Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.

Schedule More Providers

I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)

Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.

One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)

My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.

Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.

Fixed-Shift Schedules Inhibit Surge Capacity

I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.

The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.

Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.

Unit-Based Assignments

Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.

I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.

Schedule More Providers

I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)

Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.

One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)

My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.

Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.

Fixed-Shift Schedules Inhibit Surge Capacity

I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.

The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.

Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.

Unit-Based Assignments

Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.

I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.

Schedule More Providers

I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)

Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.

One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)

My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.

Of course, if I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.

Fixed-Shift Schedules Inhibit Surge Capacity

I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.

The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.

Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.

Unit-Based Assignments

Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.

I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants (www.nelsonflores.com) and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Did you happen to read a recent New York Times article (www.nytimes.com/2010/05/27/us/27hosp.html) about hospitalists? I thought the article was great, but I was surprised by some of the negative reader feedback. What did you think?

George Eppley, MD

Reed, Ga.

Dr. Hospitalist responds: I read the NYT article by Jane Gross, “New Breed of Specialist Steps in for Family Doctor,” which was published May 26. The accompanying reader comment section is available at http://newoldage.blogs.nytimes.com/2010/05/26/in-hospitals-new-fingers -on-the-pulse/?ref=us.

The article provides the statistics that all of us in HM have come to know: HM is the fastest-growing medical specialty in the U.S. and, over the past decade, the number of hospitalists in the U.S. has grown from hundreds to 30,000. Gross talks about the care a hospitalist at the Hospital of the University of Pennsylvania provides for her patient. She highlights the challenges of transitions of care and references the work being done by hospitalists and SHM to make sure patients are making safe transitions. While the article was largely supportive of HM, she does provide a shade of balance when she mentions the risks to the patient when hospitalists fail to do their job when it comes to communication.

As a practicing hospitalist, I kind of wished I had stopped reading at the end of the article. I honestly did not like most of what I read in the reader comment section. Although the article was a feel-good story, I think it is fair to say the reader comments were largely negative. I understand that readers with negative experiences with hospitalists might be more likely to post a comment; nevertheless, some of the comments are hard to ignore—mainly because I suspect some of it is true.

One reader from Raleigh, N.C., wrote, “Hospitalists proved inept at contacting the patients’ existing doctors or even talking to the patients. Then, on discharge to nursing homes for further recovery, the ball was dropped further, with very poor communication of medication dosages, etc.” Yikes! What happened to the communication and the medication reconciliation process?

A reader from Massachusetts wrote about “the hospitalist … (who) ordered five blood draws in the space of several hours to replicate tests that had already been taken by the primary-care physician before admission.” So, not only are hospitalists poor communicators and do not do a good job with transitions of care, but their care is also driving up the cost of healthcare needlessly?

The most positive comments seem to come from outpatient providers and, quite honestly, I found them lukewarm at best. A PCP from Charleston, S.C., wrote, “I no longer have to cancel the appointments of the patients at the last minute in order to attend to an emergency occurring outside my office. It is a very efficient system.” Glad to hear the hospitalist relationship is working out for you, Dr. PCP, but as a patient in the hospital, I am worried more about the competency of this doctor, whom I have never met before this hospitalization, as opposed to how this doctor is going to make you more “efficient” in your office practice.

I came away with several thoughts after reading the article and the comments.

First, we need to set the right expectations. Is this the equivalent of the star athlete who makes a brash statement followed shortly thereafter by the statement, “I was misquoted”? Well … maybe. Are we who we say we are? The headline is “New Breed of Specialist Steps in for Family Doctor.”

As a practicing hospitalist, I never describe myself as replacing the family doctor, because this is the worst position I could put myself in. A patient might have a relationship with a family doctor for three or four decades. This family doctor might not only care for this patient, but also his children and grandchildren. The patient visits the family doctor at least once a year for a checkup. But when the patient is as sick as they have ever been in their life and needs their family doctor whom they trust, I am supposed to “step in” for this family doctor? Good luck trying to meet that standard. It’s like putting me next to Justin Timberlake on stage at a teenybopper concert. Who do you think is going to look better in that sort of comparison?

We, as hospitalists, should never allow anyone to think we are replacing their family doctor. We are here to work with the family doctor to provide the best care possible. Do surgeons, medical subspecialists, or ED doctors “replace” the family doctor? No way! They are working with the family doctor. Perhaps the problem here is that we have not set the appropriate expectations for our patients.

Next, we need to be clear in saying what we say we do or doing we what we say we do. A line in this article bothers me more than any of the reader comments: “The most compelling argument in favor of hospitalists, who are now in 5,000 institutions, from academic giants like the Hospital of the University of Pennsylvania to small community hospitals to innovators like the Mayo and Cleveland Clinics—is that they are there all the time.”

Why does it bother me so much? It is troubling because it is misleading and might simply be untrue. Many hospitalists are not there “all the time.” While many of our hospitalist programs have providers in the hospital 24 hours a day, many do not. I know a number of hospitalists who make rounds at multiple hospitals throughout the day. Are they really hospitalists or are they inpatient rounders?

Hospitalists are physicians defined by their location, not unlike ED physicians. Do we have ED doctors going from hospital to hospital, leaving nurses alone to care for patients when they are at another hospital? So what do we expect from our hospitalists? Should they be in the hospital 24/7? That would seem to be more consistent with the thought that “they are there all the time.” Remember, Gross did not say hospitalists are “reachable” all the time. She did say hospitalists are “on top of everything that happens to a patient—from entry through treatment and discharge.” It is time that we, as hospitalists, uniformly meet those expectations. Patients all over the country are figuring out that not all hospitalists are doing what they are supposed to do when it comes to communications and establishing safe transitions of care. Remember the adage: It does not take many rotten apples to spoil the barrel.

Last, let us talk more about how hospitalists can provide patient-centric care, as opposed to cost savings and carrying out President Obama’s marching orders. The article describes how a study published in the Journal of the American Medical Association found that patients have a reduced length of stay in the hospital when cared for by hospitalists; how hospitalists are being viewed as leaders in healthcare reform; and how the hospitalist spends her nonclinical time “design(ing) computer programs to contain costs.” Do not get me wrong. I am supportive as anyone of the notion that hospitalists should provide cost-effective care. But the reality is that our patients’ No. 1 priority is to believe that their doctor is providing the best care possible. They do not want to feel someone is short-changing them.

Talk all you want to insurers and hospitals about cost savings, but when speaking with patients, I think it makes more sense to discuss the quality as opposed to cost of care. Ask your next patient whether they give a hoot what you do when you are not caring for them. TH

Did you happen to read a recent New York Times article (www.nytimes.com/2010/05/27/us/27hosp.html) about hospitalists? I thought the article was great, but I was surprised by some of the negative reader feedback. What did you think?

George Eppley, MD

Reed, Ga.

Dr. Hospitalist responds: I read the NYT article by Jane Gross, “New Breed of Specialist Steps in for Family Doctor,” which was published May 26. The accompanying reader comment section is available at http://newoldage.blogs.nytimes.com/2010/05/26/in-hospitals-new-fingers -on-the-pulse/?ref=us.

The article provides the statistics that all of us in HM have come to know: HM is the fastest-growing medical specialty in the U.S. and, over the past decade, the number of hospitalists in the U.S. has grown from hundreds to 30,000. Gross talks about the care a hospitalist at the Hospital of the University of Pennsylvania provides for her patient. She highlights the challenges of transitions of care and references the work being done by hospitalists and SHM to make sure patients are making safe transitions. While the article was largely supportive of HM, she does provide a shade of balance when she mentions the risks to the patient when hospitalists fail to do their job when it comes to communication.

As a practicing hospitalist, I kind of wished I had stopped reading at the end of the article. I honestly did not like most of what I read in the reader comment section. Although the article was a feel-good story, I think it is fair to say the reader comments were largely negative. I understand that readers with negative experiences with hospitalists might be more likely to post a comment; nevertheless, some of the comments are hard to ignore—mainly because I suspect some of it is true.

One reader from Raleigh, N.C., wrote, “Hospitalists proved inept at contacting the patients’ existing doctors or even talking to the patients. Then, on discharge to nursing homes for further recovery, the ball was dropped further, with very poor communication of medication dosages, etc.” Yikes! What happened to the communication and the medication reconciliation process?

A reader from Massachusetts wrote about “the hospitalist … (who) ordered five blood draws in the space of several hours to replicate tests that had already been taken by the primary-care physician before admission.” So, not only are hospitalists poor communicators and do not do a good job with transitions of care, but their care is also driving up the cost of healthcare needlessly?

The most positive comments seem to come from outpatient providers and, quite honestly, I found them lukewarm at best. A PCP from Charleston, S.C., wrote, “I no longer have to cancel the appointments of the patients at the last minute in order to attend to an emergency occurring outside my office. It is a very efficient system.” Glad to hear the hospitalist relationship is working out for you, Dr. PCP, but as a patient in the hospital, I am worried more about the competency of this doctor, whom I have never met before this hospitalization, as opposed to how this doctor is going to make you more “efficient” in your office practice.

I came away with several thoughts after reading the article and the comments.

First, we need to set the right expectations. Is this the equivalent of the star athlete who makes a brash statement followed shortly thereafter by the statement, “I was misquoted”? Well … maybe. Are we who we say we are? The headline is “New Breed of Specialist Steps in for Family Doctor.”

As a practicing hospitalist, I never describe myself as replacing the family doctor, because this is the worst position I could put myself in. A patient might have a relationship with a family doctor for three or four decades. This family doctor might not only care for this patient, but also his children and grandchildren. The patient visits the family doctor at least once a year for a checkup. But when the patient is as sick as they have ever been in their life and needs their family doctor whom they trust, I am supposed to “step in” for this family doctor? Good luck trying to meet that standard. It’s like putting me next to Justin Timberlake on stage at a teenybopper concert. Who do you think is going to look better in that sort of comparison?

We, as hospitalists, should never allow anyone to think we are replacing their family doctor. We are here to work with the family doctor to provide the best care possible. Do surgeons, medical subspecialists, or ED doctors “replace” the family doctor? No way! They are working with the family doctor. Perhaps the problem here is that we have not set the appropriate expectations for our patients.

Next, we need to be clear in saying what we say we do or doing we what we say we do. A line in this article bothers me more than any of the reader comments: “The most compelling argument in favor of hospitalists, who are now in 5,000 institutions, from academic giants like the Hospital of the University of Pennsylvania to small community hospitals to innovators like the Mayo and Cleveland Clinics—is that they are there all the time.”

Why does it bother me so much? It is troubling because it is misleading and might simply be untrue. Many hospitalists are not there “all the time.” While many of our hospitalist programs have providers in the hospital 24 hours a day, many do not. I know a number of hospitalists who make rounds at multiple hospitals throughout the day. Are they really hospitalists or are they inpatient rounders?

Hospitalists are physicians defined by their location, not unlike ED physicians. Do we have ED doctors going from hospital to hospital, leaving nurses alone to care for patients when they are at another hospital? So what do we expect from our hospitalists? Should they be in the hospital 24/7? That would seem to be more consistent with the thought that “they are there all the time.” Remember, Gross did not say hospitalists are “reachable” all the time. She did say hospitalists are “on top of everything that happens to a patient—from entry through treatment and discharge.” It is time that we, as hospitalists, uniformly meet those expectations. Patients all over the country are figuring out that not all hospitalists are doing what they are supposed to do when it comes to communications and establishing safe transitions of care. Remember the adage: It does not take many rotten apples to spoil the barrel.

Last, let us talk more about how hospitalists can provide patient-centric care, as opposed to cost savings and carrying out President Obama’s marching orders. The article describes how a study published in the Journal of the American Medical Association found that patients have a reduced length of stay in the hospital when cared for by hospitalists; how hospitalists are being viewed as leaders in healthcare reform; and how the hospitalist spends her nonclinical time “design(ing) computer programs to contain costs.” Do not get me wrong. I am supportive as anyone of the notion that hospitalists should provide cost-effective care. But the reality is that our patients’ No. 1 priority is to believe that their doctor is providing the best care possible. They do not want to feel someone is short-changing them.

Talk all you want to insurers and hospitals about cost savings, but when speaking with patients, I think it makes more sense to discuss the quality as opposed to cost of care. Ask your next patient whether they give a hoot what you do when you are not caring for them. TH

Did you happen to read a recent New York Times article (www.nytimes.com/2010/05/27/us/27hosp.html) about hospitalists? I thought the article was great, but I was surprised by some of the negative reader feedback. What did you think?

George Eppley, MD

Reed, Ga.

Dr. Hospitalist responds: I read the NYT article by Jane Gross, “New Breed of Specialist Steps in for Family Doctor,” which was published May 26. The accompanying reader comment section is available at http://newoldage.blogs.nytimes.com/2010/05/26/in-hospitals-new-fingers -on-the-pulse/?ref=us.

The article provides the statistics that all of us in HM have come to know: HM is the fastest-growing medical specialty in the U.S. and, over the past decade, the number of hospitalists in the U.S. has grown from hundreds to 30,000. Gross talks about the care a hospitalist at the Hospital of the University of Pennsylvania provides for her patient. She highlights the challenges of transitions of care and references the work being done by hospitalists and SHM to make sure patients are making safe transitions. While the article was largely supportive of HM, she does provide a shade of balance when she mentions the risks to the patient when hospitalists fail to do their job when it comes to communication.

As a practicing hospitalist, I kind of wished I had stopped reading at the end of the article. I honestly did not like most of what I read in the reader comment section. Although the article was a feel-good story, I think it is fair to say the reader comments were largely negative. I understand that readers with negative experiences with hospitalists might be more likely to post a comment; nevertheless, some of the comments are hard to ignore—mainly because I suspect some of it is true.

One reader from Raleigh, N.C., wrote, “Hospitalists proved inept at contacting the patients’ existing doctors or even talking to the patients. Then, on discharge to nursing homes for further recovery, the ball was dropped further, with very poor communication of medication dosages, etc.” Yikes! What happened to the communication and the medication reconciliation process?

A reader from Massachusetts wrote about “the hospitalist … (who) ordered five blood draws in the space of several hours to replicate tests that had already been taken by the primary-care physician before admission.” So, not only are hospitalists poor communicators and do not do a good job with transitions of care, but their care is also driving up the cost of healthcare needlessly?

The most positive comments seem to come from outpatient providers and, quite honestly, I found them lukewarm at best. A PCP from Charleston, S.C., wrote, “I no longer have to cancel the appointments of the patients at the last minute in order to attend to an emergency occurring outside my office. It is a very efficient system.” Glad to hear the hospitalist relationship is working out for you, Dr. PCP, but as a patient in the hospital, I am worried more about the competency of this doctor, whom I have never met before this hospitalization, as opposed to how this doctor is going to make you more “efficient” in your office practice.

I came away with several thoughts after reading the article and the comments.

First, we need to set the right expectations. Is this the equivalent of the star athlete who makes a brash statement followed shortly thereafter by the statement, “I was misquoted”? Well … maybe. Are we who we say we are? The headline is “New Breed of Specialist Steps in for Family Doctor.”

As a practicing hospitalist, I never describe myself as replacing the family doctor, because this is the worst position I could put myself in. A patient might have a relationship with a family doctor for three or four decades. This family doctor might not only care for this patient, but also his children and grandchildren. The patient visits the family doctor at least once a year for a checkup. But when the patient is as sick as they have ever been in their life and needs their family doctor whom they trust, I am supposed to “step in” for this family doctor? Good luck trying to meet that standard. It’s like putting me next to Justin Timberlake on stage at a teenybopper concert. Who do you think is going to look better in that sort of comparison?

We, as hospitalists, should never allow anyone to think we are replacing their family doctor. We are here to work with the family doctor to provide the best care possible. Do surgeons, medical subspecialists, or ED doctors “replace” the family doctor? No way! They are working with the family doctor. Perhaps the problem here is that we have not set the appropriate expectations for our patients.

Next, we need to be clear in saying what we say we do or doing we what we say we do. A line in this article bothers me more than any of the reader comments: “The most compelling argument in favor of hospitalists, who are now in 5,000 institutions, from academic giants like the Hospital of the University of Pennsylvania to small community hospitals to innovators like the Mayo and Cleveland Clinics—is that they are there all the time.”

Why does it bother me so much? It is troubling because it is misleading and might simply be untrue. Many hospitalists are not there “all the time.” While many of our hospitalist programs have providers in the hospital 24 hours a day, many do not. I know a number of hospitalists who make rounds at multiple hospitals throughout the day. Are they really hospitalists or are they inpatient rounders?

Hospitalists are physicians defined by their location, not unlike ED physicians. Do we have ED doctors going from hospital to hospital, leaving nurses alone to care for patients when they are at another hospital? So what do we expect from our hospitalists? Should they be in the hospital 24/7? That would seem to be more consistent with the thought that “they are there all the time.” Remember, Gross did not say hospitalists are “reachable” all the time. She did say hospitalists are “on top of everything that happens to a patient—from entry through treatment and discharge.” It is time that we, as hospitalists, uniformly meet those expectations. Patients all over the country are figuring out that not all hospitalists are doing what they are supposed to do when it comes to communications and establishing safe transitions of care. Remember the adage: It does not take many rotten apples to spoil the barrel.

Last, let us talk more about how hospitalists can provide patient-centric care, as opposed to cost savings and carrying out President Obama’s marching orders. The article describes how a study published in the Journal of the American Medical Association found that patients have a reduced length of stay in the hospital when cared for by hospitalists; how hospitalists are being viewed as leaders in healthcare reform; and how the hospitalist spends her nonclinical time “design(ing) computer programs to contain costs.” Do not get me wrong. I am supportive as anyone of the notion that hospitalists should provide cost-effective care. But the reality is that our patients’ No. 1 priority is to believe that their doctor is providing the best care possible. They do not want to feel someone is short-changing them.

Talk all you want to insurers and hospitals about cost savings, but when speaking with patients, I think it makes more sense to discuss the quality as opposed to cost of care. Ask your next patient whether they give a hoot what you do when you are not caring for them. TH

A 38-year-old woman presents with recurrent asymptomatic lesions on the palms and soles and on the sides of both feet. The lesions have been developing for 2 months, unaccompanied by fever or other systemic symptoms.

Laboratory tests of C-reactive protein, erythrocyte sedimentation rate, viral serologies, and antinuclear antibodies are normal. A pustule culture is negative, and a cutaneous biopsy shows parakeratosis and elongation of rete ridges, neutrophils migrating from papillary capillaries to the epidermis, and spongiform Kogoj pustule.

Q: Which is the most likely diagnosis?

• Pustular psoriasis
• Impetigo contagiosa
• Syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO)
• Dyshidrotic eczema
• Acute exanthematous pustulosis (drug eruption)

A: SAPHO syndrome is the most likely diagnosis. The presence of pustules and aseptic osteitis of the anterior chest wall is compatible with SAPHO syndrome. Treatment with topical clobetasol propionate (Temovate) for pustules and NSAIDs for osteitis brought a good response.

Pustular psoriasis is an uncommon type of psoriasis characterized by erythema and pustules involving the flexural and anogenital areas. Cutaneous lesions of psoriasis vulgaris may be present before an acute pustular episode. Withdrawal of systemic corticosteroids in a patient with psoriasis has been reported as a precipitating factor.

Impetigo contagiosa is a superficial cutaneous infection characterized by an erythematous macule that evolves into a vesicle or pustule. These lesions are more common in children. Culture of the fluid usually reveals Staphylococcus aureus or S pyogenes.

Dyshidrotic eczema is a pruritic vesicular eruption of unknown cause on the palm and soles (bilateral and symmetric). The typical histologic findings are spongiotic and intraepidermal vesicles.

Acute exanthematous pustulosis is a drug-induced reaction characterized by confluent erythema, blisters, and pustules, mucous membrane erosions with fever, and lymphadenopathy. Cultures of the pustules are negative, and biopsy can help confirm the diagnosis of drug eruption.

SAPHO SYNDROME

SAPHO syndrome is a rare condition of unknown pathogenesis originally described by Chamot et al¹ in 1987. The onset is usually in young adulthood, and is similar in men and women. It is characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis. Of paramount importance is the finding of a non-infectious inflammatory osteitis in a patient with skin lesions.

Clinical findings: Pustules plus rheumatic pain

SAPHO syndrome must be suspected when a patient is affected by a pustular skin disease associated with rheumatic pain. If examination shows that the pain is caused by a sterile inflammation of bone or joints, the diagnosis tends to be confirmed.²

Osteoarticular involvement tends to be limited to the anterior chest wall. It may include aseptic osteitis, hyperostosis, and symmetrical arthritis. Peripheral and axial osteitis is one of the main characteristics of the syndrome and is found in around 90% of cases.

Cutaneous manifestations are present in two-thirds of patients and consist chiefly of severe acne (acne fulminans, acne conglobata, and hidradenitis suppurativa), pustular psoriasis, and palmoplantar pustulosis. Neutrophilic dermatoses associated with this syndrome include Sweet syndrome and pyoderma gangrenosum. Acne lesions are usually seen in men, whereas palmoplantar pustulosis is seen in women,³ often accompanying osteoarticular manifestations.

Radiologic findings in the spine are spondylodiskitis, osteosclerosis, sacroiliac joint involvement, and paravertebral ossification. In anterior chest wall hyperostosis, common findings are bone hypertrophy and sclerosis with a soft-tissue component. Laboratory test results are uncharacteristic, with variable signs of inflammation, and the C-reactive protein and sedimentation rate are usually elevated in the absence of leukocytosis.

Pathogenesis remains elusive

The pathogenesis of this syndrome remains elusive. Since SAPHO syndrome usually involves the axial skeleton, some investigators have suggested a possible link between the SAPHO syndrome and the seronegative spondyloarthopathies.³ It has also been related to an infection by Propionibacterium acnes and Corynebacterium species,⁴ which have been isolated in cultures of bone and skin lesions. However, the fact that these bacteria are contaminant agents makes their involvement in the pathogenesis of this syndrome unlikely. More recently, high concentrations of tumor necrosis factor alpha in bone specimens of patients with SAPHO syndrome have been reported, thus highlighting the central role of this cytokine in maintaining inflammation.

Treatment is to relieve symptoms

Since understanding of the pathogenesis of SAPHO syndrome is limited, a wide range of therapies has been used,⁵ mostly to relieve symptoms. These include NSAIDs; steroids; antibiotics; bisphosphonates such as pamidronate (Aredia) and zoledronic acid (Reclast); and immunosuppressors and immunomodulators such as methotrexate (Trexall), leflunomide (Arava), sulfasalazine (Azulfidine), cyclosporine (Sandimmune). The results with these therapies have been quite varied. Good response has been reported with tumor necrosis factor alpha blockers—infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira).⁶

A 38-year-old woman presents with recurrent asymptomatic lesions on the palms and soles and on the sides of both feet. The lesions have been developing for 2 months, unaccompanied by fever or other systemic symptoms.

Laboratory tests of C-reactive protein, erythrocyte sedimentation rate, viral serologies, and antinuclear antibodies are normal. A pustule culture is negative, and a cutaneous biopsy shows parakeratosis and elongation of rete ridges, neutrophils migrating from papillary capillaries to the epidermis, and spongiform Kogoj pustule.

Q: Which is the most likely diagnosis?

• Pustular psoriasis
• Impetigo contagiosa
• Syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO)
• Dyshidrotic eczema
• Acute exanthematous pustulosis (drug eruption)

A: SAPHO syndrome is the most likely diagnosis. The presence of pustules and aseptic osteitis of the anterior chest wall is compatible with SAPHO syndrome. Treatment with topical clobetasol propionate (Temovate) for pustules and NSAIDs for osteitis brought a good response.

Pustular psoriasis is an uncommon type of psoriasis characterized by erythema and pustules involving the flexural and anogenital areas. Cutaneous lesions of psoriasis vulgaris may be present before an acute pustular episode. Withdrawal of systemic corticosteroids in a patient with psoriasis has been reported as a precipitating factor.

Impetigo contagiosa is a superficial cutaneous infection characterized by an erythematous macule that evolves into a vesicle or pustule. These lesions are more common in children. Culture of the fluid usually reveals Staphylococcus aureus or S pyogenes.

Dyshidrotic eczema is a pruritic vesicular eruption of unknown cause on the palm and soles (bilateral and symmetric). The typical histologic findings are spongiotic and intraepidermal vesicles.

Acute exanthematous pustulosis is a drug-induced reaction characterized by confluent erythema, blisters, and pustules, mucous membrane erosions with fever, and lymphadenopathy. Cultures of the pustules are negative, and biopsy can help confirm the diagnosis of drug eruption.

SAPHO SYNDROME

SAPHO syndrome is a rare condition of unknown pathogenesis originally described by Chamot et al¹ in 1987. The onset is usually in young adulthood, and is similar in men and women. It is characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis. Of paramount importance is the finding of a non-infectious inflammatory osteitis in a patient with skin lesions.

Clinical findings: Pustules plus rheumatic pain

SAPHO syndrome must be suspected when a patient is affected by a pustular skin disease associated with rheumatic pain. If examination shows that the pain is caused by a sterile inflammation of bone or joints, the diagnosis tends to be confirmed.²

Osteoarticular involvement tends to be limited to the anterior chest wall. It may include aseptic osteitis, hyperostosis, and symmetrical arthritis. Peripheral and axial osteitis is one of the main characteristics of the syndrome and is found in around 90% of cases.

Cutaneous manifestations are present in two-thirds of patients and consist chiefly of severe acne (acne fulminans, acne conglobata, and hidradenitis suppurativa), pustular psoriasis, and palmoplantar pustulosis. Neutrophilic dermatoses associated with this syndrome include Sweet syndrome and pyoderma gangrenosum. Acne lesions are usually seen in men, whereas palmoplantar pustulosis is seen in women,³ often accompanying osteoarticular manifestations.

Radiologic findings in the spine are spondylodiskitis, osteosclerosis, sacroiliac joint involvement, and paravertebral ossification. In anterior chest wall hyperostosis, common findings are bone hypertrophy and sclerosis with a soft-tissue component. Laboratory test results are uncharacteristic, with variable signs of inflammation, and the C-reactive protein and sedimentation rate are usually elevated in the absence of leukocytosis.

Pathogenesis remains elusive

The pathogenesis of this syndrome remains elusive. Since SAPHO syndrome usually involves the axial skeleton, some investigators have suggested a possible link between the SAPHO syndrome and the seronegative spondyloarthopathies.³ It has also been related to an infection by Propionibacterium acnes and Corynebacterium species,⁴ which have been isolated in cultures of bone and skin lesions. However, the fact that these bacteria are contaminant agents makes their involvement in the pathogenesis of this syndrome unlikely. More recently, high concentrations of tumor necrosis factor alpha in bone specimens of patients with SAPHO syndrome have been reported, thus highlighting the central role of this cytokine in maintaining inflammation.

Treatment is to relieve symptoms

Since understanding of the pathogenesis of SAPHO syndrome is limited, a wide range of therapies has been used,⁵ mostly to relieve symptoms. These include NSAIDs; steroids; antibiotics; bisphosphonates such as pamidronate (Aredia) and zoledronic acid (Reclast); and immunosuppressors and immunomodulators such as methotrexate (Trexall), leflunomide (Arava), sulfasalazine (Azulfidine), cyclosporine (Sandimmune). The results with these therapies have been quite varied. Good response has been reported with tumor necrosis factor alpha blockers—infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira).⁶

A 38-year-old woman presents with recurrent asymptomatic lesions on the palms and soles and on the sides of both feet. The lesions have been developing for 2 months, unaccompanied by fever or other systemic symptoms.

Laboratory tests of C-reactive protein, erythrocyte sedimentation rate, viral serologies, and antinuclear antibodies are normal. A pustule culture is negative, and a cutaneous biopsy shows parakeratosis and elongation of rete ridges, neutrophils migrating from papillary capillaries to the epidermis, and spongiform Kogoj pustule.

Q: Which is the most likely diagnosis?

• Pustular psoriasis
• Impetigo contagiosa
• Syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO)
• Dyshidrotic eczema
• Acute exanthematous pustulosis (drug eruption)

A: SAPHO syndrome is the most likely diagnosis. The presence of pustules and aseptic osteitis of the anterior chest wall is compatible with SAPHO syndrome. Treatment with topical clobetasol propionate (Temovate) for pustules and NSAIDs for osteitis brought a good response.

Pustular psoriasis is an uncommon type of psoriasis characterized by erythema and pustules involving the flexural and anogenital areas. Cutaneous lesions of psoriasis vulgaris may be present before an acute pustular episode. Withdrawal of systemic corticosteroids in a patient with psoriasis has been reported as a precipitating factor.

Impetigo contagiosa is a superficial cutaneous infection characterized by an erythematous macule that evolves into a vesicle or pustule. These lesions are more common in children. Culture of the fluid usually reveals Staphylococcus aureus or S pyogenes.

Dyshidrotic eczema is a pruritic vesicular eruption of unknown cause on the palm and soles (bilateral and symmetric). The typical histologic findings are spongiotic and intraepidermal vesicles.

Acute exanthematous pustulosis is a drug-induced reaction characterized by confluent erythema, blisters, and pustules, mucous membrane erosions with fever, and lymphadenopathy. Cultures of the pustules are negative, and biopsy can help confirm the diagnosis of drug eruption.

SAPHO SYNDROME

SAPHO syndrome is a rare condition of unknown pathogenesis originally described by Chamot et al¹ in 1987. The onset is usually in young adulthood, and is similar in men and women. It is characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis. Of paramount importance is the finding of a non-infectious inflammatory osteitis in a patient with skin lesions.

Clinical findings: Pustules plus rheumatic pain

SAPHO syndrome must be suspected when a patient is affected by a pustular skin disease associated with rheumatic pain. If examination shows that the pain is caused by a sterile inflammation of bone or joints, the diagnosis tends to be confirmed.²

Osteoarticular involvement tends to be limited to the anterior chest wall. It may include aseptic osteitis, hyperostosis, and symmetrical arthritis. Peripheral and axial osteitis is one of the main characteristics of the syndrome and is found in around 90% of cases.

Cutaneous manifestations are present in two-thirds of patients and consist chiefly of severe acne (acne fulminans, acne conglobata, and hidradenitis suppurativa), pustular psoriasis, and palmoplantar pustulosis. Neutrophilic dermatoses associated with this syndrome include Sweet syndrome and pyoderma gangrenosum. Acne lesions are usually seen in men, whereas palmoplantar pustulosis is seen in women,³ often accompanying osteoarticular manifestations.

Radiologic findings in the spine are spondylodiskitis, osteosclerosis, sacroiliac joint involvement, and paravertebral ossification. In anterior chest wall hyperostosis, common findings are bone hypertrophy and sclerosis with a soft-tissue component. Laboratory test results are uncharacteristic, with variable signs of inflammation, and the C-reactive protein and sedimentation rate are usually elevated in the absence of leukocytosis.

Pathogenesis remains elusive

The pathogenesis of this syndrome remains elusive. Since SAPHO syndrome usually involves the axial skeleton, some investigators have suggested a possible link between the SAPHO syndrome and the seronegative spondyloarthopathies.³ It has also been related to an infection by Propionibacterium acnes and Corynebacterium species,⁴ which have been isolated in cultures of bone and skin lesions. However, the fact that these bacteria are contaminant agents makes their involvement in the pathogenesis of this syndrome unlikely. More recently, high concentrations of tumor necrosis factor alpha in bone specimens of patients with SAPHO syndrome have been reported, thus highlighting the central role of this cytokine in maintaining inflammation.

Treatment is to relieve symptoms

Since understanding of the pathogenesis of SAPHO syndrome is limited, a wide range of therapies has been used,⁵ mostly to relieve symptoms. These include NSAIDs; steroids; antibiotics; bisphosphonates such as pamidronate (Aredia) and zoledronic acid (Reclast); and immunosuppressors and immunomodulators such as methotrexate (Trexall), leflunomide (Arava), sulfasalazine (Azulfidine), cyclosporine (Sandimmune). The results with these therapies have been quite varied. Good response has been reported with tumor necrosis factor alpha blockers—infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira).⁶

Noninvasive positive pressure ventilation (NIPPV) is any form of positive ventilatory support applied without an endotracheal tube, including continuous positive airway pressure (CPAP).¹ The role of NIPPV in acute care has been discussed in an earlier review in the Cleveland Clinic Journal of Medicine.²

NIPPV is also used at night in outpatients with stable chronic conditions, first used in the 1980s in the treatment of obstructive sleep apnea³ and neuromuscular diseases,⁴ and since then in several other conditions including sleep disorders associated with congestive heart failure (including sleep apnea and the Cheyne-Stokes respiration-central sleep apnea syndrome), chronic obstructive pulmonary disease (COPD), and the obesity-hypoventilation syndrome.

In this review, we discuss the different types of NIPPV, the specific conditions in which they can be used, and the indications, recommendations, and evidence supporting the efficacy of NIPPV in outpatients.

THE TYPES OF NIPPV AND THEIR USES

Although the conditions for which different types of NIPPV can be used overlap significantly, each type has general indications and different goals of treatment. This section begins with types of NIPPV that are predominantly used to treat sleep-disordered breathing, and then proceeds to those predominantly used for conditions associated with hypoventilation and hypercapnia.

Continuous positive airway pressure

CPAP, currently the most widely used form of NIPPV, applies a constant level of positive pressure at the airway opening during spontaneous breathing.

CPAP is commonly used to treat obstructive sleep-disordered breathing, with the goals of improving daytime sleepiness and reducing cardiovascular risk. It has also been used to treat sleep-disordered breathing associated with congestive heart failure.

CPAP’s role in the support of ventilation is limited and indirect. For instance, it has been used in the obesity-hypoventilation syndrome and in the “overlap” syndrome (in which both sleep apnea and COPD coexist). However, its benefits in those conditions are probably derived in large part from correction of underlying obstructive sleep apnea.

The mechanisms of action of CPAP include:

• Preventing intermittent narrowing and collapse of the airway in patients with obstructive sleep apnea-hypopnea syndrome by acting as a pneumatic splint during sleep^3,5,6
• Counteracting auto-positive end-expiratory pressure, thereby reducing respiratory muscle load, reducing the work of breathing, and lowering daytime Paco₂ in patients with coexistent COPD and obstructive sleep apnea-hypopnea syndrome (the overlap syndrome)^7–9
• Improving lung function (particularly the functional residual capacity) and daytime gas exchange in obstructive sleep apnea-hypopnea syndrome ¹⁰
• Improving left ventricular systolic function in patients with heart failure coexisting with obstructive sleep apnea-hypopnea syndrome.^11,12

Auto-CPAP is delivered via a self-titrating CPAP device, which uses algorithms to detect variations in the degree of obstruction and consequently adjusts the pressure level to restore normal breathing. Auto-CPAP therefore compensates for factors that modify the upper airway collapsibility, such as body posture during sleep, stage of sleep, use of alcohol, and drugs that affect upper airway muscle tone.¹³

Although one of the premises of using auto-CPAP is that it improves the patient’s satisfaction and compliance, several studies found it to be no more effective than fixed CPAP for treating obstructive sleep apnea-hypopnea syndrome.^14–16 Current guidelines of the American Academy of Sleep Medicine do not recommend self-titrating CPAP devices to diagnose obstructive sleep apnea or to treat patients with cardiopulmonary disorders or other conditions in which nocturnal desaturation may be unrelated to obstructive events.¹⁷

Adaptive servo-ventilation

Adaptive servo-ventilation was developed for Cheyne-Stokes respiration-central sleep apnea syndrome in patients with congestive heart failure, who may have periods of crescendo-decrescendo change in tidal volume (Cheyne-Stokes respiration) with possible intercalated episodes of central apnea or hypopnea. It is also applied in patients with the complex sleep apnea syndrome.

Adaptive servo-ventilation devices are usually set at an expiratory positive airway pressure (EPAP) level sufficient to control obstructive sleep apnea. The device then automatically adjusts the pressure support for each inspiration, within a prespecified range, to maintain a moving-target ventilation set at 90% of the patient’s recent average ventilation. The aim is to stabilize breathing and reduce respiratory alkalosis, which can trigger apnea reentry cycles.¹⁸

Bilevel positive airway pressure

Bilevel positive airway pressure (bilevel PAP) can be of use in sleep-disordered breathing (including cases associated with congestive heart failure), but it is predominantly applied in conditions associated with hypoventilation.

Bilevel PAP devices deliver a higher pressure during inspiration (inspiratory positive airway pressure, or IPAP) and a lower pressure during expiration (EPAP). The gradient between IPAP and EPAP is of key importance in maintaining alveolar ventilation and reducing Paco₂. The IPAP acts as pressure support to augment the patient’s effort, maintain adequate alveolar ventilation, unload respiratory muscles, decrease the work of breathing, and control obstructive hypopnea, whereas EPAP is set to maintain upper airway patency, control obstructive apnea, improve functional residual capacity, and prevent microatelectasis.

Although there is no evidence that bilevel PAP is better adhered to or more effective than CPAP, current guidelines propose it as an option for patients who require high pressures to control obstructive sleep apnea-hypopnea syndrome or for those who cannot tolerate exhaling against a high fixed CPAP pressure.¹⁹

Other, more-common uses of bilevel PAP are to treat coexisting central sleep apnea or hypoventilation,¹⁹ the obesity-hypoventilation syndrome with residual alveolar hypoventilation despite CPAP and control of concomitant obstructive sleep apnea-hypopnea syndrome,^5,20 severe stable COPD with significant nocturnal hypoventilation and daytime hypercarbia,²¹ and restrictive pulmonary diseases.²¹

Average volume-assured pressure support

CONDITIONS IN WHICH NOCTURNAL NIPPV IS USED IN OUT PATIENTS

Obstructive sleep apnea-hypopnea syndrome

Obstructive sleep apnea-hypopnea syndrome is estimated to affect 2% of women and 4% of men.²⁵ It is characterized by recurrent episodes of partial (hypopnea) or complete (apnea) upper airway obstruction during sleep despite ongoing inspiratory efforts, with associated episodes of arousal or desaturation or both. Corresponding symptoms include excessive daytime sleepiness, choking and gasping during sleep, recurrent awakenings from sleep, unrefreshing sleep, daytime fatigue, and impaired concentration that is not explained by other factors.²⁶

Current understanding of the pathophysiology of obstructive sleep apnea implicates an impairment in the balance between factors that promote collapsibility of the airway (including obesity and anatomic issues such as the volume of the soft-tissue structures surrounding the upper airway) and the compensatory neuromuscular response.^27,28

Long-standing obstructive sleep apnea-hypopnea syndrome has been linked in prospective studies to the development of hypertension,^29–31 coronary artery disease,^32,33 increased coagulation,^34,35 and stroke or death from any cause.^36,37 It is also associated with a greater rate and severity of motor vehicular accidents,³⁸ greater health care utilization, impaired work performance, and occupational injuries.³⁹

Strong evidence exists that NIPPV (most commonly CPAP) is beneficial in obstructive sleep apnea-hypopnea syndrome, improving sleep quality, sleepiness, cognitive impairment, and quality of life,^40,41 decreasing motor vehicle accidents,⁴² lowering blood pressure, ^43,44 and decreasing the rates of myocardial infarction,³² stroke,³² and death.⁴⁵

The American Academy of Sleep Medicine recommends CPAP as an optional adjunctive therapy to lower blood pressure in patients with obstructive sleep apnea-hypopnea syndrome with concomitant hypertension.¹⁹ This is supported by a recent study that suggested that CPAP may have additional benefits on blood pressure in a subgroup of patients with uncontrolled hypertension while on antihypertensive medications.⁴⁶ Indications with Medicare guidelines for reimbursement of CPAP devices are summarized in Table 2.

Complex sleep apnea syndrome

The complex sleep apnea syndrome is characterized by the emergence of significant central sleep apnea or Cheyne-Stokes respiration after obstructive events have been brought under control with NIPPV in patients who initially appear to have obstructive sleep apnea-hypopnea syndrome. A retrospective study of patients with the complex sleep apnea syndrome who continued their NIPPV use until a subsequent polysomnographic study and NIPPV titration showed that the syndrome may resolve spontaneously, but that 46% of patients had a persistently elevated apnea-hypopnea index with central apnea activity.⁴⁷

Restoration of upper airway patency by CPAP and dysregulation or delayed adaptation of chemosensitive ventilatory control to a changing Paco₂ level may be a key pathophysiologic mechanism of the complex sleep apnea syndrome.⁴⁸ In this mechanism, increased ventilation from restored airway patency and from an increase in the slope of the ventilatory response may intermittently draw the Paco₂ to below the hypocapnic apneic threshold and trigger episodes of central apnea.⁴⁸

The ideal NIPPV device for use in the complex sleep apnea syndrome should be able to provide enough pressure to resolve the obstructive sleep apnea-hypopnea syndrome while maintaining proper ventilatory support during central apnea episodes without fluctuations of Paco₂, which could further worsen the dysregulated ventilatory control. Currently, adaptive servo-ventilation appears to be superior to bilevel PAP and CPAP in the management of the complex sleep apnea syndrome.^49,50

Sleep disturbances associated with cardiac dysfunction

There are specific indications for NIPPV modes in the setting of respiratory sleep disturbances associated with heart failure.

Obstructive sleep apnea in congestive heart failure. The prevalence of obstructive sleep apnea in patients with impaired left ventricular ejection fraction is 11% to 53%.⁵¹ Obstructive sleep apnea-hypopnea syndrome can worsen congestive heart failure by causing a periodic increase in negative intrathoracic pressure from breathing against an occluded airway, by raising arterial blood pressure, and causing tachycardia from sympathetic nervous system stimulation from hypoxia, hypercarbia, and arousals.^52,53 Both heart failure and sleep apnea contribute in an additive manner to the increased sympathetic nervous activity.⁵⁴

Fortunately, treatment with CPAP has been found to reduce systolic blood pressure and improve left ventricular systolic function in medically treated patients with heart failure and coexisting obstructive sleep apnea.^11,12 Furthermore, in a randomized trial in patients with stable congestive heart failure and newly diagnosed obstructive sleep apnea-hypopnea syndrome, a greater improvement in cardiac function was observed in patients on bilevel PAP than in those on CPAP.⁵⁵ The authors speculated that bilevel PAP might provide more unloading of the respiratory muscles, reduce the work of breathing more, and result in less positive intrathoracic pressure than with CPAP, and that the higher intrathoracic pressure with CPAP could reduce the left ventricular ejection fraction in patients with low filling pressures (pulmonary capillary wedge pressure < 12 mm Hg) and low baseline left ventricular ejection fractions (< 30%).⁵⁵

Whether these interventions reduce the mortality rate is uncertain. In a prospective nonrandomized study, 9 (24%) of 37 patients who had heart failure with untreated obstructive sleep apnea died, compared with no deaths in 14 treated patients (P = .07).⁵⁶

Cheyne-Stokes respiration with central sleep apnea in congestive heart failure. A related but different situation is central apnea associated with congestive heart failure.

There are several pathophysiologic mechanisms of Cheyne-Stokes respiration with central sleep apnea. Specifically, the elevation of left ventricular filling pressures, end-diastolic volumes, and pulmonary congestion generate hyperventilation, chronic hypocapnia, and increased chemoreceptor responsiveness, which contribute to the development of central apnea by promoting a decrease in the Paco₂ during sleep to below the hypocapnic apneic threshold.^57,58 Additionally, an increase in circulation time may result in periodicity of breathing and hyperpnea.⁵⁹ Obstructive events can then occur at the end of the central events corresponding with the nadir of the inspiratory drive.^60,61

The Canadian Continuous Positive Airway Pressure for Patients With Central Sleep Apnea and Heart Failure (CANPAP) trial, a randomized trial of CPAP in this clinical setting, showed that compared with optimal medical therapy alone, CPAP plus optimal medical therapy improved the ejection fraction, reduced central sleep apnea, improved nocturnal oxygenation, and improved the 6-minute walking distance, but without a survival benefit.⁶² The disappointing survival results from CANPAP have to be interpreted in the context that CPAP may have failed to control the central apnea in some patients, such that the mean apnea-hypopnea index in treated patients (19 events/hour) remained above the entry criterion for recruitment (15 events/hour). In a post hoc analysis of this study, the heart-transplantation-free survival rate was significantly greater in the subgroup of patients in whom CPAP effectively suppressed central sleep apnea (< 15 events/hour).⁶³

Other NIPPV modes such as bilevel PAP with backup rate and adaptive servo-ventilation have been shown in some studies to be superior to CPAP in controlling respiratory events, with adaptive servo-ventilation being the most effective in controlling central, mixed, and complex sleep apnea in this setting. ^49,50 Whether more effective resolution of obstructive and central events with these treatment modes translates into improved mortality rates and transplantation-free survival rates remains to be determined.

Obesity-hypoventilation syndrome refers to daytime hypercapnia (Paco₂ > 45 mm Hg) in obese people when no other cause of hypoventilation is present.

The prevalence of obesity-hypoventilation syndrome among patients with obstructive sleep apnea-hypopnea syndrome is 20% to 30% and is greater in extremely obese patients (body mass index > 40 kg/m²).⁶⁴ However, about 10% of patients with obesity-hypoventilation syndrome do not have obstructive sleep apnea-hypopnea syndrome.⁶⁴ Additionally, nocturnal hypoxemia and diurnal hypercapnia persist in about 40% of patients with obesity-hypoventilation syndrome after CPAP eliminates their sleep apnea.⁶⁵ Therefore, factors other than sleep apnea contribute to the development of obesity-hypoventilation syndrome, and in a meta-analysis, factors associated with daytime hypercapnia included, in addition to body mass index and the apnea-hypopnea index, mean overnight oxygen saturation and severity of restrictive pulmonary function.⁶⁶ Predictors of success with CPAP include better spirometric findings, a higher apnea-hypopnea index, and adequate oxygenation.^67,68

Bilevel PAP therapy can be tried in patients in whom CPAP by itself fails. In a study of patients with obesity-hypoventilation syndrome in whom initial CPAP treatment failed, average volume-assured pressure support lowered Paco₂ compared to bilevel PAP alone, but did not further improve oxygenation, sleep quality, or quality of life.⁶⁹

Restrictive pulmonary diseases

Neuromuscular diseases and thoracic cage abnormalities. Noninvasive ventilation has been used in patients with progressive neuromuscular disorders or severe thoracic cage abnormalities, with recognized benefits including an improved survival rate and improved quality of life.^70,71 However, NIPPV is used in only 9% of patients with amyotrophic lateral sclerosis when clearly indicated.⁷² The indications and Medicare guidelines for reimbursement of NIPPV (with or without a backup rate) in this setting are shown in Table 2.

Potential contraindications to starting NIPPV in this population include upper airway obstruction, failure to clear secretions despite optimal noninvasive support, inability to achieve a mask fit, and intolerance of the intervention.^73,74

The mechanisms of benefit of NIPPV in these settings include improvements in daytime blood gas levels (including hypercapnia⁷⁵), a reduction in the oxygen cost of breathing,⁷⁶ an increase in the ventilatory response to carbon dioxide,⁷⁵ and improved lung compliance.⁷⁷

Chronic hypercapnic failure due to severe COPD

The use of NIPPV in chronic COPD is less well established than in patients with exacerbations of COPD,⁷⁸ and limitations in its use are reflected in the more stringent Medicare indications for NIPPV in this setting (Table 2).

A particular subset of patients with stable COPD who may benefit from NIPPV includes those with daytime hypercapnia and super-imposed nocturnal hypoventilation.⁷⁸ The potential benefits of NIPPV in these patients include improved daytime and nocturnal gas exchange, increased sleep duration, and improved quality of life.⁷⁸ Additionally, a recent randomized controlled trial of NIPPV plus long-term oxygen therapy compared with oxygen therapy alone in patients with severe COPD and a Paco₂ greater than 46 mm Hg demonstrated a survival benefit in favor of adding NIPPV (hazard ratio 0.6).⁷⁹

However, that study also found no reduction in hospitalization rates, an apparent worsening in general and mental health (as reflected on the 36-Item Short Form Health Survey or SF-36, a quality-of-life questionnaire), as well as increased confusion and bewilderment (reflected on the Profile of Mood States scale).⁷⁹ These potentially deleterious effects may explain why adherence to NIPPV is low in patients with stable COPD: only 37% to 57% of patients continued to use it in several reported studies.^79–81

A level of inspiratory pressure support that is insufficient to reduce hypercapnia may account for the low adherence rate and worsened quality of life in such patients. For instance, in a randomized trial,⁸² compared with low-intensity NIPPV (mean IPAP 14 cm H₂O, backup rate 8 per minute), settings that aimed to maximally reduce Paco₂ (mean IPAP 29 cm H₂O with a backup rate of 17.5 per minute) increased the daily use of NIPPV by 3.6 hours/day and improved exercise-related dyspnea, daytime Paco₂, forced expiratory volume in 1 second (FEV₁), vital capacity, and health-related quality of life.

The overlap syndrome was first described by Flenley in 1985 as a combination of chronic respiratory disease (more generally limited to COPD) and obstructive sleep apnea-hypopnea syndrome.⁸³ Epidemiologic studies do not consistently show a higher incidence of obstructive sleep apnea-hypopnea syndrome in patients with COPD, but the exaggerated oxygen desaturation during sleep in patients with this combination increases the risk of hypoxemia, hypercapnia, and pulmonary hypertension. ⁸⁴ In addition, there was evidence of higher risks of death and of hospitalization for COPD in patients with the overlap syndrome. ⁸⁵ NIPPV is the main treatment for obstructive sleep apnea-hypopnea syndrome with or without COPD.

A recent study by Marin et al⁸⁵ showed that CPAP was associated with improved survival and decreased hospitalization in patients with the overlap syndrome. However, polysomnography or nocturnal oximetry while on NIPPV alone must be done, as additional nocturnal oxygen therapy may be warranted when significant chronic respiratory illness coexists with sleep apnea.
 

Acknowledgment: The authors gratefully acknowledge the contribution of Scott Marlow, RRT, to Table 2 of this review.

Noninvasive positive pressure ventilation (NIPPV) is any form of positive ventilatory support applied without an endotracheal tube, including continuous positive airway pressure (CPAP).¹ The role of NIPPV in acute care has been discussed in an earlier review in the Cleveland Clinic Journal of Medicine.²

NIPPV is also used at night in outpatients with stable chronic conditions, first used in the 1980s in the treatment of obstructive sleep apnea³ and neuromuscular diseases,⁴ and since then in several other conditions including sleep disorders associated with congestive heart failure (including sleep apnea and the Cheyne-Stokes respiration-central sleep apnea syndrome), chronic obstructive pulmonary disease (COPD), and the obesity-hypoventilation syndrome.

In this review, we discuss the different types of NIPPV, the specific conditions in which they can be used, and the indications, recommendations, and evidence supporting the efficacy of NIPPV in outpatients.

THE TYPES OF NIPPV AND THEIR USES

Although the conditions for which different types of NIPPV can be used overlap significantly, each type has general indications and different goals of treatment. This section begins with types of NIPPV that are predominantly used to treat sleep-disordered breathing, and then proceeds to those predominantly used for conditions associated with hypoventilation and hypercapnia.

Continuous positive airway pressure

CPAP, currently the most widely used form of NIPPV, applies a constant level of positive pressure at the airway opening during spontaneous breathing.

CPAP is commonly used to treat obstructive sleep-disordered breathing, with the goals of improving daytime sleepiness and reducing cardiovascular risk. It has also been used to treat sleep-disordered breathing associated with congestive heart failure.

CPAP’s role in the support of ventilation is limited and indirect. For instance, it has been used in the obesity-hypoventilation syndrome and in the “overlap” syndrome (in which both sleep apnea and COPD coexist). However, its benefits in those conditions are probably derived in large part from correction of underlying obstructive sleep apnea.

The mechanisms of action of CPAP include:

• Preventing intermittent narrowing and collapse of the airway in patients with obstructive sleep apnea-hypopnea syndrome by acting as a pneumatic splint during sleep^3,5,6
• Counteracting auto-positive end-expiratory pressure, thereby reducing respiratory muscle load, reducing the work of breathing, and lowering daytime Paco₂ in patients with coexistent COPD and obstructive sleep apnea-hypopnea syndrome (the overlap syndrome)^7–9
• Improving lung function (particularly the functional residual capacity) and daytime gas exchange in obstructive sleep apnea-hypopnea syndrome ¹⁰
• Improving left ventricular systolic function in patients with heart failure coexisting with obstructive sleep apnea-hypopnea syndrome.^11,12

Auto-CPAP is delivered via a self-titrating CPAP device, which uses algorithms to detect variations in the degree of obstruction and consequently adjusts the pressure level to restore normal breathing. Auto-CPAP therefore compensates for factors that modify the upper airway collapsibility, such as body posture during sleep, stage of sleep, use of alcohol, and drugs that affect upper airway muscle tone.¹³

Although one of the premises of using auto-CPAP is that it improves the patient’s satisfaction and compliance, several studies found it to be no more effective than fixed CPAP for treating obstructive sleep apnea-hypopnea syndrome.^14–16 Current guidelines of the American Academy of Sleep Medicine do not recommend self-titrating CPAP devices to diagnose obstructive sleep apnea or to treat patients with cardiopulmonary disorders or other conditions in which nocturnal desaturation may be unrelated to obstructive events.¹⁷

Adaptive servo-ventilation

Adaptive servo-ventilation was developed for Cheyne-Stokes respiration-central sleep apnea syndrome in patients with congestive heart failure, who may have periods of crescendo-decrescendo change in tidal volume (Cheyne-Stokes respiration) with possible intercalated episodes of central apnea or hypopnea. It is also applied in patients with the complex sleep apnea syndrome.

Adaptive servo-ventilation devices are usually set at an expiratory positive airway pressure (EPAP) level sufficient to control obstructive sleep apnea. The device then automatically adjusts the pressure support for each inspiration, within a prespecified range, to maintain a moving-target ventilation set at 90% of the patient’s recent average ventilation. The aim is to stabilize breathing and reduce respiratory alkalosis, which can trigger apnea reentry cycles.¹⁸

Bilevel positive airway pressure

Bilevel positive airway pressure (bilevel PAP) can be of use in sleep-disordered breathing (including cases associated with congestive heart failure), but it is predominantly applied in conditions associated with hypoventilation.

Bilevel PAP devices deliver a higher pressure during inspiration (inspiratory positive airway pressure, or IPAP) and a lower pressure during expiration (EPAP). The gradient between IPAP and EPAP is of key importance in maintaining alveolar ventilation and reducing Paco₂. The IPAP acts as pressure support to augment the patient’s effort, maintain adequate alveolar ventilation, unload respiratory muscles, decrease the work of breathing, and control obstructive hypopnea, whereas EPAP is set to maintain upper airway patency, control obstructive apnea, improve functional residual capacity, and prevent microatelectasis.

Although there is no evidence that bilevel PAP is better adhered to or more effective than CPAP, current guidelines propose it as an option for patients who require high pressures to control obstructive sleep apnea-hypopnea syndrome or for those who cannot tolerate exhaling against a high fixed CPAP pressure.¹⁹

Other, more-common uses of bilevel PAP are to treat coexisting central sleep apnea or hypoventilation,¹⁹ the obesity-hypoventilation syndrome with residual alveolar hypoventilation despite CPAP and control of concomitant obstructive sleep apnea-hypopnea syndrome,^5,20 severe stable COPD with significant nocturnal hypoventilation and daytime hypercarbia,²¹ and restrictive pulmonary diseases.²¹

Average volume-assured pressure support

CONDITIONS IN WHICH NOCTURNAL NIPPV IS USED IN OUT PATIENTS

Obstructive sleep apnea-hypopnea syndrome

Obstructive sleep apnea-hypopnea syndrome is estimated to affect 2% of women and 4% of men.²⁵ It is characterized by recurrent episodes of partial (hypopnea) or complete (apnea) upper airway obstruction during sleep despite ongoing inspiratory efforts, with associated episodes of arousal or desaturation or both. Corresponding symptoms include excessive daytime sleepiness, choking and gasping during sleep, recurrent awakenings from sleep, unrefreshing sleep, daytime fatigue, and impaired concentration that is not explained by other factors.²⁶

Current understanding of the pathophysiology of obstructive sleep apnea implicates an impairment in the balance between factors that promote collapsibility of the airway (including obesity and anatomic issues such as the volume of the soft-tissue structures surrounding the upper airway) and the compensatory neuromuscular response.^27,28

Long-standing obstructive sleep apnea-hypopnea syndrome has been linked in prospective studies to the development of hypertension,^29–31 coronary artery disease,^32,33 increased coagulation,^34,35 and stroke or death from any cause.^36,37 It is also associated with a greater rate and severity of motor vehicular accidents,³⁸ greater health care utilization, impaired work performance, and occupational injuries.³⁹

Strong evidence exists that NIPPV (most commonly CPAP) is beneficial in obstructive sleep apnea-hypopnea syndrome, improving sleep quality, sleepiness, cognitive impairment, and quality of life,^40,41 decreasing motor vehicle accidents,⁴² lowering blood pressure, ^43,44 and decreasing the rates of myocardial infarction,³² stroke,³² and death.⁴⁵

The American Academy of Sleep Medicine recommends CPAP as an optional adjunctive therapy to lower blood pressure in patients with obstructive sleep apnea-hypopnea syndrome with concomitant hypertension.¹⁹ This is supported by a recent study that suggested that CPAP may have additional benefits on blood pressure in a subgroup of patients with uncontrolled hypertension while on antihypertensive medications.⁴⁶ Indications with Medicare guidelines for reimbursement of CPAP devices are summarized in Table 2.

Complex sleep apnea syndrome

The complex sleep apnea syndrome is characterized by the emergence of significant central sleep apnea or Cheyne-Stokes respiration after obstructive events have been brought under control with NIPPV in patients who initially appear to have obstructive sleep apnea-hypopnea syndrome. A retrospective study of patients with the complex sleep apnea syndrome who continued their NIPPV use until a subsequent polysomnographic study and NIPPV titration showed that the syndrome may resolve spontaneously, but that 46% of patients had a persistently elevated apnea-hypopnea index with central apnea activity.⁴⁷

Restoration of upper airway patency by CPAP and dysregulation or delayed adaptation of chemosensitive ventilatory control to a changing Paco₂ level may be a key pathophysiologic mechanism of the complex sleep apnea syndrome.⁴⁸ In this mechanism, increased ventilation from restored airway patency and from an increase in the slope of the ventilatory response may intermittently draw the Paco₂ to below the hypocapnic apneic threshold and trigger episodes of central apnea.⁴⁸

The ideal NIPPV device for use in the complex sleep apnea syndrome should be able to provide enough pressure to resolve the obstructive sleep apnea-hypopnea syndrome while maintaining proper ventilatory support during central apnea episodes without fluctuations of Paco₂, which could further worsen the dysregulated ventilatory control. Currently, adaptive servo-ventilation appears to be superior to bilevel PAP and CPAP in the management of the complex sleep apnea syndrome.^49,50

Sleep disturbances associated with cardiac dysfunction

There are specific indications for NIPPV modes in the setting of respiratory sleep disturbances associated with heart failure.

Obstructive sleep apnea in congestive heart failure. The prevalence of obstructive sleep apnea in patients with impaired left ventricular ejection fraction is 11% to 53%.⁵¹ Obstructive sleep apnea-hypopnea syndrome can worsen congestive heart failure by causing a periodic increase in negative intrathoracic pressure from breathing against an occluded airway, by raising arterial blood pressure, and causing tachycardia from sympathetic nervous system stimulation from hypoxia, hypercarbia, and arousals.^52,53 Both heart failure and sleep apnea contribute in an additive manner to the increased sympathetic nervous activity.⁵⁴

Fortunately, treatment with CPAP has been found to reduce systolic blood pressure and improve left ventricular systolic function in medically treated patients with heart failure and coexisting obstructive sleep apnea.^11,12 Furthermore, in a randomized trial in patients with stable congestive heart failure and newly diagnosed obstructive sleep apnea-hypopnea syndrome, a greater improvement in cardiac function was observed in patients on bilevel PAP than in those on CPAP.⁵⁵ The authors speculated that bilevel PAP might provide more unloading of the respiratory muscles, reduce the work of breathing more, and result in less positive intrathoracic pressure than with CPAP, and that the higher intrathoracic pressure with CPAP could reduce the left ventricular ejection fraction in patients with low filling pressures (pulmonary capillary wedge pressure < 12 mm Hg) and low baseline left ventricular ejection fractions (< 30%).⁵⁵

Whether these interventions reduce the mortality rate is uncertain. In a prospective nonrandomized study, 9 (24%) of 37 patients who had heart failure with untreated obstructive sleep apnea died, compared with no deaths in 14 treated patients (P = .07).⁵⁶

Cheyne-Stokes respiration with central sleep apnea in congestive heart failure. A related but different situation is central apnea associated with congestive heart failure.

There are several pathophysiologic mechanisms of Cheyne-Stokes respiration with central sleep apnea. Specifically, the elevation of left ventricular filling pressures, end-diastolic volumes, and pulmonary congestion generate hyperventilation, chronic hypocapnia, and increased chemoreceptor responsiveness, which contribute to the development of central apnea by promoting a decrease in the Paco₂ during sleep to below the hypocapnic apneic threshold.^57,58 Additionally, an increase in circulation time may result in periodicity of breathing and hyperpnea.⁵⁹ Obstructive events can then occur at the end of the central events corresponding with the nadir of the inspiratory drive.^60,61

The Canadian Continuous Positive Airway Pressure for Patients With Central Sleep Apnea and Heart Failure (CANPAP) trial, a randomized trial of CPAP in this clinical setting, showed that compared with optimal medical therapy alone, CPAP plus optimal medical therapy improved the ejection fraction, reduced central sleep apnea, improved nocturnal oxygenation, and improved the 6-minute walking distance, but without a survival benefit.⁶² The disappointing survival results from CANPAP have to be interpreted in the context that CPAP may have failed to control the central apnea in some patients, such that the mean apnea-hypopnea index in treated patients (19 events/hour) remained above the entry criterion for recruitment (15 events/hour). In a post hoc analysis of this study, the heart-transplantation-free survival rate was significantly greater in the subgroup of patients in whom CPAP effectively suppressed central sleep apnea (< 15 events/hour).⁶³

Other NIPPV modes such as bilevel PAP with backup rate and adaptive servo-ventilation have been shown in some studies to be superior to CPAP in controlling respiratory events, with adaptive servo-ventilation being the most effective in controlling central, mixed, and complex sleep apnea in this setting. ^49,50 Whether more effective resolution of obstructive and central events with these treatment modes translates into improved mortality rates and transplantation-free survival rates remains to be determined.

Obesity-hypoventilation syndrome refers to daytime hypercapnia (Paco₂ > 45 mm Hg) in obese people when no other cause of hypoventilation is present.

The prevalence of obesity-hypoventilation syndrome among patients with obstructive sleep apnea-hypopnea syndrome is 20% to 30% and is greater in extremely obese patients (body mass index > 40 kg/m²).⁶⁴ However, about 10% of patients with obesity-hypoventilation syndrome do not have obstructive sleep apnea-hypopnea syndrome.⁶⁴ Additionally, nocturnal hypoxemia and diurnal hypercapnia persist in about 40% of patients with obesity-hypoventilation syndrome after CPAP eliminates their sleep apnea.⁶⁵ Therefore, factors other than sleep apnea contribute to the development of obesity-hypoventilation syndrome, and in a meta-analysis, factors associated with daytime hypercapnia included, in addition to body mass index and the apnea-hypopnea index, mean overnight oxygen saturation and severity of restrictive pulmonary function.⁶⁶ Predictors of success with CPAP include better spirometric findings, a higher apnea-hypopnea index, and adequate oxygenation.^67,68

Bilevel PAP therapy can be tried in patients in whom CPAP by itself fails. In a study of patients with obesity-hypoventilation syndrome in whom initial CPAP treatment failed, average volume-assured pressure support lowered Paco₂ compared to bilevel PAP alone, but did not further improve oxygenation, sleep quality, or quality of life.⁶⁹

Restrictive pulmonary diseases

Neuromuscular diseases and thoracic cage abnormalities. Noninvasive ventilation has been used in patients with progressive neuromuscular disorders or severe thoracic cage abnormalities, with recognized benefits including an improved survival rate and improved quality of life.^70,71 However, NIPPV is used in only 9% of patients with amyotrophic lateral sclerosis when clearly indicated.⁷² The indications and Medicare guidelines for reimbursement of NIPPV (with or without a backup rate) in this setting are shown in Table 2.

Potential contraindications to starting NIPPV in this population include upper airway obstruction, failure to clear secretions despite optimal noninvasive support, inability to achieve a mask fit, and intolerance of the intervention.^73,74

The mechanisms of benefit of NIPPV in these settings include improvements in daytime blood gas levels (including hypercapnia⁷⁵), a reduction in the oxygen cost of breathing,⁷⁶ an increase in the ventilatory response to carbon dioxide,⁷⁵ and improved lung compliance.⁷⁷

Chronic hypercapnic failure due to severe COPD

The use of NIPPV in chronic COPD is less well established than in patients with exacerbations of COPD,⁷⁸ and limitations in its use are reflected in the more stringent Medicare indications for NIPPV in this setting (Table 2).

A particular subset of patients with stable COPD who may benefit from NIPPV includes those with daytime hypercapnia and super-imposed nocturnal hypoventilation.⁷⁸ The potential benefits of NIPPV in these patients include improved daytime and nocturnal gas exchange, increased sleep duration, and improved quality of life.⁷⁸ Additionally, a recent randomized controlled trial of NIPPV plus long-term oxygen therapy compared with oxygen therapy alone in patients with severe COPD and a Paco₂ greater than 46 mm Hg demonstrated a survival benefit in favor of adding NIPPV (hazard ratio 0.6).⁷⁹

However, that study also found no reduction in hospitalization rates, an apparent worsening in general and mental health (as reflected on the 36-Item Short Form Health Survey or SF-36, a quality-of-life questionnaire), as well as increased confusion and bewilderment (reflected on the Profile of Mood States scale).⁷⁹ These potentially deleterious effects may explain why adherence to NIPPV is low in patients with stable COPD: only 37% to 57% of patients continued to use it in several reported studies.^79–81

A level of inspiratory pressure support that is insufficient to reduce hypercapnia may account for the low adherence rate and worsened quality of life in such patients. For instance, in a randomized trial,⁸² compared with low-intensity NIPPV (mean IPAP 14 cm H₂O, backup rate 8 per minute), settings that aimed to maximally reduce Paco₂ (mean IPAP 29 cm H₂O with a backup rate of 17.5 per minute) increased the daily use of NIPPV by 3.6 hours/day and improved exercise-related dyspnea, daytime Paco₂, forced expiratory volume in 1 second (FEV₁), vital capacity, and health-related quality of life.

The overlap syndrome was first described by Flenley in 1985 as a combination of chronic respiratory disease (more generally limited to COPD) and obstructive sleep apnea-hypopnea syndrome.⁸³ Epidemiologic studies do not consistently show a higher incidence of obstructive sleep apnea-hypopnea syndrome in patients with COPD, but the exaggerated oxygen desaturation during sleep in patients with this combination increases the risk of hypoxemia, hypercapnia, and pulmonary hypertension. ⁸⁴ In addition, there was evidence of higher risks of death and of hospitalization for COPD in patients with the overlap syndrome. ⁸⁵ NIPPV is the main treatment for obstructive sleep apnea-hypopnea syndrome with or without COPD.

A recent study by Marin et al⁸⁵ showed that CPAP was associated with improved survival and decreased hospitalization in patients with the overlap syndrome. However, polysomnography or nocturnal oximetry while on NIPPV alone must be done, as additional nocturnal oxygen therapy may be warranted when significant chronic respiratory illness coexists with sleep apnea.
 

Acknowledgment: The authors gratefully acknowledge the contribution of Scott Marlow, RRT, to Table 2 of this review.

Noninvasive positive pressure ventilation (NIPPV) is any form of positive ventilatory support applied without an endotracheal tube, including continuous positive airway pressure (CPAP).¹ The role of NIPPV in acute care has been discussed in an earlier review in the Cleveland Clinic Journal of Medicine.²

NIPPV is also used at night in outpatients with stable chronic conditions, first used in the 1980s in the treatment of obstructive sleep apnea³ and neuromuscular diseases,⁴ and since then in several other conditions including sleep disorders associated with congestive heart failure (including sleep apnea and the Cheyne-Stokes respiration-central sleep apnea syndrome), chronic obstructive pulmonary disease (COPD), and the obesity-hypoventilation syndrome.

In this review, we discuss the different types of NIPPV, the specific conditions in which they can be used, and the indications, recommendations, and evidence supporting the efficacy of NIPPV in outpatients.

THE TYPES OF NIPPV AND THEIR USES

Although the conditions for which different types of NIPPV can be used overlap significantly, each type has general indications and different goals of treatment. This section begins with types of NIPPV that are predominantly used to treat sleep-disordered breathing, and then proceeds to those predominantly used for conditions associated with hypoventilation and hypercapnia.

Continuous positive airway pressure

CPAP, currently the most widely used form of NIPPV, applies a constant level of positive pressure at the airway opening during spontaneous breathing.

CPAP is commonly used to treat obstructive sleep-disordered breathing, with the goals of improving daytime sleepiness and reducing cardiovascular risk. It has also been used to treat sleep-disordered breathing associated with congestive heart failure.

CPAP’s role in the support of ventilation is limited and indirect. For instance, it has been used in the obesity-hypoventilation syndrome and in the “overlap” syndrome (in which both sleep apnea and COPD coexist). However, its benefits in those conditions are probably derived in large part from correction of underlying obstructive sleep apnea.

The mechanisms of action of CPAP include:

• Preventing intermittent narrowing and collapse of the airway in patients with obstructive sleep apnea-hypopnea syndrome by acting as a pneumatic splint during sleep^3,5,6
• Counteracting auto-positive end-expiratory pressure, thereby reducing respiratory muscle load, reducing the work of breathing, and lowering daytime Paco₂ in patients with coexistent COPD and obstructive sleep apnea-hypopnea syndrome (the overlap syndrome)^7–9
• Improving lung function (particularly the functional residual capacity) and daytime gas exchange in obstructive sleep apnea-hypopnea syndrome ¹⁰
• Improving left ventricular systolic function in patients with heart failure coexisting with obstructive sleep apnea-hypopnea syndrome.^11,12

Auto-CPAP is delivered via a self-titrating CPAP device, which uses algorithms to detect variations in the degree of obstruction and consequently adjusts the pressure level to restore normal breathing. Auto-CPAP therefore compensates for factors that modify the upper airway collapsibility, such as body posture during sleep, stage of sleep, use of alcohol, and drugs that affect upper airway muscle tone.¹³

Although one of the premises of using auto-CPAP is that it improves the patient’s satisfaction and compliance, several studies found it to be no more effective than fixed CPAP for treating obstructive sleep apnea-hypopnea syndrome.^14–16 Current guidelines of the American Academy of Sleep Medicine do not recommend self-titrating CPAP devices to diagnose obstructive sleep apnea or to treat patients with cardiopulmonary disorders or other conditions in which nocturnal desaturation may be unrelated to obstructive events.¹⁷

Adaptive servo-ventilation

Adaptive servo-ventilation was developed for Cheyne-Stokes respiration-central sleep apnea syndrome in patients with congestive heart failure, who may have periods of crescendo-decrescendo change in tidal volume (Cheyne-Stokes respiration) with possible intercalated episodes of central apnea or hypopnea. It is also applied in patients with the complex sleep apnea syndrome.

Adaptive servo-ventilation devices are usually set at an expiratory positive airway pressure (EPAP) level sufficient to control obstructive sleep apnea. The device then automatically adjusts the pressure support for each inspiration, within a prespecified range, to maintain a moving-target ventilation set at 90% of the patient’s recent average ventilation. The aim is to stabilize breathing and reduce respiratory alkalosis, which can trigger apnea reentry cycles.¹⁸

Bilevel positive airway pressure

Bilevel positive airway pressure (bilevel PAP) can be of use in sleep-disordered breathing (including cases associated with congestive heart failure), but it is predominantly applied in conditions associated with hypoventilation.

Bilevel PAP devices deliver a higher pressure during inspiration (inspiratory positive airway pressure, or IPAP) and a lower pressure during expiration (EPAP). The gradient between IPAP and EPAP is of key importance in maintaining alveolar ventilation and reducing Paco₂. The IPAP acts as pressure support to augment the patient’s effort, maintain adequate alveolar ventilation, unload respiratory muscles, decrease the work of breathing, and control obstructive hypopnea, whereas EPAP is set to maintain upper airway patency, control obstructive apnea, improve functional residual capacity, and prevent microatelectasis.

Although there is no evidence that bilevel PAP is better adhered to or more effective than CPAP, current guidelines propose it as an option for patients who require high pressures to control obstructive sleep apnea-hypopnea syndrome or for those who cannot tolerate exhaling against a high fixed CPAP pressure.¹⁹

Other, more-common uses of bilevel PAP are to treat coexisting central sleep apnea or hypoventilation,¹⁹ the obesity-hypoventilation syndrome with residual alveolar hypoventilation despite CPAP and control of concomitant obstructive sleep apnea-hypopnea syndrome,^5,20 severe stable COPD with significant nocturnal hypoventilation and daytime hypercarbia,²¹ and restrictive pulmonary diseases.²¹

Average volume-assured pressure support

CONDITIONS IN WHICH NOCTURNAL NIPPV IS USED IN OUT PATIENTS

Obstructive sleep apnea-hypopnea syndrome

Obstructive sleep apnea-hypopnea syndrome is estimated to affect 2% of women and 4% of men.²⁵ It is characterized by recurrent episodes of partial (hypopnea) or complete (apnea) upper airway obstruction during sleep despite ongoing inspiratory efforts, with associated episodes of arousal or desaturation or both. Corresponding symptoms include excessive daytime sleepiness, choking and gasping during sleep, recurrent awakenings from sleep, unrefreshing sleep, daytime fatigue, and impaired concentration that is not explained by other factors.²⁶

Current understanding of the pathophysiology of obstructive sleep apnea implicates an impairment in the balance between factors that promote collapsibility of the airway (including obesity and anatomic issues such as the volume of the soft-tissue structures surrounding the upper airway) and the compensatory neuromuscular response.^27,28

Long-standing obstructive sleep apnea-hypopnea syndrome has been linked in prospective studies to the development of hypertension,^29–31 coronary artery disease,^32,33 increased coagulation,^34,35 and stroke or death from any cause.^36,37 It is also associated with a greater rate and severity of motor vehicular accidents,³⁸ greater health care utilization, impaired work performance, and occupational injuries.³⁹

Strong evidence exists that NIPPV (most commonly CPAP) is beneficial in obstructive sleep apnea-hypopnea syndrome, improving sleep quality, sleepiness, cognitive impairment, and quality of life,^40,41 decreasing motor vehicle accidents,⁴² lowering blood pressure, ^43,44 and decreasing the rates of myocardial infarction,³² stroke,³² and death.⁴⁵

The American Academy of Sleep Medicine recommends CPAP as an optional adjunctive therapy to lower blood pressure in patients with obstructive sleep apnea-hypopnea syndrome with concomitant hypertension.¹⁹ This is supported by a recent study that suggested that CPAP may have additional benefits on blood pressure in a subgroup of patients with uncontrolled hypertension while on antihypertensive medications.⁴⁶ Indications with Medicare guidelines for reimbursement of CPAP devices are summarized in Table 2.

Complex sleep apnea syndrome

The complex sleep apnea syndrome is characterized by the emergence of significant central sleep apnea or Cheyne-Stokes respiration after obstructive events have been brought under control with NIPPV in patients who initially appear to have obstructive sleep apnea-hypopnea syndrome. A retrospective study of patients with the complex sleep apnea syndrome who continued their NIPPV use until a subsequent polysomnographic study and NIPPV titration showed that the syndrome may resolve spontaneously, but that 46% of patients had a persistently elevated apnea-hypopnea index with central apnea activity.⁴⁷

Restoration of upper airway patency by CPAP and dysregulation or delayed adaptation of chemosensitive ventilatory control to a changing Paco₂ level may be a key pathophysiologic mechanism of the complex sleep apnea syndrome.⁴⁸ In this mechanism, increased ventilation from restored airway patency and from an increase in the slope of the ventilatory response may intermittently draw the Paco₂ to below the hypocapnic apneic threshold and trigger episodes of central apnea.⁴⁸

The ideal NIPPV device for use in the complex sleep apnea syndrome should be able to provide enough pressure to resolve the obstructive sleep apnea-hypopnea syndrome while maintaining proper ventilatory support during central apnea episodes without fluctuations of Paco₂, which could further worsen the dysregulated ventilatory control. Currently, adaptive servo-ventilation appears to be superior to bilevel PAP and CPAP in the management of the complex sleep apnea syndrome.^49,50

Sleep disturbances associated with cardiac dysfunction

There are specific indications for NIPPV modes in the setting of respiratory sleep disturbances associated with heart failure.

Obstructive sleep apnea in congestive heart failure. The prevalence of obstructive sleep apnea in patients with impaired left ventricular ejection fraction is 11% to 53%.⁵¹ Obstructive sleep apnea-hypopnea syndrome can worsen congestive heart failure by causing a periodic increase in negative intrathoracic pressure from breathing against an occluded airway, by raising arterial blood pressure, and causing tachycardia from sympathetic nervous system stimulation from hypoxia, hypercarbia, and arousals.^52,53 Both heart failure and sleep apnea contribute in an additive manner to the increased sympathetic nervous activity.⁵⁴

Fortunately, treatment with CPAP has been found to reduce systolic blood pressure and improve left ventricular systolic function in medically treated patients with heart failure and coexisting obstructive sleep apnea.^11,12 Furthermore, in a randomized trial in patients with stable congestive heart failure and newly diagnosed obstructive sleep apnea-hypopnea syndrome, a greater improvement in cardiac function was observed in patients on bilevel PAP than in those on CPAP.⁵⁵ The authors speculated that bilevel PAP might provide more unloading of the respiratory muscles, reduce the work of breathing more, and result in less positive intrathoracic pressure than with CPAP, and that the higher intrathoracic pressure with CPAP could reduce the left ventricular ejection fraction in patients with low filling pressures (pulmonary capillary wedge pressure < 12 mm Hg) and low baseline left ventricular ejection fractions (< 30%).⁵⁵

Whether these interventions reduce the mortality rate is uncertain. In a prospective nonrandomized study, 9 (24%) of 37 patients who had heart failure with untreated obstructive sleep apnea died, compared with no deaths in 14 treated patients (P = .07).⁵⁶

Cheyne-Stokes respiration with central sleep apnea in congestive heart failure. A related but different situation is central apnea associated with congestive heart failure.

There are several pathophysiologic mechanisms of Cheyne-Stokes respiration with central sleep apnea. Specifically, the elevation of left ventricular filling pressures, end-diastolic volumes, and pulmonary congestion generate hyperventilation, chronic hypocapnia, and increased chemoreceptor responsiveness, which contribute to the development of central apnea by promoting a decrease in the Paco₂ during sleep to below the hypocapnic apneic threshold.^57,58 Additionally, an increase in circulation time may result in periodicity of breathing and hyperpnea.⁵⁹ Obstructive events can then occur at the end of the central events corresponding with the nadir of the inspiratory drive.^60,61

The Canadian Continuous Positive Airway Pressure for Patients With Central Sleep Apnea and Heart Failure (CANPAP) trial, a randomized trial of CPAP in this clinical setting, showed that compared with optimal medical therapy alone, CPAP plus optimal medical therapy improved the ejection fraction, reduced central sleep apnea, improved nocturnal oxygenation, and improved the 6-minute walking distance, but without a survival benefit.⁶² The disappointing survival results from CANPAP have to be interpreted in the context that CPAP may have failed to control the central apnea in some patients, such that the mean apnea-hypopnea index in treated patients (19 events/hour) remained above the entry criterion for recruitment (15 events/hour). In a post hoc analysis of this study, the heart-transplantation-free survival rate was significantly greater in the subgroup of patients in whom CPAP effectively suppressed central sleep apnea (< 15 events/hour).⁶³

Other NIPPV modes such as bilevel PAP with backup rate and adaptive servo-ventilation have been shown in some studies to be superior to CPAP in controlling respiratory events, with adaptive servo-ventilation being the most effective in controlling central, mixed, and complex sleep apnea in this setting. ^49,50 Whether more effective resolution of obstructive and central events with these treatment modes translates into improved mortality rates and transplantation-free survival rates remains to be determined.

Obesity-hypoventilation syndrome refers to daytime hypercapnia (Paco₂ > 45 mm Hg) in obese people when no other cause of hypoventilation is present.

The prevalence of obesity-hypoventilation syndrome among patients with obstructive sleep apnea-hypopnea syndrome is 20% to 30% and is greater in extremely obese patients (body mass index > 40 kg/m²).⁶⁴ However, about 10% of patients with obesity-hypoventilation syndrome do not have obstructive sleep apnea-hypopnea syndrome.⁶⁴ Additionally, nocturnal hypoxemia and diurnal hypercapnia persist in about 40% of patients with obesity-hypoventilation syndrome after CPAP eliminates their sleep apnea.⁶⁵ Therefore, factors other than sleep apnea contribute to the development of obesity-hypoventilation syndrome, and in a meta-analysis, factors associated with daytime hypercapnia included, in addition to body mass index and the apnea-hypopnea index, mean overnight oxygen saturation and severity of restrictive pulmonary function.⁶⁶ Predictors of success with CPAP include better spirometric findings, a higher apnea-hypopnea index, and adequate oxygenation.^67,68

Bilevel PAP therapy can be tried in patients in whom CPAP by itself fails. In a study of patients with obesity-hypoventilation syndrome in whom initial CPAP treatment failed, average volume-assured pressure support lowered Paco₂ compared to bilevel PAP alone, but did not further improve oxygenation, sleep quality, or quality of life.⁶⁹

Restrictive pulmonary diseases

Neuromuscular diseases and thoracic cage abnormalities. Noninvasive ventilation has been used in patients with progressive neuromuscular disorders or severe thoracic cage abnormalities, with recognized benefits including an improved survival rate and improved quality of life.^70,71 However, NIPPV is used in only 9% of patients with amyotrophic lateral sclerosis when clearly indicated.⁷² The indications and Medicare guidelines for reimbursement of NIPPV (with or without a backup rate) in this setting are shown in Table 2.

Potential contraindications to starting NIPPV in this population include upper airway obstruction, failure to clear secretions despite optimal noninvasive support, inability to achieve a mask fit, and intolerance of the intervention.^73,74

The mechanisms of benefit of NIPPV in these settings include improvements in daytime blood gas levels (including hypercapnia⁷⁵), a reduction in the oxygen cost of breathing,⁷⁶ an increase in the ventilatory response to carbon dioxide,⁷⁵ and improved lung compliance.⁷⁷

Chronic hypercapnic failure due to severe COPD

The use of NIPPV in chronic COPD is less well established than in patients with exacerbations of COPD,⁷⁸ and limitations in its use are reflected in the more stringent Medicare indications for NIPPV in this setting (Table 2).

A particular subset of patients with stable COPD who may benefit from NIPPV includes those with daytime hypercapnia and super-imposed nocturnal hypoventilation.⁷⁸ The potential benefits of NIPPV in these patients include improved daytime and nocturnal gas exchange, increased sleep duration, and improved quality of life.⁷⁸ Additionally, a recent randomized controlled trial of NIPPV plus long-term oxygen therapy compared with oxygen therapy alone in patients with severe COPD and a Paco₂ greater than 46 mm Hg demonstrated a survival benefit in favor of adding NIPPV (hazard ratio 0.6).⁷⁹

However, that study also found no reduction in hospitalization rates, an apparent worsening in general and mental health (as reflected on the 36-Item Short Form Health Survey or SF-36, a quality-of-life questionnaire), as well as increased confusion and bewilderment (reflected on the Profile of Mood States scale).⁷⁹ These potentially deleterious effects may explain why adherence to NIPPV is low in patients with stable COPD: only 37% to 57% of patients continued to use it in several reported studies.^79–81

A level of inspiratory pressure support that is insufficient to reduce hypercapnia may account for the low adherence rate and worsened quality of life in such patients. For instance, in a randomized trial,⁸² compared with low-intensity NIPPV (mean IPAP 14 cm H₂O, backup rate 8 per minute), settings that aimed to maximally reduce Paco₂ (mean IPAP 29 cm H₂O with a backup rate of 17.5 per minute) increased the daily use of NIPPV by 3.6 hours/day and improved exercise-related dyspnea, daytime Paco₂, forced expiratory volume in 1 second (FEV₁), vital capacity, and health-related quality of life.

The overlap syndrome was first described by Flenley in 1985 as a combination of chronic respiratory disease (more generally limited to COPD) and obstructive sleep apnea-hypopnea syndrome.⁸³ Epidemiologic studies do not consistently show a higher incidence of obstructive sleep apnea-hypopnea syndrome in patients with COPD, but the exaggerated oxygen desaturation during sleep in patients with this combination increases the risk of hypoxemia, hypercapnia, and pulmonary hypertension. ⁸⁴ In addition, there was evidence of higher risks of death and of hospitalization for COPD in patients with the overlap syndrome. ⁸⁵ NIPPV is the main treatment for obstructive sleep apnea-hypopnea syndrome with or without COPD.

A recent study by Marin et al⁸⁵ showed that CPAP was associated with improved survival and decreased hospitalization in patients with the overlap syndrome. However, polysomnography or nocturnal oximetry while on NIPPV alone must be done, as additional nocturnal oxygen therapy may be warranted when significant chronic respiratory illness coexists with sleep apnea.
 

Acknowledgment: The authors gratefully acknowledge the contribution of Scott Marlow, RRT, to Table 2 of this review.

The reality of blood pressure measurement is that human beings do not do it very well. The time has come to delegate this job to machines that can do it better.

Several automatic devices are available. Used in physicians’ offices and in patients’ homes, they can eliminate some types of observer error as well as the “white-coat effect,” ie, the tendency of some patients to have higher blood pressure when medical personnel are present than in their natural environment. Since a difference of only a few millimeters of mercury can affect the physician’s decision to start or to modify treatment, measurements that more accurately reflect a person’s average blood pressure are to be desired.

In the following pages, we review the problems that plague blood pressure measurement by human observers, and we describe the advantages of automatic devices.

SHORTCOMINGS OF OFFICE BLOOD PRESSURE MEASUREMENT

For decades, large surveys have provided invaluable information on the prevalence of hypertension, its relationship to cardiovascular disease, and the benefits of treating it.^1–3 Unfortunately, the percentage of hypertensive patients whose blood pressure is under control has remained low despite our increased knowledge about hypertension’s diagnosis and therapy.⁴

In these surveys, blood pressure was measured by auscultation by human observers using mercury or aneroid sphygmomanometers, and most physicians still use this method in clinical practice. But in spite of multiple guidelines for accurate measurement of blood pressure in the office, the overall accuracy and reproducibility of office blood pressure measurements remain poor.^5–7

The accuracy of blood pressure measurement with aneroid and mercury manometers is affected by a number of observer errors and patient factors.^8,9

Observer errors

Failure to prepare the patient. National guidelines⁵ state that before having their blood pressure taken, patients should be allowed to sit quietly for at least 5 minutes, which often does not happen. Another error is that clinicians rarely discourage patients from smoking cigarettes or drinking coffee in the 30 minutes prior to measurement.

Equipment and layout problems. Equipment should be properly calibrated and validated. ⁵ However, even if the sphygmomanometer is periodically calibrated, too often it is mounted on the wall adjacent to the examination table in the examination room, making it difficult to provide a comfortable seat with back and arm support during the reading. The measurement should be done with the patient sitting in a chair (not on an examination table), with feet on the floor and the arm supported at the level of the heart. If the forearm is not supported in the horizontal position and with the cuff at heart level, the blood pressure and heart rate tend to be higher.¹⁰ Further, the diastolic blood pressure and heart rate may be misleadingly low with the patient supine rather than seated,^11,12 so readings should be taken with the patient sitting.

Miscuffing, ie, the use of a blood pressure cuff that is too large or, more often, too small for the patient’s arm, is a common source of error. The cuff bladder should encircle at least 80% of the arm.⁵ However, some offices do not have a large blood pressure cuff for overweight patients or a pediatric cuff for children or adults with arms of small circumference. It is recommended that a large blood pressure cuff be used routinely in adults, since a smaller cuff gives falsely high readings in people with large upper arms (circumference > 29 cm).^13,14

Digit preference. Many physicians round off the blood pressure to the nearest 5 or 10 mm Hg. This problem may go along with:

Deflating the cuff too rapidly.

Talking to the patient while taking the blood pressure can contribute to higher readings.⁹

Not taking enough readings. Ideally, at the initial visit, blood pressure should be measured in both arms with the patient seated, and another reading should be taken with the patient standing. The arm with the higher pressure should be used for subsequent readings. Physicians should not make any treatment decisions based on blood pressure during an initial clinic visit, and at least two readings should be taken even on subsequent visits. However, owing to time constraints in busy clinical practices, treatment decisions are often based on single readings or on multiple readings on a single visit.

Discrepancies between observers. The blood pressure readings obtained by the nurse or medical assistant may differ significantly from those obtained by the physician. These differences can be large enough to affect treatment decisions,^15,16 and they can be partially corrected by adequate training of all medical personnel who take blood pressure, doctors as well as nurses.

Given that time is tight in busy clinical practices and a trained blood pressure nurse or technician is usually not available, we will probably not see any significant improvement in the accuracy of blood pressure measurement using older technology and current physician practices.

The white-coat effect

Most patients have a higher level of anxiety, and therefore higher blood pressure, in the physician’s office or clinic than in their normal environment (as revealed by ambulatory monitoring or home blood pressure measurements), a phenomenon commonly called the white-coat effect.

Several factors can increase this effect, such as observer-patient interaction during the measurement. The effect tends to be greatest in the initial measurement, but can persist through multiple readings by the doctor or nurse during the same visit.

Whether the white-coat effect is due purely to patient anxiety about an office visit or to a conditioned response has been a point of interest in clinical studies. Regardless, it may result in the misdiagnosis of hypertension or in overestimation of the severity of hypertension and may lead to overly aggressive therapy. Antihypertensive treatment may be unnecessary in the absence of concurrent cardiovascular risk factors.¹⁷

“White-coat hypertension” or “isolated office hypertension” is the condition in which a patient who is not on antihypertensive drug therapy has persistently elevated blood pressure in the clinic or office (> 140/90 mm Hg) but normal daytime ambulatory blood pressure (< 135/85 mm Hg).¹⁸ Since patients may have an elevated reading when seen for a first office visit, at least several visits are required to establish the diagnosis. Multiple studies have suggested that white-coat hypertension may account for 20% to 25% of the hypertensive population, particularly in older patients, mainly women.^19,20

Both white-coat hypertension and the white-coat effect can be avoided by using an automatic and programmable device that can take multiple readings after the clinician leaves the examination room (more about this below).²¹

MEASURING BLOOD PRESSURE OUTSIDE THE OFFICE

Recent studies have reported that the information obtained by 24-hour ambulatory blood pressure monitoring and by self-measurement of blood pressure in the home more accurately reflects the patient’s risk of future cardiovascular events than do conventional blood pressure measurements taken in the physician’s office. ^22–24 Current national guidelines recognize this pattern and the frequent measurement inaccuracies observed in clinical practice, and they are recommending including out-of-office measurements in the diagnosis of hypertension. ^25,26

Ambulatory monitoring provides the most accurate measurement of out-of-office blood pressure. With ambulatory monitoring, the normal mean daytime pressure is considered to be lower than 135/85 mm Hg, in contrast to the 140/90 mm Hg cutoff used in the physician’s office with standard aneroid or mercury devices.

Self-monitoring of blood pressure at home has now become widely available with single-measurement oscillometric devices. (Oscillometric means that these devices measure the blood pressure by sensing the oscillations in pressure in the cuff induced by the pulsation of the brachial artery, as opposed to auscultating the Korotkoff sounds.) Blood pressures lower than 135/85 mm Hg outside the clinician’s office are considered normal with these devices.

However, despite its proven value, ambulatory monitoring is neither widely available nor cost-effective for the long-term management of hypertension. Furthermore, few physicians recommend that patients take their blood pressure at home, although the information obtained can be of significant value in the patient’s long-term management.

AUTOMATED MEASUREMENT IN THE OFFICE

In recent years, several automated oscillometric sphygmomanometers have been developed for measuring blood pressure in the office, and more are on the way. These devices can be programmed to take multiple readings without a clinician observer in the examination room, thus reducing the white-coat response.

Omron (Kyoto, Japan) makes several devices, including the HEM-907 and the HEM-705, that have been used in the clinical setting. ^21,27–29 They can be programmed to take two or three readings at intervals of 1 to 2 minutes, with up to 5 minutes before the first reading. Unfortunately, data were not recorded with the patient alone in the room in many studies of the Omron devices, even though the devices meet national and international standards for accuracy.

The Microlife Watch BP Office (Microlife, Widnau, Switzerland) is currently undergoing development.³⁰

The BpTRU (BpTRU Medical Devices, Coquitlam, BC, Canada) has enjoyed greater clinical acceptance, since it can take up to five blood pressure readings at intervals of 1 to 5 minutes, and calculates the mean of all five readings, taken with the patient resting comfortably in a quiet room without a clinician present.

The accuracy and durability of the device has been well established. Since the BpTRU self-calibrates between every blood pressure measurement, periodic calibration has not been required. The device can be placed on a table, mounted on the wall, or mounted on a cart if used in several locations in the office.

At Cleveland Clinic, several departments are using the BpTRU on a daily basis. Soon, we will be able to transfer data directly from the BpTRU to our electronic medical record system.

Studies of the BpTRU device

To date, most of the studies of automated office blood pressure measurement have used the BpTRU with the recording interval set at 1 to 2 minutes.

Myers³¹ used the BpTRU device in 50 hypertensive patients. The physician took the patient’s blood pressure with a mercury sphygmomanometer while the BpTRU device made the first reading, and then he left the room. The next five readings were taken at 2-minute intervals with the patient alone in the room. The mean initial reading by the machine was 162/85 mm Hg; the reading by the physician was 163/86 mm Hg. The third automatic reading was the lowest (averaging 140/84 mm Hg), and the mean of the five automated readings was 142/80 mm Hg, which was significantly lower than the initial reading obtained by the physician (P < .001).

In another study, Myers et al³² compared the measurements obtained by 24-hour ambulatory monitoring and by the BpTRU device (the mean of five readings obtained at 1-minute or 2-minute intervals) in 309 hypertensive patients. The mean blood pressure with the Bp-TRU was 132/75 mm Hg, which correlated well with the mean awake ambulatory blood pressure (134/77 mm Hg; r = 0.62 for the systolic pressure and 0.72 for the diastolic pressure).

We recently reviewed the records of 278 patients seen in our preventive medicine clinic (D.G. Vidt, MD, unpublished data, November 2009). The group included patients with and without established hypertension, and among the hypertensive group, both treated and untreated individuals. We had initially set the device to take readings at 3-minute intervals following the initial nurse-initiated reading. But in view of the recent data on the Bp-TRU using shorter intervals, we also obtained readings in 51 patients with the device set to record at 2-minute intervals, and then in 72 additional patients at 1-minute intervals. In all three groups, blood pressure had stabilized by the third reading after the clinician had left the room. These observations support those reported by Myers et al.^31,32 Of particular importance is the observation that the white-coat effect dissipates within 2 to 3 minutes after the clinician leaves the room.³³

The shorter measurement intervals can add up in a busy office practice, in which the time relegated to taking blood pressure is often limited.

In fact, waiting 5 minutes between measurements may allow the patient to become too relaxed and the blood pressure to drop too low vis-a-vis the gold standard, ambulatory monitoring. Culleton and colleagues³⁴ compared the blood pressure in 107 hypertensive patients as measured four ways: by the referring physician, by a nurse who was trained to adhere to the protocol of the Canadian Hypertension Education Program, by 24-hour ambulatory monitoring, and by the BpTRU (the mean of five readings obtained at 5-minute intervals). The mean measured values were:

• 150/90 mm Hg by the referring physician
• 139/86 mm Hg by the nurse
• 142/85 mm Hg by ambulatory monitoring
• 132/82 mm Hg by the BpTRU device.

Although the BpTRU reduced the white-coat effect and white-coat hypertension, it underestimated the blood pressure, leading to misclassification of hypertension. Using 140/90 mm Hg as the cutoff for whether the patient was hypertensive and using ambulatory monitoring as the gold standard, the BpTRU misclassified more than half of the patients, agreeing with the classification of hypertensive or not hypertensive by ambulatory monitoring in only 48%. The authors recommended that the BpTRU not be set at 5-minute measurement intervals.³⁴

WHAT ROLE FOR AUTOMATED READINGS IN THE OFFICE?

Although automatic devices, by enabling the physician to leave the room, can eliminate the white-coat effect and white-coat hypertension, physicians must continue to take care to avoid the other potential errors of office blood pressure measurement addressed earlier in this review, for example, by positioning the patient correctly and using a cuff that is large enough. These issues can take on more importance as the clinician leaves the patient alone for brief periods during measurements.

In view of its perennial inaccuracies, some experts have suggested that we abandon routine office measurement of blood pressure.^35,36 In its place, ambulatory monitoring would be used for diagnosis and for periodic follow-up. In addition, patients would regularly take their pressure at home with approved, single-measurement oscillometric devices. Unfortunately, in our health care system, periodic ambulatory monitoring for hypertension management would impose a significant financial burden on patients at this time.³⁷

Of particular importance is the observation that the mean of five readings with the BpTRU device, obtained at 1- or 2-minute intervals, closely approximates the mean awake blood pressure obtained in the same patient with an ambulatory monitor.^32,38 The ability to obtain readings that correlate exceptionally well with mean daytime ambulatory pressure suggests that this device could well reduce the need for ambulatory monitoring, with its associated cost. The ability to negate the white-coat effect with the use of the BpTRU in the office setting also has particular importance, not only for patient office readings, but for the diagnosis and subsequent treatment of hypertension in individual patients.

Most clinical decisions about the treatment of hypertension are still made on the basis of office determinations of blood pressure. Most office practices still rely on the aneroid manometer or, decreasingly, mercury sphygmomanometers. As noted earlier, although auscultatory blood pressure measurement appears to be simple, it is fraught with a host of observer- or patient-induced errors that not only lead to inaccurate diagnoses, but may also result in the mismanagement of hypertension. Even single-measurement oscillometric devices, now used in a minority of clinical practices, are associated with many of the same measurement issues that lead to overestimation of blood pressure.

We believe the time has come for broader use of oscillometric devices in the outpatient setting. While many available oscillometric devices for use in the home could also be used in the physician’s office, they carry the similar disadvantage of providing only a single measurement. The major disadvantage of all single-measurement devices is the continued presence of the clinician during the reading and the associated white-coat effect observed in most patients.

It is highly likely that the next Joint National Committee Report on Hypertension will further emphasize the role of automated blood pressure devices in the outpatient setting.
 

Acknowledgment: The authors wish to acknowledge the contributions of Deborah McCoy, RN, and Maria Eckhouse, RN.

The reality of blood pressure measurement is that human beings do not do it very well. The time has come to delegate this job to machines that can do it better.

Several automatic devices are available. Used in physicians’ offices and in patients’ homes, they can eliminate some types of observer error as well as the “white-coat effect,” ie, the tendency of some patients to have higher blood pressure when medical personnel are present than in their natural environment. Since a difference of only a few millimeters of mercury can affect the physician’s decision to start or to modify treatment, measurements that more accurately reflect a person’s average blood pressure are to be desired.

In the following pages, we review the problems that plague blood pressure measurement by human observers, and we describe the advantages of automatic devices.

SHORTCOMINGS OF OFFICE BLOOD PRESSURE MEASUREMENT

For decades, large surveys have provided invaluable information on the prevalence of hypertension, its relationship to cardiovascular disease, and the benefits of treating it.^1–3 Unfortunately, the percentage of hypertensive patients whose blood pressure is under control has remained low despite our increased knowledge about hypertension’s diagnosis and therapy.⁴

In these surveys, blood pressure was measured by auscultation by human observers using mercury or aneroid sphygmomanometers, and most physicians still use this method in clinical practice. But in spite of multiple guidelines for accurate measurement of blood pressure in the office, the overall accuracy and reproducibility of office blood pressure measurements remain poor.^5–7

The accuracy of blood pressure measurement with aneroid and mercury manometers is affected by a number of observer errors and patient factors.^8,9

Observer errors

Failure to prepare the patient. National guidelines⁵ state that before having their blood pressure taken, patients should be allowed to sit quietly for at least 5 minutes, which often does not happen. Another error is that clinicians rarely discourage patients from smoking cigarettes or drinking coffee in the 30 minutes prior to measurement.

Equipment and layout problems. Equipment should be properly calibrated and validated. ⁵ However, even if the sphygmomanometer is periodically calibrated, too often it is mounted on the wall adjacent to the examination table in the examination room, making it difficult to provide a comfortable seat with back and arm support during the reading. The measurement should be done with the patient sitting in a chair (not on an examination table), with feet on the floor and the arm supported at the level of the heart. If the forearm is not supported in the horizontal position and with the cuff at heart level, the blood pressure and heart rate tend to be higher.¹⁰ Further, the diastolic blood pressure and heart rate may be misleadingly low with the patient supine rather than seated,^11,12 so readings should be taken with the patient sitting.

Miscuffing, ie, the use of a blood pressure cuff that is too large or, more often, too small for the patient’s arm, is a common source of error. The cuff bladder should encircle at least 80% of the arm.⁵ However, some offices do not have a large blood pressure cuff for overweight patients or a pediatric cuff for children or adults with arms of small circumference. It is recommended that a large blood pressure cuff be used routinely in adults, since a smaller cuff gives falsely high readings in people with large upper arms (circumference > 29 cm).^13,14

Digit preference. Many physicians round off the blood pressure to the nearest 5 or 10 mm Hg. This problem may go along with:

Deflating the cuff too rapidly.

Talking to the patient while taking the blood pressure can contribute to higher readings.⁹

Not taking enough readings. Ideally, at the initial visit, blood pressure should be measured in both arms with the patient seated, and another reading should be taken with the patient standing. The arm with the higher pressure should be used for subsequent readings. Physicians should not make any treatment decisions based on blood pressure during an initial clinic visit, and at least two readings should be taken even on subsequent visits. However, owing to time constraints in busy clinical practices, treatment decisions are often based on single readings or on multiple readings on a single visit.

Discrepancies between observers. The blood pressure readings obtained by the nurse or medical assistant may differ significantly from those obtained by the physician. These differences can be large enough to affect treatment decisions,^15,16 and they can be partially corrected by adequate training of all medical personnel who take blood pressure, doctors as well as nurses.

Given that time is tight in busy clinical practices and a trained blood pressure nurse or technician is usually not available, we will probably not see any significant improvement in the accuracy of blood pressure measurement using older technology and current physician practices.

The white-coat effect

Most patients have a higher level of anxiety, and therefore higher blood pressure, in the physician’s office or clinic than in their normal environment (as revealed by ambulatory monitoring or home blood pressure measurements), a phenomenon commonly called the white-coat effect.

Several factors can increase this effect, such as observer-patient interaction during the measurement. The effect tends to be greatest in the initial measurement, but can persist through multiple readings by the doctor or nurse during the same visit.

Whether the white-coat effect is due purely to patient anxiety about an office visit or to a conditioned response has been a point of interest in clinical studies. Regardless, it may result in the misdiagnosis of hypertension or in overestimation of the severity of hypertension and may lead to overly aggressive therapy. Antihypertensive treatment may be unnecessary in the absence of concurrent cardiovascular risk factors.¹⁷

“White-coat hypertension” or “isolated office hypertension” is the condition in which a patient who is not on antihypertensive drug therapy has persistently elevated blood pressure in the clinic or office (> 140/90 mm Hg) but normal daytime ambulatory blood pressure (< 135/85 mm Hg).¹⁸ Since patients may have an elevated reading when seen for a first office visit, at least several visits are required to establish the diagnosis. Multiple studies have suggested that white-coat hypertension may account for 20% to 25% of the hypertensive population, particularly in older patients, mainly women.^19,20

Both white-coat hypertension and the white-coat effect can be avoided by using an automatic and programmable device that can take multiple readings after the clinician leaves the examination room (more about this below).²¹

MEASURING BLOOD PRESSURE OUTSIDE THE OFFICE

Recent studies have reported that the information obtained by 24-hour ambulatory blood pressure monitoring and by self-measurement of blood pressure in the home more accurately reflects the patient’s risk of future cardiovascular events than do conventional blood pressure measurements taken in the physician’s office. ^22–24 Current national guidelines recognize this pattern and the frequent measurement inaccuracies observed in clinical practice, and they are recommending including out-of-office measurements in the diagnosis of hypertension. ^25,26

Ambulatory monitoring provides the most accurate measurement of out-of-office blood pressure. With ambulatory monitoring, the normal mean daytime pressure is considered to be lower than 135/85 mm Hg, in contrast to the 140/90 mm Hg cutoff used in the physician’s office with standard aneroid or mercury devices.

Self-monitoring of blood pressure at home has now become widely available with single-measurement oscillometric devices. (Oscillometric means that these devices measure the blood pressure by sensing the oscillations in pressure in the cuff induced by the pulsation of the brachial artery, as opposed to auscultating the Korotkoff sounds.) Blood pressures lower than 135/85 mm Hg outside the clinician’s office are considered normal with these devices.

However, despite its proven value, ambulatory monitoring is neither widely available nor cost-effective for the long-term management of hypertension. Furthermore, few physicians recommend that patients take their blood pressure at home, although the information obtained can be of significant value in the patient’s long-term management.

AUTOMATED MEASUREMENT IN THE OFFICE

In recent years, several automated oscillometric sphygmomanometers have been developed for measuring blood pressure in the office, and more are on the way. These devices can be programmed to take multiple readings without a clinician observer in the examination room, thus reducing the white-coat response.

Omron (Kyoto, Japan) makes several devices, including the HEM-907 and the HEM-705, that have been used in the clinical setting. ^21,27–29 They can be programmed to take two or three readings at intervals of 1 to 2 minutes, with up to 5 minutes before the first reading. Unfortunately, data were not recorded with the patient alone in the room in many studies of the Omron devices, even though the devices meet national and international standards for accuracy.

The Microlife Watch BP Office (Microlife, Widnau, Switzerland) is currently undergoing development.³⁰

The BpTRU (BpTRU Medical Devices, Coquitlam, BC, Canada) has enjoyed greater clinical acceptance, since it can take up to five blood pressure readings at intervals of 1 to 5 minutes, and calculates the mean of all five readings, taken with the patient resting comfortably in a quiet room without a clinician present.

The accuracy and durability of the device has been well established. Since the BpTRU self-calibrates between every blood pressure measurement, periodic calibration has not been required. The device can be placed on a table, mounted on the wall, or mounted on a cart if used in several locations in the office.

At Cleveland Clinic, several departments are using the BpTRU on a daily basis. Soon, we will be able to transfer data directly from the BpTRU to our electronic medical record system.

Studies of the BpTRU device

To date, most of the studies of automated office blood pressure measurement have used the BpTRU with the recording interval set at 1 to 2 minutes.

Myers³¹ used the BpTRU device in 50 hypertensive patients. The physician took the patient’s blood pressure with a mercury sphygmomanometer while the BpTRU device made the first reading, and then he left the room. The next five readings were taken at 2-minute intervals with the patient alone in the room. The mean initial reading by the machine was 162/85 mm Hg; the reading by the physician was 163/86 mm Hg. The third automatic reading was the lowest (averaging 140/84 mm Hg), and the mean of the five automated readings was 142/80 mm Hg, which was significantly lower than the initial reading obtained by the physician (P < .001).

In another study, Myers et al³² compared the measurements obtained by 24-hour ambulatory monitoring and by the BpTRU device (the mean of five readings obtained at 1-minute or 2-minute intervals) in 309 hypertensive patients. The mean blood pressure with the Bp-TRU was 132/75 mm Hg, which correlated well with the mean awake ambulatory blood pressure (134/77 mm Hg; r = 0.62 for the systolic pressure and 0.72 for the diastolic pressure).

We recently reviewed the records of 278 patients seen in our preventive medicine clinic (D.G. Vidt, MD, unpublished data, November 2009). The group included patients with and without established hypertension, and among the hypertensive group, both treated and untreated individuals. We had initially set the device to take readings at 3-minute intervals following the initial nurse-initiated reading. But in view of the recent data on the Bp-TRU using shorter intervals, we also obtained readings in 51 patients with the device set to record at 2-minute intervals, and then in 72 additional patients at 1-minute intervals. In all three groups, blood pressure had stabilized by the third reading after the clinician had left the room. These observations support those reported by Myers et al.^31,32 Of particular importance is the observation that the white-coat effect dissipates within 2 to 3 minutes after the clinician leaves the room.³³

The shorter measurement intervals can add up in a busy office practice, in which the time relegated to taking blood pressure is often limited.

In fact, waiting 5 minutes between measurements may allow the patient to become too relaxed and the blood pressure to drop too low vis-a-vis the gold standard, ambulatory monitoring. Culleton and colleagues³⁴ compared the blood pressure in 107 hypertensive patients as measured four ways: by the referring physician, by a nurse who was trained to adhere to the protocol of the Canadian Hypertension Education Program, by 24-hour ambulatory monitoring, and by the BpTRU (the mean of five readings obtained at 5-minute intervals). The mean measured values were:

• 150/90 mm Hg by the referring physician
• 139/86 mm Hg by the nurse
• 142/85 mm Hg by ambulatory monitoring
• 132/82 mm Hg by the BpTRU device.

Although the BpTRU reduced the white-coat effect and white-coat hypertension, it underestimated the blood pressure, leading to misclassification of hypertension. Using 140/90 mm Hg as the cutoff for whether the patient was hypertensive and using ambulatory monitoring as the gold standard, the BpTRU misclassified more than half of the patients, agreeing with the classification of hypertensive or not hypertensive by ambulatory monitoring in only 48%. The authors recommended that the BpTRU not be set at 5-minute measurement intervals.³⁴

WHAT ROLE FOR AUTOMATED READINGS IN THE OFFICE?

Although automatic devices, by enabling the physician to leave the room, can eliminate the white-coat effect and white-coat hypertension, physicians must continue to take care to avoid the other potential errors of office blood pressure measurement addressed earlier in this review, for example, by positioning the patient correctly and using a cuff that is large enough. These issues can take on more importance as the clinician leaves the patient alone for brief periods during measurements.

In view of its perennial inaccuracies, some experts have suggested that we abandon routine office measurement of blood pressure.^35,36 In its place, ambulatory monitoring would be used for diagnosis and for periodic follow-up. In addition, patients would regularly take their pressure at home with approved, single-measurement oscillometric devices. Unfortunately, in our health care system, periodic ambulatory monitoring for hypertension management would impose a significant financial burden on patients at this time.³⁷

Of particular importance is the observation that the mean of five readings with the BpTRU device, obtained at 1- or 2-minute intervals, closely approximates the mean awake blood pressure obtained in the same patient with an ambulatory monitor.^32,38 The ability to obtain readings that correlate exceptionally well with mean daytime ambulatory pressure suggests that this device could well reduce the need for ambulatory monitoring, with its associated cost. The ability to negate the white-coat effect with the use of the BpTRU in the office setting also has particular importance, not only for patient office readings, but for the diagnosis and subsequent treatment of hypertension in individual patients.

Most clinical decisions about the treatment of hypertension are still made on the basis of office determinations of blood pressure. Most office practices still rely on the aneroid manometer or, decreasingly, mercury sphygmomanometers. As noted earlier, although auscultatory blood pressure measurement appears to be simple, it is fraught with a host of observer- or patient-induced errors that not only lead to inaccurate diagnoses, but may also result in the mismanagement of hypertension. Even single-measurement oscillometric devices, now used in a minority of clinical practices, are associated with many of the same measurement issues that lead to overestimation of blood pressure.

We believe the time has come for broader use of oscillometric devices in the outpatient setting. While many available oscillometric devices for use in the home could also be used in the physician’s office, they carry the similar disadvantage of providing only a single measurement. The major disadvantage of all single-measurement devices is the continued presence of the clinician during the reading and the associated white-coat effect observed in most patients.

It is highly likely that the next Joint National Committee Report on Hypertension will further emphasize the role of automated blood pressure devices in the outpatient setting.
 

Acknowledgment: The authors wish to acknowledge the contributions of Deborah McCoy, RN, and Maria Eckhouse, RN.

The reality of blood pressure measurement is that human beings do not do it very well. The time has come to delegate this job to machines that can do it better.

Several automatic devices are available. Used in physicians’ offices and in patients’ homes, they can eliminate some types of observer error as well as the “white-coat effect,” ie, the tendency of some patients to have higher blood pressure when medical personnel are present than in their natural environment. Since a difference of only a few millimeters of mercury can affect the physician’s decision to start or to modify treatment, measurements that more accurately reflect a person’s average blood pressure are to be desired.

In the following pages, we review the problems that plague blood pressure measurement by human observers, and we describe the advantages of automatic devices.

SHORTCOMINGS OF OFFICE BLOOD PRESSURE MEASUREMENT

For decades, large surveys have provided invaluable information on the prevalence of hypertension, its relationship to cardiovascular disease, and the benefits of treating it.^1–3 Unfortunately, the percentage of hypertensive patients whose blood pressure is under control has remained low despite our increased knowledge about hypertension’s diagnosis and therapy.⁴

In these surveys, blood pressure was measured by auscultation by human observers using mercury or aneroid sphygmomanometers, and most physicians still use this method in clinical practice. But in spite of multiple guidelines for accurate measurement of blood pressure in the office, the overall accuracy and reproducibility of office blood pressure measurements remain poor.^5–7

The accuracy of blood pressure measurement with aneroid and mercury manometers is affected by a number of observer errors and patient factors.^8,9

Observer errors

Failure to prepare the patient. National guidelines⁵ state that before having their blood pressure taken, patients should be allowed to sit quietly for at least 5 minutes, which often does not happen. Another error is that clinicians rarely discourage patients from smoking cigarettes or drinking coffee in the 30 minutes prior to measurement.

Equipment and layout problems. Equipment should be properly calibrated and validated. ⁵ However, even if the sphygmomanometer is periodically calibrated, too often it is mounted on the wall adjacent to the examination table in the examination room, making it difficult to provide a comfortable seat with back and arm support during the reading. The measurement should be done with the patient sitting in a chair (not on an examination table), with feet on the floor and the arm supported at the level of the heart. If the forearm is not supported in the horizontal position and with the cuff at heart level, the blood pressure and heart rate tend to be higher.¹⁰ Further, the diastolic blood pressure and heart rate may be misleadingly low with the patient supine rather than seated,^11,12 so readings should be taken with the patient sitting.

Miscuffing, ie, the use of a blood pressure cuff that is too large or, more often, too small for the patient’s arm, is a common source of error. The cuff bladder should encircle at least 80% of the arm.⁵ However, some offices do not have a large blood pressure cuff for overweight patients or a pediatric cuff for children or adults with arms of small circumference. It is recommended that a large blood pressure cuff be used routinely in adults, since a smaller cuff gives falsely high readings in people with large upper arms (circumference > 29 cm).^13,14

Digit preference. Many physicians round off the blood pressure to the nearest 5 or 10 mm Hg. This problem may go along with:

Deflating the cuff too rapidly.

Talking to the patient while taking the blood pressure can contribute to higher readings.⁹

Not taking enough readings. Ideally, at the initial visit, blood pressure should be measured in both arms with the patient seated, and another reading should be taken with the patient standing. The arm with the higher pressure should be used for subsequent readings. Physicians should not make any treatment decisions based on blood pressure during an initial clinic visit, and at least two readings should be taken even on subsequent visits. However, owing to time constraints in busy clinical practices, treatment decisions are often based on single readings or on multiple readings on a single visit.

Discrepancies between observers. The blood pressure readings obtained by the nurse or medical assistant may differ significantly from those obtained by the physician. These differences can be large enough to affect treatment decisions,^15,16 and they can be partially corrected by adequate training of all medical personnel who take blood pressure, doctors as well as nurses.

Given that time is tight in busy clinical practices and a trained blood pressure nurse or technician is usually not available, we will probably not see any significant improvement in the accuracy of blood pressure measurement using older technology and current physician practices.

The white-coat effect

Most patients have a higher level of anxiety, and therefore higher blood pressure, in the physician’s office or clinic than in their normal environment (as revealed by ambulatory monitoring or home blood pressure measurements), a phenomenon commonly called the white-coat effect.

Several factors can increase this effect, such as observer-patient interaction during the measurement. The effect tends to be greatest in the initial measurement, but can persist through multiple readings by the doctor or nurse during the same visit.

Whether the white-coat effect is due purely to patient anxiety about an office visit or to a conditioned response has been a point of interest in clinical studies. Regardless, it may result in the misdiagnosis of hypertension or in overestimation of the severity of hypertension and may lead to overly aggressive therapy. Antihypertensive treatment may be unnecessary in the absence of concurrent cardiovascular risk factors.¹⁷

“White-coat hypertension” or “isolated office hypertension” is the condition in which a patient who is not on antihypertensive drug therapy has persistently elevated blood pressure in the clinic or office (> 140/90 mm Hg) but normal daytime ambulatory blood pressure (< 135/85 mm Hg).¹⁸ Since patients may have an elevated reading when seen for a first office visit, at least several visits are required to establish the diagnosis. Multiple studies have suggested that white-coat hypertension may account for 20% to 25% of the hypertensive population, particularly in older patients, mainly women.^19,20

Both white-coat hypertension and the white-coat effect can be avoided by using an automatic and programmable device that can take multiple readings after the clinician leaves the examination room (more about this below).²¹

MEASURING BLOOD PRESSURE OUTSIDE THE OFFICE

Recent studies have reported that the information obtained by 24-hour ambulatory blood pressure monitoring and by self-measurement of blood pressure in the home more accurately reflects the patient’s risk of future cardiovascular events than do conventional blood pressure measurements taken in the physician’s office. ^22–24 Current national guidelines recognize this pattern and the frequent measurement inaccuracies observed in clinical practice, and they are recommending including out-of-office measurements in the diagnosis of hypertension. ^25,26

Ambulatory monitoring provides the most accurate measurement of out-of-office blood pressure. With ambulatory monitoring, the normal mean daytime pressure is considered to be lower than 135/85 mm Hg, in contrast to the 140/90 mm Hg cutoff used in the physician’s office with standard aneroid or mercury devices.

Self-monitoring of blood pressure at home has now become widely available with single-measurement oscillometric devices. (Oscillometric means that these devices measure the blood pressure by sensing the oscillations in pressure in the cuff induced by the pulsation of the brachial artery, as opposed to auscultating the Korotkoff sounds.) Blood pressures lower than 135/85 mm Hg outside the clinician’s office are considered normal with these devices.

However, despite its proven value, ambulatory monitoring is neither widely available nor cost-effective for the long-term management of hypertension. Furthermore, few physicians recommend that patients take their blood pressure at home, although the information obtained can be of significant value in the patient’s long-term management.

AUTOMATED MEASUREMENT IN THE OFFICE

In recent years, several automated oscillometric sphygmomanometers have been developed for measuring blood pressure in the office, and more are on the way. These devices can be programmed to take multiple readings without a clinician observer in the examination room, thus reducing the white-coat response.

Omron (Kyoto, Japan) makes several devices, including the HEM-907 and the HEM-705, that have been used in the clinical setting. ^21,27–29 They can be programmed to take two or three readings at intervals of 1 to 2 minutes, with up to 5 minutes before the first reading. Unfortunately, data were not recorded with the patient alone in the room in many studies of the Omron devices, even though the devices meet national and international standards for accuracy.

The Microlife Watch BP Office (Microlife, Widnau, Switzerland) is currently undergoing development.³⁰

The BpTRU (BpTRU Medical Devices, Coquitlam, BC, Canada) has enjoyed greater clinical acceptance, since it can take up to five blood pressure readings at intervals of 1 to 5 minutes, and calculates the mean of all five readings, taken with the patient resting comfortably in a quiet room without a clinician present.

The accuracy and durability of the device has been well established. Since the BpTRU self-calibrates between every blood pressure measurement, periodic calibration has not been required. The device can be placed on a table, mounted on the wall, or mounted on a cart if used in several locations in the office.

At Cleveland Clinic, several departments are using the BpTRU on a daily basis. Soon, we will be able to transfer data directly from the BpTRU to our electronic medical record system.

Studies of the BpTRU device

To date, most of the studies of automated office blood pressure measurement have used the BpTRU with the recording interval set at 1 to 2 minutes.

Myers³¹ used the BpTRU device in 50 hypertensive patients. The physician took the patient’s blood pressure with a mercury sphygmomanometer while the BpTRU device made the first reading, and then he left the room. The next five readings were taken at 2-minute intervals with the patient alone in the room. The mean initial reading by the machine was 162/85 mm Hg; the reading by the physician was 163/86 mm Hg. The third automatic reading was the lowest (averaging 140/84 mm Hg), and the mean of the five automated readings was 142/80 mm Hg, which was significantly lower than the initial reading obtained by the physician (P < .001).

In another study, Myers et al³² compared the measurements obtained by 24-hour ambulatory monitoring and by the BpTRU device (the mean of five readings obtained at 1-minute or 2-minute intervals) in 309 hypertensive patients. The mean blood pressure with the Bp-TRU was 132/75 mm Hg, which correlated well with the mean awake ambulatory blood pressure (134/77 mm Hg; r = 0.62 for the systolic pressure and 0.72 for the diastolic pressure).

We recently reviewed the records of 278 patients seen in our preventive medicine clinic (D.G. Vidt, MD, unpublished data, November 2009). The group included patients with and without established hypertension, and among the hypertensive group, both treated and untreated individuals. We had initially set the device to take readings at 3-minute intervals following the initial nurse-initiated reading. But in view of the recent data on the Bp-TRU using shorter intervals, we also obtained readings in 51 patients with the device set to record at 2-minute intervals, and then in 72 additional patients at 1-minute intervals. In all three groups, blood pressure had stabilized by the third reading after the clinician had left the room. These observations support those reported by Myers et al.^31,32 Of particular importance is the observation that the white-coat effect dissipates within 2 to 3 minutes after the clinician leaves the room.³³

The shorter measurement intervals can add up in a busy office practice, in which the time relegated to taking blood pressure is often limited.

In fact, waiting 5 minutes between measurements may allow the patient to become too relaxed and the blood pressure to drop too low vis-a-vis the gold standard, ambulatory monitoring. Culleton and colleagues³⁴ compared the blood pressure in 107 hypertensive patients as measured four ways: by the referring physician, by a nurse who was trained to adhere to the protocol of the Canadian Hypertension Education Program, by 24-hour ambulatory monitoring, and by the BpTRU (the mean of five readings obtained at 5-minute intervals). The mean measured values were:

• 150/90 mm Hg by the referring physician
• 139/86 mm Hg by the nurse
• 142/85 mm Hg by ambulatory monitoring
• 132/82 mm Hg by the BpTRU device.

Although the BpTRU reduced the white-coat effect and white-coat hypertension, it underestimated the blood pressure, leading to misclassification of hypertension. Using 140/90 mm Hg as the cutoff for whether the patient was hypertensive and using ambulatory monitoring as the gold standard, the BpTRU misclassified more than half of the patients, agreeing with the classification of hypertensive or not hypertensive by ambulatory monitoring in only 48%. The authors recommended that the BpTRU not be set at 5-minute measurement intervals.³⁴

WHAT ROLE FOR AUTOMATED READINGS IN THE OFFICE?

Although automatic devices, by enabling the physician to leave the room, can eliminate the white-coat effect and white-coat hypertension, physicians must continue to take care to avoid the other potential errors of office blood pressure measurement addressed earlier in this review, for example, by positioning the patient correctly and using a cuff that is large enough. These issues can take on more importance as the clinician leaves the patient alone for brief periods during measurements.

In view of its perennial inaccuracies, some experts have suggested that we abandon routine office measurement of blood pressure.^35,36 In its place, ambulatory monitoring would be used for diagnosis and for periodic follow-up. In addition, patients would regularly take their pressure at home with approved, single-measurement oscillometric devices. Unfortunately, in our health care system, periodic ambulatory monitoring for hypertension management would impose a significant financial burden on patients at this time.³⁷

Of particular importance is the observation that the mean of five readings with the BpTRU device, obtained at 1- or 2-minute intervals, closely approximates the mean awake blood pressure obtained in the same patient with an ambulatory monitor.^32,38 The ability to obtain readings that correlate exceptionally well with mean daytime ambulatory pressure suggests that this device could well reduce the need for ambulatory monitoring, with its associated cost. The ability to negate the white-coat effect with the use of the BpTRU in the office setting also has particular importance, not only for patient office readings, but for the diagnosis and subsequent treatment of hypertension in individual patients.

Most clinical decisions about the treatment of hypertension are still made on the basis of office determinations of blood pressure. Most office practices still rely on the aneroid manometer or, decreasingly, mercury sphygmomanometers. As noted earlier, although auscultatory blood pressure measurement appears to be simple, it is fraught with a host of observer- or patient-induced errors that not only lead to inaccurate diagnoses, but may also result in the mismanagement of hypertension. Even single-measurement oscillometric devices, now used in a minority of clinical practices, are associated with many of the same measurement issues that lead to overestimation of blood pressure.

We believe the time has come for broader use of oscillometric devices in the outpatient setting. While many available oscillometric devices for use in the home could also be used in the physician’s office, they carry the similar disadvantage of providing only a single measurement. The major disadvantage of all single-measurement devices is the continued presence of the clinician during the reading and the associated white-coat effect observed in most patients.

It is highly likely that the next Joint National Committee Report on Hypertension will further emphasize the role of automated blood pressure devices in the outpatient setting.
 

Acknowledgment: The authors wish to acknowledge the contributions of Deborah McCoy, RN, and Maria Eckhouse, RN.

Mrs. Smith, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

See related editorial

Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”

CHRONIC ILLNESS: A CHALLENGE, AND AN OPPORTUNITY

The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.^1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.^3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.⁶

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (Table 1).

UNDER MEDICARE, WHO IS ELIGIBLE FOR HOME HEALTH SERVICES?

Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.⁷ Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.

Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.⁸ These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.

To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.

Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.⁹

The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.

How this applies to Mrs. Smith

In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.

Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.

The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”¹⁰ and can substitute for the revenue lost due to less-frequent office visits.¹⁰ In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.

Oversight in the computer age

Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.

Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.^11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.

NEW CONCEPTS, PROCESSES, AND TECHNOLOGIES

To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.

Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” ^13–16 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.

A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.

New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.^17–20 Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.

Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.²¹ Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.

TOWARD ONGOING CARE MANAGEMENT

In spite of these opportunities, the Medicare home health benefit rarely permits uninterrupted ongoing home care. Thus, the home health collaboration developed around Mrs. Smith’s heart failure exacerbation is likely to be temporary, and when her condition stabilizes she may no longer meet the criteria for home health services.

This episodic-payment model contrasts with the ongoing needs of the typical high-risk older patient with chronic illness. Changing the home health benefit to allow for ongoing home health care for beneficiaries like Mrs. Smith may be an opportunity for patient-centered reform. Although ongoing home health care for a given patient may not be possible, the medical home model offers the opportunity for ongoing physician-home health collaboration because at any time a physician’s practice is likely to have patients requiring these services. The independence-at-home model does provide for uninterrupted ongoing in-home physician and mid-level care for some patients, but it may require changing primary care physicians, and this may be undesirable to some patients. If a viable financing model is established for medical homes and independence-at-home practices, they may choose to contract with home health agencies to provide ongoing telephone or telemetric care management between (or outside of) episodes of eligibility for traditional home health care. All of these potential arrangements would need legal review and would need to be structured to avoid violation of the letter and spirit of laws prohibiting self-referrals and kickbacks.

PHYSICIAN HOME VISITS

In the case of Mrs. Smith, Dr. Jones has the option of making a follow-up home visit, or even ongoing home visits.

Granted, home visits may be impractical due to the time involved and the impact of that downtime on the physician’s medical practice and responsibilities to other patients. However, larger practices may employ a specific physician, nurse practitioner, or physician’s assistant to provide in-home care to patients in need.

Some communities have house-call practices to which Dr. Jones could refer Mrs. Smith for in-home physician care, and, where available, this may be a preferred care model— somewhat analogous to how a primary care physician might collaborate with a hospitalist for inpatient care of a specific patient.²² These homecare physician practices will likely become more prevalent if the independence-at-home Medicare demonstration project is successful.

In the future, even if Mrs. Smith needed more intensive inpatient care, an emerging concept called “hospital at home” may be able to provide this acute care in her home.^23,24 These in-home physician services are increasingly supported by new mobile diagnostic technologies.²⁵

However, adding or changing physicians may not be possible or desirable for Mrs. Smith and could lead to further fragmentation of care. In the future, teleconferencing may provide options for “virtual visits” that would partially solve this problem.

Whether the physician care is provided in the office, in the home, or as a virtual visit, much of the care Mrs. Smith needs can and should be done by nonphysician home health care providers in partnership with informal caregivers.

MRS. SMITH GETS BETTER AT HOME

Dr. Jones decided to refer Mrs. Smith for home health nursing and maintained close telephone contact with her and the home health nurse during the first 2 weeks. Mrs. Smith responded well to the changes in medication and diet, her leg swelling decreased, and she was feeling more like her usual self. At a follow-up office visit 3 months later, Mrs. Smith hugged Dr. Jones and thanked her profusely for helping her get better at home.

Mrs. Smith, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

See related editorial

Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”

CHRONIC ILLNESS: A CHALLENGE, AND AN OPPORTUNITY

The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.^1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.^3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.⁶

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (Table 1).

UNDER MEDICARE, WHO IS ELIGIBLE FOR HOME HEALTH SERVICES?

Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.⁷ Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.

Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.⁸ These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.

To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.

Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.⁹

The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.

How this applies to Mrs. Smith

In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.

Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.

The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”¹⁰ and can substitute for the revenue lost due to less-frequent office visits.¹⁰ In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.

Oversight in the computer age

Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.

Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.^11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.

NEW CONCEPTS, PROCESSES, AND TECHNOLOGIES

To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.

Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” ^13–16 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.

A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.

New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.^17–20 Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.

Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.²¹ Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.

TOWARD ONGOING CARE MANAGEMENT

In spite of these opportunities, the Medicare home health benefit rarely permits uninterrupted ongoing home care. Thus, the home health collaboration developed around Mrs. Smith’s heart failure exacerbation is likely to be temporary, and when her condition stabilizes she may no longer meet the criteria for home health services.

This episodic-payment model contrasts with the ongoing needs of the typical high-risk older patient with chronic illness. Changing the home health benefit to allow for ongoing home health care for beneficiaries like Mrs. Smith may be an opportunity for patient-centered reform. Although ongoing home health care for a given patient may not be possible, the medical home model offers the opportunity for ongoing physician-home health collaboration because at any time a physician’s practice is likely to have patients requiring these services. The independence-at-home model does provide for uninterrupted ongoing in-home physician and mid-level care for some patients, but it may require changing primary care physicians, and this may be undesirable to some patients. If a viable financing model is established for medical homes and independence-at-home practices, they may choose to contract with home health agencies to provide ongoing telephone or telemetric care management between (or outside of) episodes of eligibility for traditional home health care. All of these potential arrangements would need legal review and would need to be structured to avoid violation of the letter and spirit of laws prohibiting self-referrals and kickbacks.

PHYSICIAN HOME VISITS

In the case of Mrs. Smith, Dr. Jones has the option of making a follow-up home visit, or even ongoing home visits.

Granted, home visits may be impractical due to the time involved and the impact of that downtime on the physician’s medical practice and responsibilities to other patients. However, larger practices may employ a specific physician, nurse practitioner, or physician’s assistant to provide in-home care to patients in need.

Some communities have house-call practices to which Dr. Jones could refer Mrs. Smith for in-home physician care, and, where available, this may be a preferred care model— somewhat analogous to how a primary care physician might collaborate with a hospitalist for inpatient care of a specific patient.²² These homecare physician practices will likely become more prevalent if the independence-at-home Medicare demonstration project is successful.

In the future, even if Mrs. Smith needed more intensive inpatient care, an emerging concept called “hospital at home” may be able to provide this acute care in her home.^23,24 These in-home physician services are increasingly supported by new mobile diagnostic technologies.²⁵

However, adding or changing physicians may not be possible or desirable for Mrs. Smith and could lead to further fragmentation of care. In the future, teleconferencing may provide options for “virtual visits” that would partially solve this problem.

Whether the physician care is provided in the office, in the home, or as a virtual visit, much of the care Mrs. Smith needs can and should be done by nonphysician home health care providers in partnership with informal caregivers.

MRS. SMITH GETS BETTER AT HOME

Dr. Jones decided to refer Mrs. Smith for home health nursing and maintained close telephone contact with her and the home health nurse during the first 2 weeks. Mrs. Smith responded well to the changes in medication and diet, her leg swelling decreased, and she was feeling more like her usual self. At a follow-up office visit 3 months later, Mrs. Smith hugged Dr. Jones and thanked her profusely for helping her get better at home.

Mrs. Smith, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

See related editorial

Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”

CHRONIC ILLNESS: A CHALLENGE, AND AN OPPORTUNITY

The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.^1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.^3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.⁶

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (Table 1).

UNDER MEDICARE, WHO IS ELIGIBLE FOR HOME HEALTH SERVICES?

Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.⁷ Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.

Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.⁸ These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.

To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.

Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.⁹

The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.

How this applies to Mrs. Smith

In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.

Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.

The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”¹⁰ and can substitute for the revenue lost due to less-frequent office visits.¹⁰ In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.

Oversight in the computer age

Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.

Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.^11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.

NEW CONCEPTS, PROCESSES, AND TECHNOLOGIES

To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.

Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” ^13–16 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.

A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.

New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.^17–20 Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.

Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.²¹ Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.

TOWARD ONGOING CARE MANAGEMENT

In spite of these opportunities, the Medicare home health benefit rarely permits uninterrupted ongoing home care. Thus, the home health collaboration developed around Mrs. Smith’s heart failure exacerbation is likely to be temporary, and when her condition stabilizes she may no longer meet the criteria for home health services.

This episodic-payment model contrasts with the ongoing needs of the typical high-risk older patient with chronic illness. Changing the home health benefit to allow for ongoing home health care for beneficiaries like Mrs. Smith may be an opportunity for patient-centered reform. Although ongoing home health care for a given patient may not be possible, the medical home model offers the opportunity for ongoing physician-home health collaboration because at any time a physician’s practice is likely to have patients requiring these services. The independence-at-home model does provide for uninterrupted ongoing in-home physician and mid-level care for some patients, but it may require changing primary care physicians, and this may be undesirable to some patients. If a viable financing model is established for medical homes and independence-at-home practices, they may choose to contract with home health agencies to provide ongoing telephone or telemetric care management between (or outside of) episodes of eligibility for traditional home health care. All of these potential arrangements would need legal review and would need to be structured to avoid violation of the letter and spirit of laws prohibiting self-referrals and kickbacks.

PHYSICIAN HOME VISITS

In the case of Mrs. Smith, Dr. Jones has the option of making a follow-up home visit, or even ongoing home visits.

Granted, home visits may be impractical due to the time involved and the impact of that downtime on the physician’s medical practice and responsibilities to other patients. However, larger practices may employ a specific physician, nurse practitioner, or physician’s assistant to provide in-home care to patients in need.

Some communities have house-call practices to which Dr. Jones could refer Mrs. Smith for in-home physician care, and, where available, this may be a preferred care model— somewhat analogous to how a primary care physician might collaborate with a hospitalist for inpatient care of a specific patient.²² These homecare physician practices will likely become more prevalent if the independence-at-home Medicare demonstration project is successful.

In the future, even if Mrs. Smith needed more intensive inpatient care, an emerging concept called “hospital at home” may be able to provide this acute care in her home.^23,24 These in-home physician services are increasingly supported by new mobile diagnostic technologies.²⁵

However, adding or changing physicians may not be possible or desirable for Mrs. Smith and could lead to further fragmentation of care. In the future, teleconferencing may provide options for “virtual visits” that would partially solve this problem.

Whether the physician care is provided in the office, in the home, or as a virtual visit, much of the care Mrs. Smith needs can and should be done by nonphysician home health care providers in partnership with informal caregivers.

MRS. SMITH GETS BETTER AT HOME

Dr. Jones decided to refer Mrs. Smith for home health nursing and maintained close telephone contact with her and the home health nurse during the first 2 weeks. Mrs. Smith responded well to the changes in medication and diet, her leg swelling decreased, and she was feeling more like her usual self. At a follow-up office visit 3 months later, Mrs. Smith hugged Dr. Jones and thanked her profusely for helping her get better at home.