Editors note: This article features interactive region-by-region breakdowns and Team Hospitalist analysis of the latest compensation and productivity data from SHM and MGMA. Click here to open the interactive feature.

Every January, William “Tex” Landis, MD, FHM, sits in a conference room with key members of his hospital’s administration and presents what he affectionately refers to as the “state of the union” for his hospitalist group. The bar graphs, pie charts, and commentary have changed little in the past decade, Dr. Landis admits, but the information and analysis he has available to him as he begins crafting his 2011 presentation is better than ever.

Dr. Landis, medical director of Wellspan Hospitalists in York, Pa., and hospitalist group leaders across the country will have access to the State of Hospital Medicine: 2010 Report Based on 2009 Data this budget cycle. The new report, which will be available Sept. 10, offers new compensation and productivity information, new layers of detail, and new tools to help group leaders analyze the data.

“This data reflects the best numbers we have in our business,” says Dr. Landis, the chair of SHM’s Practice Analysis Committee. “We have better participation and better quality data analysis than we have ever had before. It’s a more standardized approach, and we are just going to be able to continue to build upon this. It sets the standard for moving forward, as far as I am concerned.”

The new report, which replaces SHM’s biannual survey, is the result of a partnership between SHM and the Medical Group Management Association (MGMA), an industry leader in practice-management resources. The report compiled data about 4,211 hospitalists in 443 groups, a 30% increase in survey respondents over SHM’s 2007-2008 report.

“The collaboration is really driven at providing a single set of benchmarks to the HM community,” says David Litzau, systems analyst at MGMA. “It provides a viewpoint of what’s happening elsewhere in the industry.”

click for large version

What’s happening is that hospitalists continue to see increases in compensation. The new report, which uses some different data definitions and survey methodologies, and is based on a new population, shows that median compensation for adult hospitalists is $215,000 per year, a number that doesn’t take into account benefits. Hospitalist median compensation was $183,900, according to SHM’s 2007-2008 survey, and $171,000 in SHM’s 2005-2006 survey. MGMA’s 2009 report on physician compensation showed median compensation at $210,250 per internal medicine hospitalist.

And while the compensation numbers are higher than in previous surveys, the new report also shows adult hospitalists are increasing productivity, are seeing more patients per year (reversing a somewhat declining trend), and are collecting more per encounter.

The Numbers

Although compensation is the most popular survey metric, it’s not the only number worth investigating. A handful of key productivity measures seem to be on the rise, too, according to the new report.

The national median (the midpoint of all survey respondents) for work RVUs per adult hospitalist FTE is 4,107, according to the new data. SHM’s 2007-2008 survey reported wRVUs at 3,715 per adult hospitalist.

The national median for hospitalist wRVUs per encounter is 1.86. That same figure was reported at 1.53 wRVUs per encounter in 2008 and 1.37 in 2006.

Collections per wRVU is $45.57, according to the 2010 report. The 2008 survey showed collections at $44.97 per wRVU; the 2006 survey did not report the metric.

One thing the new metrics have in common is that they show hospitalists across the nation are becoming more efficient. “The numbers essentially reaffirm the overall trends for hospital medicine, in that the productivity continues to increase and the compensation paid to a provider continues to increase,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan, which has nearly 50 hospitalists supporting three hospitals. “When you dig into the numbers, hospitalists are producing more work and more RVUs per encounter than they had been in the past.”

Financial support per hospitalist FTE, another key practice-management metric, parallels the compensation growth. Practices receive a median of $98,253 of support per hospitalist FTE, according to 2010 data. The 2008 report did not provide a median figure for support; instead, it published a mean figure of $97,375 of support per FTE. The 2010 mean (average) is $111,486.

Pediatric HM also shows signs of growth; median compensation is $160,038 in the new report. The 2008 report had pediatric hospitalist median compensation at $144,600.

The new data show a spike in HM groups providing “on site” care of patients 24 hours a day, seven days a week. More than 68% have on-site care with a physician, nurse practitioner, or physician assistant. Only 53% of groups had 24/7 coverage in the 2008 report; 51% had round-the-clock coverage in the 2006 report.

Dr. Ahlstrom, a veteran member of SHM’s Practice Analysis Committee, says he expects that trend to continue, especially with the large numbers of young hospitalists in the field interested in set schedules and work-life balance. “That’s the trend,” he says. “Younger physicians are more interested in seeing that split, where the days and nights are clearly set off. Older physicians are more than happy to have a nocturnist around, just as long as it’s not going to cost them a lot of money or productivity.”

A Word of Caution, and Unintended Benefits

The new report is based on a supplemental set of questions specifically directed at hospitalist practices in MGMA’s annual Physician Compensation and Productivity Survey. The survey is voluntary and is not audited, but it is the “best data” available for hospitalists, according to practice-management experts.

“So many people assume this data is what you should do,” says John Nelson, MD, MHM, co-founder and past president of SHM and a principal in hospitalist-consulting firm Nelson Flores Hospital Medicine Consultants. “It’s not. It is a survey of what’s happening. It’s a starting point, a frame of reference. It is the best data there is, no doubt. But you should not build your practice by trying to match the medians. You might have local data that deviates. You might be starting a program or be in a competitive situation.”

The same experts warn that the new survey population and methodologies will make it difficult to draw direct comparisons to data from previous surveys. For example, the 2007-2008 SHM survey included roughly a quarter of respondents from academic settings; the 2010 report has barely 1% of its respondents from academic settings (see Figure 1, p. 14). Traditionally, compensation and productivity levels for academic hospitalists are lower than nonacademic hospitalists. Most experts agree the “filtering” effect of the survey population factors heavily into the across- the-board increases in compensation and productivity in the 2010 report.

“The survey instrument that we use has been used historically for nonacademic physicians,” Litzau explains. “We also have an academic survey that is performed in the fall [Sept. 13 through Nov. 5], where we collect data specifically for academic faculty. We see very different trends within those two types of practice. It is difficult to draw clear comparisons between the two.”

Dr. Landis refers to the new report as a “baseline” and advises hospitalist leaders to review the caveats and cautions section (see “Survey Stipulation: Only Fools Rush In,” p. 16) before jumping right to the numbers. “This is a new set of numbers. Probably the more important comparison will be this set of numbers compared with the next set of data, next year,” he adds.

Even so, the “filtering” effect should provide nonacademic hospitalist groups a more accurate picture of compensation and productivity trends. One hospitalist leader says it’s a “win-win” for both academic and nonacademic practice leaders.

“As a community-based hospitalist, I always had to drill into those organizations that were similar to me. Being able to have more filtered information, it allows us to drill into the areas that are more important and then present that information to our CEO, CFO, VPMA,” says William D. Atchley Jr., MD, FACP, SFHM, chief of hospital medicine at Sentara Medical Group in Norfolk, Va., and a member of Team Hospitalist.

New Info, Deeper Analysis

In addition to a larger response rate and more filtered approach, the new report will offer greater frequency (annually), new data points, and in-depth breakdowns of key productivity metrics. Some of the new metrics reported include:

• Staff per FTE hospitalist physician;
• Staff turnover;
• Retirement benefits;
• Compensation to collections ratio;
• Compensation per encounter;
• Compensation per wRVU;
• Collections per encounter;
• Collections per wRVU; and
• Work RVUs per encounter.

The report will be available every fall, as compared to biannually for past SHM surveys. It also will offer more “cuts” of the data, including median, mean, 25th percentile, 75th percentile, and 90th percentile reports, along with regional breakdowns for many compensation and productivity metrics.

Practical Applications

This data reflects the best numbers we have in our business. We have better participation and better quality data analysis than we have ever had before.

—William “Tex” Landis, MD, FHM, medical director, Wellspan Hospitalists, York, Pa., SHM Practice Analysis Committee chair

Benchmarking data are used to set productivity goals and compensation levels in hospitalist practices throughout the country, and most administrators use multiple sources of data to make those decisions.

“If we are showing our hospitalists are generating 5,000 wRVUs per year, and the national median is 4,100, you can do the math. I can say, ‘We need to bring on another hospitalist. The timing is right, and we need to be recruiting,’ ” says Dr. Atchley, who has worked with benchmarking data for 15 years and currently supervises 45 full-time hospitalists who service five hospitals in southeast Virginia. “It’s always good to have national benchmarks to compare to, because that is always the question that is going to be asked. [Hospital administrators] want regional and national comparisons.”

Regional information and well-adapted data from national surveys guide James Gardner, MD, chief medical executive for Pro Health Care Inc., a two-hospital system just west of Milwaukee, when he’s hiring new hospitalists at 300-bed Waukesha Memorial Hospital or launching a new HM program at the system’s smaller, rural facility. In fact, Dr. Gardner currently is weighing options to expand the HM service at 80-bed Oconomowoc Hospital, less than a year after the program started.

“We like to look at a number of sources of data. The MGMA and SHM survey data, historically, have been two of our preferred sources,” Dr. Gardner says. “I think we tend to look at more regional data from the Midwest because the national data varies so much.

“We try to get a sense as to what our local market is.”

Dr. Gardner says he’d like to see a “couple years” to confirm the validity of the new SHM-MGMA report. That said, he says he knows how useful the data can be in regard to benchmarking hospitalist productivity.

“It’s been very helpful; it helps us know where we are at,” Dr. Gardner explains. “It’s one of the guideposts to decide when we are approaching the need for additional resources, whether that is midlevel providers or full-time hospitalists.”

Advice From a Numbers Guy

Dr. Ahlstrom

A self-described “numbers” guy, Dr. Ahlstrom agrees regional data is just as important as, if not more important than, the national numbers. He stresses knowing your market, your competitors, your hospital culture—and using that information along with the benchmarking data to formulate expectations for your group.

“Oftentimes you are measured against the guy next door,” Dr. Ahlstrom says. “You have to know the numbers, because [administrators] are going to know the numbers.”

Dr. Ahlstrom offers these tips for incorporating benchmarking data into your practice:

• Know your local market. “If you keep in mind your local needs, then you can look at the data and start to evaluate what parts are going to help you better formulate a practice that brings on the right people, does the right work, and continues to produce the amount of workload and compensation that makes sure they are happy in the future,” he says.
• Evaluate how applicable the data is. Pay attention to the total number of survey respondents in each category, and the standard deviation around the mean. “In other words, what is the central tendency of the data? You might find data in subsections that you find interesting, but it might not be data that has a central tendency,” he says. “Find data sets that are most applicable to your practice while assessing variations from the larger data sets. Consider how and why your practice might vary from the report as part of your evaluation.”
• Pick out trends and look at them in total. The key is to avoid looking at data points in isolation. “It’s important to look at trends in the data over time, and pick out where those trends are going to go,” he says.
• Involve your people. “I think that this data being available from the [provider] side and management side is a good thing,” Dr. Ahlstrom explains. “The more we are involved in understanding the trends in HM, the better we are going to plan where we are going in the future.” TH

Jason Carris is editor of The Hospitalist.

Benchmarking Basics

By Jeffrey B. Milburn, MBA, CPME

Benchmarking brings perspective and relevancy to practice issues and can serve as a guide to making effective business decisions. Along with looking at financial trends and ratios, benchmarking is one of the most important techniques well-managed practices use.

What is benchmarking? Whether you are measuring physician productivity or a practice’s financial performance, benchmarking is essentially the comparison of your data to a select peer group.

Why should my practice benchmark? Practice administrators and physician leaders frequently utilize national surveys to “benchmark” hospitalist compensation and production. A practice wants to pay market-level compensation in order to recruit and retain physicians, and also set reasonable production goals for the physicians. For legal and regulatory reasons, hospital executives want to ensure that compensation does not exceed “fair market value.”

How do I benchmark my practice? Benchmarking generally falls into two broad categories: internal and external. Internal benchmarking in a hospitalist practice might be the comparison of the number of patients seen by individual physicians during the standard weekday shift. In addition to developing your own internal data, outside sources include such surveys as the State of Hospital Medicine: 2010 Report Based on 2009 Data published by SHM and MGMA. External benchmarking would be the comparison of patients seen by practice physicians on an annual basis to their hospitalist peers across the nation, as reported in surveys.

What about hospitalist production? Depending on the physician compensation plan, there usually is a strong relationship between the level of compensation and production. When benchmarking hospitalist production, it is important to select the appropriate benchmark for comparative purposes.

Comparing gross charges from practice to practice has little value, since there is no standard methodology for setting charges. On the other hand, work RVUs is a fairly standard metric for measuring physician productivity internally and externally. The work RVUs data are generally reported in the major surveys.

Some hospitalist practices use survey benchmark data adjusted annually to determine how much physicians are paid per unit of productivity. For example, if median survey compensation is $225,000 per year and median work RVUs are 4,000 per year, the practice would pay $56.25 per work RVU to the physician. In this case, the practice has benchmarked both compensation and productivity to arrive at a value per work unit.

What does benchmarking mean for my practice? Benchmarking is a critical component to operating a successful medical practice. Use care in utilizing benchmarks, however. Rather than assuming that your practice’s variance from survey norms means you need to change, evaluate the underlying data to determine if there is a logical reason for the variance related to your practice’s specific circumstances.

Practices that utilize peer group data to benchmark often identify operational concerns and work to make their practices more effective. It has been said you can’t manage what you can’t measure, and benchmarking brings perspective and relevancy to what you measure.

Editors note: This article features interactive region-by-region breakdowns and Team Hospitalist analysis of the latest compensation and productivity data from SHM and MGMA. Click here to open the interactive feature.

Every January, William “Tex” Landis, MD, FHM, sits in a conference room with key members of his hospital’s administration and presents what he affectionately refers to as the “state of the union” for his hospitalist group. The bar graphs, pie charts, and commentary have changed little in the past decade, Dr. Landis admits, but the information and analysis he has available to him as he begins crafting his 2011 presentation is better than ever.

Dr. Landis, medical director of Wellspan Hospitalists in York, Pa., and hospitalist group leaders across the country will have access to the State of Hospital Medicine: 2010 Report Based on 2009 Data this budget cycle. The new report, which will be available Sept. 10, offers new compensation and productivity information, new layers of detail, and new tools to help group leaders analyze the data.

“This data reflects the best numbers we have in our business,” says Dr. Landis, the chair of SHM’s Practice Analysis Committee. “We have better participation and better quality data analysis than we have ever had before. It’s a more standardized approach, and we are just going to be able to continue to build upon this. It sets the standard for moving forward, as far as I am concerned.”

The new report, which replaces SHM’s biannual survey, is the result of a partnership between SHM and the Medical Group Management Association (MGMA), an industry leader in practice-management resources. The report compiled data about 4,211 hospitalists in 443 groups, a 30% increase in survey respondents over SHM’s 2007-2008 report.

“The collaboration is really driven at providing a single set of benchmarks to the HM community,” says David Litzau, systems analyst at MGMA. “It provides a viewpoint of what’s happening elsewhere in the industry.”

click for large version

What’s happening is that hospitalists continue to see increases in compensation. The new report, which uses some different data definitions and survey methodologies, and is based on a new population, shows that median compensation for adult hospitalists is $215,000 per year, a number that doesn’t take into account benefits. Hospitalist median compensation was $183,900, according to SHM’s 2007-2008 survey, and $171,000 in SHM’s 2005-2006 survey. MGMA’s 2009 report on physician compensation showed median compensation at $210,250 per internal medicine hospitalist.

And while the compensation numbers are higher than in previous surveys, the new report also shows adult hospitalists are increasing productivity, are seeing more patients per year (reversing a somewhat declining trend), and are collecting more per encounter.

The Numbers

Although compensation is the most popular survey metric, it’s not the only number worth investigating. A handful of key productivity measures seem to be on the rise, too, according to the new report.

The national median (the midpoint of all survey respondents) for work RVUs per adult hospitalist FTE is 4,107, according to the new data. SHM’s 2007-2008 survey reported wRVUs at 3,715 per adult hospitalist.

The national median for hospitalist wRVUs per encounter is 1.86. That same figure was reported at 1.53 wRVUs per encounter in 2008 and 1.37 in 2006.

Collections per wRVU is $45.57, according to the 2010 report. The 2008 survey showed collections at $44.97 per wRVU; the 2006 survey did not report the metric.

One thing the new metrics have in common is that they show hospitalists across the nation are becoming more efficient. “The numbers essentially reaffirm the overall trends for hospital medicine, in that the productivity continues to increase and the compensation paid to a provider continues to increase,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan, which has nearly 50 hospitalists supporting three hospitals. “When you dig into the numbers, hospitalists are producing more work and more RVUs per encounter than they had been in the past.”

Financial support per hospitalist FTE, another key practice-management metric, parallels the compensation growth. Practices receive a median of $98,253 of support per hospitalist FTE, according to 2010 data. The 2008 report did not provide a median figure for support; instead, it published a mean figure of $97,375 of support per FTE. The 2010 mean (average) is $111,486.

Pediatric HM also shows signs of growth; median compensation is $160,038 in the new report. The 2008 report had pediatric hospitalist median compensation at $144,600.

The new data show a spike in HM groups providing “on site” care of patients 24 hours a day, seven days a week. More than 68% have on-site care with a physician, nurse practitioner, or physician assistant. Only 53% of groups had 24/7 coverage in the 2008 report; 51% had round-the-clock coverage in the 2006 report.

Dr. Ahlstrom, a veteran member of SHM’s Practice Analysis Committee, says he expects that trend to continue, especially with the large numbers of young hospitalists in the field interested in set schedules and work-life balance. “That’s the trend,” he says. “Younger physicians are more interested in seeing that split, where the days and nights are clearly set off. Older physicians are more than happy to have a nocturnist around, just as long as it’s not going to cost them a lot of money or productivity.”

A Word of Caution, and Unintended Benefits

The new report is based on a supplemental set of questions specifically directed at hospitalist practices in MGMA’s annual Physician Compensation and Productivity Survey. The survey is voluntary and is not audited, but it is the “best data” available for hospitalists, according to practice-management experts.

“So many people assume this data is what you should do,” says John Nelson, MD, MHM, co-founder and past president of SHM and a principal in hospitalist-consulting firm Nelson Flores Hospital Medicine Consultants. “It’s not. It is a survey of what’s happening. It’s a starting point, a frame of reference. It is the best data there is, no doubt. But you should not build your practice by trying to match the medians. You might have local data that deviates. You might be starting a program or be in a competitive situation.”

The same experts warn that the new survey population and methodologies will make it difficult to draw direct comparisons to data from previous surveys. For example, the 2007-2008 SHM survey included roughly a quarter of respondents from academic settings; the 2010 report has barely 1% of its respondents from academic settings (see Figure 1, p. 14). Traditionally, compensation and productivity levels for academic hospitalists are lower than nonacademic hospitalists. Most experts agree the “filtering” effect of the survey population factors heavily into the across- the-board increases in compensation and productivity in the 2010 report.

“The survey instrument that we use has been used historically for nonacademic physicians,” Litzau explains. “We also have an academic survey that is performed in the fall [Sept. 13 through Nov. 5], where we collect data specifically for academic faculty. We see very different trends within those two types of practice. It is difficult to draw clear comparisons between the two.”

Dr. Landis refers to the new report as a “baseline” and advises hospitalist leaders to review the caveats and cautions section (see “Survey Stipulation: Only Fools Rush In,” p. 16) before jumping right to the numbers. “This is a new set of numbers. Probably the more important comparison will be this set of numbers compared with the next set of data, next year,” he adds.

Even so, the “filtering” effect should provide nonacademic hospitalist groups a more accurate picture of compensation and productivity trends. One hospitalist leader says it’s a “win-win” for both academic and nonacademic practice leaders.

“As a community-based hospitalist, I always had to drill into those organizations that were similar to me. Being able to have more filtered information, it allows us to drill into the areas that are more important and then present that information to our CEO, CFO, VPMA,” says William D. Atchley Jr., MD, FACP, SFHM, chief of hospital medicine at Sentara Medical Group in Norfolk, Va., and a member of Team Hospitalist.

New Info, Deeper Analysis

In addition to a larger response rate and more filtered approach, the new report will offer greater frequency (annually), new data points, and in-depth breakdowns of key productivity metrics. Some of the new metrics reported include:

• Staff per FTE hospitalist physician;
• Staff turnover;
• Retirement benefits;
• Compensation to collections ratio;
• Compensation per encounter;
• Compensation per wRVU;
• Collections per encounter;
• Collections per wRVU; and
• Work RVUs per encounter.

The report will be available every fall, as compared to biannually for past SHM surveys. It also will offer more “cuts” of the data, including median, mean, 25th percentile, 75th percentile, and 90th percentile reports, along with regional breakdowns for many compensation and productivity metrics.

Practical Applications

This data reflects the best numbers we have in our business. We have better participation and better quality data analysis than we have ever had before.

—William “Tex” Landis, MD, FHM, medical director, Wellspan Hospitalists, York, Pa., SHM Practice Analysis Committee chair

Benchmarking data are used to set productivity goals and compensation levels in hospitalist practices throughout the country, and most administrators use multiple sources of data to make those decisions.

“If we are showing our hospitalists are generating 5,000 wRVUs per year, and the national median is 4,100, you can do the math. I can say, ‘We need to bring on another hospitalist. The timing is right, and we need to be recruiting,’ ” says Dr. Atchley, who has worked with benchmarking data for 15 years and currently supervises 45 full-time hospitalists who service five hospitals in southeast Virginia. “It’s always good to have national benchmarks to compare to, because that is always the question that is going to be asked. [Hospital administrators] want regional and national comparisons.”

Regional information and well-adapted data from national surveys guide James Gardner, MD, chief medical executive for Pro Health Care Inc., a two-hospital system just west of Milwaukee, when he’s hiring new hospitalists at 300-bed Waukesha Memorial Hospital or launching a new HM program at the system’s smaller, rural facility. In fact, Dr. Gardner currently is weighing options to expand the HM service at 80-bed Oconomowoc Hospital, less than a year after the program started.

“We like to look at a number of sources of data. The MGMA and SHM survey data, historically, have been two of our preferred sources,” Dr. Gardner says. “I think we tend to look at more regional data from the Midwest because the national data varies so much.

“We try to get a sense as to what our local market is.”

Dr. Gardner says he’d like to see a “couple years” to confirm the validity of the new SHM-MGMA report. That said, he says he knows how useful the data can be in regard to benchmarking hospitalist productivity.

“It’s been very helpful; it helps us know where we are at,” Dr. Gardner explains. “It’s one of the guideposts to decide when we are approaching the need for additional resources, whether that is midlevel providers or full-time hospitalists.”

Advice From a Numbers Guy

Dr. Ahlstrom

A self-described “numbers” guy, Dr. Ahlstrom agrees regional data is just as important as, if not more important than, the national numbers. He stresses knowing your market, your competitors, your hospital culture—and using that information along with the benchmarking data to formulate expectations for your group.

“Oftentimes you are measured against the guy next door,” Dr. Ahlstrom says. “You have to know the numbers, because [administrators] are going to know the numbers.”

Dr. Ahlstrom offers these tips for incorporating benchmarking data into your practice:

• Know your local market. “If you keep in mind your local needs, then you can look at the data and start to evaluate what parts are going to help you better formulate a practice that brings on the right people, does the right work, and continues to produce the amount of workload and compensation that makes sure they are happy in the future,” he says.
• Evaluate how applicable the data is. Pay attention to the total number of survey respondents in each category, and the standard deviation around the mean. “In other words, what is the central tendency of the data? You might find data in subsections that you find interesting, but it might not be data that has a central tendency,” he says. “Find data sets that are most applicable to your practice while assessing variations from the larger data sets. Consider how and why your practice might vary from the report as part of your evaluation.”
• Pick out trends and look at them in total. The key is to avoid looking at data points in isolation. “It’s important to look at trends in the data over time, and pick out where those trends are going to go,” he says.
• Involve your people. “I think that this data being available from the [provider] side and management side is a good thing,” Dr. Ahlstrom explains. “The more we are involved in understanding the trends in HM, the better we are going to plan where we are going in the future.” TH

Jason Carris is editor of The Hospitalist.

Benchmarking Basics

By Jeffrey B. Milburn, MBA, CPME

Benchmarking brings perspective and relevancy to practice issues and can serve as a guide to making effective business decisions. Along with looking at financial trends and ratios, benchmarking is one of the most important techniques well-managed practices use.

What is benchmarking? Whether you are measuring physician productivity or a practice’s financial performance, benchmarking is essentially the comparison of your data to a select peer group.

Why should my practice benchmark? Practice administrators and physician leaders frequently utilize national surveys to “benchmark” hospitalist compensation and production. A practice wants to pay market-level compensation in order to recruit and retain physicians, and also set reasonable production goals for the physicians. For legal and regulatory reasons, hospital executives want to ensure that compensation does not exceed “fair market value.”

How do I benchmark my practice? Benchmarking generally falls into two broad categories: internal and external. Internal benchmarking in a hospitalist practice might be the comparison of the number of patients seen by individual physicians during the standard weekday shift. In addition to developing your own internal data, outside sources include such surveys as the State of Hospital Medicine: 2010 Report Based on 2009 Data published by SHM and MGMA. External benchmarking would be the comparison of patients seen by practice physicians on an annual basis to their hospitalist peers across the nation, as reported in surveys.

What about hospitalist production? Depending on the physician compensation plan, there usually is a strong relationship between the level of compensation and production. When benchmarking hospitalist production, it is important to select the appropriate benchmark for comparative purposes.

Comparing gross charges from practice to practice has little value, since there is no standard methodology for setting charges. On the other hand, work RVUs is a fairly standard metric for measuring physician productivity internally and externally. The work RVUs data are generally reported in the major surveys.

Some hospitalist practices use survey benchmark data adjusted annually to determine how much physicians are paid per unit of productivity. For example, if median survey compensation is $225,000 per year and median work RVUs are 4,000 per year, the practice would pay $56.25 per work RVU to the physician. In this case, the practice has benchmarked both compensation and productivity to arrive at a value per work unit.

What does benchmarking mean for my practice? Benchmarking is a critical component to operating a successful medical practice. Use care in utilizing benchmarks, however. Rather than assuming that your practice’s variance from survey norms means you need to change, evaluate the underlying data to determine if there is a logical reason for the variance related to your practice’s specific circumstances.

Practices that utilize peer group data to benchmark often identify operational concerns and work to make their practices more effective. It has been said you can’t manage what you can’t measure, and benchmarking brings perspective and relevancy to what you measure.

Editors note: This article features interactive region-by-region breakdowns and Team Hospitalist analysis of the latest compensation and productivity data from SHM and MGMA. Click here to open the interactive feature.

Every January, William “Tex” Landis, MD, FHM, sits in a conference room with key members of his hospital’s administration and presents what he affectionately refers to as the “state of the union” for his hospitalist group. The bar graphs, pie charts, and commentary have changed little in the past decade, Dr. Landis admits, but the information and analysis he has available to him as he begins crafting his 2011 presentation is better than ever.

Dr. Landis, medical director of Wellspan Hospitalists in York, Pa., and hospitalist group leaders across the country will have access to the State of Hospital Medicine: 2010 Report Based on 2009 Data this budget cycle. The new report, which will be available Sept. 10, offers new compensation and productivity information, new layers of detail, and new tools to help group leaders analyze the data.

“This data reflects the best numbers we have in our business,” says Dr. Landis, the chair of SHM’s Practice Analysis Committee. “We have better participation and better quality data analysis than we have ever had before. It’s a more standardized approach, and we are just going to be able to continue to build upon this. It sets the standard for moving forward, as far as I am concerned.”

The new report, which replaces SHM’s biannual survey, is the result of a partnership between SHM and the Medical Group Management Association (MGMA), an industry leader in practice-management resources. The report compiled data about 4,211 hospitalists in 443 groups, a 30% increase in survey respondents over SHM’s 2007-2008 report.

“The collaboration is really driven at providing a single set of benchmarks to the HM community,” says David Litzau, systems analyst at MGMA. “It provides a viewpoint of what’s happening elsewhere in the industry.”

click for large version

What’s happening is that hospitalists continue to see increases in compensation. The new report, which uses some different data definitions and survey methodologies, and is based on a new population, shows that median compensation for adult hospitalists is $215,000 per year, a number that doesn’t take into account benefits. Hospitalist median compensation was $183,900, according to SHM’s 2007-2008 survey, and $171,000 in SHM’s 2005-2006 survey. MGMA’s 2009 report on physician compensation showed median compensation at $210,250 per internal medicine hospitalist.

And while the compensation numbers are higher than in previous surveys, the new report also shows adult hospitalists are increasing productivity, are seeing more patients per year (reversing a somewhat declining trend), and are collecting more per encounter.

The Numbers

Although compensation is the most popular survey metric, it’s not the only number worth investigating. A handful of key productivity measures seem to be on the rise, too, according to the new report.

The national median (the midpoint of all survey respondents) for work RVUs per adult hospitalist FTE is 4,107, according to the new data. SHM’s 2007-2008 survey reported wRVUs at 3,715 per adult hospitalist.

The national median for hospitalist wRVUs per encounter is 1.86. That same figure was reported at 1.53 wRVUs per encounter in 2008 and 1.37 in 2006.

Collections per wRVU is $45.57, according to the 2010 report. The 2008 survey showed collections at $44.97 per wRVU; the 2006 survey did not report the metric.

One thing the new metrics have in common is that they show hospitalists across the nation are becoming more efficient. “The numbers essentially reaffirm the overall trends for hospital medicine, in that the productivity continues to increase and the compensation paid to a provider continues to increase,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan, which has nearly 50 hospitalists supporting three hospitals. “When you dig into the numbers, hospitalists are producing more work and more RVUs per encounter than they had been in the past.”

Financial support per hospitalist FTE, another key practice-management metric, parallels the compensation growth. Practices receive a median of $98,253 of support per hospitalist FTE, according to 2010 data. The 2008 report did not provide a median figure for support; instead, it published a mean figure of $97,375 of support per FTE. The 2010 mean (average) is $111,486.

Pediatric HM also shows signs of growth; median compensation is $160,038 in the new report. The 2008 report had pediatric hospitalist median compensation at $144,600.

The new data show a spike in HM groups providing “on site” care of patients 24 hours a day, seven days a week. More than 68% have on-site care with a physician, nurse practitioner, or physician assistant. Only 53% of groups had 24/7 coverage in the 2008 report; 51% had round-the-clock coverage in the 2006 report.

Dr. Ahlstrom, a veteran member of SHM’s Practice Analysis Committee, says he expects that trend to continue, especially with the large numbers of young hospitalists in the field interested in set schedules and work-life balance. “That’s the trend,” he says. “Younger physicians are more interested in seeing that split, where the days and nights are clearly set off. Older physicians are more than happy to have a nocturnist around, just as long as it’s not going to cost them a lot of money or productivity.”

A Word of Caution, and Unintended Benefits

The new report is based on a supplemental set of questions specifically directed at hospitalist practices in MGMA’s annual Physician Compensation and Productivity Survey. The survey is voluntary and is not audited, but it is the “best data” available for hospitalists, according to practice-management experts.

“So many people assume this data is what you should do,” says John Nelson, MD, MHM, co-founder and past president of SHM and a principal in hospitalist-consulting firm Nelson Flores Hospital Medicine Consultants. “It’s not. It is a survey of what’s happening. It’s a starting point, a frame of reference. It is the best data there is, no doubt. But you should not build your practice by trying to match the medians. You might have local data that deviates. You might be starting a program or be in a competitive situation.”

The same experts warn that the new survey population and methodologies will make it difficult to draw direct comparisons to data from previous surveys. For example, the 2007-2008 SHM survey included roughly a quarter of respondents from academic settings; the 2010 report has barely 1% of its respondents from academic settings (see Figure 1, p. 14). Traditionally, compensation and productivity levels for academic hospitalists are lower than nonacademic hospitalists. Most experts agree the “filtering” effect of the survey population factors heavily into the across- the-board increases in compensation and productivity in the 2010 report.

“The survey instrument that we use has been used historically for nonacademic physicians,” Litzau explains. “We also have an academic survey that is performed in the fall [Sept. 13 through Nov. 5], where we collect data specifically for academic faculty. We see very different trends within those two types of practice. It is difficult to draw clear comparisons between the two.”

Dr. Landis refers to the new report as a “baseline” and advises hospitalist leaders to review the caveats and cautions section (see “Survey Stipulation: Only Fools Rush In,” p. 16) before jumping right to the numbers. “This is a new set of numbers. Probably the more important comparison will be this set of numbers compared with the next set of data, next year,” he adds.

Even so, the “filtering” effect should provide nonacademic hospitalist groups a more accurate picture of compensation and productivity trends. One hospitalist leader says it’s a “win-win” for both academic and nonacademic practice leaders.

“As a community-based hospitalist, I always had to drill into those organizations that were similar to me. Being able to have more filtered information, it allows us to drill into the areas that are more important and then present that information to our CEO, CFO, VPMA,” says William D. Atchley Jr., MD, FACP, SFHM, chief of hospital medicine at Sentara Medical Group in Norfolk, Va., and a member of Team Hospitalist.

New Info, Deeper Analysis

In addition to a larger response rate and more filtered approach, the new report will offer greater frequency (annually), new data points, and in-depth breakdowns of key productivity metrics. Some of the new metrics reported include:

• Staff per FTE hospitalist physician;
• Staff turnover;
• Retirement benefits;
• Compensation to collections ratio;
• Compensation per encounter;
• Compensation per wRVU;
• Collections per encounter;
• Collections per wRVU; and
• Work RVUs per encounter.

The report will be available every fall, as compared to biannually for past SHM surveys. It also will offer more “cuts” of the data, including median, mean, 25th percentile, 75th percentile, and 90th percentile reports, along with regional breakdowns for many compensation and productivity metrics.

Practical Applications

This data reflects the best numbers we have in our business. We have better participation and better quality data analysis than we have ever had before.

—William “Tex” Landis, MD, FHM, medical director, Wellspan Hospitalists, York, Pa., SHM Practice Analysis Committee chair

Benchmarking data are used to set productivity goals and compensation levels in hospitalist practices throughout the country, and most administrators use multiple sources of data to make those decisions.

“If we are showing our hospitalists are generating 5,000 wRVUs per year, and the national median is 4,100, you can do the math. I can say, ‘We need to bring on another hospitalist. The timing is right, and we need to be recruiting,’ ” says Dr. Atchley, who has worked with benchmarking data for 15 years and currently supervises 45 full-time hospitalists who service five hospitals in southeast Virginia. “It’s always good to have national benchmarks to compare to, because that is always the question that is going to be asked. [Hospital administrators] want regional and national comparisons.”

Regional information and well-adapted data from national surveys guide James Gardner, MD, chief medical executive for Pro Health Care Inc., a two-hospital system just west of Milwaukee, when he’s hiring new hospitalists at 300-bed Waukesha Memorial Hospital or launching a new HM program at the system’s smaller, rural facility. In fact, Dr. Gardner currently is weighing options to expand the HM service at 80-bed Oconomowoc Hospital, less than a year after the program started.

“We like to look at a number of sources of data. The MGMA and SHM survey data, historically, have been two of our preferred sources,” Dr. Gardner says. “I think we tend to look at more regional data from the Midwest because the national data varies so much.

“We try to get a sense as to what our local market is.”

Dr. Gardner says he’d like to see a “couple years” to confirm the validity of the new SHM-MGMA report. That said, he says he knows how useful the data can be in regard to benchmarking hospitalist productivity.

“It’s been very helpful; it helps us know where we are at,” Dr. Gardner explains. “It’s one of the guideposts to decide when we are approaching the need for additional resources, whether that is midlevel providers or full-time hospitalists.”

Advice From a Numbers Guy

Dr. Ahlstrom

A self-described “numbers” guy, Dr. Ahlstrom agrees regional data is just as important as, if not more important than, the national numbers. He stresses knowing your market, your competitors, your hospital culture—and using that information along with the benchmarking data to formulate expectations for your group.

“Oftentimes you are measured against the guy next door,” Dr. Ahlstrom says. “You have to know the numbers, because [administrators] are going to know the numbers.”

Dr. Ahlstrom offers these tips for incorporating benchmarking data into your practice:

• Know your local market. “If you keep in mind your local needs, then you can look at the data and start to evaluate what parts are going to help you better formulate a practice that brings on the right people, does the right work, and continues to produce the amount of workload and compensation that makes sure they are happy in the future,” he says.
• Evaluate how applicable the data is. Pay attention to the total number of survey respondents in each category, and the standard deviation around the mean. “In other words, what is the central tendency of the data? You might find data in subsections that you find interesting, but it might not be data that has a central tendency,” he says. “Find data sets that are most applicable to your practice while assessing variations from the larger data sets. Consider how and why your practice might vary from the report as part of your evaluation.”
• Pick out trends and look at them in total. The key is to avoid looking at data points in isolation. “It’s important to look at trends in the data over time, and pick out where those trends are going to go,” he says.
• Involve your people. “I think that this data being available from the [provider] side and management side is a good thing,” Dr. Ahlstrom explains. “The more we are involved in understanding the trends in HM, the better we are going to plan where we are going in the future.” TH

Jason Carris is editor of The Hospitalist.

Benchmarking Basics

By Jeffrey B. Milburn, MBA, CPME

Benchmarking brings perspective and relevancy to practice issues and can serve as a guide to making effective business decisions. Along with looking at financial trends and ratios, benchmarking is one of the most important techniques well-managed practices use.

What is benchmarking? Whether you are measuring physician productivity or a practice’s financial performance, benchmarking is essentially the comparison of your data to a select peer group.

Why should my practice benchmark? Practice administrators and physician leaders frequently utilize national surveys to “benchmark” hospitalist compensation and production. A practice wants to pay market-level compensation in order to recruit and retain physicians, and also set reasonable production goals for the physicians. For legal and regulatory reasons, hospital executives want to ensure that compensation does not exceed “fair market value.”

How do I benchmark my practice? Benchmarking generally falls into two broad categories: internal and external. Internal benchmarking in a hospitalist practice might be the comparison of the number of patients seen by individual physicians during the standard weekday shift. In addition to developing your own internal data, outside sources include such surveys as the State of Hospital Medicine: 2010 Report Based on 2009 Data published by SHM and MGMA. External benchmarking would be the comparison of patients seen by practice physicians on an annual basis to their hospitalist peers across the nation, as reported in surveys.

What about hospitalist production? Depending on the physician compensation plan, there usually is a strong relationship between the level of compensation and production. When benchmarking hospitalist production, it is important to select the appropriate benchmark for comparative purposes.

Comparing gross charges from practice to practice has little value, since there is no standard methodology for setting charges. On the other hand, work RVUs is a fairly standard metric for measuring physician productivity internally and externally. The work RVUs data are generally reported in the major surveys.

Some hospitalist practices use survey benchmark data adjusted annually to determine how much physicians are paid per unit of productivity. For example, if median survey compensation is $225,000 per year and median work RVUs are 4,000 per year, the practice would pay $56.25 per work RVU to the physician. In this case, the practice has benchmarked both compensation and productivity to arrive at a value per work unit.

What does benchmarking mean for my practice? Benchmarking is a critical component to operating a successful medical practice. Use care in utilizing benchmarks, however. Rather than assuming that your practice’s variance from survey norms means you need to change, evaluate the underlying data to determine if there is a logical reason for the variance related to your practice’s specific circumstances.

Practices that utilize peer group data to benchmark often identify operational concerns and work to make their practices more effective. It has been said you can’t manage what you can’t measure, and benchmarking brings perspective and relevancy to what you measure.

Baseball, kick the can, Russian roulette—pick your game. Chances are good that it has worked its way into a metaphor to illustrate the infuriating, perplexing, and altogether frustrating inability of Congress to step up to the plate and pass a long-term fix to the broken sustainable growth rate (SGR) formula used to determine Medicare reimbursement rates.

On June 24, legislators avoided catastrophe by temporarily rescinding a 21.3% rate cut that went into effect June 1. The after-the-fact patch meant that some Medicare claims had to be reprocessed to recoup the full value, creating an administrative mess. The accompanying 2.2% rate increase expires Nov. 30. The reimbursement cut could reach nearly 30% next year unless Congress intervenes again.

“Obviously, there’s a lot of frustration around the issue, especially on the membership side,” says Ron Greeno, MD, FACP, SFHM, a member of SHM’s Public Policy and Leadership committees, and chief medical officer for Brentwood, Tenn.-based Cogent Healthcare. For hospitalists in many small private practices, he says, a major percentage of income comes from Medicare. “It’s a tremendous headache,” he says of the uncertainty. “It’s very hard to plan for. You’re trying to budget and you don’t know what the policy is going to be literally from week to week.”

The Blame Game

Despite the widespread sentiment among doctors that a permanent reimbursement rate fix should have been included in the healthcare reform legislation, skittishness over the price tag led legislators to drop it from the package. Based on last fall’s estimates, the total cost of a reform bill that scrapped the SGR would have ballooned by roughly $250 billion over 10 years, which would have threatened the bill’s passage.

But Congress has since been unable to pass a permanent fix as standalone legislation amid mounting concern over the national debt, and the price of inaction continues to rise. On April 30, the Congressional Budget Office (CBO) estimated that the cost of jettisoning the SGR formula and freezing rates at current levels had grown to $276 billion over 10 years.

Any serious consideration of lasting alternatives has now been pushed back to the lame-duck session, after the midterm elections. The can has been kicked down the road so many times, Dr. Greeno and others say, that most Congressional members have boot marks all over them. “So now you have a bigger problem at a more crucial time, when money is tighter than ever in a poor economy,” Dr. Greeno says. “And I just think it’s been a failure of our politicians.”

Other healthcare industry leaders have been just as critical. “Delaying the problem is not a solution,” said AMA President Cecil B. Wilson, MD, in a prepared statement after Congress passed the latest six-month reprieve in June. “It doesn’t solve the Medicare mess Congress has created with a long series of short-term Medicare patches over the last decade—including four to avert the 2010 cut alone.”

AMA-sponsored print ads have reminded legislators that delaying a fix until 2013 will again increase its cost, to $396 billion over 10 years. And the association’s June press release asserted that “Congress is playing a dangerous game of Russian roulette with seniors’ healthcare.”

Perhaps a game of “chicken” would be more apt.

Republicans have dared Democrats to spend the billions for a more lasting solution—in the absence of any cuts elsewhere in the healthcare delivery system—and be labeled as fiscally irresponsible. In turn, Democrats have dared Republicans to let the rate cut take effect and be labeled heartless as Medicare beneficiaries lose access to their healthcare providers.

Both parties blinked, resorting to almost unanimous short-term fixes that have allowed legislators to save face while putting off politically risky votes until after the November elections.

Lynne M. Allen, MN, ARNP, who works as a part-time hospitalist in hematology-oncology at 188-bed Kadlec Regional Medical Center in Richland, Wash., says she and other colleagues were initially hopeful that the Obama administration would make Congress work together to find a lasting solution. “There’s a sense of frustration because instead of that happening from our legislators, they’re playing a lot of games with the funding,” says Allen, a member of Team Hospitalist. “They’re not willing to step up to the plate, as they say, and make a decision that will allow us to go forward smoothly.”

The result, Allen says, has been a “roller-coaster ride” of uncertainty over reimbursements. Because Washington’s Tri-Cities region has a relatively high percentage of patients with private insurance, her hospital is somewhat cushioned from a precipitous drop in Medicare fees. But if CMS is ever forced to cut back on its rates, she fully expects private insurers to follow the same downward track.

Practical Concerns

Barbara Hartley, MD, a part-time hospitalist at 22-bed Benson Hospital in Benson, Ariz., says the town’s healthcare facility is somewhat protected from potential Medicare rate cuts through its official status as a Critical Access Hospital. Instead of being reimbursed through diagnosis-related group (DRG) codes, the rural hospital is repaid by Medicare for its total cost per day per patient.

The arrangement is a stable one at the moment, but not enough to dispel Dr. Hartley’s uneasy question: If the economy worsens, will Medicare be able to retain its commitment to rural hospitals? If not, the pain might be felt acutely in communities like Benson, where Dr. Hartley estimates that as much as 75% of the hospital’s in-patient business is through either Medicare or a Medicare Advantage plan.

Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Public Policy and Practice Management committees, says Medicare rate cuts also could significantly reduce the leverage of hospitalists during contract negotiations.

“Even if we’re employed by the hospital, but our professional fees that the hospital can recoup for our services are dramatically affected, it will affect how those future contracts go,” Mathews says. “We might be insulated temporarily by the strength of our current contract. But if the formula—however that works out—dramatically impacts the hospitalist reimbursement on the professional fee side, the hospital will feel that, and then hospitalists will eventually feel that as well.” In other words, it could strengthen the bargaining hand of the hospital at the expense of the hospitalist. “Therein lies the long-term threat,” he points out.

Independent Solution?

Some of the authority over physician payments might eventually be depoliticized via language in the reform legislation that empowers a new entity, the Independent Payment Advisory Board, to create policy on such critical monetary issues as reimbursement rates. Congress could still override the board’s policy decisions, but only if the Congressional alternative saves just as much money.

In the meantime, the money for a fix still has to come from somewhere, and no consensus has emerged. Advocates likewise refuse to coalesce around any single alternative. Some experts favor a new formula based on the Medicare economic index, which measures inflation in healthcare delivery costs. But the CBO estimates that per-beneficiary spending under such a formula would be 30% more by 2016 than under the current formula. Other proposals call for temporarily increasing rates, then reverting to annual GDP growth, plus a bit more to cover physician costs.

No matter how the crisis is resolved, experts say, doctors almost certainly will have to make do with less. “When healthcare reform is finally fully implemented, there are going to be less dollars to pay for more services. It’s inevitable,” Mathews says. “And whether it takes the form of SGR or some other form, I’m afraid physicians are going to have to get used to having less money in the pool of money that’s allocated to pay providers.”

It could be a whole new ballgame. TH

Bryn Nelson, PhD, is a freelance medical writer based in Seattle.

Baseball, kick the can, Russian roulette—pick your game. Chances are good that it has worked its way into a metaphor to illustrate the infuriating, perplexing, and altogether frustrating inability of Congress to step up to the plate and pass a long-term fix to the broken sustainable growth rate (SGR) formula used to determine Medicare reimbursement rates.

On June 24, legislators avoided catastrophe by temporarily rescinding a 21.3% rate cut that went into effect June 1. The after-the-fact patch meant that some Medicare claims had to be reprocessed to recoup the full value, creating an administrative mess. The accompanying 2.2% rate increase expires Nov. 30. The reimbursement cut could reach nearly 30% next year unless Congress intervenes again.

“Obviously, there’s a lot of frustration around the issue, especially on the membership side,” says Ron Greeno, MD, FACP, SFHM, a member of SHM’s Public Policy and Leadership committees, and chief medical officer for Brentwood, Tenn.-based Cogent Healthcare. For hospitalists in many small private practices, he says, a major percentage of income comes from Medicare. “It’s a tremendous headache,” he says of the uncertainty. “It’s very hard to plan for. You’re trying to budget and you don’t know what the policy is going to be literally from week to week.”

The Blame Game

Despite the widespread sentiment among doctors that a permanent reimbursement rate fix should have been included in the healthcare reform legislation, skittishness over the price tag led legislators to drop it from the package. Based on last fall’s estimates, the total cost of a reform bill that scrapped the SGR would have ballooned by roughly $250 billion over 10 years, which would have threatened the bill’s passage.

But Congress has since been unable to pass a permanent fix as standalone legislation amid mounting concern over the national debt, and the price of inaction continues to rise. On April 30, the Congressional Budget Office (CBO) estimated that the cost of jettisoning the SGR formula and freezing rates at current levels had grown to $276 billion over 10 years.

Any serious consideration of lasting alternatives has now been pushed back to the lame-duck session, after the midterm elections. The can has been kicked down the road so many times, Dr. Greeno and others say, that most Congressional members have boot marks all over them. “So now you have a bigger problem at a more crucial time, when money is tighter than ever in a poor economy,” Dr. Greeno says. “And I just think it’s been a failure of our politicians.”

Other healthcare industry leaders have been just as critical. “Delaying the problem is not a solution,” said AMA President Cecil B. Wilson, MD, in a prepared statement after Congress passed the latest six-month reprieve in June. “It doesn’t solve the Medicare mess Congress has created with a long series of short-term Medicare patches over the last decade—including four to avert the 2010 cut alone.”

AMA-sponsored print ads have reminded legislators that delaying a fix until 2013 will again increase its cost, to $396 billion over 10 years. And the association’s June press release asserted that “Congress is playing a dangerous game of Russian roulette with seniors’ healthcare.”

Perhaps a game of “chicken” would be more apt.

Republicans have dared Democrats to spend the billions for a more lasting solution—in the absence of any cuts elsewhere in the healthcare delivery system—and be labeled as fiscally irresponsible. In turn, Democrats have dared Republicans to let the rate cut take effect and be labeled heartless as Medicare beneficiaries lose access to their healthcare providers.

Both parties blinked, resorting to almost unanimous short-term fixes that have allowed legislators to save face while putting off politically risky votes until after the November elections.

Lynne M. Allen, MN, ARNP, who works as a part-time hospitalist in hematology-oncology at 188-bed Kadlec Regional Medical Center in Richland, Wash., says she and other colleagues were initially hopeful that the Obama administration would make Congress work together to find a lasting solution. “There’s a sense of frustration because instead of that happening from our legislators, they’re playing a lot of games with the funding,” says Allen, a member of Team Hospitalist. “They’re not willing to step up to the plate, as they say, and make a decision that will allow us to go forward smoothly.”

The result, Allen says, has been a “roller-coaster ride” of uncertainty over reimbursements. Because Washington’s Tri-Cities region has a relatively high percentage of patients with private insurance, her hospital is somewhat cushioned from a precipitous drop in Medicare fees. But if CMS is ever forced to cut back on its rates, she fully expects private insurers to follow the same downward track.

Practical Concerns

Barbara Hartley, MD, a part-time hospitalist at 22-bed Benson Hospital in Benson, Ariz., says the town’s healthcare facility is somewhat protected from potential Medicare rate cuts through its official status as a Critical Access Hospital. Instead of being reimbursed through diagnosis-related group (DRG) codes, the rural hospital is repaid by Medicare for its total cost per day per patient.

The arrangement is a stable one at the moment, but not enough to dispel Dr. Hartley’s uneasy question: If the economy worsens, will Medicare be able to retain its commitment to rural hospitals? If not, the pain might be felt acutely in communities like Benson, where Dr. Hartley estimates that as much as 75% of the hospital’s in-patient business is through either Medicare or a Medicare Advantage plan.

Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Public Policy and Practice Management committees, says Medicare rate cuts also could significantly reduce the leverage of hospitalists during contract negotiations.

“Even if we’re employed by the hospital, but our professional fees that the hospital can recoup for our services are dramatically affected, it will affect how those future contracts go,” Mathews says. “We might be insulated temporarily by the strength of our current contract. But if the formula—however that works out—dramatically impacts the hospitalist reimbursement on the professional fee side, the hospital will feel that, and then hospitalists will eventually feel that as well.” In other words, it could strengthen the bargaining hand of the hospital at the expense of the hospitalist. “Therein lies the long-term threat,” he points out.

Independent Solution?

Some of the authority over physician payments might eventually be depoliticized via language in the reform legislation that empowers a new entity, the Independent Payment Advisory Board, to create policy on such critical monetary issues as reimbursement rates. Congress could still override the board’s policy decisions, but only if the Congressional alternative saves just as much money.

In the meantime, the money for a fix still has to come from somewhere, and no consensus has emerged. Advocates likewise refuse to coalesce around any single alternative. Some experts favor a new formula based on the Medicare economic index, which measures inflation in healthcare delivery costs. But the CBO estimates that per-beneficiary spending under such a formula would be 30% more by 2016 than under the current formula. Other proposals call for temporarily increasing rates, then reverting to annual GDP growth, plus a bit more to cover physician costs.

No matter how the crisis is resolved, experts say, doctors almost certainly will have to make do with less. “When healthcare reform is finally fully implemented, there are going to be less dollars to pay for more services. It’s inevitable,” Mathews says. “And whether it takes the form of SGR or some other form, I’m afraid physicians are going to have to get used to having less money in the pool of money that’s allocated to pay providers.”

It could be a whole new ballgame. TH

Bryn Nelson, PhD, is a freelance medical writer based in Seattle.

Baseball, kick the can, Russian roulette—pick your game. Chances are good that it has worked its way into a metaphor to illustrate the infuriating, perplexing, and altogether frustrating inability of Congress to step up to the plate and pass a long-term fix to the broken sustainable growth rate (SGR) formula used to determine Medicare reimbursement rates.

On June 24, legislators avoided catastrophe by temporarily rescinding a 21.3% rate cut that went into effect June 1. The after-the-fact patch meant that some Medicare claims had to be reprocessed to recoup the full value, creating an administrative mess. The accompanying 2.2% rate increase expires Nov. 30. The reimbursement cut could reach nearly 30% next year unless Congress intervenes again.

“Obviously, there’s a lot of frustration around the issue, especially on the membership side,” says Ron Greeno, MD, FACP, SFHM, a member of SHM’s Public Policy and Leadership committees, and chief medical officer for Brentwood, Tenn.-based Cogent Healthcare. For hospitalists in many small private practices, he says, a major percentage of income comes from Medicare. “It’s a tremendous headache,” he says of the uncertainty. “It’s very hard to plan for. You’re trying to budget and you don’t know what the policy is going to be literally from week to week.”

The Blame Game

Despite the widespread sentiment among doctors that a permanent reimbursement rate fix should have been included in the healthcare reform legislation, skittishness over the price tag led legislators to drop it from the package. Based on last fall’s estimates, the total cost of a reform bill that scrapped the SGR would have ballooned by roughly $250 billion over 10 years, which would have threatened the bill’s passage.

But Congress has since been unable to pass a permanent fix as standalone legislation amid mounting concern over the national debt, and the price of inaction continues to rise. On April 30, the Congressional Budget Office (CBO) estimated that the cost of jettisoning the SGR formula and freezing rates at current levels had grown to $276 billion over 10 years.

Any serious consideration of lasting alternatives has now been pushed back to the lame-duck session, after the midterm elections. The can has been kicked down the road so many times, Dr. Greeno and others say, that most Congressional members have boot marks all over them. “So now you have a bigger problem at a more crucial time, when money is tighter than ever in a poor economy,” Dr. Greeno says. “And I just think it’s been a failure of our politicians.”

Other healthcare industry leaders have been just as critical. “Delaying the problem is not a solution,” said AMA President Cecil B. Wilson, MD, in a prepared statement after Congress passed the latest six-month reprieve in June. “It doesn’t solve the Medicare mess Congress has created with a long series of short-term Medicare patches over the last decade—including four to avert the 2010 cut alone.”

AMA-sponsored print ads have reminded legislators that delaying a fix until 2013 will again increase its cost, to $396 billion over 10 years. And the association’s June press release asserted that “Congress is playing a dangerous game of Russian roulette with seniors’ healthcare.”

Perhaps a game of “chicken” would be more apt.

Republicans have dared Democrats to spend the billions for a more lasting solution—in the absence of any cuts elsewhere in the healthcare delivery system—and be labeled as fiscally irresponsible. In turn, Democrats have dared Republicans to let the rate cut take effect and be labeled heartless as Medicare beneficiaries lose access to their healthcare providers.

Both parties blinked, resorting to almost unanimous short-term fixes that have allowed legislators to save face while putting off politically risky votes until after the November elections.

Lynne M. Allen, MN, ARNP, who works as a part-time hospitalist in hematology-oncology at 188-bed Kadlec Regional Medical Center in Richland, Wash., says she and other colleagues were initially hopeful that the Obama administration would make Congress work together to find a lasting solution. “There’s a sense of frustration because instead of that happening from our legislators, they’re playing a lot of games with the funding,” says Allen, a member of Team Hospitalist. “They’re not willing to step up to the plate, as they say, and make a decision that will allow us to go forward smoothly.”

The result, Allen says, has been a “roller-coaster ride” of uncertainty over reimbursements. Because Washington’s Tri-Cities region has a relatively high percentage of patients with private insurance, her hospital is somewhat cushioned from a precipitous drop in Medicare fees. But if CMS is ever forced to cut back on its rates, she fully expects private insurers to follow the same downward track.

Practical Concerns

Barbara Hartley, MD, a part-time hospitalist at 22-bed Benson Hospital in Benson, Ariz., says the town’s healthcare facility is somewhat protected from potential Medicare rate cuts through its official status as a Critical Access Hospital. Instead of being reimbursed through diagnosis-related group (DRG) codes, the rural hospital is repaid by Medicare for its total cost per day per patient.

The arrangement is a stable one at the moment, but not enough to dispel Dr. Hartley’s uneasy question: If the economy worsens, will Medicare be able to retain its commitment to rural hospitals? If not, the pain might be felt acutely in communities like Benson, where Dr. Hartley estimates that as much as 75% of the hospital’s in-patient business is through either Medicare or a Medicare Advantage plan.

Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Public Policy and Practice Management committees, says Medicare rate cuts also could significantly reduce the leverage of hospitalists during contract negotiations.

“Even if we’re employed by the hospital, but our professional fees that the hospital can recoup for our services are dramatically affected, it will affect how those future contracts go,” Mathews says. “We might be insulated temporarily by the strength of our current contract. But if the formula—however that works out—dramatically impacts the hospitalist reimbursement on the professional fee side, the hospital will feel that, and then hospitalists will eventually feel that as well.” In other words, it could strengthen the bargaining hand of the hospital at the expense of the hospitalist. “Therein lies the long-term threat,” he points out.

Independent Solution?

Some of the authority over physician payments might eventually be depoliticized via language in the reform legislation that empowers a new entity, the Independent Payment Advisory Board, to create policy on such critical monetary issues as reimbursement rates. Congress could still override the board’s policy decisions, but only if the Congressional alternative saves just as much money.

In the meantime, the money for a fix still has to come from somewhere, and no consensus has emerged. Advocates likewise refuse to coalesce around any single alternative. Some experts favor a new formula based on the Medicare economic index, which measures inflation in healthcare delivery costs. But the CBO estimates that per-beneficiary spending under such a formula would be 30% more by 2016 than under the current formula. Other proposals call for temporarily increasing rates, then reverting to annual GDP growth, plus a bit more to cover physician costs.

No matter how the crisis is resolved, experts say, doctors almost certainly will have to make do with less. “When healthcare reform is finally fully implemented, there are going to be less dollars to pay for more services. It’s inevitable,” Mathews says. “And whether it takes the form of SGR or some other form, I’m afraid physicians are going to have to get used to having less money in the pool of money that’s allocated to pay providers.”

It could be a whole new ballgame. TH

Bryn Nelson, PhD, is a freelance medical writer based in Seattle.

Hospitalists might want to incorporate questions about how much time a patient spends sitting into their diagnostic interview—then consider the same question for themselves.

A study published this spring in Medicine & Science in Sports & Exercise reports that time spent watching TV or riding in a car “were significant cardiovascular disease (CVD) mortality predictors” (Med Sci Sports Exerc. 2010;42(5):879-885). The research gained traction in medical publications and was highlighted in The New York Times. But for one of the researchers at the University of South Carolina, more work is needed.

“This is sort of a new way of looking at the equation,” says Steven Hooker, PhD, director of the university's Prevention Research Center. “We really don’t have any formal guidelines or recommendations on limiting sedentary behavior, although I think at some point in time we’ll get to that stage.”

Until then, hospitalists are in a prime position to determine a patient’s lifestyle—sedentary or active—via routine checklist questions they ask upon admission. Although some HM groups already ask questions about how often a patient exercises, Dr. Hooker suspects only a few groups ask how often a patient breaks up long periods of sitting.

Further, he suggests that while there are no standard recommendations, hospitalists would serve their patients well by incorporating helpful hints in discharge instructions or admission interviews.

“Encourage a person to build in standing or slight walking breaks in a daily routine, recommend they stand periodically while attending long meetings or during long periods of travel,” Dr. Hooker says. “Common sense reigns here.”

On the flip side, hospitalists would do well to remember that while their workday might include a high level of light-intensity activity, they face the same pitfalls as their patients: commuting, sitting in meetings, long periods of time in front of the computer, TV, or PlayStation.

“We have to get the public looking at physical activity and physical inactivity as two completely separate things,” says study first author Tatiana Warren, MS, a doctoral student in the department of exercise science at the University of South Carolina's Arnold School of Public Health. “We have to continue to do more research and get the word out.”

Hospitalists might want to incorporate questions about how much time a patient spends sitting into their diagnostic interview—then consider the same question for themselves.

A study published this spring in Medicine & Science in Sports & Exercise reports that time spent watching TV or riding in a car “were significant cardiovascular disease (CVD) mortality predictors” (Med Sci Sports Exerc. 2010;42(5):879-885). The research gained traction in medical publications and was highlighted in The New York Times. But for one of the researchers at the University of South Carolina, more work is needed.

“This is sort of a new way of looking at the equation,” says Steven Hooker, PhD, director of the university's Prevention Research Center. “We really don’t have any formal guidelines or recommendations on limiting sedentary behavior, although I think at some point in time we’ll get to that stage.”

Until then, hospitalists are in a prime position to determine a patient’s lifestyle—sedentary or active—via routine checklist questions they ask upon admission. Although some HM groups already ask questions about how often a patient exercises, Dr. Hooker suspects only a few groups ask how often a patient breaks up long periods of sitting.

Further, he suggests that while there are no standard recommendations, hospitalists would serve their patients well by incorporating helpful hints in discharge instructions or admission interviews.

“Encourage a person to build in standing or slight walking breaks in a daily routine, recommend they stand periodically while attending long meetings or during long periods of travel,” Dr. Hooker says. “Common sense reigns here.”

On the flip side, hospitalists would do well to remember that while their workday might include a high level of light-intensity activity, they face the same pitfalls as their patients: commuting, sitting in meetings, long periods of time in front of the computer, TV, or PlayStation.

“We have to get the public looking at physical activity and physical inactivity as two completely separate things,” says study first author Tatiana Warren, MS, a doctoral student in the department of exercise science at the University of South Carolina's Arnold School of Public Health. “We have to continue to do more research and get the word out.”

Hospitalists might want to incorporate questions about how much time a patient spends sitting into their diagnostic interview—then consider the same question for themselves.

A study published this spring in Medicine & Science in Sports & Exercise reports that time spent watching TV or riding in a car “were significant cardiovascular disease (CVD) mortality predictors” (Med Sci Sports Exerc. 2010;42(5):879-885). The research gained traction in medical publications and was highlighted in The New York Times. But for one of the researchers at the University of South Carolina, more work is needed.

“This is sort of a new way of looking at the equation,” says Steven Hooker, PhD, director of the university's Prevention Research Center. “We really don’t have any formal guidelines or recommendations on limiting sedentary behavior, although I think at some point in time we’ll get to that stage.”

Until then, hospitalists are in a prime position to determine a patient’s lifestyle—sedentary or active—via routine checklist questions they ask upon admission. Although some HM groups already ask questions about how often a patient exercises, Dr. Hooker suspects only a few groups ask how often a patient breaks up long periods of sitting.

Further, he suggests that while there are no standard recommendations, hospitalists would serve their patients well by incorporating helpful hints in discharge instructions or admission interviews.

“Encourage a person to build in standing or slight walking breaks in a daily routine, recommend they stand periodically while attending long meetings or during long periods of travel,” Dr. Hooker says. “Common sense reigns here.”

On the flip side, hospitalists would do well to remember that while their workday might include a high level of light-intensity activity, they face the same pitfalls as their patients: commuting, sitting in meetings, long periods of time in front of the computer, TV, or PlayStation.

“We have to get the public looking at physical activity and physical inactivity as two completely separate things,” says study first author Tatiana Warren, MS, a doctoral student in the department of exercise science at the University of South Carolina's Arnold School of Public Health. “We have to continue to do more research and get the word out.”

Suzanne Wilson, MD, is a self-proclaimed “outdoor-sy girl”—so much so that when the opportunity arose to work as a hospitalist in the golf mecca of Pinehurst, N.C., she didn’t think twice.

“My husband and I wanted to live somewhere we wanted to be,” says Dr. Wilson, a hospitalist for 10 years.

Pinehurst is home to one of the world’s most elegant and famous golf resorts, but it was at Moore Regional Hospital that Dr. Wilson was recently named Physician of the Year. She is Moore Regional’s first hospitalist to receive the honor.

The award process begins with the nurses, who are in charge of nominations. An independent board “reads the stories” about the nominees and their outstanding care, then chooses the winner.

Although Dr. Wilson says she was “stunned” when she was told she received the award, her colleagues were not. “Dr. Wilson is a consistent professional. It’s the way she relates to patients; her manner is very comfortable and easy going, and her ability to communicate with them—it’s like going home,” says Katherine Marsh, an oncology nurse at Moore Regional.

Dan Barnes, MD, director of the 23-hospitalist program at Moore Regional, says Dr. Wilson’s extensive interaction with the hospital’s nurses has helped improve the relationship between doctors and other staff.

“She is a true advocate for quality improvement and is always willing to help with that,” Dr. Barnes says, citing a soon-to-be-live Computerized Physician Order Entry (CPOE) initiative at the hospital, a project for which Dr. Wilson serves as officer.

Dr. Wilson’s focus on forging relationships between varying medical staff can be traced back to her early exposure to medicine. She grew up in southern Indiana with an RN mother and medical photographer father. She says that combination made for “interesting dinner conversations” as a child.

“We have to keep asking ourselves, ‘How can we do this better?'” Dr. Wilson says. “It’s all about the patient.”

Suzanne Wilson, MD, is a self-proclaimed “outdoor-sy girl”—so much so that when the opportunity arose to work as a hospitalist in the golf mecca of Pinehurst, N.C., she didn’t think twice.

“My husband and I wanted to live somewhere we wanted to be,” says Dr. Wilson, a hospitalist for 10 years.

Pinehurst is home to one of the world’s most elegant and famous golf resorts, but it was at Moore Regional Hospital that Dr. Wilson was recently named Physician of the Year. She is Moore Regional’s first hospitalist to receive the honor.

The award process begins with the nurses, who are in charge of nominations. An independent board “reads the stories” about the nominees and their outstanding care, then chooses the winner.

Although Dr. Wilson says she was “stunned” when she was told she received the award, her colleagues were not. “Dr. Wilson is a consistent professional. It’s the way she relates to patients; her manner is very comfortable and easy going, and her ability to communicate with them—it’s like going home,” says Katherine Marsh, an oncology nurse at Moore Regional.

Dan Barnes, MD, director of the 23-hospitalist program at Moore Regional, says Dr. Wilson’s extensive interaction with the hospital’s nurses has helped improve the relationship between doctors and other staff.

“She is a true advocate for quality improvement and is always willing to help with that,” Dr. Barnes says, citing a soon-to-be-live Computerized Physician Order Entry (CPOE) initiative at the hospital, a project for which Dr. Wilson serves as officer.

Dr. Wilson’s focus on forging relationships between varying medical staff can be traced back to her early exposure to medicine. She grew up in southern Indiana with an RN mother and medical photographer father. She says that combination made for “interesting dinner conversations” as a child.

“We have to keep asking ourselves, ‘How can we do this better?'” Dr. Wilson says. “It’s all about the patient.”

Suzanne Wilson, MD, is a self-proclaimed “outdoor-sy girl”—so much so that when the opportunity arose to work as a hospitalist in the golf mecca of Pinehurst, N.C., she didn’t think twice.

“My husband and I wanted to live somewhere we wanted to be,” says Dr. Wilson, a hospitalist for 10 years.

Pinehurst is home to one of the world’s most elegant and famous golf resorts, but it was at Moore Regional Hospital that Dr. Wilson was recently named Physician of the Year. She is Moore Regional’s first hospitalist to receive the honor.

The award process begins with the nurses, who are in charge of nominations. An independent board “reads the stories” about the nominees and their outstanding care, then chooses the winner.

Although Dr. Wilson says she was “stunned” when she was told she received the award, her colleagues were not. “Dr. Wilson is a consistent professional. It’s the way she relates to patients; her manner is very comfortable and easy going, and her ability to communicate with them—it’s like going home,” says Katherine Marsh, an oncology nurse at Moore Regional.

Dan Barnes, MD, director of the 23-hospitalist program at Moore Regional, says Dr. Wilson’s extensive interaction with the hospital’s nurses has helped improve the relationship between doctors and other staff.

“She is a true advocate for quality improvement and is always willing to help with that,” Dr. Barnes says, citing a soon-to-be-live Computerized Physician Order Entry (CPOE) initiative at the hospital, a project for which Dr. Wilson serves as officer.

Dr. Wilson’s focus on forging relationships between varying medical staff can be traced back to her early exposure to medicine. She grew up in southern Indiana with an RN mother and medical photographer father. She says that combination made for “interesting dinner conversations” as a child.

“We have to keep asking ourselves, ‘How can we do this better?'” Dr. Wilson says. “It’s all about the patient.”

More than 400 people attended the Pediatric Hospital Medicine annual conference July 22-25 in Minneapolis. The annual meeting is the premier networking and educational event for pediatric hospitalists and is sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA).

Innovation and improvement were popular topics throughout the conference. Keynote speaker George Buckley, CEO of manufacturing and technology conglomerate 3M, spoke about inspiring innovation, and a large percentage of the sessions and posters had quality-improvement (QI) themes. Experts from Cincinnati Children’s Hospital, led by Steve Muething, MD, assistant vice president of patient safety, and Shannon Phillips, MD, MPH, Cleveland Clinic’s patient safety officer, guided several popular sessions on QI.

A major innovation announced at the conference was the planned launch of a journal of pediatric hospital medicine, which will be sponsored by the AAP. (Update 09.14.2010--The journal has yet to officially announce an editor).

Research presentations have continued to increase in this young field, and the meeting was full of poster and platform presentations in the areas of clinical research, QI, educational research, and health services research. Vineeta Mittal, MD, of the University of Texas Southwestern and Children’s Medical Center in Dallas presented research on family-centered rounds, which was recently published in Pediatrics and picked up by the National Association of Children’s Hospitals (NACHRI) for dissemination.¹ Patrick Brady, MD, of Cincinnati Children’s Hospital presented his research on short- versus long-course IV therapy for pediatric urinary tract infections, also published in Pediatrics.²

Other buzzed-about sessions included Vanderbilt University pediatric hospitalist Dr. Paul Hain’s ambitious attempt to create a PHM performance dashboard, and a case of “situational” epilepsy presented by Dr. Lisa Zaoutis of CHOP.

As in years past, the hottest ticket was for the luncheon presentation of the “Top Articles in Pediatric Hospital Medicine,” paneled this year by Drs. John Pope, Kris Rehm, and Brian Alverson. Raj Srivastava, MD, of Primary Children’s Medical Center in Salt Lake City and chairperson of the Pediatric Research in Inpatient Settings network, announced that the network had been awarded major grant funding.

Dan Rauch, MD, chair of the AAP’s Section on Hospital Medicine, dropped the biggest bombshell of all: He announced that the American Board of Pediatrics will support the development of pediatric HM as a full-fledged subspecialty in the near future. TH

Dr. Ralston is associate professor of pediatrics and chief of the division of inpatient pediatrics at the University of Texas Health Science Center in San Antonio, and medical director of inpatient services at Christus Santa Rosa Children’s Hospital.

References

1. Mittal VS, Sigrest T, Ottolini MC, et al. Family-centered rounds on pediatric wards: a PRIS network survey of U.S. and Canadian hospitalists. Pediatrics. 2010;126(1):37-43.
2. Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary track infections. Pediatrics. 2010;126(2):196-203.

More than 400 people attended the Pediatric Hospital Medicine annual conference July 22-25 in Minneapolis. The annual meeting is the premier networking and educational event for pediatric hospitalists and is sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA).

Innovation and improvement were popular topics throughout the conference. Keynote speaker George Buckley, CEO of manufacturing and technology conglomerate 3M, spoke about inspiring innovation, and a large percentage of the sessions and posters had quality-improvement (QI) themes. Experts from Cincinnati Children’s Hospital, led by Steve Muething, MD, assistant vice president of patient safety, and Shannon Phillips, MD, MPH, Cleveland Clinic’s patient safety officer, guided several popular sessions on QI.

A major innovation announced at the conference was the planned launch of a journal of pediatric hospital medicine, which will be sponsored by the AAP. (Update 09.14.2010--The journal has yet to officially announce an editor).

Research presentations have continued to increase in this young field, and the meeting was full of poster and platform presentations in the areas of clinical research, QI, educational research, and health services research. Vineeta Mittal, MD, of the University of Texas Southwestern and Children’s Medical Center in Dallas presented research on family-centered rounds, which was recently published in Pediatrics and picked up by the National Association of Children’s Hospitals (NACHRI) for dissemination.¹ Patrick Brady, MD, of Cincinnati Children’s Hospital presented his research on short- versus long-course IV therapy for pediatric urinary tract infections, also published in Pediatrics.²

Other buzzed-about sessions included Vanderbilt University pediatric hospitalist Dr. Paul Hain’s ambitious attempt to create a PHM performance dashboard, and a case of “situational” epilepsy presented by Dr. Lisa Zaoutis of CHOP.

As in years past, the hottest ticket was for the luncheon presentation of the “Top Articles in Pediatric Hospital Medicine,” paneled this year by Drs. John Pope, Kris Rehm, and Brian Alverson. Raj Srivastava, MD, of Primary Children’s Medical Center in Salt Lake City and chairperson of the Pediatric Research in Inpatient Settings network, announced that the network had been awarded major grant funding.

Dan Rauch, MD, chair of the AAP’s Section on Hospital Medicine, dropped the biggest bombshell of all: He announced that the American Board of Pediatrics will support the development of pediatric HM as a full-fledged subspecialty in the near future. TH

Dr. Ralston is associate professor of pediatrics and chief of the division of inpatient pediatrics at the University of Texas Health Science Center in San Antonio, and medical director of inpatient services at Christus Santa Rosa Children’s Hospital.

References

1. Mittal VS, Sigrest T, Ottolini MC, et al. Family-centered rounds on pediatric wards: a PRIS network survey of U.S. and Canadian hospitalists. Pediatrics. 2010;126(1):37-43.
2. Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary track infections. Pediatrics. 2010;126(2):196-203.

More than 400 people attended the Pediatric Hospital Medicine annual conference July 22-25 in Minneapolis. The annual meeting is the premier networking and educational event for pediatric hospitalists and is sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA).

Innovation and improvement were popular topics throughout the conference. Keynote speaker George Buckley, CEO of manufacturing and technology conglomerate 3M, spoke about inspiring innovation, and a large percentage of the sessions and posters had quality-improvement (QI) themes. Experts from Cincinnati Children’s Hospital, led by Steve Muething, MD, assistant vice president of patient safety, and Shannon Phillips, MD, MPH, Cleveland Clinic’s patient safety officer, guided several popular sessions on QI.

A major innovation announced at the conference was the planned launch of a journal of pediatric hospital medicine, which will be sponsored by the AAP. (Update 09.14.2010--The journal has yet to officially announce an editor).

Research presentations have continued to increase in this young field, and the meeting was full of poster and platform presentations in the areas of clinical research, QI, educational research, and health services research. Vineeta Mittal, MD, of the University of Texas Southwestern and Children’s Medical Center in Dallas presented research on family-centered rounds, which was recently published in Pediatrics and picked up by the National Association of Children’s Hospitals (NACHRI) for dissemination.¹ Patrick Brady, MD, of Cincinnati Children’s Hospital presented his research on short- versus long-course IV therapy for pediatric urinary tract infections, also published in Pediatrics.²

Other buzzed-about sessions included Vanderbilt University pediatric hospitalist Dr. Paul Hain’s ambitious attempt to create a PHM performance dashboard, and a case of “situational” epilepsy presented by Dr. Lisa Zaoutis of CHOP.

As in years past, the hottest ticket was for the luncheon presentation of the “Top Articles in Pediatric Hospital Medicine,” paneled this year by Drs. John Pope, Kris Rehm, and Brian Alverson. Raj Srivastava, MD, of Primary Children’s Medical Center in Salt Lake City and chairperson of the Pediatric Research in Inpatient Settings network, announced that the network had been awarded major grant funding.

Dan Rauch, MD, chair of the AAP’s Section on Hospital Medicine, dropped the biggest bombshell of all: He announced that the American Board of Pediatrics will support the development of pediatric HM as a full-fledged subspecialty in the near future. TH

Dr. Ralston is associate professor of pediatrics and chief of the division of inpatient pediatrics at the University of Texas Health Science Center in San Antonio, and medical director of inpatient services at Christus Santa Rosa Children’s Hospital.

References

1. Mittal VS, Sigrest T, Ottolini MC, et al. Family-centered rounds on pediatric wards: a PRIS network survey of U.S. and Canadian hospitalists. Pediatrics. 2010;126(1):37-43.
2. Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary track infections. Pediatrics. 2010;126(2):196-203.

As the field of HM continues to mature, branch out, and is called upon to lead in the care of a larger cross-section of hospitalized patients, it is only natural that this includes the critically ill patient. Hospitalists already care for—and are the attending of record for—this patient population in most U.S. hospitals. It is my position that a technically proficient hospitalist service, which is facility-exclusive and offers 24/7 coverage, is able to offer the same quality of care as an intensivist group. An important feature of this model is the inclusion and “buy in” from community pulmonologists in order to provide backup and consultative assistance when warranted.

Our program at Westside Regional Medical Center in Plantation, Fla., has made great strides as we continue to integrate this model in the hospital. We are actively tracking ICU length of stay and throughput, incidence of ventilator-associated pneumonia (VAP), central-line infection rates, and ICU mortality.

I believe that a clinically competent and aggressive HM service is able to drive down costs and generate revenue by establishing clinically beneficial quality-improvement (QI) protocols; drive down ICU length of stay; provide effective and timely procedural services; and incur a lower cost burden (i.e., hospitalists cost less than intensivists). And I believe all of these benefits are available without sacrificing quality or patient care.

Leadership from medical staff and administration is imperative to establish the appropriate vision and drive toward hospitalist/intensivist implementation. Finding the right supporting physicians who bring excitement and energy is equally as important. Establishing expectations for skill sets, as well as the opportunity and mechanism by which these skill sets might be acquired and refined, is a must. The following technical skills should be required of hospitalist/intensivists:

• Ultrasound-guided central line insertion;
• PICC line insertion;
• Endotracheal intubation;
• Advanced airway management;
• Thoracostomy tube insertion;
• Arterial-line insertion;
• Transvenous pacing wire insertion;
• Lumbar puncture;
• Thoracentesis; and
• Paracentesis.

An important starting point is the identification of skill sets for each hospitalist. Once this information is ascertained, the next step is to understand what the credentialing requirements for the individual procedures are. This usually consists of a certain number of “logged” cases, which must be put forward for review by the medical staff leadership. Most physicians completing residency are required to keep a procedural log where cases are documented. Any deficiencies within the log can be supplemented by establishing a practice log where proctored cases are documented until the recommended number of cases are completed and put forward for credentialing.

Obtaining buy-in from the medical staff is important. They can serve as allies in many areas, specifically as proctors in the credentialing process. The key to successful interface is in awakening them to the beneficial impact a service such as this can have on patients and on the lifestyle of providers.

As an example, before our group started the hybrid model at Westside, the nursing staff would call anesthesia to evaluate patients for endotracheal intubation. This system took anesthesia away from its OR cases, causing delays and frustration. After a conversation, the anesthesia director realized the benefits that would come with assisting the hospitalists in becoming more proficient with intubations. This same scenario has been true in our experience with ED physicians, cardiothoracic surgeons (chest tubes), and so on.

Other resources for hospitalists include the National Procedure Institute, which offers CME credit and certification toward “Hospitalist Procedures.” Additionally, difficult airway or advanced airway courses provide certification.

Hospitalists have long been called on to provide emergency services for unstable patients via rapid response or codes. In many facilities hospitalists serve as the lead physicians in the management of critically ill patients. Our hospitalist model serves as a great launching pad for the development and evolution of this new breed of physician.

There exists no clinical evidence to assert inferiority between the care provided by an in-house, 24/7 hospitalist group with assistance from pulmonary medicine versus an intensivist group. It is my belief that if the appropriate infrastructure, fostered skill sets, pulmonologist partnership, and QI protocols are implemented, there will be no measurable difference in scope of care or outcomes.

The inpatient management of critically ill and unstable patients continues to be a significant and important subgroup of hospital patient populations. As patients continue to live longer with debilitating chronic diseases, the fallout from decompensation can be devastating. Many facilities have hospitalists leading the charge in the care of these patients. It is undeniable that the next evolution in HM will require a more proactive inpatient physician, with both the clinical and technical acumen to manage all patients across the hospital spectrum.

Ulises A. Perez, MD,

medical director, hospitalist division,

Westside Regional Medical Center, Plantation, Fla.,

Kendall Regional Medical Center, Miami

As the field of HM continues to mature, branch out, and is called upon to lead in the care of a larger cross-section of hospitalized patients, it is only natural that this includes the critically ill patient. Hospitalists already care for—and are the attending of record for—this patient population in most U.S. hospitals. It is my position that a technically proficient hospitalist service, which is facility-exclusive and offers 24/7 coverage, is able to offer the same quality of care as an intensivist group. An important feature of this model is the inclusion and “buy in” from community pulmonologists in order to provide backup and consultative assistance when warranted.

Our program at Westside Regional Medical Center in Plantation, Fla., has made great strides as we continue to integrate this model in the hospital. We are actively tracking ICU length of stay and throughput, incidence of ventilator-associated pneumonia (VAP), central-line infection rates, and ICU mortality.

I believe that a clinically competent and aggressive HM service is able to drive down costs and generate revenue by establishing clinically beneficial quality-improvement (QI) protocols; drive down ICU length of stay; provide effective and timely procedural services; and incur a lower cost burden (i.e., hospitalists cost less than intensivists). And I believe all of these benefits are available without sacrificing quality or patient care.

Leadership from medical staff and administration is imperative to establish the appropriate vision and drive toward hospitalist/intensivist implementation. Finding the right supporting physicians who bring excitement and energy is equally as important. Establishing expectations for skill sets, as well as the opportunity and mechanism by which these skill sets might be acquired and refined, is a must. The following technical skills should be required of hospitalist/intensivists:

• Ultrasound-guided central line insertion;
• PICC line insertion;
• Endotracheal intubation;
• Advanced airway management;
• Thoracostomy tube insertion;
• Arterial-line insertion;
• Transvenous pacing wire insertion;
• Lumbar puncture;
• Thoracentesis; and
• Paracentesis.

An important starting point is the identification of skill sets for each hospitalist. Once this information is ascertained, the next step is to understand what the credentialing requirements for the individual procedures are. This usually consists of a certain number of “logged” cases, which must be put forward for review by the medical staff leadership. Most physicians completing residency are required to keep a procedural log where cases are documented. Any deficiencies within the log can be supplemented by establishing a practice log where proctored cases are documented until the recommended number of cases are completed and put forward for credentialing.

Obtaining buy-in from the medical staff is important. They can serve as allies in many areas, specifically as proctors in the credentialing process. The key to successful interface is in awakening them to the beneficial impact a service such as this can have on patients and on the lifestyle of providers.

As an example, before our group started the hybrid model at Westside, the nursing staff would call anesthesia to evaluate patients for endotracheal intubation. This system took anesthesia away from its OR cases, causing delays and frustration. After a conversation, the anesthesia director realized the benefits that would come with assisting the hospitalists in becoming more proficient with intubations. This same scenario has been true in our experience with ED physicians, cardiothoracic surgeons (chest tubes), and so on.

Other resources for hospitalists include the National Procedure Institute, which offers CME credit and certification toward “Hospitalist Procedures.” Additionally, difficult airway or advanced airway courses provide certification.

Hospitalists have long been called on to provide emergency services for unstable patients via rapid response or codes. In many facilities hospitalists serve as the lead physicians in the management of critically ill patients. Our hospitalist model serves as a great launching pad for the development and evolution of this new breed of physician.

There exists no clinical evidence to assert inferiority between the care provided by an in-house, 24/7 hospitalist group with assistance from pulmonary medicine versus an intensivist group. It is my belief that if the appropriate infrastructure, fostered skill sets, pulmonologist partnership, and QI protocols are implemented, there will be no measurable difference in scope of care or outcomes.

The inpatient management of critically ill and unstable patients continues to be a significant and important subgroup of hospital patient populations. As patients continue to live longer with debilitating chronic diseases, the fallout from decompensation can be devastating. Many facilities have hospitalists leading the charge in the care of these patients. It is undeniable that the next evolution in HM will require a more proactive inpatient physician, with both the clinical and technical acumen to manage all patients across the hospital spectrum.

Ulises A. Perez, MD,

medical director, hospitalist division,

Westside Regional Medical Center, Plantation, Fla.,

Kendall Regional Medical Center, Miami

As the field of HM continues to mature, branch out, and is called upon to lead in the care of a larger cross-section of hospitalized patients, it is only natural that this includes the critically ill patient. Hospitalists already care for—and are the attending of record for—this patient population in most U.S. hospitals. It is my position that a technically proficient hospitalist service, which is facility-exclusive and offers 24/7 coverage, is able to offer the same quality of care as an intensivist group. An important feature of this model is the inclusion and “buy in” from community pulmonologists in order to provide backup and consultative assistance when warranted.

Our program at Westside Regional Medical Center in Plantation, Fla., has made great strides as we continue to integrate this model in the hospital. We are actively tracking ICU length of stay and throughput, incidence of ventilator-associated pneumonia (VAP), central-line infection rates, and ICU mortality.

I believe that a clinically competent and aggressive HM service is able to drive down costs and generate revenue by establishing clinically beneficial quality-improvement (QI) protocols; drive down ICU length of stay; provide effective and timely procedural services; and incur a lower cost burden (i.e., hospitalists cost less than intensivists). And I believe all of these benefits are available without sacrificing quality or patient care.

Leadership from medical staff and administration is imperative to establish the appropriate vision and drive toward hospitalist/intensivist implementation. Finding the right supporting physicians who bring excitement and energy is equally as important. Establishing expectations for skill sets, as well as the opportunity and mechanism by which these skill sets might be acquired and refined, is a must. The following technical skills should be required of hospitalist/intensivists:

• Ultrasound-guided central line insertion;
• PICC line insertion;
• Endotracheal intubation;
• Advanced airway management;
• Thoracostomy tube insertion;
• Arterial-line insertion;
• Transvenous pacing wire insertion;
• Lumbar puncture;
• Thoracentesis; and
• Paracentesis.

An important starting point is the identification of skill sets for each hospitalist. Once this information is ascertained, the next step is to understand what the credentialing requirements for the individual procedures are. This usually consists of a certain number of “logged” cases, which must be put forward for review by the medical staff leadership. Most physicians completing residency are required to keep a procedural log where cases are documented. Any deficiencies within the log can be supplemented by establishing a practice log where proctored cases are documented until the recommended number of cases are completed and put forward for credentialing.

Obtaining buy-in from the medical staff is important. They can serve as allies in many areas, specifically as proctors in the credentialing process. The key to successful interface is in awakening them to the beneficial impact a service such as this can have on patients and on the lifestyle of providers.

As an example, before our group started the hybrid model at Westside, the nursing staff would call anesthesia to evaluate patients for endotracheal intubation. This system took anesthesia away from its OR cases, causing delays and frustration. After a conversation, the anesthesia director realized the benefits that would come with assisting the hospitalists in becoming more proficient with intubations. This same scenario has been true in our experience with ED physicians, cardiothoracic surgeons (chest tubes), and so on.

Other resources for hospitalists include the National Procedure Institute, which offers CME credit and certification toward “Hospitalist Procedures.” Additionally, difficult airway or advanced airway courses provide certification.

Hospitalists have long been called on to provide emergency services for unstable patients via rapid response or codes. In many facilities hospitalists serve as the lead physicians in the management of critically ill patients. Our hospitalist model serves as a great launching pad for the development and evolution of this new breed of physician.

There exists no clinical evidence to assert inferiority between the care provided by an in-house, 24/7 hospitalist group with assistance from pulmonary medicine versus an intensivist group. It is my belief that if the appropriate infrastructure, fostered skill sets, pulmonologist partnership, and QI protocols are implemented, there will be no measurable difference in scope of care or outcomes.

The inpatient management of critically ill and unstable patients continues to be a significant and important subgroup of hospital patient populations. As patients continue to live longer with debilitating chronic diseases, the fallout from decompensation can be devastating. Many facilities have hospitalists leading the charge in the care of these patients. It is undeniable that the next evolution in HM will require a more proactive inpatient physician, with both the clinical and technical acumen to manage all patients across the hospital spectrum.

Ulises A. Perez, MD,

medical director, hospitalist division,

Westside Regional Medical Center, Plantation, Fla.,

Kendall Regional Medical Center, Miami

As HM continues to grow, the need for clear and accurate data about the specialty will only become more intense. Hospitalists and HM group leaders use survey information to better understand how they compare to other practices across the country, in terms of size and practice characteristics, as well as compensation and productivity.

Increasingly, healthcare executives are turning to survey data—either independently or via their hospitalist group leaders—to get a grasp on the best practices in the industry.

That’s why SHM teamed up with the Medical Group Management Association (MGMA), the industry leader for professional administrators and leaders of medical group practices, to research and develop the State of Hospital Medicine: 2010 Report Based on 2009 Data.

Previously, SHM created and fielded a biannual survey, then analyzed the results independently.

Our partnership with MGMA expands our survey population, delivers more information, and brings MGMA’s 90 years of industry credibility in the medical practice management field.

—Leslie A. Flores, MHA, SHM senior advisor for practice management

“Our partnership with MGMA expands our survey population, delivers more information, and brings MGMA’s 90 years of industry credibility in the medical practice management field,” says Leslie A. Flores, MHA, SHM senior advisor for practice management. “The 2010 survey gives hospitalists and hospital administrators an unprecedented snapshot of the state of hospital medicine.”

The 2010 report will be available this month in the “Practice Resources” section of the SHM website (www.hospitalmedicine.org).

The print version will be available to SHM members for $125; for $175, members receive both the print version and the report on CD-ROM.

“This is a first-ever opportunity for hospitalists, group leaders, and healthcare executives to get the clearest picture possible of a rapidly changing industry,” Flores says. TH

Brendon Shank is a freelance writer based in Philadelphia.

SHM Adopts Strict Code for Industry Relations

A long with nearly 20 other organizations, SHM has adopted the Code for Industry Relations (http://cmss.org/) established by the Council on Medical Specialty Societies (CMSS). In an era of digital communication, SHM has created a Web area (www.hospital medicine.org/industry) to continuously update its policies toward industry, display its current partnerships, and disclose the potential conflicts of interest of its board or directors, editors, and CEO.

The message from SHM leadership: SHM is committed to being a leader in an era of transparency and disclosure.

Transparency serves an important role for medical specialty societies, says Norman B. Kahn Jr., MD, executive vice president and CEO of CMSS. The code developed by CMSS and adopted by SHM “assures in interactions with industry that the patients’ needs come first,” Dr. Kahn says. “The bottom line is that this is all about protecting the independence of societies from industry without abrogating the relationship.”

From its early days, SHM has been aware of the need to balance the responsibilities of speaking for HM and the need to disclose any potential conflicts of interests. In 2000, SHM developed its Principles of Organizational Relationships (www.hospitalmedicine.org/OrgRelationships), which have guided the society’s efforts.

The principles call for a clear, bright line that is a barrier between the support of a partner and SHM’s control of content. Among other activities, SHM has applied those principles to meetings and educational initiatives, quality-improvement (QI) projects, and publications.

The principles also were the foundation for the tough conflict-of-interest policies (www.hospital medicine.org/interestpolicies) the board approved in 2005.

Over the last decade, as HM has grown, national hospitalist leaders have become the experts on a wide range of topics and are asked to speak, write, or advise government agencies, foundations, and industry.

As SHM has developed its resources to help hospitalists improve glycemic control, reduce unnecessary DVTs and PEs, and improve the transitions of care, SHM has engaged in partnerships with government agencies, foundations, and industry as well.

“SHM’s leadership recognizes that it has a fiduciary responsibility to its members—a responsibility to provide expert direction, and necessary resources, to enable the hospitalist to ensure the best possible care of his or her patients, and to advance the quality of the hospital system,” says SHM President Jeff Wiese, MD, SFHM. “But SHM cannot do this alone, and when external partnerships are established, it is the organization’s responsibility to enter into these partnerships judiciously, and to be fully transparent to the membership with respect to the arrangements of these partnerships.

“We are confident that no other organization has a more robust disclosure policy than SHM.”

Today’s Nominations, Tomorrow’s Leaders

HM leaders aren’t born that way—they’re nominated.

SHM is accepting nominations for its board election; new members will take office in May at HM11 in Dallas.

The nomination deadline is Oct. 31. Online ballots will be available to all SHM members in late 2010. The results of the election will be announced online in early 2011.

Nominees must be SHM members in good standing. SHM members may nominate themselves or be nominated by another SHM member. Nominations must include a letter of nomination, a one-page CV, and a recent photo.

The nomination committee considers candidates based on length of SHM membership, activity as a hospitalist and SHM member, the prominence of the candidate within the specialty, and a number of other factors.

Board members serve a three-year term and normally serve on one or more committees.

“Participating in SHM’s leadership is one of the best ways to help guide the future of hospital medicine,” says Larry Wellikson, MD, SFHM, CEO of SHM. “That begins by submitting a board nomination to SHM this year.”

Chapter Updates

Chicago

The Chicago chapter met May 19 at Sullivan’s Steakhouse. Twenty-five hospitalists from the Chicago area, including hospitalists at Loyola Hospital, Lutheran General Hospital, Illinois Masonic Medical Center, Trinity Hospital, Silver Cross, and Evanston Hospital, as well as hospitalist groups like Cogent and Vista, attended the meeting.

Dr. Robin Ross of Season Hospice and Palliative Care, which sponsored the event, presented clinical pearls for end-of-life care for the busy hospitalist. The meeting also featured a town-hall discussion, with topics relevant to everyday hospitalist practice—coding, consultations, and the use of observation units. Notification of chapter elections were summated to all chapter members in July and August.

Harrisburg/South Central Pennsylvania

Thirty hospitalists representing six HM programs attended the Harrisburg/South Central Pennsylvania chapter of SHM June 9 at Passage to India in Harrisburg.

Eric Kupersmith, MD, SFHM, division head of the hospitalist program at Cooper University Hospital in Camden, N.J., led an open discussion regarding “Transition of Care and the Hospitalist’s Role.” Chapter members had the opportunity to discuss how each individual program actively seeks to decrease readmission rates. Discharge-planning specifics generated group discussion, and a handful of hospitalists offered testimonials about what is working in their practices.

The meeting was sponsored by Merck.

A BOOST for all seasons: Discharge improvement resources now available year round

When Project BOOST (Better Outcomes for Older Adults through Safer Transitions), SHM’s groundbreaking program to reduce readmissions, first began in 2008, hospital sites applied to participate in a yearlong program of one-on-one mentorships, regular sessions to share best practices, and a resource toolkit.

Since then, Project BOOST has grown and evolved. Some BOOST iterations now include third parties, such as the University of Michigan, Blue Cross/Blue Shield of Michigan, and the California HealthCare Foundation. SHM also recently introduced a nationwide, tuition-based version of the BOOST initiative.

Now, SHM is announcing that new resources are available to all hospitals, regardless of their participation in Project BOOST, all year. Some resources were previously available only to Project BOOST participants; others are brand-new materials available to any hospital or hospitalist trying to reduce unplanned readmissions to their hospital.

“No matter where you are in the hospital, you have an opportunity to improve discharge,” says Tina Budnitz, MPH, senior advisor for quality improvement. “The response to Project BOOST has been overwhelmingly positive. That’s why we’re so excited to make these new materials available to anyone responsible for lowering readmissions.”

Individuals can download the Project BOOST implementation course, a new training program specifically designed to help nurses use the proven “teachback” method, and the Project BOOST patient PASS form.

Budnitz and Project BOOST organizers also plan to launch supplemental products for self-implementers, including access to Project BOOST e-mail listservs, data centers, and webinars.

Prepare Now for Flu Season

With most of the country still enjoying warm weather, it’s easy to forget that flu season is right around the corner. Hospitals can either be part of the solution—or part of the problem.

Compared to friends and family outside of the hospital, patients in the hospital are especially at risk. The chances of contracting the flu are higher, given decreased immune responses and increased proximity to caregivers and other potentially infected patients. Plus, the impact of the flu on healthcare providers can be significantly more severe.

By now, most hospitals have protocols for preparing for flu season and isolating infected patients, says Danielle Scheurer, MD, MSc, SFHM, assistant professor of medicine at Harvard Medical School in Boston and director of general medical service at Brigham and Women’s Hospitalist Service. Hospitalists play a special role within those protocols, she adds.

“Hospitalists can be instrumental in preventing the spread of flu within the hospital by having a low threshold for diagnostic testing of patients, immediate isolation of those patients, and strict adherence to infection-control measures in those with suspected influenza,” Dr. Scheurer says.

Dr. Scheurer also emphasizes the fact that flu prevention doesn’t end with better clinical practices. Patient education is key.

“Hospitalists can be vital in educating patients about how to avoid symptomatic contacts,” she says, “and how to advocate for themselves in insisting that all care providers use strict handwashing protocols to avoid transmitting influenza among patients.” TH

As HM continues to grow, the need for clear and accurate data about the specialty will only become more intense. Hospitalists and HM group leaders use survey information to better understand how they compare to other practices across the country, in terms of size and practice characteristics, as well as compensation and productivity.

Increasingly, healthcare executives are turning to survey data—either independently or via their hospitalist group leaders—to get a grasp on the best practices in the industry.

That’s why SHM teamed up with the Medical Group Management Association (MGMA), the industry leader for professional administrators and leaders of medical group practices, to research and develop the State of Hospital Medicine: 2010 Report Based on 2009 Data.

Previously, SHM created and fielded a biannual survey, then analyzed the results independently.

Our partnership with MGMA expands our survey population, delivers more information, and brings MGMA’s 90 years of industry credibility in the medical practice management field.

—Leslie A. Flores, MHA, SHM senior advisor for practice management

“Our partnership with MGMA expands our survey population, delivers more information, and brings MGMA’s 90 years of industry credibility in the medical practice management field,” says Leslie A. Flores, MHA, SHM senior advisor for practice management. “The 2010 survey gives hospitalists and hospital administrators an unprecedented snapshot of the state of hospital medicine.”

The 2010 report will be available this month in the “Practice Resources” section of the SHM website (www.hospitalmedicine.org).

The print version will be available to SHM members for $125; for $175, members receive both the print version and the report on CD-ROM.

“This is a first-ever opportunity for hospitalists, group leaders, and healthcare executives to get the clearest picture possible of a rapidly changing industry,” Flores says. TH

Brendon Shank is a freelance writer based in Philadelphia.

SHM Adopts Strict Code for Industry Relations

A long with nearly 20 other organizations, SHM has adopted the Code for Industry Relations (http://cmss.org/) established by the Council on Medical Specialty Societies (CMSS). In an era of digital communication, SHM has created a Web area (www.hospital medicine.org/industry) to continuously update its policies toward industry, display its current partnerships, and disclose the potential conflicts of interest of its board or directors, editors, and CEO.

The message from SHM leadership: SHM is committed to being a leader in an era of transparency and disclosure.

Transparency serves an important role for medical specialty societies, says Norman B. Kahn Jr., MD, executive vice president and CEO of CMSS. The code developed by CMSS and adopted by SHM “assures in interactions with industry that the patients’ needs come first,” Dr. Kahn says. “The bottom line is that this is all about protecting the independence of societies from industry without abrogating the relationship.”

From its early days, SHM has been aware of the need to balance the responsibilities of speaking for HM and the need to disclose any potential conflicts of interests. In 2000, SHM developed its Principles of Organizational Relationships (www.hospitalmedicine.org/OrgRelationships), which have guided the society’s efforts.

The principles call for a clear, bright line that is a barrier between the support of a partner and SHM’s control of content. Among other activities, SHM has applied those principles to meetings and educational initiatives, quality-improvement (QI) projects, and publications.

The principles also were the foundation for the tough conflict-of-interest policies (www.hospital medicine.org/interestpolicies) the board approved in 2005.

Over the last decade, as HM has grown, national hospitalist leaders have become the experts on a wide range of topics and are asked to speak, write, or advise government agencies, foundations, and industry.

As SHM has developed its resources to help hospitalists improve glycemic control, reduce unnecessary DVTs and PEs, and improve the transitions of care, SHM has engaged in partnerships with government agencies, foundations, and industry as well.

“SHM’s leadership recognizes that it has a fiduciary responsibility to its members—a responsibility to provide expert direction, and necessary resources, to enable the hospitalist to ensure the best possible care of his or her patients, and to advance the quality of the hospital system,” says SHM President Jeff Wiese, MD, SFHM. “But SHM cannot do this alone, and when external partnerships are established, it is the organization’s responsibility to enter into these partnerships judiciously, and to be fully transparent to the membership with respect to the arrangements of these partnerships.

“We are confident that no other organization has a more robust disclosure policy than SHM.”

Today’s Nominations, Tomorrow’s Leaders

HM leaders aren’t born that way—they’re nominated.

SHM is accepting nominations for its board election; new members will take office in May at HM11 in Dallas.

The nomination deadline is Oct. 31. Online ballots will be available to all SHM members in late 2010. The results of the election will be announced online in early 2011.

Nominees must be SHM members in good standing. SHM members may nominate themselves or be nominated by another SHM member. Nominations must include a letter of nomination, a one-page CV, and a recent photo.

The nomination committee considers candidates based on length of SHM membership, activity as a hospitalist and SHM member, the prominence of the candidate within the specialty, and a number of other factors.

Board members serve a three-year term and normally serve on one or more committees.

“Participating in SHM’s leadership is one of the best ways to help guide the future of hospital medicine,” says Larry Wellikson, MD, SFHM, CEO of SHM. “That begins by submitting a board nomination to SHM this year.”

Chapter Updates

Chicago

The Chicago chapter met May 19 at Sullivan’s Steakhouse. Twenty-five hospitalists from the Chicago area, including hospitalists at Loyola Hospital, Lutheran General Hospital, Illinois Masonic Medical Center, Trinity Hospital, Silver Cross, and Evanston Hospital, as well as hospitalist groups like Cogent and Vista, attended the meeting.

Dr. Robin Ross of Season Hospice and Palliative Care, which sponsored the event, presented clinical pearls for end-of-life care for the busy hospitalist. The meeting also featured a town-hall discussion, with topics relevant to everyday hospitalist practice—coding, consultations, and the use of observation units. Notification of chapter elections were summated to all chapter members in July and August.

Harrisburg/South Central Pennsylvania

Thirty hospitalists representing six HM programs attended the Harrisburg/South Central Pennsylvania chapter of SHM June 9 at Passage to India in Harrisburg.

Eric Kupersmith, MD, SFHM, division head of the hospitalist program at Cooper University Hospital in Camden, N.J., led an open discussion regarding “Transition of Care and the Hospitalist’s Role.” Chapter members had the opportunity to discuss how each individual program actively seeks to decrease readmission rates. Discharge-planning specifics generated group discussion, and a handful of hospitalists offered testimonials about what is working in their practices.

The meeting was sponsored by Merck.

A BOOST for all seasons: Discharge improvement resources now available year round

When Project BOOST (Better Outcomes for Older Adults through Safer Transitions), SHM’s groundbreaking program to reduce readmissions, first began in 2008, hospital sites applied to participate in a yearlong program of one-on-one mentorships, regular sessions to share best practices, and a resource toolkit.

Since then, Project BOOST has grown and evolved. Some BOOST iterations now include third parties, such as the University of Michigan, Blue Cross/Blue Shield of Michigan, and the California HealthCare Foundation. SHM also recently introduced a nationwide, tuition-based version of the BOOST initiative.

Now, SHM is announcing that new resources are available to all hospitals, regardless of their participation in Project BOOST, all year. Some resources were previously available only to Project BOOST participants; others are brand-new materials available to any hospital or hospitalist trying to reduce unplanned readmissions to their hospital.

“No matter where you are in the hospital, you have an opportunity to improve discharge,” says Tina Budnitz, MPH, senior advisor for quality improvement. “The response to Project BOOST has been overwhelmingly positive. That’s why we’re so excited to make these new materials available to anyone responsible for lowering readmissions.”

Individuals can download the Project BOOST implementation course, a new training program specifically designed to help nurses use the proven “teachback” method, and the Project BOOST patient PASS form.

Budnitz and Project BOOST organizers also plan to launch supplemental products for self-implementers, including access to Project BOOST e-mail listservs, data centers, and webinars.

Prepare Now for Flu Season

With most of the country still enjoying warm weather, it’s easy to forget that flu season is right around the corner. Hospitals can either be part of the solution—or part of the problem.

Compared to friends and family outside of the hospital, patients in the hospital are especially at risk. The chances of contracting the flu are higher, given decreased immune responses and increased proximity to caregivers and other potentially infected patients. Plus, the impact of the flu on healthcare providers can be significantly more severe.

By now, most hospitals have protocols for preparing for flu season and isolating infected patients, says Danielle Scheurer, MD, MSc, SFHM, assistant professor of medicine at Harvard Medical School in Boston and director of general medical service at Brigham and Women’s Hospitalist Service. Hospitalists play a special role within those protocols, she adds.

“Hospitalists can be instrumental in preventing the spread of flu within the hospital by having a low threshold for diagnostic testing of patients, immediate isolation of those patients, and strict adherence to infection-control measures in those with suspected influenza,” Dr. Scheurer says.

Dr. Scheurer also emphasizes the fact that flu prevention doesn’t end with better clinical practices. Patient education is key.

“Hospitalists can be vital in educating patients about how to avoid symptomatic contacts,” she says, “and how to advocate for themselves in insisting that all care providers use strict handwashing protocols to avoid transmitting influenza among patients.” TH

As HM continues to grow, the need for clear and accurate data about the specialty will only become more intense. Hospitalists and HM group leaders use survey information to better understand how they compare to other practices across the country, in terms of size and practice characteristics, as well as compensation and productivity.

Increasingly, healthcare executives are turning to survey data—either independently or via their hospitalist group leaders—to get a grasp on the best practices in the industry.

That’s why SHM teamed up with the Medical Group Management Association (MGMA), the industry leader for professional administrators and leaders of medical group practices, to research and develop the State of Hospital Medicine: 2010 Report Based on 2009 Data.

Previously, SHM created and fielded a biannual survey, then analyzed the results independently.

Our partnership with MGMA expands our survey population, delivers more information, and brings MGMA’s 90 years of industry credibility in the medical practice management field.

—Leslie A. Flores, MHA, SHM senior advisor for practice management

“Our partnership with MGMA expands our survey population, delivers more information, and brings MGMA’s 90 years of industry credibility in the medical practice management field,” says Leslie A. Flores, MHA, SHM senior advisor for practice management. “The 2010 survey gives hospitalists and hospital administrators an unprecedented snapshot of the state of hospital medicine.”

The 2010 report will be available this month in the “Practice Resources” section of the SHM website (www.hospitalmedicine.org).

The print version will be available to SHM members for $125; for $175, members receive both the print version and the report on CD-ROM.

“This is a first-ever opportunity for hospitalists, group leaders, and healthcare executives to get the clearest picture possible of a rapidly changing industry,” Flores says. TH

Brendon Shank is a freelance writer based in Philadelphia.

SHM Adopts Strict Code for Industry Relations

A long with nearly 20 other organizations, SHM has adopted the Code for Industry Relations (http://cmss.org/) established by the Council on Medical Specialty Societies (CMSS). In an era of digital communication, SHM has created a Web area (www.hospital medicine.org/industry) to continuously update its policies toward industry, display its current partnerships, and disclose the potential conflicts of interest of its board or directors, editors, and CEO.

The message from SHM leadership: SHM is committed to being a leader in an era of transparency and disclosure.

Transparency serves an important role for medical specialty societies, says Norman B. Kahn Jr., MD, executive vice president and CEO of CMSS. The code developed by CMSS and adopted by SHM “assures in interactions with industry that the patients’ needs come first,” Dr. Kahn says. “The bottom line is that this is all about protecting the independence of societies from industry without abrogating the relationship.”

From its early days, SHM has been aware of the need to balance the responsibilities of speaking for HM and the need to disclose any potential conflicts of interests. In 2000, SHM developed its Principles of Organizational Relationships (www.hospitalmedicine.org/OrgRelationships), which have guided the society’s efforts.

The principles call for a clear, bright line that is a barrier between the support of a partner and SHM’s control of content. Among other activities, SHM has applied those principles to meetings and educational initiatives, quality-improvement (QI) projects, and publications.

The principles also were the foundation for the tough conflict-of-interest policies (www.hospital medicine.org/interestpolicies) the board approved in 2005.

Over the last decade, as HM has grown, national hospitalist leaders have become the experts on a wide range of topics and are asked to speak, write, or advise government agencies, foundations, and industry.

As SHM has developed its resources to help hospitalists improve glycemic control, reduce unnecessary DVTs and PEs, and improve the transitions of care, SHM has engaged in partnerships with government agencies, foundations, and industry as well.

“SHM’s leadership recognizes that it has a fiduciary responsibility to its members—a responsibility to provide expert direction, and necessary resources, to enable the hospitalist to ensure the best possible care of his or her patients, and to advance the quality of the hospital system,” says SHM President Jeff Wiese, MD, SFHM. “But SHM cannot do this alone, and when external partnerships are established, it is the organization’s responsibility to enter into these partnerships judiciously, and to be fully transparent to the membership with respect to the arrangements of these partnerships.

“We are confident that no other organization has a more robust disclosure policy than SHM.”

Today’s Nominations, Tomorrow’s Leaders

HM leaders aren’t born that way—they’re nominated.

SHM is accepting nominations for its board election; new members will take office in May at HM11 in Dallas.

The nomination deadline is Oct. 31. Online ballots will be available to all SHM members in late 2010. The results of the election will be announced online in early 2011.

Nominees must be SHM members in good standing. SHM members may nominate themselves or be nominated by another SHM member. Nominations must include a letter of nomination, a one-page CV, and a recent photo.

The nomination committee considers candidates based on length of SHM membership, activity as a hospitalist and SHM member, the prominence of the candidate within the specialty, and a number of other factors.

Board members serve a three-year term and normally serve on one or more committees.

“Participating in SHM’s leadership is one of the best ways to help guide the future of hospital medicine,” says Larry Wellikson, MD, SFHM, CEO of SHM. “That begins by submitting a board nomination to SHM this year.”

Chapter Updates

Chicago

The Chicago chapter met May 19 at Sullivan’s Steakhouse. Twenty-five hospitalists from the Chicago area, including hospitalists at Loyola Hospital, Lutheran General Hospital, Illinois Masonic Medical Center, Trinity Hospital, Silver Cross, and Evanston Hospital, as well as hospitalist groups like Cogent and Vista, attended the meeting.

Dr. Robin Ross of Season Hospice and Palliative Care, which sponsored the event, presented clinical pearls for end-of-life care for the busy hospitalist. The meeting also featured a town-hall discussion, with topics relevant to everyday hospitalist practice—coding, consultations, and the use of observation units. Notification of chapter elections were summated to all chapter members in July and August.

Harrisburg/South Central Pennsylvania

Thirty hospitalists representing six HM programs attended the Harrisburg/South Central Pennsylvania chapter of SHM June 9 at Passage to India in Harrisburg.

Eric Kupersmith, MD, SFHM, division head of the hospitalist program at Cooper University Hospital in Camden, N.J., led an open discussion regarding “Transition of Care and the Hospitalist’s Role.” Chapter members had the opportunity to discuss how each individual program actively seeks to decrease readmission rates. Discharge-planning specifics generated group discussion, and a handful of hospitalists offered testimonials about what is working in their practices.

The meeting was sponsored by Merck.

A BOOST for all seasons: Discharge improvement resources now available year round

When Project BOOST (Better Outcomes for Older Adults through Safer Transitions), SHM’s groundbreaking program to reduce readmissions, first began in 2008, hospital sites applied to participate in a yearlong program of one-on-one mentorships, regular sessions to share best practices, and a resource toolkit.

Since then, Project BOOST has grown and evolved. Some BOOST iterations now include third parties, such as the University of Michigan, Blue Cross/Blue Shield of Michigan, and the California HealthCare Foundation. SHM also recently introduced a nationwide, tuition-based version of the BOOST initiative.

Now, SHM is announcing that new resources are available to all hospitals, regardless of their participation in Project BOOST, all year. Some resources were previously available only to Project BOOST participants; others are brand-new materials available to any hospital or hospitalist trying to reduce unplanned readmissions to their hospital.

“No matter where you are in the hospital, you have an opportunity to improve discharge,” says Tina Budnitz, MPH, senior advisor for quality improvement. “The response to Project BOOST has been overwhelmingly positive. That’s why we’re so excited to make these new materials available to anyone responsible for lowering readmissions.”

Individuals can download the Project BOOST implementation course, a new training program specifically designed to help nurses use the proven “teachback” method, and the Project BOOST patient PASS form.

Budnitz and Project BOOST organizers also plan to launch supplemental products for self-implementers, including access to Project BOOST e-mail listservs, data centers, and webinars.

Prepare Now for Flu Season

With most of the country still enjoying warm weather, it’s easy to forget that flu season is right around the corner. Hospitals can either be part of the solution—or part of the problem.

Compared to friends and family outside of the hospital, patients in the hospital are especially at risk. The chances of contracting the flu are higher, given decreased immune responses and increased proximity to caregivers and other potentially infected patients. Plus, the impact of the flu on healthcare providers can be significantly more severe.

By now, most hospitals have protocols for preparing for flu season and isolating infected patients, says Danielle Scheurer, MD, MSc, SFHM, assistant professor of medicine at Harvard Medical School in Boston and director of general medical service at Brigham and Women’s Hospitalist Service. Hospitalists play a special role within those protocols, she adds.

“Hospitalists can be instrumental in preventing the spread of flu within the hospital by having a low threshold for diagnostic testing of patients, immediate isolation of those patients, and strict adherence to infection-control measures in those with suspected influenza,” Dr. Scheurer says.

Dr. Scheurer also emphasizes the fact that flu prevention doesn’t end with better clinical practices. Patient education is key.

“Hospitalists can be vital in educating patients about how to avoid symptomatic contacts,” she says, “and how to advocate for themselves in insisting that all care providers use strict handwashing protocols to avoid transmitting influenza among patients.” TH

In This Edition

Literature at a Glance

A guide to this month’s studies

• Antibiotics after drainage of uncomplicated skin abscesses
• Clopidogrel vs. combined aspirin-dipyridamole for acute ischemic stroke
• BNP-guided therapy in chronic heart failure outpatients
• Cognitive decline and dementia after hospitalization
• Clopidogrel delays up risks for DES implantation patients
• Clinical score identifies prolonged length of stay
• Time to therapy reduces mortality in sepsis patients
• PEEP associated with lower mortality for ARDS patients

Antibiotics Might Be Unnecessary after Drainage of Uncomplicated Skin Abscesses

Clinical question: Does trimethoprim/sulfamethoxazole (TMP/SMX) treatment after drainage of a skin abscess reduce treatment failure at seven days or development of new lesions at 30 days?

Background: Community ac-quired methicillin-resistant Staphylococcus aureus (MRSA) skin abscesses are increasing in frequency. The benefit of antibiotic treatment after incision and drainage is not clear, as there is a high cure rate without antibiotics.

Study design: Multicenter, double-blinded, randomized, placebo-controlled trial.

Setting: Four military EDs treating civilians and military patients.

Synopsis: The study enrolled a convenience sample of 220 patients, each of whom presented to EDs with uncomplicated skin abscesses from November 2007 to June 2009. Abscesses were drained in the ED, then patients were randomized to either placebo or to TMP/SMX (two DS tablets twice daily) for seven days. Re-evaluation for wound checks occurred at two days and seven days.

Treatment failure at seven days, defined as worsening infection, new lesions, or absence of clinical improvement, occurred in 26% of placebo patients and 17% of patients in the treatment arm, a nonsignificant difference (P=0.12). Fewer patients in the treatment arm had new lesions at 30 days (28% vs. 9%, P=0.02). MRSA was cultured from 53% of patients overall; all samples were sensitive to TMP/SMX.

The study was limited by the fact that only 69% of patients were evaluated at 30 days.

Bottom line: TMP/SMX treatment of uncomplicated skin abscess after drainage in EDs does not decrease treatment failure at seven days, but might decrease the development of new lesions.

Citation: Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection [published online ahead of print March 29, 2010]. Ann Emerg Med. doi:10.1016/j.annemerg med.2010.03.002.

Clopidogrel and Combined Aspirin-Dipyridamole Have Similar Safety and Efficacy Profiles for Acute Ischemic Stroke

Clinical question: What is the efficacy and safety of combined aspirin and extended-release dipyridamole (Asp/ER-DP) compared to clopidogrel in patients with acute ischemic stroke?

Background: Long-term antiplatelet therapy is effective at reducing recurrence after ischemic stroke. However, the relative safety and efficacy of Asp/ER-DP or clopidogrel is not known in patients with acute ischemic stroke.

Study design: Randomized, controlled trial.

Setting: A multicenter trial involving 695 sites in 35 countries.

Synopsis: This post-hoc subgroup analysis of the PRoFESS (Prevention Regimen for Effectively Avoiding Second Strokes) trial assessed the relative safety and efficacy of Asp/ER-DP versus clopidogrel administered within 72 hours of stroke onset in 1,360 patients. The primary endpoint was functional outcome at 30 days.

Secondary outcomes included symptomatic hemorrhagic transformation of the infarct, cerebral edema, recurrent stroke, myocardial infarction (MI), composite vascular events (combination of nonfatal stroke, nonfatal MI, and vascular death), death, cognition, bleeding, and serious adverse events studied at seven, 30, and 90 days.

Combined death or dependency did not differ between treatment groups. Nonsignificant trends to reduced recurrence and vascular events were present with Asp/ER-DP. Rates of death, major bleeding, and serious adverse events did not differ between treatment groups.

Bottom line: Either clopidogrel or combined aspirin and extended-release dipyridamole can be used to treat acute ischemic stroke, with similar outcomes and safety profiles.

Citation: Bath PM, Cotton D, Martin RH, et al. Effect of combined aspirin and extended-release dipyridamole versus clopidogrel on functional outcome and recurrence in acute, mild ischemic stroke: PRoFESS subgroup analysis. Stroke. 2010;41(4):732-738.

BNP-Guided Therapy Reduces All-Cause Mortality in Outpatients with Chronic Heart Failure

Clinical question: Is there a clinical benefit in using B-type natriuretic peptide (BNP) to guide adjustment of proven medications in chronic heart failure?

Background: BNP is secreted by the heart in response to increased volume. It has been shown to be useful in the diagnosis of decompensated heart failure, and it can be decreased by treatment with proven heart failure medications. It is unclear if this effect provides clinical benefit on mortality and hospitalization.

Study design: Meta-analysis of prospective randomized controlled trials.

Setting: Eight studies involving 1,726 patients, published internationally from 2005-2009.

Synopsis: Study sizes ranged from 41 to 499 patients, with three- to 24-month follow-up. Patients had New York Heart Association (NYHA) class II or greater heart failure, with ejection fractions <50%.

All-cause mortality was significantly lower in BNP-guided therapy compared with clinical-guided therapy (RR=0.76; 95% CI, 0.63-0.91; P=0.003), specifically in patients younger than 75 years old (RR=0.52; 95% CI, 0.33-0.82; P=0.005).

A proposed mechanism for this result was a statistically significant increase in adjustment of most heart failure medications for BNP-guided therapy compared with clinical-guided therapy (75% vs. 58%, P<0.001 in diuretics; 49.6% vs. 30.9%, P<0.001 in ACE inhibitors or Angiotensin II receptor blockers (ARBs); and 51.1% vs. 41.6%, P=0.02 in beta-blockers) and a higher percentage reaching target doses in the BNP-guided therapy group. However, there was no significant decrease in all-cause hospitalization or survival free of hospitalization.

The study limitations include: Hospitalization for heart failure was not meta-analyzed, the pooled data were weighted toward one study, and BNP-guided titration parameters varied across studies.

Bottom line: BNP-guided therapy reduces all-cause mortality in chronic heart failure patients younger than 75 years old, but not all-cause hospitalization or survival free of hospitalization.

Citation: Porapakkham P, Porapakkham P, Zimmet H, Billah B, Krum H. B-type natriuretic peptide-guided heart failure therapy: A meta-analysis. Arch Intern Med. 2010;170(6):507-514.

Hospitalization Is Associated with Cognitive Decline and Subsequent Risk for Dementia in the Elderly

Clinical question: Is critical illness in patients 65 and older associated with long-term cognitive impairment, and does it affect the incidence of dementia?

Background: There is literature suggesting that survivors of critical illness suffer long-term cognitive impairment, but premorbid measures of cognitive function have not been researched. No studies have evaluated the risk of incident dementia among this patient population.

Study design: Prospective cohort study.

Setting: Group Health Cooperative in Seattle.

Synopsis: This study analyzed data from 2,929 community-dwelling adults older than 65 without baseline dementia. From 1994 to 2007, the individuals were screened with the Cognitive Abilities Screening Instrument (CASI) at follow-up visits every two years. CASI scores lower than 86 (out of 100) led to an examination for dementia; the diagnosis of dementia was an outcome measure. Scores were adjusted for baseline cognitive scores, age, and other risk factors.

For patients following acute-care hospitalization, adjusted CASI scores were 1.01 points lower on average than for those not hospitalized. For patients following critical-illness hospitalization, scores were 2.14 points lower. The dementia rate was 14.6 cases per 1,000 person-years among patients not hospitalized, and 33.6 among those admitted for noncritical illness.

As suspected, hospitalization might be a marker for cognitive decline in the elderly after adjusting for premorbid CASI scores and comorbid illness. Some factors in acute illness—and moreso in critical illness—might be causally related to cognitive decline.

Bottom line: In elderly patients without dementia at baseline, hospitalization for acute care and critical illness increases the likelihood of cognitive decline compared with patients who were not hospitalized. Only noncritical-illness hospitalization was not associated with the development of dementia.

Citation: Ehlenbach WJ, Hough CL, Crane PK, et al. Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA. 2010;303(8): 763-770.

Increased Risk of Death and Myocardial Infarction in Patients Who Delay Filling Clopidogrel Prescription after Drug-Eluting Stent Implantation

Clinical question: Is there an increased risk of death or myocardial infarction (MI) in patients with recent drug-eluting stent (DES) implantation who delayed filling their clopidogrel prescription compared with those who filled their prescription on the day of hospital discharge?

Background: Filling an initial prescription of clopidogrel on the day of discharge is important after DES implantation, as prior studies suggest that lack of thienopyridine therapy is a risk factor for early stent thrombosis.

Study design: Retrospective cohort study.

Setting: Three large, integrated healthcare systems.

Synopsis: The cohort included 7,042 patients discharged after DES implantation. Filling of a clopidogrel prescription was based on pharmacy dispensing data. Primary analysis divided patients based on whether they filled the prescription on the day of discharge or any time after discharge. Secondary analysis further characterized delays as >1 day, >3 days, or >5 days after discharge.

One in 6 patients delayed filling the initial prescription. Patients with any degree of delay had significantly higher death and MI rates during follow-up (14.2% vs. 7.9%, P<0.001), as well as an increased risk of death/MI (hazard ratio 1.53; 95% CI, 1.25-1.87). Factors associated with a delay in filling clopidogrel included older age, prior MI, diabetes, renal dysfunction, prior revascularization, cardiogenic shock, in-hospital bleeding, and use of clopidogrel upon admission.

The study was limited in that data were based on pharmacy records, and that patients might have received medication at discharge or outside the healthcare system.

Bottom line: The delay in filling a clopidogrel prescription is associated with an increased risk of death and MI in patients with recent DES implantation.

Citation: Ho PM, Tsai TT, Maddox TM, et al. Delays in filling clopidogrel prescription after hospital discharge and adverse outcomes after drug-eluting stent implantation: implications for transitions of care. Circ Cardiovasc Qual Outcomes. 2010;3(3):261-266.

Predicting Length of Stay after Stroke

Clinical question: Does a clinical score accurately predict prolonged length of stay after stroke?

Background: Stroke is a costly health problem, and length of stay is the most prominent factor contributing to the high costs. The factors leading to prolonged length of stay are varied, and there are no established tools to predict length of stay.

Study design: Prospective cohort study.

Setting: All 28 Israeli hospitals that admit stroke patients.

Synopsis: All patients admitted to Israeli hospitals during established two-month periods in 2004 (1,700 patients) and 2007 (1,648 patients) were included in the National Acute Stroke Israeli Survey (NASIS), and served as the derivation and validation cohort for development of a Prolonged Length of Stay (PLOS) score.

Using the 2004 data, investigators identified stroke severity using the National Institutes of Health Stroke Scale (NIHSS), history of congestive heart failure (CHF), history of atrial fibrillation, decreased level of consciousness on presentation, and intracerebral hemorrhage (as opposed to ischemic stroke) as predictors of prolonged length of stay. Four of these factors were expressed as dichotomous variables, whereas the stroke severity by NIHSS class was incorporated as a range; all were incorporated into a PLOS score.

Higher PLOS score correlated with longer length of stay. In the derivation cohort, 22% of patients with a PLOS score of 0 had a prolonged length of stay, whereas 85% of patients with PLOS scores of 6 or 7 had a prolonged length of stay. In the validation cohort, the corresponding figures were 19% and 72%.

Bottom line: Use of a simple score can predict risk of prolonged length of stay after stroke.

Citation: Koton S, Bornstein NM, Tsabari R, Tanne D, NASIS Investigators. Derivation and validation of the prolonged length of stay score in acute stroke patients. Neurology. 2010;74(19);1511-1516.

Earlier Administration of Appropriate Antimicrobials Decreases Mortality in Patients with Severe Sepsis and Septic Shock

Clinical question: Is the timing of antimicrobial administration an important determinant of survival in patients diagnosed with severe sepsis and septic shock?

Background: Severe sepsis and septic shock are associated with a 25% to 50% mortality rate. Early goal-directed therapy has been shown to increase survival in these patients. Antimicrobial treatment is a mainstay of this therapy, but the most effective timing of this treatment remains unclear.

Study design: Retrospective, single-center cohort study.

Setting: ED at an academic tertiary-care center.

Synopsis: Two hundred sixty-one patients in the ED in 2005-2006 presenting with severe sepsis or septic shock were enrolled in the hospital’s early goal-directed therapy (EGDT) algorithm, either at triage or later during their ED stay. Labs showed 56.7% of patients were culture-positive, with the most common sources being respiratory (30.6%), genitourinary (22.8%), and gastrointestinal (19.7%).

All patients received antibiotics and were stratified in one-hour intervals by the following categories: time from triage to antibiotics; time from qualification for EGDT to antibiotics; time from triage to appropriate antibiotics; and time from qualification for EGDT to appropriate antibiotics.

Total in-hospital mortality was 31% (35.1% for culture-positive patients vs. 25.7% for culture-negative patients, P=0.11). A significant decrease in mortality was only found when appropriate antibiotics were administered within one hour of triage, or within one hour of qualification for EGDT (OR=0.30; 95% CI, 0.11-0.83; P=0.02, and OR=0.50; 95% CI, 0.27-0.92; P=0.03, respectively).

Study limitations included the single-center site and small sample size.

Bottom line: In patients with severe sepsis and septic shock, initiating appropriate antimicrobial therapy within one hour of triage or entry into goal-directed therapy significantly reduces mortality.

Citation: Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045-1053.

Treatment with Higher Levels of Positive End-Expiratory Pressure Has Limited Affect on Hospital Survival

Clinical question: Is treatment with higher versus lower levels of positive end-expiratory pressure (PEEP) associated with improved hospital survival?

Background: In the management of patients with acute lung injury or acute respiratory distress syndrome (ARDS), a fundamental goal is to protect the lungs from ventilation-induced injury, but the optimal PEEP level has not been established.

Study design: Systematic review and meta-analysis.

Setting: N/A.

Synopsis: Three randomized-controlled trials eligible for this review included 2,299 critically ill adults with acute lung injury, as defined by the American-European Consensus Conference. The meta-analysis compared higher and lower PEEP levels with a mean difference of at least 3 cm H2O, incorporated a target tidal volume of less than 8 mL/kg of predicted body weight in both ventilation strategies, and provided patient follow-up until death or for at least 20 days.

This review demonstrated no statistically significant difference in hospital mortality between the groups. However, in patients with ARDS, higher levels of PEEP were associated with a relative reduction in mortality of 10%. This is supported by a recent cohort study in patients with acute lung injury or ARDS, which showed that the effect of PEEP on lung recruitment was associated with the proportion of potentially recruitable lung, as determined by computed tomography.

Since patients with ARDS have more pulmonary edema than those with acute lung injury without ARDS, the former have greater recruitability, and thus might benefit more from higher levels of PEEP.

Bottom line: Higher levels of PEEP might be associated with lower hospital mortality in patients with ARDS, but such a benefit is unlikely in patients with less severe lung injuries, and could actually be harmful.

Citation: Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-873. TH

PEDIATRIC HM LITERATURE

By Mark Shen, MD

High-Performing State Healthcare Systems Have Higher Children’s Hospital Readmission Rates

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

Clinical question: What is the relationship between a hospital’s readmission rate and performance of the surrounding healthcare system?

Background: Hospital readmission rates might be influenced by factors related to the specific patient and hospital care, as well as such external factors as the performance of the surrounding healthcare system. Traditionally, readmission rates are thought to most accurately reflect the quality of hospital care; however, the relative contributions of patient, hospital, and external factors to hospital readmission rates have not been delineated.

Study design: Multilevel cohort study.

Setting: Thirty-nine children’s hospitals in 24 states.

Synopsis: The Pediatric Health Information System (PHIS) administrative database was sampled for the 2005 calendar year to review discharges from 39 participating children’s hospitals. Patients 2 to 18 years were included, and out of a total of 198,422 patients, 32,196 were readmitted within 365 days of discharge.

The Commonwealth Fund’s 2008 State Variations in Child Health System Performance ranking was used to define the state-level health system performance. Higher readmission rates correlated with higher-ranked state child health systems after adjustment for patient-level characteristics.

This surprising result calls into question the often-assumed link between hospital readmission rates and poor systems of care. However, despite the strength of its large sample size, this study’s macro-level view of the healthcare system might be too crude to truly define the external factors that play a role in readmission. State-level healthcare rankings might not accurately reflect the healthcare ecosystem surrounding each children’s hospital, and children’s hospitals do not care for the majority of children in the U.S.

Bottom line: Children’s hospital readmissions correlate with higher state child health system performance.

Citation: Feudtner C, Pati S, Goodman DM, et al. State-level child health system performance and the likelihood of readmission to children’s hospitals. J Pediatr. 2010;157(1):98-102.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Antibiotics after drainage of uncomplicated skin abscesses
• Clopidogrel vs. combined aspirin-dipyridamole for acute ischemic stroke
• BNP-guided therapy in chronic heart failure outpatients
• Cognitive decline and dementia after hospitalization
• Clopidogrel delays up risks for DES implantation patients
• Clinical score identifies prolonged length of stay
• Time to therapy reduces mortality in sepsis patients
• PEEP associated with lower mortality for ARDS patients

Antibiotics Might Be Unnecessary after Drainage of Uncomplicated Skin Abscesses

Clinical question: Does trimethoprim/sulfamethoxazole (TMP/SMX) treatment after drainage of a skin abscess reduce treatment failure at seven days or development of new lesions at 30 days?

Background: Community ac-quired methicillin-resistant Staphylococcus aureus (MRSA) skin abscesses are increasing in frequency. The benefit of antibiotic treatment after incision and drainage is not clear, as there is a high cure rate without antibiotics.

Study design: Multicenter, double-blinded, randomized, placebo-controlled trial.

Setting: Four military EDs treating civilians and military patients.

Synopsis: The study enrolled a convenience sample of 220 patients, each of whom presented to EDs with uncomplicated skin abscesses from November 2007 to June 2009. Abscesses were drained in the ED, then patients were randomized to either placebo or to TMP/SMX (two DS tablets twice daily) for seven days. Re-evaluation for wound checks occurred at two days and seven days.

Treatment failure at seven days, defined as worsening infection, new lesions, or absence of clinical improvement, occurred in 26% of placebo patients and 17% of patients in the treatment arm, a nonsignificant difference (P=0.12). Fewer patients in the treatment arm had new lesions at 30 days (28% vs. 9%, P=0.02). MRSA was cultured from 53% of patients overall; all samples were sensitive to TMP/SMX.

The study was limited by the fact that only 69% of patients were evaluated at 30 days.

Bottom line: TMP/SMX treatment of uncomplicated skin abscess after drainage in EDs does not decrease treatment failure at seven days, but might decrease the development of new lesions.

Citation: Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection [published online ahead of print March 29, 2010]. Ann Emerg Med. doi:10.1016/j.annemerg med.2010.03.002.

Clopidogrel and Combined Aspirin-Dipyridamole Have Similar Safety and Efficacy Profiles for Acute Ischemic Stroke

Clinical question: What is the efficacy and safety of combined aspirin and extended-release dipyridamole (Asp/ER-DP) compared to clopidogrel in patients with acute ischemic stroke?

Background: Long-term antiplatelet therapy is effective at reducing recurrence after ischemic stroke. However, the relative safety and efficacy of Asp/ER-DP or clopidogrel is not known in patients with acute ischemic stroke.

Study design: Randomized, controlled trial.

Setting: A multicenter trial involving 695 sites in 35 countries.

Synopsis: This post-hoc subgroup analysis of the PRoFESS (Prevention Regimen for Effectively Avoiding Second Strokes) trial assessed the relative safety and efficacy of Asp/ER-DP versus clopidogrel administered within 72 hours of stroke onset in 1,360 patients. The primary endpoint was functional outcome at 30 days.

Secondary outcomes included symptomatic hemorrhagic transformation of the infarct, cerebral edema, recurrent stroke, myocardial infarction (MI), composite vascular events (combination of nonfatal stroke, nonfatal MI, and vascular death), death, cognition, bleeding, and serious adverse events studied at seven, 30, and 90 days.

Combined death or dependency did not differ between treatment groups. Nonsignificant trends to reduced recurrence and vascular events were present with Asp/ER-DP. Rates of death, major bleeding, and serious adverse events did not differ between treatment groups.

Bottom line: Either clopidogrel or combined aspirin and extended-release dipyridamole can be used to treat acute ischemic stroke, with similar outcomes and safety profiles.

Citation: Bath PM, Cotton D, Martin RH, et al. Effect of combined aspirin and extended-release dipyridamole versus clopidogrel on functional outcome and recurrence in acute, mild ischemic stroke: PRoFESS subgroup analysis. Stroke. 2010;41(4):732-738.

BNP-Guided Therapy Reduces All-Cause Mortality in Outpatients with Chronic Heart Failure

Clinical question: Is there a clinical benefit in using B-type natriuretic peptide (BNP) to guide adjustment of proven medications in chronic heart failure?

Background: BNP is secreted by the heart in response to increased volume. It has been shown to be useful in the diagnosis of decompensated heart failure, and it can be decreased by treatment with proven heart failure medications. It is unclear if this effect provides clinical benefit on mortality and hospitalization.

Study design: Meta-analysis of prospective randomized controlled trials.

Setting: Eight studies involving 1,726 patients, published internationally from 2005-2009.

Synopsis: Study sizes ranged from 41 to 499 patients, with three- to 24-month follow-up. Patients had New York Heart Association (NYHA) class II or greater heart failure, with ejection fractions <50%.

All-cause mortality was significantly lower in BNP-guided therapy compared with clinical-guided therapy (RR=0.76; 95% CI, 0.63-0.91; P=0.003), specifically in patients younger than 75 years old (RR=0.52; 95% CI, 0.33-0.82; P=0.005).

A proposed mechanism for this result was a statistically significant increase in adjustment of most heart failure medications for BNP-guided therapy compared with clinical-guided therapy (75% vs. 58%, P<0.001 in diuretics; 49.6% vs. 30.9%, P<0.001 in ACE inhibitors or Angiotensin II receptor blockers (ARBs); and 51.1% vs. 41.6%, P=0.02 in beta-blockers) and a higher percentage reaching target doses in the BNP-guided therapy group. However, there was no significant decrease in all-cause hospitalization or survival free of hospitalization.

The study limitations include: Hospitalization for heart failure was not meta-analyzed, the pooled data were weighted toward one study, and BNP-guided titration parameters varied across studies.

Bottom line: BNP-guided therapy reduces all-cause mortality in chronic heart failure patients younger than 75 years old, but not all-cause hospitalization or survival free of hospitalization.

Citation: Porapakkham P, Porapakkham P, Zimmet H, Billah B, Krum H. B-type natriuretic peptide-guided heart failure therapy: A meta-analysis. Arch Intern Med. 2010;170(6):507-514.

Hospitalization Is Associated with Cognitive Decline and Subsequent Risk for Dementia in the Elderly

Clinical question: Is critical illness in patients 65 and older associated with long-term cognitive impairment, and does it affect the incidence of dementia?

Background: There is literature suggesting that survivors of critical illness suffer long-term cognitive impairment, but premorbid measures of cognitive function have not been researched. No studies have evaluated the risk of incident dementia among this patient population.

Study design: Prospective cohort study.

Setting: Group Health Cooperative in Seattle.

Synopsis: This study analyzed data from 2,929 community-dwelling adults older than 65 without baseline dementia. From 1994 to 2007, the individuals were screened with the Cognitive Abilities Screening Instrument (CASI) at follow-up visits every two years. CASI scores lower than 86 (out of 100) led to an examination for dementia; the diagnosis of dementia was an outcome measure. Scores were adjusted for baseline cognitive scores, age, and other risk factors.

For patients following acute-care hospitalization, adjusted CASI scores were 1.01 points lower on average than for those not hospitalized. For patients following critical-illness hospitalization, scores were 2.14 points lower. The dementia rate was 14.6 cases per 1,000 person-years among patients not hospitalized, and 33.6 among those admitted for noncritical illness.

As suspected, hospitalization might be a marker for cognitive decline in the elderly after adjusting for premorbid CASI scores and comorbid illness. Some factors in acute illness—and moreso in critical illness—might be causally related to cognitive decline.

Bottom line: In elderly patients without dementia at baseline, hospitalization for acute care and critical illness increases the likelihood of cognitive decline compared with patients who were not hospitalized. Only noncritical-illness hospitalization was not associated with the development of dementia.

Citation: Ehlenbach WJ, Hough CL, Crane PK, et al. Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA. 2010;303(8): 763-770.

Increased Risk of Death and Myocardial Infarction in Patients Who Delay Filling Clopidogrel Prescription after Drug-Eluting Stent Implantation

Clinical question: Is there an increased risk of death or myocardial infarction (MI) in patients with recent drug-eluting stent (DES) implantation who delayed filling their clopidogrel prescription compared with those who filled their prescription on the day of hospital discharge?

Background: Filling an initial prescription of clopidogrel on the day of discharge is important after DES implantation, as prior studies suggest that lack of thienopyridine therapy is a risk factor for early stent thrombosis.

Study design: Retrospective cohort study.

Setting: Three large, integrated healthcare systems.

Synopsis: The cohort included 7,042 patients discharged after DES implantation. Filling of a clopidogrel prescription was based on pharmacy dispensing data. Primary analysis divided patients based on whether they filled the prescription on the day of discharge or any time after discharge. Secondary analysis further characterized delays as >1 day, >3 days, or >5 days after discharge.

One in 6 patients delayed filling the initial prescription. Patients with any degree of delay had significantly higher death and MI rates during follow-up (14.2% vs. 7.9%, P<0.001), as well as an increased risk of death/MI (hazard ratio 1.53; 95% CI, 1.25-1.87). Factors associated with a delay in filling clopidogrel included older age, prior MI, diabetes, renal dysfunction, prior revascularization, cardiogenic shock, in-hospital bleeding, and use of clopidogrel upon admission.

The study was limited in that data were based on pharmacy records, and that patients might have received medication at discharge or outside the healthcare system.

Bottom line: The delay in filling a clopidogrel prescription is associated with an increased risk of death and MI in patients with recent DES implantation.

Citation: Ho PM, Tsai TT, Maddox TM, et al. Delays in filling clopidogrel prescription after hospital discharge and adverse outcomes after drug-eluting stent implantation: implications for transitions of care. Circ Cardiovasc Qual Outcomes. 2010;3(3):261-266.

Predicting Length of Stay after Stroke

Clinical question: Does a clinical score accurately predict prolonged length of stay after stroke?

Background: Stroke is a costly health problem, and length of stay is the most prominent factor contributing to the high costs. The factors leading to prolonged length of stay are varied, and there are no established tools to predict length of stay.

Study design: Prospective cohort study.

Setting: All 28 Israeli hospitals that admit stroke patients.

Synopsis: All patients admitted to Israeli hospitals during established two-month periods in 2004 (1,700 patients) and 2007 (1,648 patients) were included in the National Acute Stroke Israeli Survey (NASIS), and served as the derivation and validation cohort for development of a Prolonged Length of Stay (PLOS) score.

Using the 2004 data, investigators identified stroke severity using the National Institutes of Health Stroke Scale (NIHSS), history of congestive heart failure (CHF), history of atrial fibrillation, decreased level of consciousness on presentation, and intracerebral hemorrhage (as opposed to ischemic stroke) as predictors of prolonged length of stay. Four of these factors were expressed as dichotomous variables, whereas the stroke severity by NIHSS class was incorporated as a range; all were incorporated into a PLOS score.

Higher PLOS score correlated with longer length of stay. In the derivation cohort, 22% of patients with a PLOS score of 0 had a prolonged length of stay, whereas 85% of patients with PLOS scores of 6 or 7 had a prolonged length of stay. In the validation cohort, the corresponding figures were 19% and 72%.

Bottom line: Use of a simple score can predict risk of prolonged length of stay after stroke.

Citation: Koton S, Bornstein NM, Tsabari R, Tanne D, NASIS Investigators. Derivation and validation of the prolonged length of stay score in acute stroke patients. Neurology. 2010;74(19);1511-1516.

Earlier Administration of Appropriate Antimicrobials Decreases Mortality in Patients with Severe Sepsis and Septic Shock

Clinical question: Is the timing of antimicrobial administration an important determinant of survival in patients diagnosed with severe sepsis and septic shock?

Background: Severe sepsis and septic shock are associated with a 25% to 50% mortality rate. Early goal-directed therapy has been shown to increase survival in these patients. Antimicrobial treatment is a mainstay of this therapy, but the most effective timing of this treatment remains unclear.

Study design: Retrospective, single-center cohort study.

Setting: ED at an academic tertiary-care center.

Synopsis: Two hundred sixty-one patients in the ED in 2005-2006 presenting with severe sepsis or septic shock were enrolled in the hospital’s early goal-directed therapy (EGDT) algorithm, either at triage or later during their ED stay. Labs showed 56.7% of patients were culture-positive, with the most common sources being respiratory (30.6%), genitourinary (22.8%), and gastrointestinal (19.7%).

All patients received antibiotics and were stratified in one-hour intervals by the following categories: time from triage to antibiotics; time from qualification for EGDT to antibiotics; time from triage to appropriate antibiotics; and time from qualification for EGDT to appropriate antibiotics.

Total in-hospital mortality was 31% (35.1% for culture-positive patients vs. 25.7% for culture-negative patients, P=0.11). A significant decrease in mortality was only found when appropriate antibiotics were administered within one hour of triage, or within one hour of qualification for EGDT (OR=0.30; 95% CI, 0.11-0.83; P=0.02, and OR=0.50; 95% CI, 0.27-0.92; P=0.03, respectively).

Study limitations included the single-center site and small sample size.

Bottom line: In patients with severe sepsis and septic shock, initiating appropriate antimicrobial therapy within one hour of triage or entry into goal-directed therapy significantly reduces mortality.

Citation: Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045-1053.

Treatment with Higher Levels of Positive End-Expiratory Pressure Has Limited Affect on Hospital Survival

Clinical question: Is treatment with higher versus lower levels of positive end-expiratory pressure (PEEP) associated with improved hospital survival?

Background: In the management of patients with acute lung injury or acute respiratory distress syndrome (ARDS), a fundamental goal is to protect the lungs from ventilation-induced injury, but the optimal PEEP level has not been established.

Study design: Systematic review and meta-analysis.

Setting: N/A.

Synopsis: Three randomized-controlled trials eligible for this review included 2,299 critically ill adults with acute lung injury, as defined by the American-European Consensus Conference. The meta-analysis compared higher and lower PEEP levels with a mean difference of at least 3 cm H2O, incorporated a target tidal volume of less than 8 mL/kg of predicted body weight in both ventilation strategies, and provided patient follow-up until death or for at least 20 days.

This review demonstrated no statistically significant difference in hospital mortality between the groups. However, in patients with ARDS, higher levels of PEEP were associated with a relative reduction in mortality of 10%. This is supported by a recent cohort study in patients with acute lung injury or ARDS, which showed that the effect of PEEP on lung recruitment was associated with the proportion of potentially recruitable lung, as determined by computed tomography.

Since patients with ARDS have more pulmonary edema than those with acute lung injury without ARDS, the former have greater recruitability, and thus might benefit more from higher levels of PEEP.

Bottom line: Higher levels of PEEP might be associated with lower hospital mortality in patients with ARDS, but such a benefit is unlikely in patients with less severe lung injuries, and could actually be harmful.

Citation: Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-873. TH

PEDIATRIC HM LITERATURE

By Mark Shen, MD

High-Performing State Healthcare Systems Have Higher Children’s Hospital Readmission Rates

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

Clinical question: What is the relationship between a hospital’s readmission rate and performance of the surrounding healthcare system?

Background: Hospital readmission rates might be influenced by factors related to the specific patient and hospital care, as well as such external factors as the performance of the surrounding healthcare system. Traditionally, readmission rates are thought to most accurately reflect the quality of hospital care; however, the relative contributions of patient, hospital, and external factors to hospital readmission rates have not been delineated.

Study design: Multilevel cohort study.

Setting: Thirty-nine children’s hospitals in 24 states.

Synopsis: The Pediatric Health Information System (PHIS) administrative database was sampled for the 2005 calendar year to review discharges from 39 participating children’s hospitals. Patients 2 to 18 years were included, and out of a total of 198,422 patients, 32,196 were readmitted within 365 days of discharge.

The Commonwealth Fund’s 2008 State Variations in Child Health System Performance ranking was used to define the state-level health system performance. Higher readmission rates correlated with higher-ranked state child health systems after adjustment for patient-level characteristics.

This surprising result calls into question the often-assumed link between hospital readmission rates and poor systems of care. However, despite the strength of its large sample size, this study’s macro-level view of the healthcare system might be too crude to truly define the external factors that play a role in readmission. State-level healthcare rankings might not accurately reflect the healthcare ecosystem surrounding each children’s hospital, and children’s hospitals do not care for the majority of children in the U.S.

Bottom line: Children’s hospital readmissions correlate with higher state child health system performance.

Citation: Feudtner C, Pati S, Goodman DM, et al. State-level child health system performance and the likelihood of readmission to children’s hospitals. J Pediatr. 2010;157(1):98-102.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Antibiotics after drainage of uncomplicated skin abscesses
• Clopidogrel vs. combined aspirin-dipyridamole for acute ischemic stroke
• BNP-guided therapy in chronic heart failure outpatients
• Cognitive decline and dementia after hospitalization
• Clopidogrel delays up risks for DES implantation patients
• Clinical score identifies prolonged length of stay
• Time to therapy reduces mortality in sepsis patients
• PEEP associated with lower mortality for ARDS patients

Antibiotics Might Be Unnecessary after Drainage of Uncomplicated Skin Abscesses

Clinical question: Does trimethoprim/sulfamethoxazole (TMP/SMX) treatment after drainage of a skin abscess reduce treatment failure at seven days or development of new lesions at 30 days?

Background: Community ac-quired methicillin-resistant Staphylococcus aureus (MRSA) skin abscesses are increasing in frequency. The benefit of antibiotic treatment after incision and drainage is not clear, as there is a high cure rate without antibiotics.

Study design: Multicenter, double-blinded, randomized, placebo-controlled trial.

Setting: Four military EDs treating civilians and military patients.

Synopsis: The study enrolled a convenience sample of 220 patients, each of whom presented to EDs with uncomplicated skin abscesses from November 2007 to June 2009. Abscesses were drained in the ED, then patients were randomized to either placebo or to TMP/SMX (two DS tablets twice daily) for seven days. Re-evaluation for wound checks occurred at two days and seven days.

Treatment failure at seven days, defined as worsening infection, new lesions, or absence of clinical improvement, occurred in 26% of placebo patients and 17% of patients in the treatment arm, a nonsignificant difference (P=0.12). Fewer patients in the treatment arm had new lesions at 30 days (28% vs. 9%, P=0.02). MRSA was cultured from 53% of patients overall; all samples were sensitive to TMP/SMX.

The study was limited by the fact that only 69% of patients were evaluated at 30 days.

Bottom line: TMP/SMX treatment of uncomplicated skin abscess after drainage in EDs does not decrease treatment failure at seven days, but might decrease the development of new lesions.

Citation: Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection [published online ahead of print March 29, 2010]. Ann Emerg Med. doi:10.1016/j.annemerg med.2010.03.002.

Clopidogrel and Combined Aspirin-Dipyridamole Have Similar Safety and Efficacy Profiles for Acute Ischemic Stroke

Clinical question: What is the efficacy and safety of combined aspirin and extended-release dipyridamole (Asp/ER-DP) compared to clopidogrel in patients with acute ischemic stroke?

Background: Long-term antiplatelet therapy is effective at reducing recurrence after ischemic stroke. However, the relative safety and efficacy of Asp/ER-DP or clopidogrel is not known in patients with acute ischemic stroke.

Study design: Randomized, controlled trial.

Setting: A multicenter trial involving 695 sites in 35 countries.

Synopsis: This post-hoc subgroup analysis of the PRoFESS (Prevention Regimen for Effectively Avoiding Second Strokes) trial assessed the relative safety and efficacy of Asp/ER-DP versus clopidogrel administered within 72 hours of stroke onset in 1,360 patients. The primary endpoint was functional outcome at 30 days.

Secondary outcomes included symptomatic hemorrhagic transformation of the infarct, cerebral edema, recurrent stroke, myocardial infarction (MI), composite vascular events (combination of nonfatal stroke, nonfatal MI, and vascular death), death, cognition, bleeding, and serious adverse events studied at seven, 30, and 90 days.

Combined death or dependency did not differ between treatment groups. Nonsignificant trends to reduced recurrence and vascular events were present with Asp/ER-DP. Rates of death, major bleeding, and serious adverse events did not differ between treatment groups.

Bottom line: Either clopidogrel or combined aspirin and extended-release dipyridamole can be used to treat acute ischemic stroke, with similar outcomes and safety profiles.

Citation: Bath PM, Cotton D, Martin RH, et al. Effect of combined aspirin and extended-release dipyridamole versus clopidogrel on functional outcome and recurrence in acute, mild ischemic stroke: PRoFESS subgroup analysis. Stroke. 2010;41(4):732-738.

BNP-Guided Therapy Reduces All-Cause Mortality in Outpatients with Chronic Heart Failure

Clinical question: Is there a clinical benefit in using B-type natriuretic peptide (BNP) to guide adjustment of proven medications in chronic heart failure?

Background: BNP is secreted by the heart in response to increased volume. It has been shown to be useful in the diagnosis of decompensated heart failure, and it can be decreased by treatment with proven heart failure medications. It is unclear if this effect provides clinical benefit on mortality and hospitalization.

Study design: Meta-analysis of prospective randomized controlled trials.

Setting: Eight studies involving 1,726 patients, published internationally from 2005-2009.

Synopsis: Study sizes ranged from 41 to 499 patients, with three- to 24-month follow-up. Patients had New York Heart Association (NYHA) class II or greater heart failure, with ejection fractions <50%.

All-cause mortality was significantly lower in BNP-guided therapy compared with clinical-guided therapy (RR=0.76; 95% CI, 0.63-0.91; P=0.003), specifically in patients younger than 75 years old (RR=0.52; 95% CI, 0.33-0.82; P=0.005).

A proposed mechanism for this result was a statistically significant increase in adjustment of most heart failure medications for BNP-guided therapy compared with clinical-guided therapy (75% vs. 58%, P<0.001 in diuretics; 49.6% vs. 30.9%, P<0.001 in ACE inhibitors or Angiotensin II receptor blockers (ARBs); and 51.1% vs. 41.6%, P=0.02 in beta-blockers) and a higher percentage reaching target doses in the BNP-guided therapy group. However, there was no significant decrease in all-cause hospitalization or survival free of hospitalization.

The study limitations include: Hospitalization for heart failure was not meta-analyzed, the pooled data were weighted toward one study, and BNP-guided titration parameters varied across studies.

Bottom line: BNP-guided therapy reduces all-cause mortality in chronic heart failure patients younger than 75 years old, but not all-cause hospitalization or survival free of hospitalization.

Citation: Porapakkham P, Porapakkham P, Zimmet H, Billah B, Krum H. B-type natriuretic peptide-guided heart failure therapy: A meta-analysis. Arch Intern Med. 2010;170(6):507-514.

Hospitalization Is Associated with Cognitive Decline and Subsequent Risk for Dementia in the Elderly

Clinical question: Is critical illness in patients 65 and older associated with long-term cognitive impairment, and does it affect the incidence of dementia?

Background: There is literature suggesting that survivors of critical illness suffer long-term cognitive impairment, but premorbid measures of cognitive function have not been researched. No studies have evaluated the risk of incident dementia among this patient population.

Study design: Prospective cohort study.

Setting: Group Health Cooperative in Seattle.

Synopsis: This study analyzed data from 2,929 community-dwelling adults older than 65 without baseline dementia. From 1994 to 2007, the individuals were screened with the Cognitive Abilities Screening Instrument (CASI) at follow-up visits every two years. CASI scores lower than 86 (out of 100) led to an examination for dementia; the diagnosis of dementia was an outcome measure. Scores were adjusted for baseline cognitive scores, age, and other risk factors.

For patients following acute-care hospitalization, adjusted CASI scores were 1.01 points lower on average than for those not hospitalized. For patients following critical-illness hospitalization, scores were 2.14 points lower. The dementia rate was 14.6 cases per 1,000 person-years among patients not hospitalized, and 33.6 among those admitted for noncritical illness.

As suspected, hospitalization might be a marker for cognitive decline in the elderly after adjusting for premorbid CASI scores and comorbid illness. Some factors in acute illness—and moreso in critical illness—might be causally related to cognitive decline.

Bottom line: In elderly patients without dementia at baseline, hospitalization for acute care and critical illness increases the likelihood of cognitive decline compared with patients who were not hospitalized. Only noncritical-illness hospitalization was not associated with the development of dementia.

Citation: Ehlenbach WJ, Hough CL, Crane PK, et al. Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA. 2010;303(8): 763-770.

Increased Risk of Death and Myocardial Infarction in Patients Who Delay Filling Clopidogrel Prescription after Drug-Eluting Stent Implantation

Clinical question: Is there an increased risk of death or myocardial infarction (MI) in patients with recent drug-eluting stent (DES) implantation who delayed filling their clopidogrel prescription compared with those who filled their prescription on the day of hospital discharge?

Background: Filling an initial prescription of clopidogrel on the day of discharge is important after DES implantation, as prior studies suggest that lack of thienopyridine therapy is a risk factor for early stent thrombosis.

Study design: Retrospective cohort study.

Setting: Three large, integrated healthcare systems.

Synopsis: The cohort included 7,042 patients discharged after DES implantation. Filling of a clopidogrel prescription was based on pharmacy dispensing data. Primary analysis divided patients based on whether they filled the prescription on the day of discharge or any time after discharge. Secondary analysis further characterized delays as >1 day, >3 days, or >5 days after discharge.

One in 6 patients delayed filling the initial prescription. Patients with any degree of delay had significantly higher death and MI rates during follow-up (14.2% vs. 7.9%, P<0.001), as well as an increased risk of death/MI (hazard ratio 1.53; 95% CI, 1.25-1.87). Factors associated with a delay in filling clopidogrel included older age, prior MI, diabetes, renal dysfunction, prior revascularization, cardiogenic shock, in-hospital bleeding, and use of clopidogrel upon admission.

The study was limited in that data were based on pharmacy records, and that patients might have received medication at discharge or outside the healthcare system.

Bottom line: The delay in filling a clopidogrel prescription is associated with an increased risk of death and MI in patients with recent DES implantation.

Citation: Ho PM, Tsai TT, Maddox TM, et al. Delays in filling clopidogrel prescription after hospital discharge and adverse outcomes after drug-eluting stent implantation: implications for transitions of care. Circ Cardiovasc Qual Outcomes. 2010;3(3):261-266.

Predicting Length of Stay after Stroke

Clinical question: Does a clinical score accurately predict prolonged length of stay after stroke?

Background: Stroke is a costly health problem, and length of stay is the most prominent factor contributing to the high costs. The factors leading to prolonged length of stay are varied, and there are no established tools to predict length of stay.

Study design: Prospective cohort study.

Setting: All 28 Israeli hospitals that admit stroke patients.

Synopsis: All patients admitted to Israeli hospitals during established two-month periods in 2004 (1,700 patients) and 2007 (1,648 patients) were included in the National Acute Stroke Israeli Survey (NASIS), and served as the derivation and validation cohort for development of a Prolonged Length of Stay (PLOS) score.

Using the 2004 data, investigators identified stroke severity using the National Institutes of Health Stroke Scale (NIHSS), history of congestive heart failure (CHF), history of atrial fibrillation, decreased level of consciousness on presentation, and intracerebral hemorrhage (as opposed to ischemic stroke) as predictors of prolonged length of stay. Four of these factors were expressed as dichotomous variables, whereas the stroke severity by NIHSS class was incorporated as a range; all were incorporated into a PLOS score.

Higher PLOS score correlated with longer length of stay. In the derivation cohort, 22% of patients with a PLOS score of 0 had a prolonged length of stay, whereas 85% of patients with PLOS scores of 6 or 7 had a prolonged length of stay. In the validation cohort, the corresponding figures were 19% and 72%.

Bottom line: Use of a simple score can predict risk of prolonged length of stay after stroke.

Citation: Koton S, Bornstein NM, Tsabari R, Tanne D, NASIS Investigators. Derivation and validation of the prolonged length of stay score in acute stroke patients. Neurology. 2010;74(19);1511-1516.

Earlier Administration of Appropriate Antimicrobials Decreases Mortality in Patients with Severe Sepsis and Septic Shock

Clinical question: Is the timing of antimicrobial administration an important determinant of survival in patients diagnosed with severe sepsis and septic shock?

Background: Severe sepsis and septic shock are associated with a 25% to 50% mortality rate. Early goal-directed therapy has been shown to increase survival in these patients. Antimicrobial treatment is a mainstay of this therapy, but the most effective timing of this treatment remains unclear.

Study design: Retrospective, single-center cohort study.

Setting: ED at an academic tertiary-care center.

Synopsis: Two hundred sixty-one patients in the ED in 2005-2006 presenting with severe sepsis or septic shock were enrolled in the hospital’s early goal-directed therapy (EGDT) algorithm, either at triage or later during their ED stay. Labs showed 56.7% of patients were culture-positive, with the most common sources being respiratory (30.6%), genitourinary (22.8%), and gastrointestinal (19.7%).

All patients received antibiotics and were stratified in one-hour intervals by the following categories: time from triage to antibiotics; time from qualification for EGDT to antibiotics; time from triage to appropriate antibiotics; and time from qualification for EGDT to appropriate antibiotics.

Total in-hospital mortality was 31% (35.1% for culture-positive patients vs. 25.7% for culture-negative patients, P=0.11). A significant decrease in mortality was only found when appropriate antibiotics were administered within one hour of triage, or within one hour of qualification for EGDT (OR=0.30; 95% CI, 0.11-0.83; P=0.02, and OR=0.50; 95% CI, 0.27-0.92; P=0.03, respectively).

Study limitations included the single-center site and small sample size.

Bottom line: In patients with severe sepsis and septic shock, initiating appropriate antimicrobial therapy within one hour of triage or entry into goal-directed therapy significantly reduces mortality.

Citation: Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045-1053.

Treatment with Higher Levels of Positive End-Expiratory Pressure Has Limited Affect on Hospital Survival

Clinical question: Is treatment with higher versus lower levels of positive end-expiratory pressure (PEEP) associated with improved hospital survival?

Background: In the management of patients with acute lung injury or acute respiratory distress syndrome (ARDS), a fundamental goal is to protect the lungs from ventilation-induced injury, but the optimal PEEP level has not been established.

Study design: Systematic review and meta-analysis.

Setting: N/A.

Synopsis: Three randomized-controlled trials eligible for this review included 2,299 critically ill adults with acute lung injury, as defined by the American-European Consensus Conference. The meta-analysis compared higher and lower PEEP levels with a mean difference of at least 3 cm H2O, incorporated a target tidal volume of less than 8 mL/kg of predicted body weight in both ventilation strategies, and provided patient follow-up until death or for at least 20 days.

This review demonstrated no statistically significant difference in hospital mortality between the groups. However, in patients with ARDS, higher levels of PEEP were associated with a relative reduction in mortality of 10%. This is supported by a recent cohort study in patients with acute lung injury or ARDS, which showed that the effect of PEEP on lung recruitment was associated with the proportion of potentially recruitable lung, as determined by computed tomography.

Since patients with ARDS have more pulmonary edema than those with acute lung injury without ARDS, the former have greater recruitability, and thus might benefit more from higher levels of PEEP.

Bottom line: Higher levels of PEEP might be associated with lower hospital mortality in patients with ARDS, but such a benefit is unlikely in patients with less severe lung injuries, and could actually be harmful.

Citation: Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-873. TH

PEDIATRIC HM LITERATURE

By Mark Shen, MD

High-Performing State Healthcare Systems Have Higher Children’s Hospital Readmission Rates

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

Clinical question: What is the relationship between a hospital’s readmission rate and performance of the surrounding healthcare system?

Background: Hospital readmission rates might be influenced by factors related to the specific patient and hospital care, as well as such external factors as the performance of the surrounding healthcare system. Traditionally, readmission rates are thought to most accurately reflect the quality of hospital care; however, the relative contributions of patient, hospital, and external factors to hospital readmission rates have not been delineated.

Study design: Multilevel cohort study.

Setting: Thirty-nine children’s hospitals in 24 states.

Synopsis: The Pediatric Health Information System (PHIS) administrative database was sampled for the 2005 calendar year to review discharges from 39 participating children’s hospitals. Patients 2 to 18 years were included, and out of a total of 198,422 patients, 32,196 were readmitted within 365 days of discharge.

The Commonwealth Fund’s 2008 State Variations in Child Health System Performance ranking was used to define the state-level health system performance. Higher readmission rates correlated with higher-ranked state child health systems after adjustment for patient-level characteristics.

This surprising result calls into question the often-assumed link between hospital readmission rates and poor systems of care. However, despite the strength of its large sample size, this study’s macro-level view of the healthcare system might be too crude to truly define the external factors that play a role in readmission. State-level healthcare rankings might not accurately reflect the healthcare ecosystem surrounding each children’s hospital, and children’s hospitals do not care for the majority of children in the U.S.

Bottom line: Children’s hospital readmissions correlate with higher state child health system performance.

Citation: Feudtner C, Pati S, Goodman DM, et al. State-level child health system performance and the likelihood of readmission to children’s hospitals. J Pediatr. 2010;157(1):98-102.

New Generics

• Desloratadine tablets (generic Clarinex)¹
• Didanosine delayed-release capsules (Generic Videx EC)²

New Indications, Dosage Forms, and Recommendations

• Ganciclovir ophthalmic gel 0.15% (Zirgan) has been approved by the FDA for treating acute herpetic keratitis.³ The recommended dose is one drop in the affected eye five times daily until the ulcer heals, then one drop three times daily for seven more days. The most common side effects in clinical trials were blurred vision, eye irritation, punctate keratitis, and conjunctival hyperemia. It will be available in a 5-g tube.
• Immune globulin intravenous 10% liquid (human) (Privigen) has received an updated approval from the FDA, which allows for room temperature storage throughout its entire 36-month shelf life.⁴ The agent is used to treat patients with primary immunodeficiency disorders.
• Miconazole buccal tablets (Oravig) have been approved by the FDA for treating oropharyngeal candidiasis in adults and children 16 years of age and older. It is the first, and currently the only local, buccal prescription formulation of miconazole.⁵ The buccal tablet was developed to adhere to the gum. It should not be crushed, chewed, or swallowed. The most common adverse effects in clinical trials were diarrhea, nausea, headache, dysgeusia, upper abdominal pain, and vomiting. It is recommended to monitor patients with a history of hypersensitivity to azoles, as there is no information regarding cross-reactivity between miconazole and other azole agents.
• A supplemental new drug application (sNDA) has been submitted to the FDA for naltrexone extended-release injectable suspension (Vivitrol) for treating opioid dependence.⁶ It is administered as a once-monthly intramuscular injection and currently is approved by the FDA for treating alcohol dependence.
• Oxycodone controlled-release (OxyContin) has been approved by the FDA in a new, abuse-deterrent formulation.⁷
• Pancrelipase delayed-release capsules (Pancreaze) joins Creon (Abbott Labs) and Zenpep (Eurand) as the third pancreatic enzyme product (PEP) to be approved by the FDA for treating exocrine pancreatic insufficiency.⁸
• Pramipexole extended-release tablets (Mirapex ER) have been approved by the FDA as a once-daily treatment for the signs and symptoms of idiopathic Parkinson’s disease (early and late).⁹
• The active ingredient in the vaccine Diamyd, rhGAD65, has received orphan drug status for treating Type 1 diabetes mellitus (T1DM) with residual beta cell function.^10,11 This agent is in Phase 3 clinical trials and is being investigated to determine whether it can stop or slow the autoimmune destruction of insulin-producing beta cell function. The DiaPrevent study is enrolling patients. In Phase 2 studies, the agent preserved remaining beta cell function in adolescents and children recently diagnosed with T1DM.
• Warfarin genetic diagnostic: Machaon Diagnostics has received FDA approval for an array-based diagnostic technology that detects genetic variation and could aid in determining an accurate initial warfarin dose.¹² At least 40% of Americans have at least one genetic variation involved in warfarin metabolism, which can cause a more than fivefold disparity in the weekly warfarin dose. This test can be used to more accurately determine dosing for warfarin-treated patients.

Pipeline

• The NDA for DM-1796 (gabapentin extended-release tablet) has been submitted to the FDA for treatment of postherpetic neuralgia.¹³ It is a once-daily, extended-release formulation of gabapentin.
• The “quad” combination of elvitegravir, cobicistat (formerly GS 9350), emtricitabine, and tenofovir disoproxil fumarate in a fixed-dose single tablet is currently in Phase 3 clinical trials for treatment of HIV.¹⁴
• FTY720 is an investigational oral immune modulator agent for treating relapsing-remitting multiple sclerosis (RR-MS).¹⁵ The NDA for this agent was submitted in December 2009; the FDA granted it a priority review in February. Two-year data from the FREEDOMS trial showed that FTY720 reduced annual relapse rates by 62%, compared with treatment-naive patients. For patients that had received prior treatments, the annual relapse rate was reduced by 44%. At two years, FTY720 delayed disability progression by 30% for patients treated with 0.5 mg, compared with placebo. The serious infection rate was comparable in the different “immune modulator” treatment groups.

Product Removal

Inhalers containing ozone-depleting chlorofluorocarbons (CFCs) are continuing to be phased out.¹⁶ These agents are used to treat asthma and COPD, and alternate products that do not contain CFCs are available. Some pharmacies might be depleting stock after the “last-sale date.” The affected products and their phase-out dates are:

• Tilade (nedocromil): June 14, 2010;
• Alupent (metaproterenol): June 14, 2010;
• Aerobid (flunisolide): June 30, 2010;
• Azmacort (triamcinolone): Dec. 31, 2010;
• Intal (cromolyn): Dec. 31, 2010;
• Combivent (albuterol/ipratropium): December 31, 2013; and
• Maxair (pirbuterol) autohaler: December 31, 2013. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Orange Book: Approved drug products with therapeutic equivalence evaluations. U.S. Food and Drug Administration website. Available at: www.accessdata.fda.gov/scripts/cder/ob/docs/obdetail.cfm?Appl_No=078357&TABLE1=OB_Rx. Accessed April 27, 2010.
2. Mylan announces approval under PEPFAR for generic version of Videx EC HIV treatment. Medical News Today website. Available at: www.medicalnewstoday.com/articles/186273.php. Accessed April 27, 2010.
3. Sirion Therapeutics announces availability of Zirgan (ganciclovir ophthalmic gel) 0.15% for ocular herpes. PR Newswire website. Available at: www.prnewswire.com/news-releases/sirion-therapeutics-announces-availability-of-zirgantm-ganciclovir-ophthalmic-gel-015-for-ocular-herpes-92084614.html. Accessed April 27, 2010.
4. CSL Behring receives FDA approval to extend shelf life for Privigen from 24 to 36 months. CSL Behring website. Available at: www.cslbehring-us.com/s1/cs/enus/1154272074489/news/1255923905944/prdetail.htm. Accessed April 27, 2010.
5. FDA approves Oravig (miconazole) buccal tablets for treatment of oropharyngeal candidiasis. PAR Pharmaceuticals website. Available at: investors.parpharm.com/phoenix.zhtml?c=81806&p=irol-newsArticle&ID=1413993&highlight=. Accessed April 27, 2010.
6. Alkermes submits supplemental new drug application for Vivitrol for the treatment of opioid dependence. Medical News Today website. Available at: www.medicalnewstoday.com/articles/185456.php. Accessed April 27, 2010.
7. FDA approves reformulated oxycontin. Contract Pharma website. www.contractpharma.com/news/2010/04/07/fda_approves_reformulated_oxycontin. Accessed April 27, 2010.
8. Gansz Bobo E. FDA approves pancreatic enzyme product, Pancreaze. FDA website. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm208135.htm. Accessed April 27, 2010.
9. Once-daily Mirapex ER now approved by FDA for both early and advanced Parkinson’s disease. Medical News Today website. Available at: www.medicalnewstoday.com/printerfriendlynews.php?newsid=183272. Accessed April 27, 2010.
10. DiaPrevent diabetes research. DiaPrevent website. Available at: www.diaprevent.diamyd.com/. Accessed April 27, 2010.
11. Diamyd granted orphan drug designation in the US. Diamyd website. Available at: www.diamyd.com/docs/pressClip.aspx?section=investor&ClipID=479460. Accessed April 27, 2010.
12. Same-day genetic testing service available for safer warfarin dosing. Monthly Prescribing Reference website. Available at: www.empr.com/same-day-genetic-testing-service-available-for-safer-warfarin-dosing/article/167586/. Accessed April 27, 2010.
13. NDA submitted for DM-1796 for postherpetic neuralgia (PHN). Monthly Prescribing Reference website. Available at: www.empr.com/nda-submitted-for-dm-1796-for-postherpetic-neuralgia-phn/article/167056/. Accessed April 26, 2010.
14. Gilead initiates Phase III clinical program evaluating single-table, once-daily “quad” regimen for HIV. Gilead website. Available at: www.gilead.com/pr_1411934. Accessed April 27, 2010.
15. Novartis investigational multiple sclerosis therapy Gilenia (FTY720) shown to reduce relapse rates regardless of treatment history. Drugs.com website. Available at: www.drugs.com/clinical_trials/novartis-investigational-multiple-sclerosis-therapy-gilenia-fty720-shown-reduce-relapse-rates-9139.html. Accessed April 27, 2010.
16. Inhalers containing CFCs being eliminated. Pharamacist eLink website. Available at: www.pharmacistelink.com/index.php/Drugs-and-Treatment/Inhalers-containing-CFC-s-being-eliminated.html. Accessed April 27, 2010.

New Generics

• Desloratadine tablets (generic Clarinex)¹
• Didanosine delayed-release capsules (Generic Videx EC)²

New Indications, Dosage Forms, and Recommendations

• Ganciclovir ophthalmic gel 0.15% (Zirgan) has been approved by the FDA for treating acute herpetic keratitis.³ The recommended dose is one drop in the affected eye five times daily until the ulcer heals, then one drop three times daily for seven more days. The most common side effects in clinical trials were blurred vision, eye irritation, punctate keratitis, and conjunctival hyperemia. It will be available in a 5-g tube.
• Immune globulin intravenous 10% liquid (human) (Privigen) has received an updated approval from the FDA, which allows for room temperature storage throughout its entire 36-month shelf life.⁴ The agent is used to treat patients with primary immunodeficiency disorders.
• Miconazole buccal tablets (Oravig) have been approved by the FDA for treating oropharyngeal candidiasis in adults and children 16 years of age and older. It is the first, and currently the only local, buccal prescription formulation of miconazole.⁵ The buccal tablet was developed to adhere to the gum. It should not be crushed, chewed, or swallowed. The most common adverse effects in clinical trials were diarrhea, nausea, headache, dysgeusia, upper abdominal pain, and vomiting. It is recommended to monitor patients with a history of hypersensitivity to azoles, as there is no information regarding cross-reactivity between miconazole and other azole agents.
• A supplemental new drug application (sNDA) has been submitted to the FDA for naltrexone extended-release injectable suspension (Vivitrol) for treating opioid dependence.⁶ It is administered as a once-monthly intramuscular injection and currently is approved by the FDA for treating alcohol dependence.
• Oxycodone controlled-release (OxyContin) has been approved by the FDA in a new, abuse-deterrent formulation.⁷
• Pancrelipase delayed-release capsules (Pancreaze) joins Creon (Abbott Labs) and Zenpep (Eurand) as the third pancreatic enzyme product (PEP) to be approved by the FDA for treating exocrine pancreatic insufficiency.⁸
• Pramipexole extended-release tablets (Mirapex ER) have been approved by the FDA as a once-daily treatment for the signs and symptoms of idiopathic Parkinson’s disease (early and late).⁹
• The active ingredient in the vaccine Diamyd, rhGAD65, has received orphan drug status for treating Type 1 diabetes mellitus (T1DM) with residual beta cell function.^10,11 This agent is in Phase 3 clinical trials and is being investigated to determine whether it can stop or slow the autoimmune destruction of insulin-producing beta cell function. The DiaPrevent study is enrolling patients. In Phase 2 studies, the agent preserved remaining beta cell function in adolescents and children recently diagnosed with T1DM.
• Warfarin genetic diagnostic: Machaon Diagnostics has received FDA approval for an array-based diagnostic technology that detects genetic variation and could aid in determining an accurate initial warfarin dose.¹² At least 40% of Americans have at least one genetic variation involved in warfarin metabolism, which can cause a more than fivefold disparity in the weekly warfarin dose. This test can be used to more accurately determine dosing for warfarin-treated patients.

Pipeline

• The NDA for DM-1796 (gabapentin extended-release tablet) has been submitted to the FDA for treatment of postherpetic neuralgia.¹³ It is a once-daily, extended-release formulation of gabapentin.
• The “quad” combination of elvitegravir, cobicistat (formerly GS 9350), emtricitabine, and tenofovir disoproxil fumarate in a fixed-dose single tablet is currently in Phase 3 clinical trials for treatment of HIV.¹⁴
• FTY720 is an investigational oral immune modulator agent for treating relapsing-remitting multiple sclerosis (RR-MS).¹⁵ The NDA for this agent was submitted in December 2009; the FDA granted it a priority review in February. Two-year data from the FREEDOMS trial showed that FTY720 reduced annual relapse rates by 62%, compared with treatment-naive patients. For patients that had received prior treatments, the annual relapse rate was reduced by 44%. At two years, FTY720 delayed disability progression by 30% for patients treated with 0.5 mg, compared with placebo. The serious infection rate was comparable in the different “immune modulator” treatment groups.

Product Removal

Inhalers containing ozone-depleting chlorofluorocarbons (CFCs) are continuing to be phased out.¹⁶ These agents are used to treat asthma and COPD, and alternate products that do not contain CFCs are available. Some pharmacies might be depleting stock after the “last-sale date.” The affected products and their phase-out dates are:

• Tilade (nedocromil): June 14, 2010;
• Alupent (metaproterenol): June 14, 2010;
• Aerobid (flunisolide): June 30, 2010;
• Azmacort (triamcinolone): Dec. 31, 2010;
• Intal (cromolyn): Dec. 31, 2010;
• Combivent (albuterol/ipratropium): December 31, 2013; and
• Maxair (pirbuterol) autohaler: December 31, 2013. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Orange Book: Approved drug products with therapeutic equivalence evaluations. U.S. Food and Drug Administration website. Available at: www.accessdata.fda.gov/scripts/cder/ob/docs/obdetail.cfm?Appl_No=078357&TABLE1=OB_Rx. Accessed April 27, 2010.
2. Mylan announces approval under PEPFAR for generic version of Videx EC HIV treatment. Medical News Today website. Available at: www.medicalnewstoday.com/articles/186273.php. Accessed April 27, 2010.
3. Sirion Therapeutics announces availability of Zirgan (ganciclovir ophthalmic gel) 0.15% for ocular herpes. PR Newswire website. Available at: www.prnewswire.com/news-releases/sirion-therapeutics-announces-availability-of-zirgantm-ganciclovir-ophthalmic-gel-015-for-ocular-herpes-92084614.html. Accessed April 27, 2010.
4. CSL Behring receives FDA approval to extend shelf life for Privigen from 24 to 36 months. CSL Behring website. Available at: www.cslbehring-us.com/s1/cs/enus/1154272074489/news/1255923905944/prdetail.htm. Accessed April 27, 2010.
5. FDA approves Oravig (miconazole) buccal tablets for treatment of oropharyngeal candidiasis. PAR Pharmaceuticals website. Available at: investors.parpharm.com/phoenix.zhtml?c=81806&p=irol-newsArticle&ID=1413993&highlight=. Accessed April 27, 2010.
6. Alkermes submits supplemental new drug application for Vivitrol for the treatment of opioid dependence. Medical News Today website. Available at: www.medicalnewstoday.com/articles/185456.php. Accessed April 27, 2010.
7. FDA approves reformulated oxycontin. Contract Pharma website. www.contractpharma.com/news/2010/04/07/fda_approves_reformulated_oxycontin. Accessed April 27, 2010.
8. Gansz Bobo E. FDA approves pancreatic enzyme product, Pancreaze. FDA website. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm208135.htm. Accessed April 27, 2010.
9. Once-daily Mirapex ER now approved by FDA for both early and advanced Parkinson’s disease. Medical News Today website. Available at: www.medicalnewstoday.com/printerfriendlynews.php?newsid=183272. Accessed April 27, 2010.
10. DiaPrevent diabetes research. DiaPrevent website. Available at: www.diaprevent.diamyd.com/. Accessed April 27, 2010.
11. Diamyd granted orphan drug designation in the US. Diamyd website. Available at: www.diamyd.com/docs/pressClip.aspx?section=investor&ClipID=479460. Accessed April 27, 2010.
12. Same-day genetic testing service available for safer warfarin dosing. Monthly Prescribing Reference website. Available at: www.empr.com/same-day-genetic-testing-service-available-for-safer-warfarin-dosing/article/167586/. Accessed April 27, 2010.
13. NDA submitted for DM-1796 for postherpetic neuralgia (PHN). Monthly Prescribing Reference website. Available at: www.empr.com/nda-submitted-for-dm-1796-for-postherpetic-neuralgia-phn/article/167056/. Accessed April 26, 2010.
14. Gilead initiates Phase III clinical program evaluating single-table, once-daily “quad” regimen for HIV. Gilead website. Available at: www.gilead.com/pr_1411934. Accessed April 27, 2010.
15. Novartis investigational multiple sclerosis therapy Gilenia (FTY720) shown to reduce relapse rates regardless of treatment history. Drugs.com website. Available at: www.drugs.com/clinical_trials/novartis-investigational-multiple-sclerosis-therapy-gilenia-fty720-shown-reduce-relapse-rates-9139.html. Accessed April 27, 2010.
16. Inhalers containing CFCs being eliminated. Pharamacist eLink website. Available at: www.pharmacistelink.com/index.php/Drugs-and-Treatment/Inhalers-containing-CFC-s-being-eliminated.html. Accessed April 27, 2010.

New Generics

• Desloratadine tablets (generic Clarinex)¹
• Didanosine delayed-release capsules (Generic Videx EC)²

New Indications, Dosage Forms, and Recommendations

• Ganciclovir ophthalmic gel 0.15% (Zirgan) has been approved by the FDA for treating acute herpetic keratitis.³ The recommended dose is one drop in the affected eye five times daily until the ulcer heals, then one drop three times daily for seven more days. The most common side effects in clinical trials were blurred vision, eye irritation, punctate keratitis, and conjunctival hyperemia. It will be available in a 5-g tube.
• Immune globulin intravenous 10% liquid (human) (Privigen) has received an updated approval from the FDA, which allows for room temperature storage throughout its entire 36-month shelf life.⁴ The agent is used to treat patients with primary immunodeficiency disorders.
• Miconazole buccal tablets (Oravig) have been approved by the FDA for treating oropharyngeal candidiasis in adults and children 16 years of age and older. It is the first, and currently the only local, buccal prescription formulation of miconazole.⁵ The buccal tablet was developed to adhere to the gum. It should not be crushed, chewed, or swallowed. The most common adverse effects in clinical trials were diarrhea, nausea, headache, dysgeusia, upper abdominal pain, and vomiting. It is recommended to monitor patients with a history of hypersensitivity to azoles, as there is no information regarding cross-reactivity between miconazole and other azole agents.
• A supplemental new drug application (sNDA) has been submitted to the FDA for naltrexone extended-release injectable suspension (Vivitrol) for treating opioid dependence.⁶ It is administered as a once-monthly intramuscular injection and currently is approved by the FDA for treating alcohol dependence.
• Oxycodone controlled-release (OxyContin) has been approved by the FDA in a new, abuse-deterrent formulation.⁷
• Pancrelipase delayed-release capsules (Pancreaze) joins Creon (Abbott Labs) and Zenpep (Eurand) as the third pancreatic enzyme product (PEP) to be approved by the FDA for treating exocrine pancreatic insufficiency.⁸
• Pramipexole extended-release tablets (Mirapex ER) have been approved by the FDA as a once-daily treatment for the signs and symptoms of idiopathic Parkinson’s disease (early and late).⁹
• The active ingredient in the vaccine Diamyd, rhGAD65, has received orphan drug status for treating Type 1 diabetes mellitus (T1DM) with residual beta cell function.^10,11 This agent is in Phase 3 clinical trials and is being investigated to determine whether it can stop or slow the autoimmune destruction of insulin-producing beta cell function. The DiaPrevent study is enrolling patients. In Phase 2 studies, the agent preserved remaining beta cell function in adolescents and children recently diagnosed with T1DM.
• Warfarin genetic diagnostic: Machaon Diagnostics has received FDA approval for an array-based diagnostic technology that detects genetic variation and could aid in determining an accurate initial warfarin dose.¹² At least 40% of Americans have at least one genetic variation involved in warfarin metabolism, which can cause a more than fivefold disparity in the weekly warfarin dose. This test can be used to more accurately determine dosing for warfarin-treated patients.

Pipeline

• The NDA for DM-1796 (gabapentin extended-release tablet) has been submitted to the FDA for treatment of postherpetic neuralgia.¹³ It is a once-daily, extended-release formulation of gabapentin.
• The “quad” combination of elvitegravir, cobicistat (formerly GS 9350), emtricitabine, and tenofovir disoproxil fumarate in a fixed-dose single tablet is currently in Phase 3 clinical trials for treatment of HIV.¹⁴
• FTY720 is an investigational oral immune modulator agent for treating relapsing-remitting multiple sclerosis (RR-MS).¹⁵ The NDA for this agent was submitted in December 2009; the FDA granted it a priority review in February. Two-year data from the FREEDOMS trial showed that FTY720 reduced annual relapse rates by 62%, compared with treatment-naive patients. For patients that had received prior treatments, the annual relapse rate was reduced by 44%. At two years, FTY720 delayed disability progression by 30% for patients treated with 0.5 mg, compared with placebo. The serious infection rate was comparable in the different “immune modulator” treatment groups.

Product Removal

Inhalers containing ozone-depleting chlorofluorocarbons (CFCs) are continuing to be phased out.¹⁶ These agents are used to treat asthma and COPD, and alternate products that do not contain CFCs are available. Some pharmacies might be depleting stock after the “last-sale date.” The affected products and their phase-out dates are:

• Tilade (nedocromil): June 14, 2010;
• Alupent (metaproterenol): June 14, 2010;
• Aerobid (flunisolide): June 30, 2010;
• Azmacort (triamcinolone): Dec. 31, 2010;
• Intal (cromolyn): Dec. 31, 2010;
• Combivent (albuterol/ipratropium): December 31, 2013; and
• Maxair (pirbuterol) autohaler: December 31, 2013. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Orange Book: Approved drug products with therapeutic equivalence evaluations. U.S. Food and Drug Administration website. Available at: www.accessdata.fda.gov/scripts/cder/ob/docs/obdetail.cfm?Appl_No=078357&TABLE1=OB_Rx. Accessed April 27, 2010.
2. Mylan announces approval under PEPFAR for generic version of Videx EC HIV treatment. Medical News Today website. Available at: www.medicalnewstoday.com/articles/186273.php. Accessed April 27, 2010.
3. Sirion Therapeutics announces availability of Zirgan (ganciclovir ophthalmic gel) 0.15% for ocular herpes. PR Newswire website. Available at: www.prnewswire.com/news-releases/sirion-therapeutics-announces-availability-of-zirgantm-ganciclovir-ophthalmic-gel-015-for-ocular-herpes-92084614.html. Accessed April 27, 2010.
4. CSL Behring receives FDA approval to extend shelf life for Privigen from 24 to 36 months. CSL Behring website. Available at: www.cslbehring-us.com/s1/cs/enus/1154272074489/news/1255923905944/prdetail.htm. Accessed April 27, 2010.
5. FDA approves Oravig (miconazole) buccal tablets for treatment of oropharyngeal candidiasis. PAR Pharmaceuticals website. Available at: investors.parpharm.com/phoenix.zhtml?c=81806&p=irol-newsArticle&ID=1413993&highlight=. Accessed April 27, 2010.
6. Alkermes submits supplemental new drug application for Vivitrol for the treatment of opioid dependence. Medical News Today website. Available at: www.medicalnewstoday.com/articles/185456.php. Accessed April 27, 2010.
7. FDA approves reformulated oxycontin. Contract Pharma website. www.contractpharma.com/news/2010/04/07/fda_approves_reformulated_oxycontin. Accessed April 27, 2010.
8. Gansz Bobo E. FDA approves pancreatic enzyme product, Pancreaze. FDA website. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm208135.htm. Accessed April 27, 2010.
9. Once-daily Mirapex ER now approved by FDA for both early and advanced Parkinson’s disease. Medical News Today website. Available at: www.medicalnewstoday.com/printerfriendlynews.php?newsid=183272. Accessed April 27, 2010.
10. DiaPrevent diabetes research. DiaPrevent website. Available at: www.diaprevent.diamyd.com/. Accessed April 27, 2010.
11. Diamyd granted orphan drug designation in the US. Diamyd website. Available at: www.diamyd.com/docs/pressClip.aspx?section=investor&ClipID=479460. Accessed April 27, 2010.
12. Same-day genetic testing service available for safer warfarin dosing. Monthly Prescribing Reference website. Available at: www.empr.com/same-day-genetic-testing-service-available-for-safer-warfarin-dosing/article/167586/. Accessed April 27, 2010.
13. NDA submitted for DM-1796 for postherpetic neuralgia (PHN). Monthly Prescribing Reference website. Available at: www.empr.com/nda-submitted-for-dm-1796-for-postherpetic-neuralgia-phn/article/167056/. Accessed April 26, 2010.
14. Gilead initiates Phase III clinical program evaluating single-table, once-daily “quad” regimen for HIV. Gilead website. Available at: www.gilead.com/pr_1411934. Accessed April 27, 2010.
15. Novartis investigational multiple sclerosis therapy Gilenia (FTY720) shown to reduce relapse rates regardless of treatment history. Drugs.com website. Available at: www.drugs.com/clinical_trials/novartis-investigational-multiple-sclerosis-therapy-gilenia-fty720-shown-reduce-relapse-rates-9139.html. Accessed April 27, 2010.
16. Inhalers containing CFCs being eliminated. Pharamacist eLink website. Available at: www.pharmacistelink.com/index.php/Drugs-and-Treatment/Inhalers-containing-CFC-s-being-eliminated.html. Accessed April 27, 2010.

Case

A 66-year-old woman with metastatic, non-small-cell carcinoma of the lung, chronic obstructive pulmonary disease (COPD), and hypertension presents with progressive shortness of breath and back pain. Her vital signs are normal, with the exception of tachypnea and an oxygen saturation of 84% on room air. A CT scan shows marked progression of her disease and new metastases to her spine. You begin a discussion about advance directives and code status. During the exchange, the patient asks for guidance regarding resuscitation. How can you best answer her questions about the likelihood of surviving an in-hospital arrest?

Background

Discussion regarding resuscitation status is a challenge for most hospitalists. The absence of an established relationship, limited time, patient emotion, and difficulty applying general scientific data to a single patient coalesce into a complex interaction. Further complicating matters, patients frequently have unrealistic expectations and overestimate their chance of survival.

Experience has shown that many patients pursue what physicians consider inappropriately aggressive resuscitation measures. Before you have an informed discussion about cardiopulmonary resuscitation (CPR) outcomes, patients tend to overestimate their likelihood of survival.¹ In 2009, Kaldjian and colleagues found that patients’ initial mean prediction of post-arrest survival was 60.4%, compared with the actual mean of approximately 17%.2,3 Furthermore, nearly half of the patients who initially expressed a desire to receive CPR in the event of cardiac arrest opted to change their code status after they were informed of the actual survival estimates.^1,2

Patient autonomy and the law, as defined by the 1990 Patient Self-Determination Act, require that physicians share responsibility with patients in making prospective resuscitation decisions.⁴ Shared decision-making necessitates a basic discussion on admission within the context of the patient’s prognosis and previously expressed wishes. It might simply include an acknowledgment of a previously completed advance directive. A more complex discussion might require in-depth conversation to address patient performance status, prognosis of acute and chronic illnesses, and education about the typical resuscitation procedures. After listening to the patient’s perspective, the admitting physician can provide input and an interpretation of available data regarding the patient’s likelihood of surviving an in-hospital arrest.

Review of the Data

In the past 40 years, the overall survival rates for cardiac arrest have changed little. Despite numerous advances made in the delivery of medical care, on average, only 17% of all adult arrest patients survive to hospital discharge.³ A variety of factors influence this overall survival rate, both pre-arrest and intra-arrest. Clinical experience allows most physicians to sense what probability a patient has for survival and quality of life following a cardiac arrest. However, anecdotal evidence alone does not provide a patient and their family with the information necessary to make an informed decision regarding code status.

click for large version

Numerous studies have investigated the patient factors that might influence how likely one is to survive a cardiac arrest. Researchers have paid particular attention to such factors as age, race, presence or absence of a cancer diagnosis, and associated comorbidities. Not surprisingly, older age has been shown to be significantly associated with a lower likelihood of survival to discharge following cardiac arrest.^5,6

Ehlenbach and colleagues examined medical data from 433,985 Medicare patients 65 and older who underwent in-hospital CPR.⁵ Both older age and prior residence in a skilled nursing facility were found to be associated with poorer survival rates.⁵ Although neither study was able to define an upper-age cutoff for certain peri-arrest mortality, age affects overall survival likelihood in an inverse fashion, with those 85 and older having only a 6% chance of surviving to hospital discharge (see Figure 1, p. 18).^1,5,6

The degree of comorbid illness can be used to help predict mortality following cardiac arrest. Review of data from the National Registry of Cardiopulmonary Resuscitation (NRCPR) identified particular comorbidities that portend poor post-arrest prognosis.⁶ In general, the more pre-existing comorbidities a patient has, the less likely they are to survive.⁶ The presence of hepatic insufficiency, acute stroke, immunodeficiency, renal failure, or dialysis were associated with lower survival rates (see Figure 2, right).^6,7

Poor performance status on admission, defined as severe disability, coma, or vegetative state, was predictive of worse outcomes.⁶ Understandably, patients with hypotension and those who required vasopressors or mechanical ventilation also tended to have lower post-arrest survival rates.⁶

The presence of a cancer diagnosis is another prognostic factor of interest when considering the chances of surviving an arrest. Classically, CPR was thought to be a futile intervention in this patient population. Specific characteristics within this subset of patients have been shown to influence prognosis, and multiple studies have confirmed that cancer patients generally do worse after an arrest with an overall survival rate of only 6.2%.⁸ Survival rates tend to be lower in patients with metastatic disease, hematologic malignancies, a history of stem cell transplant, those who arrest within an ICU, and inpatients whose cardiac arrest was anticipated.^8,9

click for large version

In fact, cancer patients whose hospital course followed a path of gradual deterioration showed a 0% survival rate.⁹ In patients with metastatic disease, poor performance status prior to arrest appeared to account for their particularly poor survival odds (this supports the intuitive, rule-of-thumb that sicker cancer patients have worse outcomes).⁸

Growing evidence suggests the probability of post-arrest survival is not equal between racial groups. Specifically, black or nonwhite race is associated with higher utilization of CPR and lower survival rates (see Figure 3, right).¹⁰ Among Medicare patients, Ehlenbach and colleagues found that black and nonwhite patients were much more likely to undergo CPR, presumably as a result of being less likely to opt for DNR status.^5,10 Although this could account for the differences seen in survival rates among these populations, these findings also raise concerns about the possibility of racial disparities in medical care. A subsequent cohort study also suggested that blacks and nonwhites were less likely to survive following cardiac arrest.¹⁰ However, adjusted analysis revealed that these differences were strongly associated with the medical center at which these patients received care. Therefore, although being nonwhite does portend worse outcomes following an arrest, the increased risk is likely attributed to the fact that many of these patients receive care at hospitals that have poorer overall CPR performance measures.^5,10

Survival is not the only outcome measure patients need to take into account when deciding whether to undergo CPR. Quality of life following resuscitation also warrants consideration. Interestingly, research has shown that neurologic outcomes among the majority of cardiac arrest survivors are generally good.³

click for large version

Approximately 86% of survivors with intact pre-arrest cerebral performance maintain it on discharge, and only a minority of survivors are eventually declared brain-dead.³ Still, there are certain peri-arrest factors that pose risk for poorer neurologic and functional outcomes. For arrest from a shockable rhythm, time to defibrillation is a key determinant.¹¹ In patients for whom time to defibrillation is greater than two minutes, there is significantly higher risk of permanent disability following cardiac arrest.¹¹

In the event of coma following resuscitation, particular clinical findings can be used to accurately predict poor outcome.¹² The absence of pupillary reflexes, corneal reflexes, or absent or extensor motor responses three days after arrest are poor prognostic indicators.¹² As a general rule, if a patient does not awaken within three days, neurologic and functional impairment can be expected.¹² For those patients who do survive to hospital discharge, more than 50% ultimately will be able to be discharged home.³

However, nearly a quarter will need to be newly placed in a rehabilitation or skilled nursing facility.³

Back to the Case

The patient was admitted with hypoxia secondary to both progressive lung malignancy and COPD exacerbation. She had no advanced directives, so the admitting hospitalist, in collaboration with her oncologist, had a detailed discussion regarding her understanding of her disease progression, prognosis, and goals for her remaining time. Her questions regarding survivability of cardiac arrest were answered directly with an estimate of 5% to 10%, based on her age, comorbidities, and the presence of advanced malignancy.

click for large version

After hearing this information, the patient responded, “I still want everything done.” The hospitalist acknowledged her feelings of wanting to fight on, but asked her to think about what “everything” meant to her. After taking some additional time to reflect with friends and family, the patient was clear that she wanted to continue disease-focused therapies, but did not want to be resuscitated in the event of cardiac or pulmonary arrest.

Eventually, her hypoxia improved with antibiotics, steroids, and bronchodilators. She was discharged home with follow-up in the oncology clinic for additional chemotherapy and palliative radiation.

Bottom Line

For hospitalized adults, the average survival rate to discharge after cardiac arrest is about 17%. Many factors lower a patient’s chance of survival, including advanced age, performance status, malignancy, and presence of multiple comorbidities. TH

Dr. Neagle and Dr. Wachsberg are hospitalists and instructors in the division of hospital medicine at Northwestern University Medical Center in Chicago.

References

1. Murphy DJ, Burrows D, Santali S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med. 1994;330(8):545-549.
2. Kaldjian LC, Erekson ZD, Haberle TH, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics. 2009;35(6):338-342.
3. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58(3):297-308.
4. La Puma J, Orentlicher D, Moss RJ. Advance directives on admission. Clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA. 1991;266(3):402-405.
5. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.
6. Larkin GL, Copes WS, Nathanson BH, Kaye W. Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation. 2010;81(3):302-311.
7. de Vos R, Koster RW, De Haan RJ, Oosting H, van der Wouw PA, Lampe-Schoenmaeckers AJ. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Arch Intern Med. 1999;159(8):845-850.
8. Reisfield GM, Wallace SK, Munsell MF, Webb FJ, Alvarez ER, Wilson GR. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006;71(2):152-160.
9. Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer. 2001;92(7):1905-1912.
10. Chan PS, Nichol G, Krumholz HM, et al. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302(11):1195-1201.
11. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
12. Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;67(2):203-210.

Case

A 66-year-old woman with metastatic, non-small-cell carcinoma of the lung, chronic obstructive pulmonary disease (COPD), and hypertension presents with progressive shortness of breath and back pain. Her vital signs are normal, with the exception of tachypnea and an oxygen saturation of 84% on room air. A CT scan shows marked progression of her disease and new metastases to her spine. You begin a discussion about advance directives and code status. During the exchange, the patient asks for guidance regarding resuscitation. How can you best answer her questions about the likelihood of surviving an in-hospital arrest?

Background

Discussion regarding resuscitation status is a challenge for most hospitalists. The absence of an established relationship, limited time, patient emotion, and difficulty applying general scientific data to a single patient coalesce into a complex interaction. Further complicating matters, patients frequently have unrealistic expectations and overestimate their chance of survival.

Experience has shown that many patients pursue what physicians consider inappropriately aggressive resuscitation measures. Before you have an informed discussion about cardiopulmonary resuscitation (CPR) outcomes, patients tend to overestimate their likelihood of survival.¹ In 2009, Kaldjian and colleagues found that patients’ initial mean prediction of post-arrest survival was 60.4%, compared with the actual mean of approximately 17%.2,3 Furthermore, nearly half of the patients who initially expressed a desire to receive CPR in the event of cardiac arrest opted to change their code status after they were informed of the actual survival estimates.^1,2

Patient autonomy and the law, as defined by the 1990 Patient Self-Determination Act, require that physicians share responsibility with patients in making prospective resuscitation decisions.⁴ Shared decision-making necessitates a basic discussion on admission within the context of the patient’s prognosis and previously expressed wishes. It might simply include an acknowledgment of a previously completed advance directive. A more complex discussion might require in-depth conversation to address patient performance status, prognosis of acute and chronic illnesses, and education about the typical resuscitation procedures. After listening to the patient’s perspective, the admitting physician can provide input and an interpretation of available data regarding the patient’s likelihood of surviving an in-hospital arrest.

Review of the Data

In the past 40 years, the overall survival rates for cardiac arrest have changed little. Despite numerous advances made in the delivery of medical care, on average, only 17% of all adult arrest patients survive to hospital discharge.³ A variety of factors influence this overall survival rate, both pre-arrest and intra-arrest. Clinical experience allows most physicians to sense what probability a patient has for survival and quality of life following a cardiac arrest. However, anecdotal evidence alone does not provide a patient and their family with the information necessary to make an informed decision regarding code status.

click for large version

Numerous studies have investigated the patient factors that might influence how likely one is to survive a cardiac arrest. Researchers have paid particular attention to such factors as age, race, presence or absence of a cancer diagnosis, and associated comorbidities. Not surprisingly, older age has been shown to be significantly associated with a lower likelihood of survival to discharge following cardiac arrest.^5,6

Ehlenbach and colleagues examined medical data from 433,985 Medicare patients 65 and older who underwent in-hospital CPR.⁵ Both older age and prior residence in a skilled nursing facility were found to be associated with poorer survival rates.⁵ Although neither study was able to define an upper-age cutoff for certain peri-arrest mortality, age affects overall survival likelihood in an inverse fashion, with those 85 and older having only a 6% chance of surviving to hospital discharge (see Figure 1, p. 18).^1,5,6

The degree of comorbid illness can be used to help predict mortality following cardiac arrest. Review of data from the National Registry of Cardiopulmonary Resuscitation (NRCPR) identified particular comorbidities that portend poor post-arrest prognosis.⁶ In general, the more pre-existing comorbidities a patient has, the less likely they are to survive.⁶ The presence of hepatic insufficiency, acute stroke, immunodeficiency, renal failure, or dialysis were associated with lower survival rates (see Figure 2, right).^6,7

Poor performance status on admission, defined as severe disability, coma, or vegetative state, was predictive of worse outcomes.⁶ Understandably, patients with hypotension and those who required vasopressors or mechanical ventilation also tended to have lower post-arrest survival rates.⁶

The presence of a cancer diagnosis is another prognostic factor of interest when considering the chances of surviving an arrest. Classically, CPR was thought to be a futile intervention in this patient population. Specific characteristics within this subset of patients have been shown to influence prognosis, and multiple studies have confirmed that cancer patients generally do worse after an arrest with an overall survival rate of only 6.2%.⁸ Survival rates tend to be lower in patients with metastatic disease, hematologic malignancies, a history of stem cell transplant, those who arrest within an ICU, and inpatients whose cardiac arrest was anticipated.^8,9

click for large version

In fact, cancer patients whose hospital course followed a path of gradual deterioration showed a 0% survival rate.⁹ In patients with metastatic disease, poor performance status prior to arrest appeared to account for their particularly poor survival odds (this supports the intuitive, rule-of-thumb that sicker cancer patients have worse outcomes).⁸

Growing evidence suggests the probability of post-arrest survival is not equal between racial groups. Specifically, black or nonwhite race is associated with higher utilization of CPR and lower survival rates (see Figure 3, right).¹⁰ Among Medicare patients, Ehlenbach and colleagues found that black and nonwhite patients were much more likely to undergo CPR, presumably as a result of being less likely to opt for DNR status.^5,10 Although this could account for the differences seen in survival rates among these populations, these findings also raise concerns about the possibility of racial disparities in medical care. A subsequent cohort study also suggested that blacks and nonwhites were less likely to survive following cardiac arrest.¹⁰ However, adjusted analysis revealed that these differences were strongly associated with the medical center at which these patients received care. Therefore, although being nonwhite does portend worse outcomes following an arrest, the increased risk is likely attributed to the fact that many of these patients receive care at hospitals that have poorer overall CPR performance measures.^5,10

Survival is not the only outcome measure patients need to take into account when deciding whether to undergo CPR. Quality of life following resuscitation also warrants consideration. Interestingly, research has shown that neurologic outcomes among the majority of cardiac arrest survivors are generally good.³

click for large version

Approximately 86% of survivors with intact pre-arrest cerebral performance maintain it on discharge, and only a minority of survivors are eventually declared brain-dead.³ Still, there are certain peri-arrest factors that pose risk for poorer neurologic and functional outcomes. For arrest from a shockable rhythm, time to defibrillation is a key determinant.¹¹ In patients for whom time to defibrillation is greater than two minutes, there is significantly higher risk of permanent disability following cardiac arrest.¹¹

In the event of coma following resuscitation, particular clinical findings can be used to accurately predict poor outcome.¹² The absence of pupillary reflexes, corneal reflexes, or absent or extensor motor responses three days after arrest are poor prognostic indicators.¹² As a general rule, if a patient does not awaken within three days, neurologic and functional impairment can be expected.¹² For those patients who do survive to hospital discharge, more than 50% ultimately will be able to be discharged home.³

However, nearly a quarter will need to be newly placed in a rehabilitation or skilled nursing facility.³

Back to the Case

The patient was admitted with hypoxia secondary to both progressive lung malignancy and COPD exacerbation. She had no advanced directives, so the admitting hospitalist, in collaboration with her oncologist, had a detailed discussion regarding her understanding of her disease progression, prognosis, and goals for her remaining time. Her questions regarding survivability of cardiac arrest were answered directly with an estimate of 5% to 10%, based on her age, comorbidities, and the presence of advanced malignancy.

click for large version

After hearing this information, the patient responded, “I still want everything done.” The hospitalist acknowledged her feelings of wanting to fight on, but asked her to think about what “everything” meant to her. After taking some additional time to reflect with friends and family, the patient was clear that she wanted to continue disease-focused therapies, but did not want to be resuscitated in the event of cardiac or pulmonary arrest.

Eventually, her hypoxia improved with antibiotics, steroids, and bronchodilators. She was discharged home with follow-up in the oncology clinic for additional chemotherapy and palliative radiation.

Bottom Line

For hospitalized adults, the average survival rate to discharge after cardiac arrest is about 17%. Many factors lower a patient’s chance of survival, including advanced age, performance status, malignancy, and presence of multiple comorbidities. TH

Dr. Neagle and Dr. Wachsberg are hospitalists and instructors in the division of hospital medicine at Northwestern University Medical Center in Chicago.

References

1. Murphy DJ, Burrows D, Santali S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med. 1994;330(8):545-549.
2. Kaldjian LC, Erekson ZD, Haberle TH, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics. 2009;35(6):338-342.
3. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58(3):297-308.
4. La Puma J, Orentlicher D, Moss RJ. Advance directives on admission. Clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA. 1991;266(3):402-405.
5. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.
6. Larkin GL, Copes WS, Nathanson BH, Kaye W. Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation. 2010;81(3):302-311.
7. de Vos R, Koster RW, De Haan RJ, Oosting H, van der Wouw PA, Lampe-Schoenmaeckers AJ. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Arch Intern Med. 1999;159(8):845-850.
8. Reisfield GM, Wallace SK, Munsell MF, Webb FJ, Alvarez ER, Wilson GR. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006;71(2):152-160.
9. Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer. 2001;92(7):1905-1912.
10. Chan PS, Nichol G, Krumholz HM, et al. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302(11):1195-1201.
11. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
12. Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;67(2):203-210.

Case

A 66-year-old woman with metastatic, non-small-cell carcinoma of the lung, chronic obstructive pulmonary disease (COPD), and hypertension presents with progressive shortness of breath and back pain. Her vital signs are normal, with the exception of tachypnea and an oxygen saturation of 84% on room air. A CT scan shows marked progression of her disease and new metastases to her spine. You begin a discussion about advance directives and code status. During the exchange, the patient asks for guidance regarding resuscitation. How can you best answer her questions about the likelihood of surviving an in-hospital arrest?

Background

Discussion regarding resuscitation status is a challenge for most hospitalists. The absence of an established relationship, limited time, patient emotion, and difficulty applying general scientific data to a single patient coalesce into a complex interaction. Further complicating matters, patients frequently have unrealistic expectations and overestimate their chance of survival.

Experience has shown that many patients pursue what physicians consider inappropriately aggressive resuscitation measures. Before you have an informed discussion about cardiopulmonary resuscitation (CPR) outcomes, patients tend to overestimate their likelihood of survival.¹ In 2009, Kaldjian and colleagues found that patients’ initial mean prediction of post-arrest survival was 60.4%, compared with the actual mean of approximately 17%.2,3 Furthermore, nearly half of the patients who initially expressed a desire to receive CPR in the event of cardiac arrest opted to change their code status after they were informed of the actual survival estimates.^1,2

Patient autonomy and the law, as defined by the 1990 Patient Self-Determination Act, require that physicians share responsibility with patients in making prospective resuscitation decisions.⁴ Shared decision-making necessitates a basic discussion on admission within the context of the patient’s prognosis and previously expressed wishes. It might simply include an acknowledgment of a previously completed advance directive. A more complex discussion might require in-depth conversation to address patient performance status, prognosis of acute and chronic illnesses, and education about the typical resuscitation procedures. After listening to the patient’s perspective, the admitting physician can provide input and an interpretation of available data regarding the patient’s likelihood of surviving an in-hospital arrest.

Review of the Data

In the past 40 years, the overall survival rates for cardiac arrest have changed little. Despite numerous advances made in the delivery of medical care, on average, only 17% of all adult arrest patients survive to hospital discharge.³ A variety of factors influence this overall survival rate, both pre-arrest and intra-arrest. Clinical experience allows most physicians to sense what probability a patient has for survival and quality of life following a cardiac arrest. However, anecdotal evidence alone does not provide a patient and their family with the information necessary to make an informed decision regarding code status.

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Numerous studies have investigated the patient factors that might influence how likely one is to survive a cardiac arrest. Researchers have paid particular attention to such factors as age, race, presence or absence of a cancer diagnosis, and associated comorbidities. Not surprisingly, older age has been shown to be significantly associated with a lower likelihood of survival to discharge following cardiac arrest.^5,6

Ehlenbach and colleagues examined medical data from 433,985 Medicare patients 65 and older who underwent in-hospital CPR.⁵ Both older age and prior residence in a skilled nursing facility were found to be associated with poorer survival rates.⁵ Although neither study was able to define an upper-age cutoff for certain peri-arrest mortality, age affects overall survival likelihood in an inverse fashion, with those 85 and older having only a 6% chance of surviving to hospital discharge (see Figure 1, p. 18).^1,5,6

The degree of comorbid illness can be used to help predict mortality following cardiac arrest. Review of data from the National Registry of Cardiopulmonary Resuscitation (NRCPR) identified particular comorbidities that portend poor post-arrest prognosis.⁶ In general, the more pre-existing comorbidities a patient has, the less likely they are to survive.⁶ The presence of hepatic insufficiency, acute stroke, immunodeficiency, renal failure, or dialysis were associated with lower survival rates (see Figure 2, right).^6,7

Poor performance status on admission, defined as severe disability, coma, or vegetative state, was predictive of worse outcomes.⁶ Understandably, patients with hypotension and those who required vasopressors or mechanical ventilation also tended to have lower post-arrest survival rates.⁶

The presence of a cancer diagnosis is another prognostic factor of interest when considering the chances of surviving an arrest. Classically, CPR was thought to be a futile intervention in this patient population. Specific characteristics within this subset of patients have been shown to influence prognosis, and multiple studies have confirmed that cancer patients generally do worse after an arrest with an overall survival rate of only 6.2%.⁸ Survival rates tend to be lower in patients with metastatic disease, hematologic malignancies, a history of stem cell transplant, those who arrest within an ICU, and inpatients whose cardiac arrest was anticipated.^8,9

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In fact, cancer patients whose hospital course followed a path of gradual deterioration showed a 0% survival rate.⁹ In patients with metastatic disease, poor performance status prior to arrest appeared to account for their particularly poor survival odds (this supports the intuitive, rule-of-thumb that sicker cancer patients have worse outcomes).⁸

Growing evidence suggests the probability of post-arrest survival is not equal between racial groups. Specifically, black or nonwhite race is associated with higher utilization of CPR and lower survival rates (see Figure 3, right).¹⁰ Among Medicare patients, Ehlenbach and colleagues found that black and nonwhite patients were much more likely to undergo CPR, presumably as a result of being less likely to opt for DNR status.^5,10 Although this could account for the differences seen in survival rates among these populations, these findings also raise concerns about the possibility of racial disparities in medical care. A subsequent cohort study also suggested that blacks and nonwhites were less likely to survive following cardiac arrest.¹⁰ However, adjusted analysis revealed that these differences were strongly associated with the medical center at which these patients received care. Therefore, although being nonwhite does portend worse outcomes following an arrest, the increased risk is likely attributed to the fact that many of these patients receive care at hospitals that have poorer overall CPR performance measures.^5,10

Survival is not the only outcome measure patients need to take into account when deciding whether to undergo CPR. Quality of life following resuscitation also warrants consideration. Interestingly, research has shown that neurologic outcomes among the majority of cardiac arrest survivors are generally good.³

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Approximately 86% of survivors with intact pre-arrest cerebral performance maintain it on discharge, and only a minority of survivors are eventually declared brain-dead.³ Still, there are certain peri-arrest factors that pose risk for poorer neurologic and functional outcomes. For arrest from a shockable rhythm, time to defibrillation is a key determinant.¹¹ In patients for whom time to defibrillation is greater than two minutes, there is significantly higher risk of permanent disability following cardiac arrest.¹¹

In the event of coma following resuscitation, particular clinical findings can be used to accurately predict poor outcome.¹² The absence of pupillary reflexes, corneal reflexes, or absent or extensor motor responses three days after arrest are poor prognostic indicators.¹² As a general rule, if a patient does not awaken within three days, neurologic and functional impairment can be expected.¹² For those patients who do survive to hospital discharge, more than 50% ultimately will be able to be discharged home.³

However, nearly a quarter will need to be newly placed in a rehabilitation or skilled nursing facility.³

Back to the Case

The patient was admitted with hypoxia secondary to both progressive lung malignancy and COPD exacerbation. She had no advanced directives, so the admitting hospitalist, in collaboration with her oncologist, had a detailed discussion regarding her understanding of her disease progression, prognosis, and goals for her remaining time. Her questions regarding survivability of cardiac arrest were answered directly with an estimate of 5% to 10%, based on her age, comorbidities, and the presence of advanced malignancy.

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After hearing this information, the patient responded, “I still want everything done.” The hospitalist acknowledged her feelings of wanting to fight on, but asked her to think about what “everything” meant to her. After taking some additional time to reflect with friends and family, the patient was clear that she wanted to continue disease-focused therapies, but did not want to be resuscitated in the event of cardiac or pulmonary arrest.

Eventually, her hypoxia improved with antibiotics, steroids, and bronchodilators. She was discharged home with follow-up in the oncology clinic for additional chemotherapy and palliative radiation.

Bottom Line

For hospitalized adults, the average survival rate to discharge after cardiac arrest is about 17%. Many factors lower a patient’s chance of survival, including advanced age, performance status, malignancy, and presence of multiple comorbidities. TH

Dr. Neagle and Dr. Wachsberg are hospitalists and instructors in the division of hospital medicine at Northwestern University Medical Center in Chicago.

References

1. Murphy DJ, Burrows D, Santali S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med. 1994;330(8):545-549.
2. Kaldjian LC, Erekson ZD, Haberle TH, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics. 2009;35(6):338-342.
3. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58(3):297-308.
4. La Puma J, Orentlicher D, Moss RJ. Advance directives on admission. Clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA. 1991;266(3):402-405.
5. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.
6. Larkin GL, Copes WS, Nathanson BH, Kaye W. Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation. 2010;81(3):302-311.
7. de Vos R, Koster RW, De Haan RJ, Oosting H, van der Wouw PA, Lampe-Schoenmaeckers AJ. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Arch Intern Med. 1999;159(8):845-850.
8. Reisfield GM, Wallace SK, Munsell MF, Webb FJ, Alvarez ER, Wilson GR. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006;71(2):152-160.
9. Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer. 2001;92(7):1905-1912.
10. Chan PS, Nichol G, Krumholz HM, et al. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302(11):1195-1201.
11. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
12. Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;67(2):203-210.