An 85‐year‐old male from rural southern New Jersey with history of innumerable tick bites over many years was admitted for fever of unknown origin. On hospital day 2, his hemoglobin dropped from 11.3 g/dL to 7.5 g/dL, with an associated elevated indirect bilirubin and lactate dehydrogenase. Blood smear showed numerous intracellular and extracellular trophozoites, with approximately 10% to 30% of red cells infected, consistent with severe babesiosis. Given his high parasitemia, new hypoxia, lethargy, and advanced age, treatment was initiated with intravenous antibiotics and red cell exchange transfusion.

Babesiosis should be considered on the differential diagnosis of hemolytic anemia in patients that live in or have traveled to endemic areas, especially with history of tick bites. The most common appearance on blood smear is round to oval rings with pale blue cytoplasm and a red‐staining nucleus (Fig. 1). Exoerythrocytic parasites or the pathognomonic Maltese Cross tetrad forms (not present in our patient's smear) help to differentiate from falciparum malaria.

The patient's parasite burden and clinical status markedly improved with treatment and he was discharged home. 0

Figure 1

An 85‐year‐old male from rural southern New Jersey with history of innumerable tick bites over many years was admitted for fever of unknown origin. On hospital day 2, his hemoglobin dropped from 11.3 g/dL to 7.5 g/dL, with an associated elevated indirect bilirubin and lactate dehydrogenase. Blood smear showed numerous intracellular and extracellular trophozoites, with approximately 10% to 30% of red cells infected, consistent with severe babesiosis. Given his high parasitemia, new hypoxia, lethargy, and advanced age, treatment was initiated with intravenous antibiotics and red cell exchange transfusion.

Babesiosis should be considered on the differential diagnosis of hemolytic anemia in patients that live in or have traveled to endemic areas, especially with history of tick bites. The most common appearance on blood smear is round to oval rings with pale blue cytoplasm and a red‐staining nucleus (Fig. 1). Exoerythrocytic parasites or the pathognomonic Maltese Cross tetrad forms (not present in our patient's smear) help to differentiate from falciparum malaria.

The patient's parasite burden and clinical status markedly improved with treatment and he was discharged home. 0

Figure 1

An 85‐year‐old male from rural southern New Jersey with history of innumerable tick bites over many years was admitted for fever of unknown origin. On hospital day 2, his hemoglobin dropped from 11.3 g/dL to 7.5 g/dL, with an associated elevated indirect bilirubin and lactate dehydrogenase. Blood smear showed numerous intracellular and extracellular trophozoites, with approximately 10% to 30% of red cells infected, consistent with severe babesiosis. Given his high parasitemia, new hypoxia, lethargy, and advanced age, treatment was initiated with intravenous antibiotics and red cell exchange transfusion.

Babesiosis should be considered on the differential diagnosis of hemolytic anemia in patients that live in or have traveled to endemic areas, especially with history of tick bites. The most common appearance on blood smear is round to oval rings with pale blue cytoplasm and a red‐staining nucleus (Fig. 1). Exoerythrocytic parasites or the pathognomonic Maltese Cross tetrad forms (not present in our patient's smear) help to differentiate from falciparum malaria.

The patient's parasite burden and clinical status markedly improved with treatment and he was discharged home. 0

Figure 1

It is well established that patients have difficulty understanding written health materials,1 medical terminology,2, 3 and other aspects of provider‐patient communication.4, 5 Such difficulties in communication can be magnified at transitions of care like hospital discharge.6 Patients often receive a large amount of information in a short period of time at discharge, and this information may be delivered in a way that is not straightforward or standardized.7, 8 When asked, patients commonly report a poor understanding of important self‐care instructions such as how to take medications upon returning home.9, 10 One study even showed that more than half of patients did not recall anyone providing instructions about how they should care for themselves after hospitalization.11 Poor medication management after hospital discharge contributes to adverse events,1215 inadequate disease control,16 and in the setting of cardiovascular disease, higher mortality.17, 18 Most adverse events after hospital discharge could be prevented or ameliorated through relatively simple means, including better communication among patients and providers.6, 1416, 1921 Greater attention to communication and care transitions could also reduce the number of unplanned rehospitalizations in the United States.22

Patients' health literacy is an important factor in effective health communication, yet little research has examined the role of health literacy in care transitions. Health literacy is defined as the extent to which an individual is able to obtain, process and understand basic health information and services needed to make appropriate health decisions.23, 24 Low health literacy is a prevalent problem in the United States, affecting approximately 40% of adults.25 Research has shown that low health literacy is associated with low self‐efficacy26 and less interaction in physician‐patient encounters,27 which in combination with physicians' use of complex medical language,28 may contribute to poor physician‐patient communication. Patients with low health literacy also have greater difficulty understanding prescription drug labels,29 limited knowledge of disease self‐management skills,30 a higher incidence of hospitalization,31 and higher mortality rates.3234

In order to elucidate the relationship between patient‐provider communication and health literacy in the hospital setting, we analyzed patients' ratings of their communication experience during their hospitalization. We report patients' perceptions of the clarity of communication and how this may vary by level of health literacy and other important patient characteristics.

Methods

Results

Discussion

We used a validated instrument, the IPC,40 to examine patients' ratings of the quality and clarity of hospital‐based communication. Overall, patients provided favorable ratings in many domains, including those pertaining to Responsiveness to patient concerns and Explanations of condition and prognosis. Clinicians' consideration of patients' desire and ability to comply with recommendations was rated least favorably overall. This represents an important area for improvement, particularly when considering the prevalence of nonadherence to medical therapy after hospital discharge, which may be as high as 50%.9, 42 Nonadherence after hospital discharge contributes to avoidable emergency department visits,43 hospital readmissions,44 and higher mortality.18, 45 The results of this study suggest that hospital physicians should give greater consideration to patients' preferences and problems that they may have in following the treatment recommendations.16 Future research will determine the extent to which this may enhance post‐discharge adherence.

Another important finding is that patients with inadequate health literacy rated hospital‐based communication less favorably than did patients with marginal or adequate literacy. In bivariate analyses, this effect was seen on several domains, including general clarity, Responsiveness to patient concerns, and explanations of processes of care. The latter 2 relationships persisted after adjustment for age, cognitive impairment, and educational attainment. To our knowledge, this is the first study which examines the effect of health literacy on patients' ratings of hospital‐based communication.

The majority of the literature on health communication and health literacy focuses on the outpatient setting.34, 46 However, the quality and clarity of patient‐provider communication in the hospital is also critically important. Ineffective communication in the hospital contributes to poor care transitions and post‐discharge complications. Patients commonly leave the hospital with a poor understanding of what transpired (eg, diagnoses, treatment provided, major test results) and inadequate knowledge about the self‐care activities that they must perform upon returning home (eg, medication management, physical activity, follow‐up appointments).911 Poor communication is often cited as the main underlying and remediable factor behind medical errors, adverse events, and the readmissions that commonly occur after hospital discharge.6, 16, 20 The results of this study provide complementary evidence, showing that patients often feel they have experienced suboptimal communication in the hospital setting. These findings highlight an opportunity for improvement in care transitions and patient safety, particularly among patients with inadequate health literacy.

In outpatient research that utilized the IPC, Schillinger et al.41 found that patients with inadequate functional health literacy reported significantly worse communication on the domains of general clarity, explanations of processes of care, and Explanations of condition and prognosis. Subsequent analyses by Sudore et al.47 demonstrated that patients with inadequate or marginal health literacy more often reported that physicians did not give them enough time to say what they thought was important, did not explain processes of care well, and did not ask about problems in following the recommended treatment (Table 3, IPC items 3, 12, and 26, respectively). Our findings were very similar. These relatively consistent results across studies and populations strengthen the conclusion that patients with inadequate health literacy feel their physicians do not communicate as effectively in these areas.

Importantly, the differences in patient responses by literacy category were driven by a few IPC items. These items pertained to physicians' use of medical terminology, the amount of time they gave patients to express their concerns, and how well they explained the patients' medical care. Training physicians to improve their communication skills in these specific areas may improve their ability to communicate effectively with patients who have limited literacy skills. Indeed, published recommendations on how to improve the clarity of verbal communication emphasize just a few major areas, including limiting the amount of medical terminology used, effectively encouraging patients to ask questions and express their concerns, and asking patients to teach‐back key points to make sure the physician has provided adequate explanation.4851 The present study provides some evidence for those recommendations, which for the most part, have been based on clinical experience and expert opinion.

There remains a need for professional education about health literacy and techniques to improve communication with patients who may have limited literacy skills. Many experts advocate clear verbal communication with all patients, so‐called Universal Precautions.52 Although 10 years have passed since the American Medical Association (AMA) called for more work in this area,53 few curricula have been described in the literature.48, 5456 The extent to which health literacy curricula have been implemented in medical schools and other professional schools is unknown. The impact of such training on the communication skills of health care providers and patient outcomes is also unclear.

The strengths of this study include a relatively good response rate and use of a validated measure to grade the quality of physician‐patient communication. This measure, the IPC, has been used previously in the context of health literacy.41 Nevertheless, certain limitations should be acknowledged. First, the study was performed at a single teaching hospital, where patients had a high prevalence of inadequate health literacy. The findings may not generalize to other institutions that serve a different patient population or to nonacademic programs. Second, communication was assessed by patient report, rather than by recording patient‐provider discussions for rating by independent observers. While patient report is inherently more subjective, patients' own perceptions about the effectiveness of health communication are arguably more important than those of independent raters, and thus, the data source may not represent a true limitation. Third, patient responses were obtained approximately 2 weeks after hospital discharge, and accordingly, they are subject to recall bias, which may be greater among those with cognitive impairment. Finally, patients were directed to rate the communication of the overall group of physicians who took care of them in the hospital. Given the academic setting, patients typically received care from a team that included medical students, interns, a resident, and an attending physician. We were not able to determine whether patients' ratings were influenced by a specific member of the team, nor how ratings may have been influenced by certain characteristics of that team member (eg, year of training, prior communication skills training, race or gender concordance, etc).

In summary, by surveying patients soon after an acute care hospitalization, we determined that certain areas held room for improvement, such as consideration of patients' desire and ability to comply with treatment recommendations. Patients with inadequate health literacy reported lower quality physician‐patient communication on several domains. They expressed particular concern about physicians' use of medical terminology, not getting enough time to express their concerns, and not receiving clear enough explanations about the medical care. Efforts are needed to improve physicians' communication skills in these areas. Such training should be evaluated to determine if it has a beneficial effect on physician communication skills and patient outcomes.

It is well established that patients have difficulty understanding written health materials,1 medical terminology,2, 3 and other aspects of provider‐patient communication.4, 5 Such difficulties in communication can be magnified at transitions of care like hospital discharge.6 Patients often receive a large amount of information in a short period of time at discharge, and this information may be delivered in a way that is not straightforward or standardized.7, 8 When asked, patients commonly report a poor understanding of important self‐care instructions such as how to take medications upon returning home.9, 10 One study even showed that more than half of patients did not recall anyone providing instructions about how they should care for themselves after hospitalization.11 Poor medication management after hospital discharge contributes to adverse events,1215 inadequate disease control,16 and in the setting of cardiovascular disease, higher mortality.17, 18 Most adverse events after hospital discharge could be prevented or ameliorated through relatively simple means, including better communication among patients and providers.6, 1416, 1921 Greater attention to communication and care transitions could also reduce the number of unplanned rehospitalizations in the United States.22

Patients' health literacy is an important factor in effective health communication, yet little research has examined the role of health literacy in care transitions. Health literacy is defined as the extent to which an individual is able to obtain, process and understand basic health information and services needed to make appropriate health decisions.23, 24 Low health literacy is a prevalent problem in the United States, affecting approximately 40% of adults.25 Research has shown that low health literacy is associated with low self‐efficacy26 and less interaction in physician‐patient encounters,27 which in combination with physicians' use of complex medical language,28 may contribute to poor physician‐patient communication. Patients with low health literacy also have greater difficulty understanding prescription drug labels,29 limited knowledge of disease self‐management skills,30 a higher incidence of hospitalization,31 and higher mortality rates.3234

In order to elucidate the relationship between patient‐provider communication and health literacy in the hospital setting, we analyzed patients' ratings of their communication experience during their hospitalization. We report patients' perceptions of the clarity of communication and how this may vary by level of health literacy and other important patient characteristics.

Methods

Results

Discussion

We used a validated instrument, the IPC,40 to examine patients' ratings of the quality and clarity of hospital‐based communication. Overall, patients provided favorable ratings in many domains, including those pertaining to Responsiveness to patient concerns and Explanations of condition and prognosis. Clinicians' consideration of patients' desire and ability to comply with recommendations was rated least favorably overall. This represents an important area for improvement, particularly when considering the prevalence of nonadherence to medical therapy after hospital discharge, which may be as high as 50%.9, 42 Nonadherence after hospital discharge contributes to avoidable emergency department visits,43 hospital readmissions,44 and higher mortality.18, 45 The results of this study suggest that hospital physicians should give greater consideration to patients' preferences and problems that they may have in following the treatment recommendations.16 Future research will determine the extent to which this may enhance post‐discharge adherence.

Another important finding is that patients with inadequate health literacy rated hospital‐based communication less favorably than did patients with marginal or adequate literacy. In bivariate analyses, this effect was seen on several domains, including general clarity, Responsiveness to patient concerns, and explanations of processes of care. The latter 2 relationships persisted after adjustment for age, cognitive impairment, and educational attainment. To our knowledge, this is the first study which examines the effect of health literacy on patients' ratings of hospital‐based communication.

The majority of the literature on health communication and health literacy focuses on the outpatient setting.34, 46 However, the quality and clarity of patient‐provider communication in the hospital is also critically important. Ineffective communication in the hospital contributes to poor care transitions and post‐discharge complications. Patients commonly leave the hospital with a poor understanding of what transpired (eg, diagnoses, treatment provided, major test results) and inadequate knowledge about the self‐care activities that they must perform upon returning home (eg, medication management, physical activity, follow‐up appointments).911 Poor communication is often cited as the main underlying and remediable factor behind medical errors, adverse events, and the readmissions that commonly occur after hospital discharge.6, 16, 20 The results of this study provide complementary evidence, showing that patients often feel they have experienced suboptimal communication in the hospital setting. These findings highlight an opportunity for improvement in care transitions and patient safety, particularly among patients with inadequate health literacy.

In outpatient research that utilized the IPC, Schillinger et al.41 found that patients with inadequate functional health literacy reported significantly worse communication on the domains of general clarity, explanations of processes of care, and Explanations of condition and prognosis. Subsequent analyses by Sudore et al.47 demonstrated that patients with inadequate or marginal health literacy more often reported that physicians did not give them enough time to say what they thought was important, did not explain processes of care well, and did not ask about problems in following the recommended treatment (Table 3, IPC items 3, 12, and 26, respectively). Our findings were very similar. These relatively consistent results across studies and populations strengthen the conclusion that patients with inadequate health literacy feel their physicians do not communicate as effectively in these areas.

Importantly, the differences in patient responses by literacy category were driven by a few IPC items. These items pertained to physicians' use of medical terminology, the amount of time they gave patients to express their concerns, and how well they explained the patients' medical care. Training physicians to improve their communication skills in these specific areas may improve their ability to communicate effectively with patients who have limited literacy skills. Indeed, published recommendations on how to improve the clarity of verbal communication emphasize just a few major areas, including limiting the amount of medical terminology used, effectively encouraging patients to ask questions and express their concerns, and asking patients to teach‐back key points to make sure the physician has provided adequate explanation.4851 The present study provides some evidence for those recommendations, which for the most part, have been based on clinical experience and expert opinion.

There remains a need for professional education about health literacy and techniques to improve communication with patients who may have limited literacy skills. Many experts advocate clear verbal communication with all patients, so‐called Universal Precautions.52 Although 10 years have passed since the American Medical Association (AMA) called for more work in this area,53 few curricula have been described in the literature.48, 5456 The extent to which health literacy curricula have been implemented in medical schools and other professional schools is unknown. The impact of such training on the communication skills of health care providers and patient outcomes is also unclear.

The strengths of this study include a relatively good response rate and use of a validated measure to grade the quality of physician‐patient communication. This measure, the IPC, has been used previously in the context of health literacy.41 Nevertheless, certain limitations should be acknowledged. First, the study was performed at a single teaching hospital, where patients had a high prevalence of inadequate health literacy. The findings may not generalize to other institutions that serve a different patient population or to nonacademic programs. Second, communication was assessed by patient report, rather than by recording patient‐provider discussions for rating by independent observers. While patient report is inherently more subjective, patients' own perceptions about the effectiveness of health communication are arguably more important than those of independent raters, and thus, the data source may not represent a true limitation. Third, patient responses were obtained approximately 2 weeks after hospital discharge, and accordingly, they are subject to recall bias, which may be greater among those with cognitive impairment. Finally, patients were directed to rate the communication of the overall group of physicians who took care of them in the hospital. Given the academic setting, patients typically received care from a team that included medical students, interns, a resident, and an attending physician. We were not able to determine whether patients' ratings were influenced by a specific member of the team, nor how ratings may have been influenced by certain characteristics of that team member (eg, year of training, prior communication skills training, race or gender concordance, etc).

In summary, by surveying patients soon after an acute care hospitalization, we determined that certain areas held room for improvement, such as consideration of patients' desire and ability to comply with treatment recommendations. Patients with inadequate health literacy reported lower quality physician‐patient communication on several domains. They expressed particular concern about physicians' use of medical terminology, not getting enough time to express their concerns, and not receiving clear enough explanations about the medical care. Efforts are needed to improve physicians' communication skills in these areas. Such training should be evaluated to determine if it has a beneficial effect on physician communication skills and patient outcomes.

It is well established that patients have difficulty understanding written health materials,1 medical terminology,2, 3 and other aspects of provider‐patient communication.4, 5 Such difficulties in communication can be magnified at transitions of care like hospital discharge.6 Patients often receive a large amount of information in a short period of time at discharge, and this information may be delivered in a way that is not straightforward or standardized.7, 8 When asked, patients commonly report a poor understanding of important self‐care instructions such as how to take medications upon returning home.9, 10 One study even showed that more than half of patients did not recall anyone providing instructions about how they should care for themselves after hospitalization.11 Poor medication management after hospital discharge contributes to adverse events,1215 inadequate disease control,16 and in the setting of cardiovascular disease, higher mortality.17, 18 Most adverse events after hospital discharge could be prevented or ameliorated through relatively simple means, including better communication among patients and providers.6, 1416, 1921 Greater attention to communication and care transitions could also reduce the number of unplanned rehospitalizations in the United States.22

Patients' health literacy is an important factor in effective health communication, yet little research has examined the role of health literacy in care transitions. Health literacy is defined as the extent to which an individual is able to obtain, process and understand basic health information and services needed to make appropriate health decisions.23, 24 Low health literacy is a prevalent problem in the United States, affecting approximately 40% of adults.25 Research has shown that low health literacy is associated with low self‐efficacy26 and less interaction in physician‐patient encounters,27 which in combination with physicians' use of complex medical language,28 may contribute to poor physician‐patient communication. Patients with low health literacy also have greater difficulty understanding prescription drug labels,29 limited knowledge of disease self‐management skills,30 a higher incidence of hospitalization,31 and higher mortality rates.3234

In order to elucidate the relationship between patient‐provider communication and health literacy in the hospital setting, we analyzed patients' ratings of their communication experience during their hospitalization. We report patients' perceptions of the clarity of communication and how this may vary by level of health literacy and other important patient characteristics.

Methods

Results

Discussion

We used a validated instrument, the IPC,40 to examine patients' ratings of the quality and clarity of hospital‐based communication. Overall, patients provided favorable ratings in many domains, including those pertaining to Responsiveness to patient concerns and Explanations of condition and prognosis. Clinicians' consideration of patients' desire and ability to comply with recommendations was rated least favorably overall. This represents an important area for improvement, particularly when considering the prevalence of nonadherence to medical therapy after hospital discharge, which may be as high as 50%.9, 42 Nonadherence after hospital discharge contributes to avoidable emergency department visits,43 hospital readmissions,44 and higher mortality.18, 45 The results of this study suggest that hospital physicians should give greater consideration to patients' preferences and problems that they may have in following the treatment recommendations.16 Future research will determine the extent to which this may enhance post‐discharge adherence.

Another important finding is that patients with inadequate health literacy rated hospital‐based communication less favorably than did patients with marginal or adequate literacy. In bivariate analyses, this effect was seen on several domains, including general clarity, Responsiveness to patient concerns, and explanations of processes of care. The latter 2 relationships persisted after adjustment for age, cognitive impairment, and educational attainment. To our knowledge, this is the first study which examines the effect of health literacy on patients' ratings of hospital‐based communication.

The majority of the literature on health communication and health literacy focuses on the outpatient setting.34, 46 However, the quality and clarity of patient‐provider communication in the hospital is also critically important. Ineffective communication in the hospital contributes to poor care transitions and post‐discharge complications. Patients commonly leave the hospital with a poor understanding of what transpired (eg, diagnoses, treatment provided, major test results) and inadequate knowledge about the self‐care activities that they must perform upon returning home (eg, medication management, physical activity, follow‐up appointments).911 Poor communication is often cited as the main underlying and remediable factor behind medical errors, adverse events, and the readmissions that commonly occur after hospital discharge.6, 16, 20 The results of this study provide complementary evidence, showing that patients often feel they have experienced suboptimal communication in the hospital setting. These findings highlight an opportunity for improvement in care transitions and patient safety, particularly among patients with inadequate health literacy.

In outpatient research that utilized the IPC, Schillinger et al.41 found that patients with inadequate functional health literacy reported significantly worse communication on the domains of general clarity, explanations of processes of care, and Explanations of condition and prognosis. Subsequent analyses by Sudore et al.47 demonstrated that patients with inadequate or marginal health literacy more often reported that physicians did not give them enough time to say what they thought was important, did not explain processes of care well, and did not ask about problems in following the recommended treatment (Table 3, IPC items 3, 12, and 26, respectively). Our findings were very similar. These relatively consistent results across studies and populations strengthen the conclusion that patients with inadequate health literacy feel their physicians do not communicate as effectively in these areas.

Importantly, the differences in patient responses by literacy category were driven by a few IPC items. These items pertained to physicians' use of medical terminology, the amount of time they gave patients to express their concerns, and how well they explained the patients' medical care. Training physicians to improve their communication skills in these specific areas may improve their ability to communicate effectively with patients who have limited literacy skills. Indeed, published recommendations on how to improve the clarity of verbal communication emphasize just a few major areas, including limiting the amount of medical terminology used, effectively encouraging patients to ask questions and express their concerns, and asking patients to teach‐back key points to make sure the physician has provided adequate explanation.4851 The present study provides some evidence for those recommendations, which for the most part, have been based on clinical experience and expert opinion.

There remains a need for professional education about health literacy and techniques to improve communication with patients who may have limited literacy skills. Many experts advocate clear verbal communication with all patients, so‐called Universal Precautions.52 Although 10 years have passed since the American Medical Association (AMA) called for more work in this area,53 few curricula have been described in the literature.48, 5456 The extent to which health literacy curricula have been implemented in medical schools and other professional schools is unknown. The impact of such training on the communication skills of health care providers and patient outcomes is also unclear.

The strengths of this study include a relatively good response rate and use of a validated measure to grade the quality of physician‐patient communication. This measure, the IPC, has been used previously in the context of health literacy.41 Nevertheless, certain limitations should be acknowledged. First, the study was performed at a single teaching hospital, where patients had a high prevalence of inadequate health literacy. The findings may not generalize to other institutions that serve a different patient population or to nonacademic programs. Second, communication was assessed by patient report, rather than by recording patient‐provider discussions for rating by independent observers. While patient report is inherently more subjective, patients' own perceptions about the effectiveness of health communication are arguably more important than those of independent raters, and thus, the data source may not represent a true limitation. Third, patient responses were obtained approximately 2 weeks after hospital discharge, and accordingly, they are subject to recall bias, which may be greater among those with cognitive impairment. Finally, patients were directed to rate the communication of the overall group of physicians who took care of them in the hospital. Given the academic setting, patients typically received care from a team that included medical students, interns, a resident, and an attending physician. We were not able to determine whether patients' ratings were influenced by a specific member of the team, nor how ratings may have been influenced by certain characteristics of that team member (eg, year of training, prior communication skills training, race or gender concordance, etc).

In summary, by surveying patients soon after an acute care hospitalization, we determined that certain areas held room for improvement, such as consideration of patients' desire and ability to comply with treatment recommendations. Patients with inadequate health literacy reported lower quality physician‐patient communication on several domains. They expressed particular concern about physicians' use of medical terminology, not getting enough time to express their concerns, and not receiving clear enough explanations about the medical care. Efforts are needed to improve physicians' communication skills in these areas. Such training should be evaluated to determine if it has a beneficial effect on physician communication skills and patient outcomes.

Hospitalists have been suggested to offer rational and efficient medical care through specialized knowledge about inpatient care services.1 The goal that hospitalists will use care resources more efficiently presumes hospitalists' accurate knowledge about charges and costs.

Data regarding physicians' awareness of care charges and its impact upon care is limited. An international meta‐analysis of clinicians' awareness of pharmaceutical prices demonstrated poor accuracy of physicians' estimates of charges, but effects of increasing their knowledge remained unexamined.2 Continuous exposure to education and alerts about charges have been demonstrated to diminish physicians' unnecessary use of specific laboratory assays in a single teaching hospital, in a pediatric emergency department, and an outpatient primary care system; test use declined when physicians were alerted to test charges at the point‐of‐care without negative impact upon clinical outcomes; when the notices ceased, utilization climbed back towards baseline levels. Specific to inpatient care, a single‐center study evaluated the impact of price‐alerts upon laboratory and imaging use, but showed no effects.36

Applicability of these existing data for contemporary hospitalists are limited, and most data were collected before hospitalists developed as an organized focus of practice. A review of existing literature revealed no published data demonstrating hospitalists' higher expert awareness of charges generated by inpatient care. Published comparisons of the care expense generated by hospitalists' care versus that of general internists or academic teams have shown minimal and inconsistent effects.79 Those data showing reduced costs from hospitalists were associated with small length‐of‐stay reductions, rather than more expert resource utilization.7 We measured the accuracy and precision of hospitalist's estimates of charges associated with services commonly used in inpatient care.

Setting

Two community‐based private, academic‐affiliated hospitals operated by a not‐for‐profit health system in Washington State, comprising together 895 inpatient beds. The questionnaire instrument was approved by the governing Institutional Review Board (IRB).

Methods

A list of true charges for 14 services, procedures, tests, and physician charges commonly ordered by adult medicine hospitalists was acquired directly from the responsible departments of a multi‐hospital system operated by a single non‐profit entity using a unified chargemaster. Specifically, we acquired the charge that a hypothetical self‐paying patient would receive for each service, excluding any adjustments exercised by other payer sources. The list of charges was reported to the organization's financial officers for affirmation. Physician charges were standardized to geographically‐adjusted Medicare charges obtained directly from the American Medical Assocation's online Common Procedural Terminology tool.10 A cross‐section of hospitalists (n = 25) was surveyed from a private hospitalist group and an academically‐affiliated hospitalist service. Hospitalists included US and international medical graduates, new‐graduates from residency training and clinicians with a range of prior experiences in academic centers, government hospital systems, and private primary care. Respondents were asked to estimate to the nearest dollar the billing charge that a hypothetical self‐pay patient would receive for each care item. Direct data collection was arranged through the groups' medical directors and occurred in the hospitalist groups' regular business meetings. The design gathered no data on individual characteristics of respondents such as domestic or international education, sex, age, or time in practice, nor from which practice‐group a given respondent originated, to affirm to participants that their responses could not be used to imply performance measures or quality profiles.

Findings

Hospitalists tended to rank the expense of items in essentially the correct order, as reflected by the rough trend of rising estimates compared to true‐charges (Figure 1). Of note, we did not ask hospitalists to discern the different charges of 2 appropriate competing clinical choices, but asked for estimated prices of diverse services. The range of respondents' estimates about each item was broad. The mean‐value of hospitalists' estimates for each care item was less revealing than the range and diversity of estimates about each care item. Accuracy of hospitalists' estimates of charges was poor. Only 10.8% of hospitalists' estimates were within 10% of the actual unadjusted charge, 17.8% within 20% of that charge, and 24.8% were within a 30% margin of accuracy. Summary results are presented (Table 1). Pearson's r correlation value between the unadjusted charges and the estimates made by hospitalists was 0.548, a coefficient of determination equal to 0.300. Thus, the true charges list we obtained had only a low‐grade association with hospitalists' estimates (Figure 1). Hospitalists' estimates about the charges of relatively‐expensive items (abdominal computed tomography [CT]) overlapped with their estimates about the least‐expensive items (such as a urine culture ). Inter‐hospitalist agreement about charges associated with each care item was also low; estimates for each care item charge varied over logarithmic orders of magnitude.

Figure 1

Discussion

To date, hospitalist programs have shown little impact upon care costs when compared with other inpatient care staffing models. One limiting factor may be the opacity of medical care pricing. Patients have been demonstrated to have little access to knowledge of what care will cost them and complex barriers prevent them from gaining pricing information.11, 12 Hospitalists may be conjectured to serve as expert sources on the costs and values of medical care services on behalf of inpatients, but our observations suggest that hospitalists' actual knowledge of patient‐charges is lacking. The opacity of US medical prices to patients appears to extend to hospital‐care physicians as well. We observe that no widespread mechanism exists by which hospitalists would be well‐positioned to become informed about the actual charges their patients receive. Unadjusted chargemaster lists are generally restricted information, and would be difficult to access outside of participation in the charge‐notifications used in the existing studies cited above.

The inquiry was specifically limited to how closely hospitalists' estimates of the unadjusted charges for some commonly‐ordered items compare to the actual unadjusted chargemaster at their own institutions. We did not assess the hospitalists' perceptions about the accuracy of their estimates, nor the impact of specific hospitalist characteristics upon accuracy. Our sample's representation of the larger national population of hospital physicians is not established, but engenders no expectation that these clinicians' charge‐awareness is substantively different from that of hospitalists in most other institutions. It is not known what specific clinician or practice‐setting characteristics will direct charge‐awareness, or will influence the impact of charge‐awareness upon clinical practices.

The range of estimates different hospitalists made about the same care items in the same facilities was very broad, which argues that respondents did not estimate charges based upon a different knowledge base of which the investigators were unaware. This is important because our use of unadjusted charges to self‐pay patients as true prices is necessarily somewhat arbitrary. Chargemaster price may not reflect the institution's cost of performing the service, the different prices paid for a single service by different payer sources, nor reflect services' true value based upon outcomes. However, recognizing that these actual prices are somewhat artificial, the use of these prices suffices for the current inquiry, and does not negate our findings of hospitalists' low accuracy and low agreement. Also noteworthy, an unadjusted chargemaster can often represent the charges received by those uninsured US patients for whom payer‐source adjustment is inaccessible, and informs downstream accounting such as the value of unpaid care a hospital delivers annually.

The most immediate matter for examination among hospitalists is what effects increased charge‐awareness may exert upon clinical decisions and practice processes. It appears that the premise that hospitalists' exercise expert knowledge of costs is likely not valid; but it is unknown whether accurate charge‐awareness among hospitalists will improve cost‐reductions by hospitalists. In some payer‐arrangements, accurate charge‐awareness might engender reduced care quantity, rather than increased efficiency or quality. The impact of upgrading hospitalists' knowledge about the charges and costs they generate, and the most effective method to do so, is worthy of investigation; based upon this initial data we encourage and are undertaking a larger‐scale study and exploration of the effects of enhanced hospitalist charge‐awareness.

Conclusion

Hospitalists have low awareness of the charges associated with inpatient care. The opacity of hospital care pricing to patient populations extends also to hospitalist physicians. Hospitalists likely do not improve cost‐efficiency through expert knowledge of services' costs to patients. Education and reminder systems to apprise hospitalists of charges should be examined as possible tools to optimize the use of inpatient care resources.

Hospitalists have been suggested to offer rational and efficient medical care through specialized knowledge about inpatient care services.1 The goal that hospitalists will use care resources more efficiently presumes hospitalists' accurate knowledge about charges and costs.

Data regarding physicians' awareness of care charges and its impact upon care is limited. An international meta‐analysis of clinicians' awareness of pharmaceutical prices demonstrated poor accuracy of physicians' estimates of charges, but effects of increasing their knowledge remained unexamined.2 Continuous exposure to education and alerts about charges have been demonstrated to diminish physicians' unnecessary use of specific laboratory assays in a single teaching hospital, in a pediatric emergency department, and an outpatient primary care system; test use declined when physicians were alerted to test charges at the point‐of‐care without negative impact upon clinical outcomes; when the notices ceased, utilization climbed back towards baseline levels. Specific to inpatient care, a single‐center study evaluated the impact of price‐alerts upon laboratory and imaging use, but showed no effects.36

Applicability of these existing data for contemporary hospitalists are limited, and most data were collected before hospitalists developed as an organized focus of practice. A review of existing literature revealed no published data demonstrating hospitalists' higher expert awareness of charges generated by inpatient care. Published comparisons of the care expense generated by hospitalists' care versus that of general internists or academic teams have shown minimal and inconsistent effects.79 Those data showing reduced costs from hospitalists were associated with small length‐of‐stay reductions, rather than more expert resource utilization.7 We measured the accuracy and precision of hospitalist's estimates of charges associated with services commonly used in inpatient care.

Setting

Two community‐based private, academic‐affiliated hospitals operated by a not‐for‐profit health system in Washington State, comprising together 895 inpatient beds. The questionnaire instrument was approved by the governing Institutional Review Board (IRB).

Methods

A list of true charges for 14 services, procedures, tests, and physician charges commonly ordered by adult medicine hospitalists was acquired directly from the responsible departments of a multi‐hospital system operated by a single non‐profit entity using a unified chargemaster. Specifically, we acquired the charge that a hypothetical self‐paying patient would receive for each service, excluding any adjustments exercised by other payer sources. The list of charges was reported to the organization's financial officers for affirmation. Physician charges were standardized to geographically‐adjusted Medicare charges obtained directly from the American Medical Assocation's online Common Procedural Terminology tool.10 A cross‐section of hospitalists (n = 25) was surveyed from a private hospitalist group and an academically‐affiliated hospitalist service. Hospitalists included US and international medical graduates, new‐graduates from residency training and clinicians with a range of prior experiences in academic centers, government hospital systems, and private primary care. Respondents were asked to estimate to the nearest dollar the billing charge that a hypothetical self‐pay patient would receive for each care item. Direct data collection was arranged through the groups' medical directors and occurred in the hospitalist groups' regular business meetings. The design gathered no data on individual characteristics of respondents such as domestic or international education, sex, age, or time in practice, nor from which practice‐group a given respondent originated, to affirm to participants that their responses could not be used to imply performance measures or quality profiles.

Findings

Hospitalists tended to rank the expense of items in essentially the correct order, as reflected by the rough trend of rising estimates compared to true‐charges (Figure 1). Of note, we did not ask hospitalists to discern the different charges of 2 appropriate competing clinical choices, but asked for estimated prices of diverse services. The range of respondents' estimates about each item was broad. The mean‐value of hospitalists' estimates for each care item was less revealing than the range and diversity of estimates about each care item. Accuracy of hospitalists' estimates of charges was poor. Only 10.8% of hospitalists' estimates were within 10% of the actual unadjusted charge, 17.8% within 20% of that charge, and 24.8% were within a 30% margin of accuracy. Summary results are presented (Table 1). Pearson's r correlation value between the unadjusted charges and the estimates made by hospitalists was 0.548, a coefficient of determination equal to 0.300. Thus, the true charges list we obtained had only a low‐grade association with hospitalists' estimates (Figure 1). Hospitalists' estimates about the charges of relatively‐expensive items (abdominal computed tomography [CT]) overlapped with their estimates about the least‐expensive items (such as a urine culture ). Inter‐hospitalist agreement about charges associated with each care item was also low; estimates for each care item charge varied over logarithmic orders of magnitude.

Figure 1

Discussion

To date, hospitalist programs have shown little impact upon care costs when compared with other inpatient care staffing models. One limiting factor may be the opacity of medical care pricing. Patients have been demonstrated to have little access to knowledge of what care will cost them and complex barriers prevent them from gaining pricing information.11, 12 Hospitalists may be conjectured to serve as expert sources on the costs and values of medical care services on behalf of inpatients, but our observations suggest that hospitalists' actual knowledge of patient‐charges is lacking. The opacity of US medical prices to patients appears to extend to hospital‐care physicians as well. We observe that no widespread mechanism exists by which hospitalists would be well‐positioned to become informed about the actual charges their patients receive. Unadjusted chargemaster lists are generally restricted information, and would be difficult to access outside of participation in the charge‐notifications used in the existing studies cited above.

The inquiry was specifically limited to how closely hospitalists' estimates of the unadjusted charges for some commonly‐ordered items compare to the actual unadjusted chargemaster at their own institutions. We did not assess the hospitalists' perceptions about the accuracy of their estimates, nor the impact of specific hospitalist characteristics upon accuracy. Our sample's representation of the larger national population of hospital physicians is not established, but engenders no expectation that these clinicians' charge‐awareness is substantively different from that of hospitalists in most other institutions. It is not known what specific clinician or practice‐setting characteristics will direct charge‐awareness, or will influence the impact of charge‐awareness upon clinical practices.

The range of estimates different hospitalists made about the same care items in the same facilities was very broad, which argues that respondents did not estimate charges based upon a different knowledge base of which the investigators were unaware. This is important because our use of unadjusted charges to self‐pay patients as true prices is necessarily somewhat arbitrary. Chargemaster price may not reflect the institution's cost of performing the service, the different prices paid for a single service by different payer sources, nor reflect services' true value based upon outcomes. However, recognizing that these actual prices are somewhat artificial, the use of these prices suffices for the current inquiry, and does not negate our findings of hospitalists' low accuracy and low agreement. Also noteworthy, an unadjusted chargemaster can often represent the charges received by those uninsured US patients for whom payer‐source adjustment is inaccessible, and informs downstream accounting such as the value of unpaid care a hospital delivers annually.

The most immediate matter for examination among hospitalists is what effects increased charge‐awareness may exert upon clinical decisions and practice processes. It appears that the premise that hospitalists' exercise expert knowledge of costs is likely not valid; but it is unknown whether accurate charge‐awareness among hospitalists will improve cost‐reductions by hospitalists. In some payer‐arrangements, accurate charge‐awareness might engender reduced care quantity, rather than increased efficiency or quality. The impact of upgrading hospitalists' knowledge about the charges and costs they generate, and the most effective method to do so, is worthy of investigation; based upon this initial data we encourage and are undertaking a larger‐scale study and exploration of the effects of enhanced hospitalist charge‐awareness.

Conclusion

Hospitalists have low awareness of the charges associated with inpatient care. The opacity of hospital care pricing to patient populations extends also to hospitalist physicians. Hospitalists likely do not improve cost‐efficiency through expert knowledge of services' costs to patients. Education and reminder systems to apprise hospitalists of charges should be examined as possible tools to optimize the use of inpatient care resources.

Hospitalists have been suggested to offer rational and efficient medical care through specialized knowledge about inpatient care services.1 The goal that hospitalists will use care resources more efficiently presumes hospitalists' accurate knowledge about charges and costs.

Data regarding physicians' awareness of care charges and its impact upon care is limited. An international meta‐analysis of clinicians' awareness of pharmaceutical prices demonstrated poor accuracy of physicians' estimates of charges, but effects of increasing their knowledge remained unexamined.2 Continuous exposure to education and alerts about charges have been demonstrated to diminish physicians' unnecessary use of specific laboratory assays in a single teaching hospital, in a pediatric emergency department, and an outpatient primary care system; test use declined when physicians were alerted to test charges at the point‐of‐care without negative impact upon clinical outcomes; when the notices ceased, utilization climbed back towards baseline levels. Specific to inpatient care, a single‐center study evaluated the impact of price‐alerts upon laboratory and imaging use, but showed no effects.36

Applicability of these existing data for contemporary hospitalists are limited, and most data were collected before hospitalists developed as an organized focus of practice. A review of existing literature revealed no published data demonstrating hospitalists' higher expert awareness of charges generated by inpatient care. Published comparisons of the care expense generated by hospitalists' care versus that of general internists or academic teams have shown minimal and inconsistent effects.79 Those data showing reduced costs from hospitalists were associated with small length‐of‐stay reductions, rather than more expert resource utilization.7 We measured the accuracy and precision of hospitalist's estimates of charges associated with services commonly used in inpatient care.

Setting

Two community‐based private, academic‐affiliated hospitals operated by a not‐for‐profit health system in Washington State, comprising together 895 inpatient beds. The questionnaire instrument was approved by the governing Institutional Review Board (IRB).

Methods

A list of true charges for 14 services, procedures, tests, and physician charges commonly ordered by adult medicine hospitalists was acquired directly from the responsible departments of a multi‐hospital system operated by a single non‐profit entity using a unified chargemaster. Specifically, we acquired the charge that a hypothetical self‐paying patient would receive for each service, excluding any adjustments exercised by other payer sources. The list of charges was reported to the organization's financial officers for affirmation. Physician charges were standardized to geographically‐adjusted Medicare charges obtained directly from the American Medical Assocation's online Common Procedural Terminology tool.10 A cross‐section of hospitalists (n = 25) was surveyed from a private hospitalist group and an academically‐affiliated hospitalist service. Hospitalists included US and international medical graduates, new‐graduates from residency training and clinicians with a range of prior experiences in academic centers, government hospital systems, and private primary care. Respondents were asked to estimate to the nearest dollar the billing charge that a hypothetical self‐pay patient would receive for each care item. Direct data collection was arranged through the groups' medical directors and occurred in the hospitalist groups' regular business meetings. The design gathered no data on individual characteristics of respondents such as domestic or international education, sex, age, or time in practice, nor from which practice‐group a given respondent originated, to affirm to participants that their responses could not be used to imply performance measures or quality profiles.

Findings

Hospitalists tended to rank the expense of items in essentially the correct order, as reflected by the rough trend of rising estimates compared to true‐charges (Figure 1). Of note, we did not ask hospitalists to discern the different charges of 2 appropriate competing clinical choices, but asked for estimated prices of diverse services. The range of respondents' estimates about each item was broad. The mean‐value of hospitalists' estimates for each care item was less revealing than the range and diversity of estimates about each care item. Accuracy of hospitalists' estimates of charges was poor. Only 10.8% of hospitalists' estimates were within 10% of the actual unadjusted charge, 17.8% within 20% of that charge, and 24.8% were within a 30% margin of accuracy. Summary results are presented (Table 1). Pearson's r correlation value between the unadjusted charges and the estimates made by hospitalists was 0.548, a coefficient of determination equal to 0.300. Thus, the true charges list we obtained had only a low‐grade association with hospitalists' estimates (Figure 1). Hospitalists' estimates about the charges of relatively‐expensive items (abdominal computed tomography [CT]) overlapped with their estimates about the least‐expensive items (such as a urine culture ). Inter‐hospitalist agreement about charges associated with each care item was also low; estimates for each care item charge varied over logarithmic orders of magnitude.

Figure 1

Discussion

To date, hospitalist programs have shown little impact upon care costs when compared with other inpatient care staffing models. One limiting factor may be the opacity of medical care pricing. Patients have been demonstrated to have little access to knowledge of what care will cost them and complex barriers prevent them from gaining pricing information.11, 12 Hospitalists may be conjectured to serve as expert sources on the costs and values of medical care services on behalf of inpatients, but our observations suggest that hospitalists' actual knowledge of patient‐charges is lacking. The opacity of US medical prices to patients appears to extend to hospital‐care physicians as well. We observe that no widespread mechanism exists by which hospitalists would be well‐positioned to become informed about the actual charges their patients receive. Unadjusted chargemaster lists are generally restricted information, and would be difficult to access outside of participation in the charge‐notifications used in the existing studies cited above.

The inquiry was specifically limited to how closely hospitalists' estimates of the unadjusted charges for some commonly‐ordered items compare to the actual unadjusted chargemaster at their own institutions. We did not assess the hospitalists' perceptions about the accuracy of their estimates, nor the impact of specific hospitalist characteristics upon accuracy. Our sample's representation of the larger national population of hospital physicians is not established, but engenders no expectation that these clinicians' charge‐awareness is substantively different from that of hospitalists in most other institutions. It is not known what specific clinician or practice‐setting characteristics will direct charge‐awareness, or will influence the impact of charge‐awareness upon clinical practices.

The range of estimates different hospitalists made about the same care items in the same facilities was very broad, which argues that respondents did not estimate charges based upon a different knowledge base of which the investigators were unaware. This is important because our use of unadjusted charges to self‐pay patients as true prices is necessarily somewhat arbitrary. Chargemaster price may not reflect the institution's cost of performing the service, the different prices paid for a single service by different payer sources, nor reflect services' true value based upon outcomes. However, recognizing that these actual prices are somewhat artificial, the use of these prices suffices for the current inquiry, and does not negate our findings of hospitalists' low accuracy and low agreement. Also noteworthy, an unadjusted chargemaster can often represent the charges received by those uninsured US patients for whom payer‐source adjustment is inaccessible, and informs downstream accounting such as the value of unpaid care a hospital delivers annually.

The most immediate matter for examination among hospitalists is what effects increased charge‐awareness may exert upon clinical decisions and practice processes. It appears that the premise that hospitalists' exercise expert knowledge of costs is likely not valid; but it is unknown whether accurate charge‐awareness among hospitalists will improve cost‐reductions by hospitalists. In some payer‐arrangements, accurate charge‐awareness might engender reduced care quantity, rather than increased efficiency or quality. The impact of upgrading hospitalists' knowledge about the charges and costs they generate, and the most effective method to do so, is worthy of investigation; based upon this initial data we encourage and are undertaking a larger‐scale study and exploration of the effects of enhanced hospitalist charge‐awareness.

Conclusion

Hospitalists have low awareness of the charges associated with inpatient care. The opacity of hospital care pricing to patient populations extends also to hospitalist physicians. Hospitalists likely do not improve cost‐efficiency through expert knowledge of services' costs to patients. Education and reminder systems to apprise hospitalists of charges should be examined as possible tools to optimize the use of inpatient care resources.

The demand for physician talent is intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures. Not only will 78 million retiring baby‐boomers require significant healthcare resources, but tens of thousands of practicing physicians will themselves reach retirement age within the next decade.1 At the same time, factors like the large increase in the percentage of female physicians (who are more likely to work part time), the growth of nonpractice opportunities for MDs, and generational demands for greater worklife balance are creating a major supply‐demand mismatch within the physician workforce.2 In this demographic atmosphere, the ability to recruit and retain physician leaders confers tremendous value to healthcare enterprisesboth public and private. Recruiting and retaining strategies already weigh heavily in the most palpable shortage areas, like primary care, but the system faces widespread unmet demand for a variety of specialist and generalist practitioners.36

This article does not address the public policy implications of the upcoming physician shortage, recognition of which will lead to the largest increase in new medical school slots in decades.7 Rather, we set out to illustrate how successful nonmedical businesses are embracing a thoughtful, systematic approach to retaining talent, based on the philosophy that keeping and engaging valued employees is more efficient than recruiting and orienting replacements. We posit that the innovations used by progressive companies could apply to recruitment and retention challenges confronting medicine.

How Industry Approaches the Talent Vacuum: Talent Facilitation

Leaders outside of medicine have long acknowledged that changing demographics and a global economy are driving unprecedented employee turnover.8 In confronting a talent vacuum, forward‐thinking managers have prioritized retaining key talent (rather than hiring anew) in planning for the future.9, 10 Doing so begins with attempts to understand the relationship between workers and the workplace, with a particular emphasis on appreciating workers' priorities. Indeed, new executive positions with titles like Chief Learning Officer and Chief Experience Officer are appearing as companies realize a need for focused expertise beyond traditional human resource departments. These companies understand that offering higher salaries is not the only retention strategyand often not even the most effective one.

The Four Actions of Talent Facilitation

The talent facilitation process centers on four actions: attract, engage, develop, and retain. None of these actions can stand alone, and all should be present, to some degree, at all stages of a worker's tenure. To attract or engage an employee or practice partner is not a 1‐time hook, but a constant and dynamic process.

Importantly, the concepts addressed here are not specific to 1 type of corporate system, size, or management level. Although the early business focus had been on upper‐level and executive talent within large corporate settings, there is an increasing recognition that a dedicated talent strategy is useful wherever recruiting and retaining talented people is important (and where is it not?).

The ideas presented here may seem most applicable to leaders of large physician corporations, hospital‐owned physician groups, or large integrated healthcare systems (such as Kaiser) that employ physicians. However, we also believe that the ideas apply across‐the‐board in medicine, including entities such as small, private, physician‐owned groups. We argue that regardless of the exact practice structure, a limited pool of resources must be dedicated to the attraction and retention of talented partners or employees, or to the cost of replacing those people if they pursue other opportunities (or the cost of inefficient and disengaged physicians). While an integrated health system may have the resources and scale to hire a Chief Experience Officer, we do not anticipate that a 5‐partner private practice would. Rather, we point to examples to illustrate the talent facilitation paradigm as a tool to systematically frame the allocation of those resources. Undoubtedly, the specific shape of a thoughtful talent facilitation effort will vary when applied in a large urban academic medical center vs. an integrated healthcare system vs. a small physician private practice, but the basic principles remain the same.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1

Lessons From Industry

Doctors frequently assume that the challenges and obstacles confronted in healthcare are unique to medicine. But, for every phrase like When I started practice, I decided how long office visits were, not the insurance company, or Young doctors just don't want to work as hard, there is a parallel utterance in the greater business world. Luckily, there are now examples of the healthcare world learning lessons from business. For example, innovators in medical quality improvement found value in the experience of other industries.20 Airlines and automakers have long honed systems for error prevention and possess expertise that may curb errors in the hospital.2123

We suspect that the ideas and practice of talent facilitation have already made their way into some medical settings. A Google search reveals multiple opportunities for hospital‐based talent managers, and websites advertise the availability of talent consultants ready to lend their expertise to the medical world. In the arena of academic medicine, the University of California, San Francisco (UCSF) Division of Hospital Medicine put some of the ideas of talent facilitation into practice over the past year, in part in response to an increasingly competitive market for academic hospitalists.24 Leaders introduced a formal faculty development program that links junior faculty with mentors and facilitates early and frequent feedback across hierarchical boundaries.25 These more intentional mentoring efforts were accompanied by a seminar series aimed at the needs of new faculty members, a research incubator program, divisional grand rounds, and other web‐based and in‐person forums for sharing best practices and innovations. Less formal social events have also been promoted. Importantly, these sweeping strategies seek to encompass the needs of both teaching and nonteaching hospitalists within UCSF.26

Clearly, an academic hospitalist group with 45 faculty physicians has unique characteristics that inform the specifics of its talent facilitation strategy. The interventions discussed above are meant to represent examples of the types of strategies that may be utilized by physician groups once a decision is made to focus on talent management. Undoubtedly, the shape of such efforts will vary in diverse practice settings, but physician leaders have much to gain through further exploration of where these core principles already exist within medicine and where they may be more effectively deployed. By examining how multinational businesses are systematically applying the concepts of talent facilitation to address a global talent shortage, the doctoring profession might again take an outside hint to help inform its future.

The demand for physician talent is intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures. Not only will 78 million retiring baby‐boomers require significant healthcare resources, but tens of thousands of practicing physicians will themselves reach retirement age within the next decade.1 At the same time, factors like the large increase in the percentage of female physicians (who are more likely to work part time), the growth of nonpractice opportunities for MDs, and generational demands for greater worklife balance are creating a major supply‐demand mismatch within the physician workforce.2 In this demographic atmosphere, the ability to recruit and retain physician leaders confers tremendous value to healthcare enterprisesboth public and private. Recruiting and retaining strategies already weigh heavily in the most palpable shortage areas, like primary care, but the system faces widespread unmet demand for a variety of specialist and generalist practitioners.36

This article does not address the public policy implications of the upcoming physician shortage, recognition of which will lead to the largest increase in new medical school slots in decades.7 Rather, we set out to illustrate how successful nonmedical businesses are embracing a thoughtful, systematic approach to retaining talent, based on the philosophy that keeping and engaging valued employees is more efficient than recruiting and orienting replacements. We posit that the innovations used by progressive companies could apply to recruitment and retention challenges confronting medicine.

How Industry Approaches the Talent Vacuum: Talent Facilitation

Leaders outside of medicine have long acknowledged that changing demographics and a global economy are driving unprecedented employee turnover.8 In confronting a talent vacuum, forward‐thinking managers have prioritized retaining key talent (rather than hiring anew) in planning for the future.9, 10 Doing so begins with attempts to understand the relationship between workers and the workplace, with a particular emphasis on appreciating workers' priorities. Indeed, new executive positions with titles like Chief Learning Officer and Chief Experience Officer are appearing as companies realize a need for focused expertise beyond traditional human resource departments. These companies understand that offering higher salaries is not the only retention strategyand often not even the most effective one.

The Four Actions of Talent Facilitation

The talent facilitation process centers on four actions: attract, engage, develop, and retain. None of these actions can stand alone, and all should be present, to some degree, at all stages of a worker's tenure. To attract or engage an employee or practice partner is not a 1‐time hook, but a constant and dynamic process.

Importantly, the concepts addressed here are not specific to 1 type of corporate system, size, or management level. Although the early business focus had been on upper‐level and executive talent within large corporate settings, there is an increasing recognition that a dedicated talent strategy is useful wherever recruiting and retaining talented people is important (and where is it not?).

The ideas presented here may seem most applicable to leaders of large physician corporations, hospital‐owned physician groups, or large integrated healthcare systems (such as Kaiser) that employ physicians. However, we also believe that the ideas apply across‐the‐board in medicine, including entities such as small, private, physician‐owned groups. We argue that regardless of the exact practice structure, a limited pool of resources must be dedicated to the attraction and retention of talented partners or employees, or to the cost of replacing those people if they pursue other opportunities (or the cost of inefficient and disengaged physicians). While an integrated health system may have the resources and scale to hire a Chief Experience Officer, we do not anticipate that a 5‐partner private practice would. Rather, we point to examples to illustrate the talent facilitation paradigm as a tool to systematically frame the allocation of those resources. Undoubtedly, the specific shape of a thoughtful talent facilitation effort will vary when applied in a large urban academic medical center vs. an integrated healthcare system vs. a small physician private practice, but the basic principles remain the same.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1

Lessons From Industry

Doctors frequently assume that the challenges and obstacles confronted in healthcare are unique to medicine. But, for every phrase like When I started practice, I decided how long office visits were, not the insurance company, or Young doctors just don't want to work as hard, there is a parallel utterance in the greater business world. Luckily, there are now examples of the healthcare world learning lessons from business. For example, innovators in medical quality improvement found value in the experience of other industries.20 Airlines and automakers have long honed systems for error prevention and possess expertise that may curb errors in the hospital.2123

We suspect that the ideas and practice of talent facilitation have already made their way into some medical settings. A Google search reveals multiple opportunities for hospital‐based talent managers, and websites advertise the availability of talent consultants ready to lend their expertise to the medical world. In the arena of academic medicine, the University of California, San Francisco (UCSF) Division of Hospital Medicine put some of the ideas of talent facilitation into practice over the past year, in part in response to an increasingly competitive market for academic hospitalists.24 Leaders introduced a formal faculty development program that links junior faculty with mentors and facilitates early and frequent feedback across hierarchical boundaries.25 These more intentional mentoring efforts were accompanied by a seminar series aimed at the needs of new faculty members, a research incubator program, divisional grand rounds, and other web‐based and in‐person forums for sharing best practices and innovations. Less formal social events have also been promoted. Importantly, these sweeping strategies seek to encompass the needs of both teaching and nonteaching hospitalists within UCSF.26

Clearly, an academic hospitalist group with 45 faculty physicians has unique characteristics that inform the specifics of its talent facilitation strategy. The interventions discussed above are meant to represent examples of the types of strategies that may be utilized by physician groups once a decision is made to focus on talent management. Undoubtedly, the shape of such efforts will vary in diverse practice settings, but physician leaders have much to gain through further exploration of where these core principles already exist within medicine and where they may be more effectively deployed. By examining how multinational businesses are systematically applying the concepts of talent facilitation to address a global talent shortage, the doctoring profession might again take an outside hint to help inform its future.

The demand for physician talent is intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures. Not only will 78 million retiring baby‐boomers require significant healthcare resources, but tens of thousands of practicing physicians will themselves reach retirement age within the next decade.1 At the same time, factors like the large increase in the percentage of female physicians (who are more likely to work part time), the growth of nonpractice opportunities for MDs, and generational demands for greater worklife balance are creating a major supply‐demand mismatch within the physician workforce.2 In this demographic atmosphere, the ability to recruit and retain physician leaders confers tremendous value to healthcare enterprisesboth public and private. Recruiting and retaining strategies already weigh heavily in the most palpable shortage areas, like primary care, but the system faces widespread unmet demand for a variety of specialist and generalist practitioners.36

This article does not address the public policy implications of the upcoming physician shortage, recognition of which will lead to the largest increase in new medical school slots in decades.7 Rather, we set out to illustrate how successful nonmedical businesses are embracing a thoughtful, systematic approach to retaining talent, based on the philosophy that keeping and engaging valued employees is more efficient than recruiting and orienting replacements. We posit that the innovations used by progressive companies could apply to recruitment and retention challenges confronting medicine.

How Industry Approaches the Talent Vacuum: Talent Facilitation

Leaders outside of medicine have long acknowledged that changing demographics and a global economy are driving unprecedented employee turnover.8 In confronting a talent vacuum, forward‐thinking managers have prioritized retaining key talent (rather than hiring anew) in planning for the future.9, 10 Doing so begins with attempts to understand the relationship between workers and the workplace, with a particular emphasis on appreciating workers' priorities. Indeed, new executive positions with titles like Chief Learning Officer and Chief Experience Officer are appearing as companies realize a need for focused expertise beyond traditional human resource departments. These companies understand that offering higher salaries is not the only retention strategyand often not even the most effective one.

The Four Actions of Talent Facilitation

The talent facilitation process centers on four actions: attract, engage, develop, and retain. None of these actions can stand alone, and all should be present, to some degree, at all stages of a worker's tenure. To attract or engage an employee or practice partner is not a 1‐time hook, but a constant and dynamic process.

Importantly, the concepts addressed here are not specific to 1 type of corporate system, size, or management level. Although the early business focus had been on upper‐level and executive talent within large corporate settings, there is an increasing recognition that a dedicated talent strategy is useful wherever recruiting and retaining talented people is important (and where is it not?).

The ideas presented here may seem most applicable to leaders of large physician corporations, hospital‐owned physician groups, or large integrated healthcare systems (such as Kaiser) that employ physicians. However, we also believe that the ideas apply across‐the‐board in medicine, including entities such as small, private, physician‐owned groups. We argue that regardless of the exact practice structure, a limited pool of resources must be dedicated to the attraction and retention of talented partners or employees, or to the cost of replacing those people if they pursue other opportunities (or the cost of inefficient and disengaged physicians). While an integrated health system may have the resources and scale to hire a Chief Experience Officer, we do not anticipate that a 5‐partner private practice would. Rather, we point to examples to illustrate the talent facilitation paradigm as a tool to systematically frame the allocation of those resources. Undoubtedly, the specific shape of a thoughtful talent facilitation effort will vary when applied in a large urban academic medical center vs. an integrated healthcare system vs. a small physician private practice, but the basic principles remain the same.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1

Lessons From Industry

Doctors frequently assume that the challenges and obstacles confronted in healthcare are unique to medicine. But, for every phrase like When I started practice, I decided how long office visits were, not the insurance company, or Young doctors just don't want to work as hard, there is a parallel utterance in the greater business world. Luckily, there are now examples of the healthcare world learning lessons from business. For example, innovators in medical quality improvement found value in the experience of other industries.20 Airlines and automakers have long honed systems for error prevention and possess expertise that may curb errors in the hospital.2123

We suspect that the ideas and practice of talent facilitation have already made their way into some medical settings. A Google search reveals multiple opportunities for hospital‐based talent managers, and websites advertise the availability of talent consultants ready to lend their expertise to the medical world. In the arena of academic medicine, the University of California, San Francisco (UCSF) Division of Hospital Medicine put some of the ideas of talent facilitation into practice over the past year, in part in response to an increasingly competitive market for academic hospitalists.24 Leaders introduced a formal faculty development program that links junior faculty with mentors and facilitates early and frequent feedback across hierarchical boundaries.25 These more intentional mentoring efforts were accompanied by a seminar series aimed at the needs of new faculty members, a research incubator program, divisional grand rounds, and other web‐based and in‐person forums for sharing best practices and innovations. Less formal social events have also been promoted. Importantly, these sweeping strategies seek to encompass the needs of both teaching and nonteaching hospitalists within UCSF.26

Clearly, an academic hospitalist group with 45 faculty physicians has unique characteristics that inform the specifics of its talent facilitation strategy. The interventions discussed above are meant to represent examples of the types of strategies that may be utilized by physician groups once a decision is made to focus on talent management. Undoubtedly, the shape of such efforts will vary in diverse practice settings, but physician leaders have much to gain through further exploration of where these core principles already exist within medicine and where they may be more effectively deployed. By examining how multinational businesses are systematically applying the concepts of talent facilitation to address a global talent shortage, the doctoring profession might again take an outside hint to help inform its future.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are responsible for more than 600,000 hospitalizations annually, resulting in direct costs of over $20 billion.1 Bacterial infections appear responsible for 50% of such exacerbations,25 and current COPD guidelines recommend treatment with antibiotics for patients with severe exacerbations or a change in sputum.1^,69 These recommendations are based on a number of small randomized trials, most of which were conducted more than 20 years ago using narrow spectrum antibiotics that are no longer commonly used.10 Only 4 studies, totaling 321 subjects, included hospitalized patients, and most studies excluded patients who required steroids. Because no clinical trials have compared different antibiotic regimens for AECOPD, existing guidelines offer a range of treatment options, including amoxicillin‐clavulonate, macrolides, quinolones, cephalosporins, aminopenicillins, and tetracyclines.

Among hospitalized patients, macrolides and quinolones appear to be the most frequently prescribed antibiotics.11 Both are available in oral formulations, have excellent bioavailability, and are administered once daily. In addition to their antimicrobial activity, macrolides are believed to have antiinflammatory effects, which could be especially advantageous in AECOPD.1214 In trials of chronic bronchitis, however, fluoroquinolones have been shown to reduce the risk of recurrent exacerbation when compared to macrolides.15 The wide variation that has been observed in antibiotic selection for patients hospitalized for AECOPD suggests a high degree of uncertainty among clinicians about the benefits of different treatment options.11 Given the limited evidence from randomized trials, we sought to evaluate the comparative effectiveness of macrolides and quinolones among a large, representative sample of patients hospitalized with AECOPD.

Subjects and Methods

Results

Of 26,248 AECOPD patients treated with antibiotics, 19,608 patients met the inclusion criteria; of these, 6139 (31%) were treated initially with a macrolide; the median age was 70 years; 60% were female; and 78% were white. A total of 86% of patients had a primary diagnosis of obstructive chronic bronchitis with acute exacerbation, and 6% had respiratory failure. The most common comorbidities were hypertension, diabetes, and congestive heart failure. Twenty‐two percent had been admitted at least once in the preceding 12 months. Treatment failure occurred in 7.7% of patients, and 1.3% died in the hospital. Mean length of stay was 4.8 days. Hospital prescribing rates for macrolides varied from 0% to 100%, with a mean of 33% and an interquartile range of 14% to 46% (Supporting Appendix Figure 1).

Compared to patients receiving macrolides, those receiving quinolones were older, more likely to have respiratory failure, to be cared for by a pulmonologist, and to have an admission in the previous year (Table 1). They were also more likely to be treated with bronchodilators, methylxanthines, steroids, diuretics, and noninvasive positive pressure ventilation, and to have an arterial blood gas, but less likely to receive concomitant treatment with a cephalosporin (11% vs. 57%). With the exception of cephalosporin treatment, these differences were small, but due to the large sample were statistically significant. Comorbidities were similar in both groups. Patients in the quinolone group were also more likely to experience treatment failure (8.1% vs. 6.8%), death (1.5% vs. 1.0%), and antibiotic‐associated diarrhea (1.1% vs. 0.5%).

In the unadjusted analysis, compared to patients receiving quinolones, those treated with macrolides were less likely to experience treatment failure (OR, 0.83; 95% CI, 0.740.94) (Table 2). Adjusting for all patient, hospital, and physician covariates, including the propensity for treatment with macrolides, increased the OR to 0.89 and the results were no longer significant (95% CI, 0.781.01). Propensity matching successfully balanced all measured covariates except for the use of short‐acting bronchodilators and additional antibiotics (Table 1). In the propensity‐matched sample (Figure 1), quinolone‐treated patients were more likely to experience antibiotic‐associated diarrhea (1.2% vs. 0.6%; P = 0.0003) and late mechanical ventilation (1.3% vs. 0.8%; P = 0.02). There were no differences in adjusted cost or length of stay between the 2 groups. The results of the grouped treatment analysis, substituting the hospital's specific rate of macrolide use in place of the actual treatment that each patient received suggested that the 2 antibiotics were associated with similar rates of treatment failure. The OR for a 100% hospital rate of macrolide treatment vs. a 0% rate was 1.01 (95% CI, 0.751.35).

Figure 1

Discussion

In this large observational study conducted at 375 hospitals, we took advantage of a natural experiment in which antibiotic prescribing patterns varied widely across hospitals to compare the effectiveness of 2 common antibiotic regimens for AECOPD. Treatment with macrolides and quinolones were associated with a similar risk of treatment failure, costs, and length of stay; however, patients treated with macrolides were less likely to experience late mechanical ventilation or treatment for antibiotic‐associated diarrhea.

Despite broad consensus in COPD guidelines that patients with severe acute exacerbations should receive antibiotics, there is little agreement about the preferred empiric agent. Controversy exists regarding antibiotics' comparative effectiveness, and even over which pathogens cause COPD exacerbations. Given the frequency of hospitalization for AECOPD, understanding the comparative effectiveness of treatments in this setting could have important implications for health outcomes and costs. Unfortunately, most antibiotic studies in AECOPD were conducted >20 years ago, using antibiotics that rarely appeared in our sample.26 Consequently, clinical practice guidelines offer conflicting recommendations. For example, the National Institute for Clinical Excellence recommends empirical treatment with an aminopenicillin, a macrolide, or a tetracycline,8 while the American Thoracic Society recommends amoxicillin‐clavulonate or a fluoroquinolone.9

As might be expected in light of so much uncertainty, we found wide variation in prescribing patterns across hospitals. Overall, approximately one‐third of patients received a macrolide and two‐thirds a quinolone. Both regimens provide adequate coverage of H. influenza, S. pneumoniae, and M. catarrhalis, and conform to at least 1 COPD guideline. Nevertheless, patients receiving macrolides often received a cephalosporin as well; this pattern of treatment suggests that antibiotic selection is likely to have been influenced more by guidelines for the treatment of community‐acquired pneumonia than COPD.

Previous studies comparing antibiotic effectiveness suffer from shortcomings that limit their application to patients hospitalized with AECOPD. First, they enrolled patients with chronic bronchitis, and included patients without obstructive lung disease, and most studies included patients as young as 18 years old. Second, many either did not include treatment with steroids or excluded patients receiving more than 10 mg of prednisone daily. Third, almost all enrolled only ambulatory patients.

While there are no studies comparing quinolones and macrolides in patients hospitalized for AECOPD, a meta‐analysis comparing quinolones, macrolides, and amoxicillin‐clavulonate identified 19 trials of ambulatory patients with chronic bronchitis. That study found that all 3 drugs had similar efficacy initially, but that quinolones resulted in the fewest relapses over a 26‐week period.27 Macrolides and quinolones had similar rates of adverse effects. In contrast, we did not find a difference in treatment failure, cost, or length of stay, but did find a higher rate of diarrhea associated with quinolones. Others have also documented an association between fluoroquinolones and C. difficile diarrhea.2830 This trend, first noted in 2001, is of particular concern because the fluoroquinolone‐resistant strains appear to be hypervirulent and have been associated with nosocomial epidemics.3134

Our study has several limitations. First, its observational design leaves open the possibility of selection bias. For this reason we analyzed our data in several ways, including using a grouped treatment approach, an adaptation of the instrumental variable technique, and accepted only those differences which were consistent across all models. Second, our study used claims data, and therefore we could not directly adjust for physiological measures of severity. However, the highly detailed nature of the data allowed us to adjust for numerous tests and treatments that reflected the clinician's assessment of the patient's severity, as well as the number of prior COPD admissions. Third, we cannot exclude the possibility that some patients may have had concurrent pneumonia without an ICD‐9 code. We think that the number would be small because reimbursement for pneumonia is generally higher than for COPD, so hospitals have an incentive to code pneumonia as the principal diagnosis when present. Finally, we compared initial antibiotics only. More than one‐quarter of our patients received an additional antibiotic before discharge. In particular, patients receiving macrolides were often prescribed a concomitant cephalosporin. We do not know to what extent these additional antibiotics may have affected the outcomes.

Despite the large number of patients hospitalized annually for AECOPD, there are no randomized trials comparing different antibiotics in this population. Studies comparing antibiotics in chronic bronchitis can offer little guidance, since they have primarily focused on proving equivalence between existing antibiotics and newer, more expensive formulations.35 Because many of the patients enrolled in such trials do not benefit from antibiotics at all, either because they do not have COPD or because their exacerbation is not caused by bacteria, it is relatively easy to prove equivalence. Given that AECOPD is one of the leading causes of hospitalization in the United States, large, randomized trials comparing the effectiveness of different antibiotics should be a high priority. In the meantime, macrolides (often given together with cephalosporins) and quinolones appear to be equally effective initial antibiotic choices; considering antibiotic‐associated diarrhea, macrolides appear to be the safer of the 2.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are responsible for more than 600,000 hospitalizations annually, resulting in direct costs of over $20 billion.1 Bacterial infections appear responsible for 50% of such exacerbations,25 and current COPD guidelines recommend treatment with antibiotics for patients with severe exacerbations or a change in sputum.1^,69 These recommendations are based on a number of small randomized trials, most of which were conducted more than 20 years ago using narrow spectrum antibiotics that are no longer commonly used.10 Only 4 studies, totaling 321 subjects, included hospitalized patients, and most studies excluded patients who required steroids. Because no clinical trials have compared different antibiotic regimens for AECOPD, existing guidelines offer a range of treatment options, including amoxicillin‐clavulonate, macrolides, quinolones, cephalosporins, aminopenicillins, and tetracyclines.

Among hospitalized patients, macrolides and quinolones appear to be the most frequently prescribed antibiotics.11 Both are available in oral formulations, have excellent bioavailability, and are administered once daily. In addition to their antimicrobial activity, macrolides are believed to have antiinflammatory effects, which could be especially advantageous in AECOPD.1214 In trials of chronic bronchitis, however, fluoroquinolones have been shown to reduce the risk of recurrent exacerbation when compared to macrolides.15 The wide variation that has been observed in antibiotic selection for patients hospitalized for AECOPD suggests a high degree of uncertainty among clinicians about the benefits of different treatment options.11 Given the limited evidence from randomized trials, we sought to evaluate the comparative effectiveness of macrolides and quinolones among a large, representative sample of patients hospitalized with AECOPD.

Subjects and Methods

Results

Of 26,248 AECOPD patients treated with antibiotics, 19,608 patients met the inclusion criteria; of these, 6139 (31%) were treated initially with a macrolide; the median age was 70 years; 60% were female; and 78% were white. A total of 86% of patients had a primary diagnosis of obstructive chronic bronchitis with acute exacerbation, and 6% had respiratory failure. The most common comorbidities were hypertension, diabetes, and congestive heart failure. Twenty‐two percent had been admitted at least once in the preceding 12 months. Treatment failure occurred in 7.7% of patients, and 1.3% died in the hospital. Mean length of stay was 4.8 days. Hospital prescribing rates for macrolides varied from 0% to 100%, with a mean of 33% and an interquartile range of 14% to 46% (Supporting Appendix Figure 1).

Compared to patients receiving macrolides, those receiving quinolones were older, more likely to have respiratory failure, to be cared for by a pulmonologist, and to have an admission in the previous year (Table 1). They were also more likely to be treated with bronchodilators, methylxanthines, steroids, diuretics, and noninvasive positive pressure ventilation, and to have an arterial blood gas, but less likely to receive concomitant treatment with a cephalosporin (11% vs. 57%). With the exception of cephalosporin treatment, these differences were small, but due to the large sample were statistically significant. Comorbidities were similar in both groups. Patients in the quinolone group were also more likely to experience treatment failure (8.1% vs. 6.8%), death (1.5% vs. 1.0%), and antibiotic‐associated diarrhea (1.1% vs. 0.5%).