of staff and director of hospitalist services, Huntington Hospital, Huntington, N.Y., assistant professor of medicine, Hofstra University School of Medicine

Chithra R. Perumalswami, MD

Assistant professor of medicine, division of hospital medicine, section of palliative care, Northwestern University Feinberg School of Medicine, Chicago

Edward Ma, MD

Principal, The Hospitalist Consulting Group, LLC, Glen Mills, Pa., hospitalist, Chester County Hospital, West Chester, Pa.

Four hospitalists have joined Team Hospitalist, the only readerinvolvement group of its kind in HM. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Rajan Gurunathan, MD

Chief, section of hospital medicine, Division of General Medicine, associate attending, Department of Medicine, St. Luke’s-Roosevelt Hospital Center, New York, N.Y.

Nick Fitterman, MD, FACp, SFHM

Chief of staff and director of hospitalist services, Huntington Hospital, Huntington, N.Y., assistant professor of medicine, Hofstra University School of Medicine

Chithra R. Perumalswami, MD

Assistant professor of medicine, division of hospital medicine, section of palliative care, Northwestern University Feinberg School of Medicine, Chicago

Edward Ma, MD

Principal, The Hospitalist Consulting Group, LLC, Glen Mills, Pa., hospitalist, Chester County Hospital, West Chester, Pa.

Four hospitalists have joined Team Hospitalist, the only readerinvolvement group of its kind in HM. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Rajan Gurunathan, MD

Chief, section of hospital medicine, Division of General Medicine, associate attending, Department of Medicine, St. Luke’s-Roosevelt Hospital Center, New York, N.Y.

Nick Fitterman, MD, FACp, SFHM

Chief of staff and director of hospitalist services, Huntington Hospital, Huntington, N.Y., assistant professor of medicine, Hofstra University School of Medicine

Chithra R. Perumalswami, MD

Assistant professor of medicine, division of hospital medicine, section of palliative care, Northwestern University Feinberg School of Medicine, Chicago

Edward Ma, MD

Principal, The Hospitalist Consulting Group, LLC, Glen Mills, Pa., hospitalist, Chester County Hospital, West Chester, Pa.

In addition to the annual meeting, SHM and its partners bring hospitalists the very best in education, professional development, and networking in the form of in-person meetings.

July: Pediatric Hospital Medicine

Every year, hundreds of pediatric hospitalists come together to share their passion for caring for hospitalized children. This year, Pediatric Hospital Medicine 2012 will convene July 19-22 at the Northern Kentucky Convention Center, just outside Cincinnati. The meeting is co-sponsored by the Academic Pediatric Association, SHM, and the American Academy of Pediatrics.

For details and to register, visit www.hospitalmedicine.org/events.

October: Leadership Academy

SHM’s Leadership Academy continues to create the next generation of hospitalist leaders and sharpen the skills of existing leaders.

SHM will present its next industry-leading Leadership Academy Oct. 1-4 in Scottsdale, Ariz. The program will feature the popular “Foundations of Effective Leadership” course and the second-level “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” course.

Both courses build leadership skills for hospitalists, or, as more than one hospitalist has called the curriculum, “everything they don’t teach you in medical school.”

In the highly interactive, four-day “Foundations of Effective Leadership” course, hospitalists learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, and examine how hospital metrics are derived.

The “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” program provides skills building for hospitalists who want to drive culture change through specific leadership behaviors and actions. It also delves deep into financial storytelling, effective professional negotiation activities with proven techniques, and more.

“Advanced Leadership” is a second-level course and is open only to hospitalists who have completed the “Foundations of Effective Leadership” course, or who have earned an advanced management degree, such as an MBA.

Both courses are required for the new Leadership Certification program, which gives hospitalists the ability to demonstrate their leadership skills through certification.

Hospitalists planning to take any Leadership Academy course should note that, starting in 2013, Leadership Academy courses will be offered only in the fall.

For details and registration, visit www.hospitalmedicine.org/leadership.

Anytime: Online Education

Hospitalists working to demonstrate their expertise and commitment to HM through the Focused Practice in Hospital Medicine designation can earn Maintenance of Certification (MOC) self-evaluation points and CME credit online at www.hospitalmedicine.org/mkm.

SHM’s Medical Knowledge Modules are online learning and self-evaluation tools that provide the user with industry-leading instruction on quality-improvement (QI) theory; project design; system processes; measurement; chance science; tools for implementation; epidemiology of patient safety; and error types, disclosure, prevention strategies, and theory.

Three Medical Knowledge Modules are available: Hospital QI and Patient Safety, Hospital QI and Patient Safety II, and Pediatric Hospital QI and Patient Safety. Each online module consists of 25 multiple-choice questions. If the correct answer is chosen, the module provides a rationale explaining why that answer was correct. When an incorrect answer is selected, users are encouraged to try again.

Each module will earn hospitalists 10 self-evaluation points for diplomates enrolled in ABIM’s MOC program and three AMA PRA Category 1 CME Credits.

SHM will continue to roll out other topics throughout 2012.

Brendon Shank is SHM associate vice president of communications.

In addition to the annual meeting, SHM and its partners bring hospitalists the very best in education, professional development, and networking in the form of in-person meetings.

July: Pediatric Hospital Medicine

Every year, hundreds of pediatric hospitalists come together to share their passion for caring for hospitalized children. This year, Pediatric Hospital Medicine 2012 will convene July 19-22 at the Northern Kentucky Convention Center, just outside Cincinnati. The meeting is co-sponsored by the Academic Pediatric Association, SHM, and the American Academy of Pediatrics.

For details and to register, visit www.hospitalmedicine.org/events.

October: Leadership Academy

SHM’s Leadership Academy continues to create the next generation of hospitalist leaders and sharpen the skills of existing leaders.

SHM will present its next industry-leading Leadership Academy Oct. 1-4 in Scottsdale, Ariz. The program will feature the popular “Foundations of Effective Leadership” course and the second-level “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” course.

Both courses build leadership skills for hospitalists, or, as more than one hospitalist has called the curriculum, “everything they don’t teach you in medical school.”

In the highly interactive, four-day “Foundations of Effective Leadership” course, hospitalists learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, and examine how hospital metrics are derived.

The “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” program provides skills building for hospitalists who want to drive culture change through specific leadership behaviors and actions. It also delves deep into financial storytelling, effective professional negotiation activities with proven techniques, and more.

“Advanced Leadership” is a second-level course and is open only to hospitalists who have completed the “Foundations of Effective Leadership” course, or who have earned an advanced management degree, such as an MBA.

Both courses are required for the new Leadership Certification program, which gives hospitalists the ability to demonstrate their leadership skills through certification.

Hospitalists planning to take any Leadership Academy course should note that, starting in 2013, Leadership Academy courses will be offered only in the fall.

For details and registration, visit www.hospitalmedicine.org/leadership.

Anytime: Online Education

Hospitalists working to demonstrate their expertise and commitment to HM through the Focused Practice in Hospital Medicine designation can earn Maintenance of Certification (MOC) self-evaluation points and CME credit online at www.hospitalmedicine.org/mkm.

SHM’s Medical Knowledge Modules are online learning and self-evaluation tools that provide the user with industry-leading instruction on quality-improvement (QI) theory; project design; system processes; measurement; chance science; tools for implementation; epidemiology of patient safety; and error types, disclosure, prevention strategies, and theory.

Three Medical Knowledge Modules are available: Hospital QI and Patient Safety, Hospital QI and Patient Safety II, and Pediatric Hospital QI and Patient Safety. Each online module consists of 25 multiple-choice questions. If the correct answer is chosen, the module provides a rationale explaining why that answer was correct. When an incorrect answer is selected, users are encouraged to try again.

Each module will earn hospitalists 10 self-evaluation points for diplomates enrolled in ABIM’s MOC program and three AMA PRA Category 1 CME Credits.

SHM will continue to roll out other topics throughout 2012.

Brendon Shank is SHM associate vice president of communications.

In addition to the annual meeting, SHM and its partners bring hospitalists the very best in education, professional development, and networking in the form of in-person meetings.

July: Pediatric Hospital Medicine

Every year, hundreds of pediatric hospitalists come together to share their passion for caring for hospitalized children. This year, Pediatric Hospital Medicine 2012 will convene July 19-22 at the Northern Kentucky Convention Center, just outside Cincinnati. The meeting is co-sponsored by the Academic Pediatric Association, SHM, and the American Academy of Pediatrics.

For details and to register, visit www.hospitalmedicine.org/events.

October: Leadership Academy

SHM’s Leadership Academy continues to create the next generation of hospitalist leaders and sharpen the skills of existing leaders.

SHM will present its next industry-leading Leadership Academy Oct. 1-4 in Scottsdale, Ariz. The program will feature the popular “Foundations of Effective Leadership” course and the second-level “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” course.

Both courses build leadership skills for hospitalists, or, as more than one hospitalist has called the curriculum, “everything they don’t teach you in medical school.”

In the highly interactive, four-day “Foundations of Effective Leadership” course, hospitalists learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, and examine how hospital metrics are derived.

The “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” program provides skills building for hospitalists who want to drive culture change through specific leadership behaviors and actions. It also delves deep into financial storytelling, effective professional negotiation activities with proven techniques, and more.

“Advanced Leadership” is a second-level course and is open only to hospitalists who have completed the “Foundations of Effective Leadership” course, or who have earned an advanced management degree, such as an MBA.

Both courses are required for the new Leadership Certification program, which gives hospitalists the ability to demonstrate their leadership skills through certification.

Hospitalists planning to take any Leadership Academy course should note that, starting in 2013, Leadership Academy courses will be offered only in the fall.

For details and registration, visit www.hospitalmedicine.org/leadership.

Anytime: Online Education

Hospitalists working to demonstrate their expertise and commitment to HM through the Focused Practice in Hospital Medicine designation can earn Maintenance of Certification (MOC) self-evaluation points and CME credit online at www.hospitalmedicine.org/mkm.

SHM’s Medical Knowledge Modules are online learning and self-evaluation tools that provide the user with industry-leading instruction on quality-improvement (QI) theory; project design; system processes; measurement; chance science; tools for implementation; epidemiology of patient safety; and error types, disclosure, prevention strategies, and theory.

Three Medical Knowledge Modules are available: Hospital QI and Patient Safety, Hospital QI and Patient Safety II, and Pediatric Hospital QI and Patient Safety. Each online module consists of 25 multiple-choice questions. If the correct answer is chosen, the module provides a rationale explaining why that answer was correct. When an incorrect answer is selected, users are encouraged to try again.

Each module will earn hospitalists 10 self-evaluation points for diplomates enrolled in ABIM’s MOC program and three AMA PRA Category 1 CME Credits.

SHM will continue to roll out other topics throughout 2012.

Brendon Shank is SHM associate vice president of communications.