Acknowledging striking deficiencies in the quality and safety of healthcare, the Institute of Medicine, policy makers, and payors have called for transformation of the US healthcare system.1 Public reporting of hospital performance is one key strategy for accelerating improvement2 and may improve quality in several ways. First, feedback about performance relative to peers may stimulate quality improvement activities by appealing to professionalism. Second, the desire to preserve one's reputation by not appearing on a list of poor performers may be a powerful incentive. Finally, patients and referring providers could use reports to select high‐quality hospitals, thereby shifting care from low‐quality to high‐quality hospitals and stimulating quality improvement efforts to maintain or enhance market share.

Almost 20 years after New York and Pennsylvania began reporting cardiac surgery outcomes,3 the evidence that public reporting improves healthcare quality is equivocal.4 Moreover, stakeholders have embraced public reporting to differing degrees. Public reporting does lead to greater engagement in quality improvement activities,58 and additional financial incentives provide modest incremental benefits.9 Purchasers, too, are starting to pay attention.10 In New York State, payors appear to contract more with high‐quality surgeons and avoid poorly performing outliers.11 Some payors are creating tiered systems, assigning higher patient copayments for hospitals with poor quality metrics. These new systems have not been rigorously studied and should raise concern among hospitals.12

In contrast to hospitals and payors, patients have been slow to embrace public reporting. In a survey of coronary artery bypass graft (CABG) patients in Pennsylvania, only 2% said that public reporting of mortality rates affected their decision making.13 Eight years later, only 11% of patients sought information about hospitals before deciding on elective major surgery,14 although a majority of patients in both studies expressed interest in the information. It is not clear whether recent proliferation of information on the internet will change patient behavior, but to date public reporting appears not to effect market share.5, 15, 16

Barriers to patients' use of public reporting include difficulty accessing the information, lack of trust, information that is not salient, and data that are difficult to interpret.17 In the absence of consensus on what or how to report, a growing number of organizations, including state and federal government, accrediting bodies, private foundations, and for‐profit companies report a variety of measures relating to structure, processes, and outcomes. Although these sites purport to target consumers, they sometimes offer conflicting information18 and are not easily interpreted by lay readers.19

To realize the benefits of public reporting, and minimize the unintended consequences, rating systems must report salient information in a way that is comprehensible to patients and trusted by the doctors who advise them. At the same time, they should be fair to hospitals and offer useful data for quality improvement. We offer 10 recommendations for improving the public reporting of healthcare quality information: 5 describing what to report and 5 detailing how it should be reported (Figure 1). We also examine 3 leading performance reporting programs to see how well they implement these recommendations.

Figure 1

Recommendations to Make Data Salient for Patients

Recommendations to Ensure That Data Reflects Hospital Quality

Discussion

The growing commitment to making hospital performance data public could transform the quality and safety of care in the US, introducing competition on quality and price and fostering informed consumer choice. To date, the promise of public reporting remains only partially fulfilled. Few hospitals have done more than comply with regulatory mandates and payer incentives, and consumers have failed to respond. To capture the full benefits of public reporting, we have made 10 recommendations to benefit patients and better engage hospitals. We suggest that reporting be patient‐centered, with an emphasis on making the data useful, meaningful, important, interpretable, and relevant. At the same time, hospitals, which are being judged on their performance, should have a level playing field, with measures that are timely, consistent, severity‐adjusted, evidence‐based, and which foster good clinical care. Of the 3 services we examined, Hospital Compare came closest to meeting these recommendations.

Although this blueprint for public reporting is easy to draft, it is challenging to implement. In particular, some of our suggestions, such as the one regarding risk adjustment, may not currently be feasible, because the complexity and cost of collecting clinical data, even in the era of electronic medical records, may be prohibitive. Until such data are readily available, it may be preferable to report nothing at all, rather than report data that are misleading. In the rush to make hospitals accountable, enthusiasm has often outstripped science,31 and several measures have had to be revised for unintended consequences.32

Any initiative to improve public reporting should have the buy‐in of all stakeholders, but particularly hospitals, which stand to benefit in several ways. By receiving regular feedback, they can focus on improving care, becoming better organizations. These improvements may be rewarded through direct compensation (pay‐for‐performance), decreased costs from complications, or increased market share. Hospitals will be more engaged if the data reflect actual quality, are adequately adjusted for severity, and acknowledge the role of chance. Otherwise, they will merely comply, or worse, look for opportunities to game the system. To succeed, public reporting needs to involve hospitals in establishing standards for reporting and validation, as well as auditing procedures to prevent fraud.33 The Hospital Quality Alliance (HQA, Washington, DC), a first step in this direction, at present has few measures. NSQIP (American College of Surgeons, Chicago, IL) is perhaps a better example of hospitals cooperating to set measurement standards to promote best‐practices. Public release of NSQIP data might accelerate progress. Alternatively, the National Quality Forum (NQF, Washington, DC) could expand its role from endorsing quality measures to include standardizing the way these measures are used in public reporting.

Still, if you build it, will they come? To date, public reporting has not been embraced by the public, despite its stated interest in the information. Several explanations could be offered. First, we may be presenting the wrong data. Process measures and mortality rates are important but represent abstract concepts for most patients. Surveys tell us that patients value most the experiences of other patients.14, 21 They want to know whether their pain will be controlled, whether the doctor will listen to them, whether the nurse will come when they call. The recent advent of the HCAHPS survey (AHRQ, Washington, DC) is another positive step. Stratifying the results by diagnosis and adding a few diagnosis‐specific questions would make HCAHPS even more valuable. Second, the data may not be readily available. Although most public reporting is done on the web, older patients who are deciding about hospitals may not have Internet access. Some reports are still proprietary, and cost could present another obstacle. Finally, even if freely‐available and patient‐centered, the results may not be interpretable by physicians, let alone patients.34

If public reporting is to succeed, it will require measures that better reflect patients' concerns. In order to collect the massive amounts of data required and present them in a timely fashion, better electronic record systems will be necessary. But these are no panacea; others have noted that the Department of Veterans Affairs, a leader in electronic records, still invests considerable time and money to review charts for NSQIP.35 Given the value that Americans place on transparency in other facets of their lives, it is clear that public reporting is here to stay. While much progress has been made over the past 5 years, additional research is needed to better measure quality from the patient's perspective, and to determine how this information can be used to help guide decision‐making, and to reward hospitals for offering the highest‐quality care.

Acknowledging striking deficiencies in the quality and safety of healthcare, the Institute of Medicine, policy makers, and payors have called for transformation of the US healthcare system.1 Public reporting of hospital performance is one key strategy for accelerating improvement2 and may improve quality in several ways. First, feedback about performance relative to peers may stimulate quality improvement activities by appealing to professionalism. Second, the desire to preserve one's reputation by not appearing on a list of poor performers may be a powerful incentive. Finally, patients and referring providers could use reports to select high‐quality hospitals, thereby shifting care from low‐quality to high‐quality hospitals and stimulating quality improvement efforts to maintain or enhance market share.

Almost 20 years after New York and Pennsylvania began reporting cardiac surgery outcomes,3 the evidence that public reporting improves healthcare quality is equivocal.4 Moreover, stakeholders have embraced public reporting to differing degrees. Public reporting does lead to greater engagement in quality improvement activities,58 and additional financial incentives provide modest incremental benefits.9 Purchasers, too, are starting to pay attention.10 In New York State, payors appear to contract more with high‐quality surgeons and avoid poorly performing outliers.11 Some payors are creating tiered systems, assigning higher patient copayments for hospitals with poor quality metrics. These new systems have not been rigorously studied and should raise concern among hospitals.12

In contrast to hospitals and payors, patients have been slow to embrace public reporting. In a survey of coronary artery bypass graft (CABG) patients in Pennsylvania, only 2% said that public reporting of mortality rates affected their decision making.13 Eight years later, only 11% of patients sought information about hospitals before deciding on elective major surgery,14 although a majority of patients in both studies expressed interest in the information. It is not clear whether recent proliferation of information on the internet will change patient behavior, but to date public reporting appears not to effect market share.5, 15, 16

Barriers to patients' use of public reporting include difficulty accessing the information, lack of trust, information that is not salient, and data that are difficult to interpret.17 In the absence of consensus on what or how to report, a growing number of organizations, including state and federal government, accrediting bodies, private foundations, and for‐profit companies report a variety of measures relating to structure, processes, and outcomes. Although these sites purport to target consumers, they sometimes offer conflicting information18 and are not easily interpreted by lay readers.19

To realize the benefits of public reporting, and minimize the unintended consequences, rating systems must report salient information in a way that is comprehensible to patients and trusted by the doctors who advise them. At the same time, they should be fair to hospitals and offer useful data for quality improvement. We offer 10 recommendations for improving the public reporting of healthcare quality information: 5 describing what to report and 5 detailing how it should be reported (Figure 1). We also examine 3 leading performance reporting programs to see how well they implement these recommendations.

Figure 1

Recommendations to Make Data Salient for Patients

Recommendations to Ensure That Data Reflects Hospital Quality

Discussion

The growing commitment to making hospital performance data public could transform the quality and safety of care in the US, introducing competition on quality and price and fostering informed consumer choice. To date, the promise of public reporting remains only partially fulfilled. Few hospitals have done more than comply with regulatory mandates and payer incentives, and consumers have failed to respond. To capture the full benefits of public reporting, we have made 10 recommendations to benefit patients and better engage hospitals. We suggest that reporting be patient‐centered, with an emphasis on making the data useful, meaningful, important, interpretable, and relevant. At the same time, hospitals, which are being judged on their performance, should have a level playing field, with measures that are timely, consistent, severity‐adjusted, evidence‐based, and which foster good clinical care. Of the 3 services we examined, Hospital Compare came closest to meeting these recommendations.

Although this blueprint for public reporting is easy to draft, it is challenging to implement. In particular, some of our suggestions, such as the one regarding risk adjustment, may not currently be feasible, because the complexity and cost of collecting clinical data, even in the era of electronic medical records, may be prohibitive. Until such data are readily available, it may be preferable to report nothing at all, rather than report data that are misleading. In the rush to make hospitals accountable, enthusiasm has often outstripped science,31 and several measures have had to be revised for unintended consequences.32

Any initiative to improve public reporting should have the buy‐in of all stakeholders, but particularly hospitals, which stand to benefit in several ways. By receiving regular feedback, they can focus on improving care, becoming better organizations. These improvements may be rewarded through direct compensation (pay‐for‐performance), decreased costs from complications, or increased market share. Hospitals will be more engaged if the data reflect actual quality, are adequately adjusted for severity, and acknowledge the role of chance. Otherwise, they will merely comply, or worse, look for opportunities to game the system. To succeed, public reporting needs to involve hospitals in establishing standards for reporting and validation, as well as auditing procedures to prevent fraud.33 The Hospital Quality Alliance (HQA, Washington, DC), a first step in this direction, at present has few measures. NSQIP (American College of Surgeons, Chicago, IL) is perhaps a better example of hospitals cooperating to set measurement standards to promote best‐practices. Public release of NSQIP data might accelerate progress. Alternatively, the National Quality Forum (NQF, Washington, DC) could expand its role from endorsing quality measures to include standardizing the way these measures are used in public reporting.

Still, if you build it, will they come? To date, public reporting has not been embraced by the public, despite its stated interest in the information. Several explanations could be offered. First, we may be presenting the wrong data. Process measures and mortality rates are important but represent abstract concepts for most patients. Surveys tell us that patients value most the experiences of other patients.14, 21 They want to know whether their pain will be controlled, whether the doctor will listen to them, whether the nurse will come when they call. The recent advent of the HCAHPS survey (AHRQ, Washington, DC) is another positive step. Stratifying the results by diagnosis and adding a few diagnosis‐specific questions would make HCAHPS even more valuable. Second, the data may not be readily available. Although most public reporting is done on the web, older patients who are deciding about hospitals may not have Internet access. Some reports are still proprietary, and cost could present another obstacle. Finally, even if freely‐available and patient‐centered, the results may not be interpretable by physicians, let alone patients.34

If public reporting is to succeed, it will require measures that better reflect patients' concerns. In order to collect the massive amounts of data required and present them in a timely fashion, better electronic record systems will be necessary. But these are no panacea; others have noted that the Department of Veterans Affairs, a leader in electronic records, still invests considerable time and money to review charts for NSQIP.35 Given the value that Americans place on transparency in other facets of their lives, it is clear that public reporting is here to stay. While much progress has been made over the past 5 years, additional research is needed to better measure quality from the patient's perspective, and to determine how this information can be used to help guide decision‐making, and to reward hospitals for offering the highest‐quality care.

Acknowledging striking deficiencies in the quality and safety of healthcare, the Institute of Medicine, policy makers, and payors have called for transformation of the US healthcare system.1 Public reporting of hospital performance is one key strategy for accelerating improvement2 and may improve quality in several ways. First, feedback about performance relative to peers may stimulate quality improvement activities by appealing to professionalism. Second, the desire to preserve one's reputation by not appearing on a list of poor performers may be a powerful incentive. Finally, patients and referring providers could use reports to select high‐quality hospitals, thereby shifting care from low‐quality to high‐quality hospitals and stimulating quality improvement efforts to maintain or enhance market share.

Almost 20 years after New York and Pennsylvania began reporting cardiac surgery outcomes,3 the evidence that public reporting improves healthcare quality is equivocal.4 Moreover, stakeholders have embraced public reporting to differing degrees. Public reporting does lead to greater engagement in quality improvement activities,58 and additional financial incentives provide modest incremental benefits.9 Purchasers, too, are starting to pay attention.10 In New York State, payors appear to contract more with high‐quality surgeons and avoid poorly performing outliers.11 Some payors are creating tiered systems, assigning higher patient copayments for hospitals with poor quality metrics. These new systems have not been rigorously studied and should raise concern among hospitals.12

In contrast to hospitals and payors, patients have been slow to embrace public reporting. In a survey of coronary artery bypass graft (CABG) patients in Pennsylvania, only 2% said that public reporting of mortality rates affected their decision making.13 Eight years later, only 11% of patients sought information about hospitals before deciding on elective major surgery,14 although a majority of patients in both studies expressed interest in the information. It is not clear whether recent proliferation of information on the internet will change patient behavior, but to date public reporting appears not to effect market share.5, 15, 16

Barriers to patients' use of public reporting include difficulty accessing the information, lack of trust, information that is not salient, and data that are difficult to interpret.17 In the absence of consensus on what or how to report, a growing number of organizations, including state and federal government, accrediting bodies, private foundations, and for‐profit companies report a variety of measures relating to structure, processes, and outcomes. Although these sites purport to target consumers, they sometimes offer conflicting information18 and are not easily interpreted by lay readers.19

To realize the benefits of public reporting, and minimize the unintended consequences, rating systems must report salient information in a way that is comprehensible to patients and trusted by the doctors who advise them. At the same time, they should be fair to hospitals and offer useful data for quality improvement. We offer 10 recommendations for improving the public reporting of healthcare quality information: 5 describing what to report and 5 detailing how it should be reported (Figure 1). We also examine 3 leading performance reporting programs to see how well they implement these recommendations.

Figure 1

Recommendations to Make Data Salient for Patients

Recommendations to Ensure That Data Reflects Hospital Quality

Discussion

The growing commitment to making hospital performance data public could transform the quality and safety of care in the US, introducing competition on quality and price and fostering informed consumer choice. To date, the promise of public reporting remains only partially fulfilled. Few hospitals have done more than comply with regulatory mandates and payer incentives, and consumers have failed to respond. To capture the full benefits of public reporting, we have made 10 recommendations to benefit patients and better engage hospitals. We suggest that reporting be patient‐centered, with an emphasis on making the data useful, meaningful, important, interpretable, and relevant. At the same time, hospitals, which are being judged on their performance, should have a level playing field, with measures that are timely, consistent, severity‐adjusted, evidence‐based, and which foster good clinical care. Of the 3 services we examined, Hospital Compare came closest to meeting these recommendations.

Although this blueprint for public reporting is easy to draft, it is challenging to implement. In particular, some of our suggestions, such as the one regarding risk adjustment, may not currently be feasible, because the complexity and cost of collecting clinical data, even in the era of electronic medical records, may be prohibitive. Until such data are readily available, it may be preferable to report nothing at all, rather than report data that are misleading. In the rush to make hospitals accountable, enthusiasm has often outstripped science,31 and several measures have had to be revised for unintended consequences.32

Any initiative to improve public reporting should have the buy‐in of all stakeholders, but particularly hospitals, which stand to benefit in several ways. By receiving regular feedback, they can focus on improving care, becoming better organizations. These improvements may be rewarded through direct compensation (pay‐for‐performance), decreased costs from complications, or increased market share. Hospitals will be more engaged if the data reflect actual quality, are adequately adjusted for severity, and acknowledge the role of chance. Otherwise, they will merely comply, or worse, look for opportunities to game the system. To succeed, public reporting needs to involve hospitals in establishing standards for reporting and validation, as well as auditing procedures to prevent fraud.33 The Hospital Quality Alliance (HQA, Washington, DC), a first step in this direction, at present has few measures. NSQIP (American College of Surgeons, Chicago, IL) is perhaps a better example of hospitals cooperating to set measurement standards to promote best‐practices. Public release of NSQIP data might accelerate progress. Alternatively, the National Quality Forum (NQF, Washington, DC) could expand its role from endorsing quality measures to include standardizing the way these measures are used in public reporting.

Still, if you build it, will they come? To date, public reporting has not been embraced by the public, despite its stated interest in the information. Several explanations could be offered. First, we may be presenting the wrong data. Process measures and mortality rates are important but represent abstract concepts for most patients. Surveys tell us that patients value most the experiences of other patients.14, 21 They want to know whether their pain will be controlled, whether the doctor will listen to them, whether the nurse will come when they call. The recent advent of the HCAHPS survey (AHRQ, Washington, DC) is another positive step. Stratifying the results by diagnosis and adding a few diagnosis‐specific questions would make HCAHPS even more valuable. Second, the data may not be readily available. Although most public reporting is done on the web, older patients who are deciding about hospitals may not have Internet access. Some reports are still proprietary, and cost could present another obstacle. Finally, even if freely‐available and patient‐centered, the results may not be interpretable by physicians, let alone patients.34

If public reporting is to succeed, it will require measures that better reflect patients' concerns. In order to collect the massive amounts of data required and present them in a timely fashion, better electronic record systems will be necessary. But these are no panacea; others have noted that the Department of Veterans Affairs, a leader in electronic records, still invests considerable time and money to review charts for NSQIP.35 Given the value that Americans place on transparency in other facets of their lives, it is clear that public reporting is here to stay. While much progress has been made over the past 5 years, additional research is needed to better measure quality from the patient's perspective, and to determine how this information can be used to help guide decision‐making, and to reward hospitals for offering the highest‐quality care.

An 89‐year‐old female presents to the Emergency Department with lower back pain for the past 5 days. The patient has a past medical history of polymyalgia rheumatica and hypothyroidism. Her medications include prednisone 10 mg daily and levothyroxine 50 g daily. Aside from tenderness over the third lumbar vertebra, her physical exam is unremarkable. An x‐ray shows a fracture of the third lumbar vertebra. Basic laboratory studies, including calcium and creatinine are normal.

The Clinical Problem and Impact

Vertebral fractures (often termed vertebral compression fractures) affect approximately 25% of all postmenopausal women.1, 2 Only one‐third of vertebral fractures are brought to medical attention.3, 4 In the remaining two‐thirds, patients are either asymptomatic or do not seek medical attention. The lifetime risk of a clinical vertebral fracture is approximately 16% and 5% in white women and men, respectively.1 The risk of vertebral fracture increases with age, lower bone mineral density (BMD), and prior vertebral fracture.1, 5 Women with a preexisting vertebral fracture have a 5‐fold increased risk for a new vertebral fracture relative to those without a history of vertebral fracture.5, 6 Approximately 20% of women who sustain a vertebral fracture will have a new vertebral fracture in the subsequent year.5, 6 Vertebral fractures are frequently overlooked on chest x‐rays and hence there is a need for increased awareness and improved recognition of radiographically‐demonstrated fractures.7 Hospitalists must appreciate that a vertebral fracture is often the first clue to underlying osteoporosis. At least 90% of vertebral and hip fractures are attributable to osteoporosis.5

Typically, the pain related to an acute vertebral fracture improves over 4 to 6 weeks.8, 9 However, pain can persist, resulting in functional impairment, and a decline in the quality of life.1013 Vertebral fractures may lead to kyphosis and reduced lung function. This, in turn, may increase the risk for pneumonia, the most common cause of death in patients with osteoporosis.4 Both clinical and subclinical vertebral fractures are, in fact, independently associated with increased mortality,4, 14, 15 particularly in the period immediately following the event.16 The economic impact of osteoporosis and its related fractures is substantial.1719 In 1995, the annual direct medical cost for the inpatient care of vertebral fractures was estimated to be $575 million.19

Evidence‐Based Approach to the Hospitalized Patient

Management

Short Term

Short‐term management goals include the relief of pain and recovery of mobility. Nonsteroidal antiinflammatory drugs (NSAIDs) and low‐dose opioid medications should be used first in an effort to relieve pain. Beyond its potential effect on bone density, calcitonin (Miacalcin, Fortical) has long been used in acute vertebral fractures for analgesia. A systematic review of 5 randomized controlled trials concluded that calcitonin significantly reduced the pain from acute vertebral fractures.27 Calcitonin improved pain as early as 1 week into treatment and the benefit was persistent at 4 weeks. The analgesic mechanism of action for calcitonin is not entirely clear. Proposed mechanisms include increased ‐endorphin release, an antiinflammatory effect, and a direct effect on specific receptors in the central nervous system.27, 28

Pamidronate (Aredia) also has shown efficacy at reducing acute fracture pain. In a double‐blinded trial, Armigeat et al.29 evaluated pamidronate 30 mg daily for 3 days as compared to placebo in 32 patients. Pain scores were improved at 7 and 30 days with pamidronate. The mechanism of analgesia is unclear. Bisphosphonates are known to inhibit osteoclast activity, but may also work by blocking the effect of inflammatory cytokines.29

Early pain relief is critical in order to encourage physical activity. Bed rest should be avoided, as immobility may increase the risk for pressure ulcers, venous thromboembolism, and pneumonia.3033 Although bracing is frequently used in acute vertebral fracture, the modality has not been formally studied. Although also not well studied in the acute setting, physical therapy has been shown to reduce pain and improve functioning for patients with chronic pain from vertebral fracture,34 and is generally recommended.35

Percutaneous vertebral augmentation procedures include vertebroplasty and kyphoplasty. In vertebroplasty, polymethylmethacrylate cement is injected through a needle under fluoroscopic guidance into the collapsed vertebral body. With kyphoplasty, balloon tamps are used to elevate vertebral endplates prior to injection of cement (Figure 1).36 The proposed mechanism of action for both procedures is stabilization of the fracture by the hardened polymethylmethacrylate cement. These procedures are commonly performed by interventional radiologists without the need for general anesthesia; however, depending on the institution, they may be done by orthopedic surgeons, neurosurgeons, or anesthesiologists. The procedure can be performed as an outpatient, if indicated. Although the volume of these procedures has grown dramatically in recent years,37, 38 the quality of evidence supporting their use is relatively weak.3941 Only 1 randomized controlled trial has been published evaluating the potential benefit of vertebroplasty over conservative management.42 Voormolen et al.42 evaluated patients with vertebral fractures and pain refractive to 6 weeks of optimal medical therapy. Patients were treated with vertebroplasty or continuation of medical therapy. Vertebroplasty significantly improved pain initially, but not after 2 weeks. Like the study by Voormolen et al.,42 most studies evaluating percutaneous vertebral augmentation procedures have been conducted on patients with long‐term pain refractory to medical management. One notable exception is a nonrandomized trial published by Diamond et al.6 In that study, 55 patients were treated with vertebroplasty while 24 were treated conservatively. Pain at 24 hours was significantly improved in patients treated with vertebroplasty. At 6 weeks, however, there was no difference among the 2 groups.

Figure 1

The risk of short‐term complications from vertebral augmentation procedures is difficult to assess in light of the small sample sizes and methodological limitations of existing studies. Cement leakage occurs in 40% to 41% of patients treated with vertebroplasty, as compared with 8% to 9% with kyphoplasty.39, 41 Pulmonary emboli occur in 0.6% and 0.01% of patients treated with vertebroplasty and kyphoplasty, respectively, while neurologic complications occur in 0.6% and 0.03% of patients.41 Concern exists about whether percutaneous vertebral augmentation procedures might increase the risk for subsequent fractures,43, 44 as the incidence of new fractures appears to be elevated in the period immediately following the procedure and approximately two‐thirds of new fractures occur in vertebrae adjacent to the augmented vertebra.39, 41, 44 However, the 20% incidence of new vertebral fractures in the year following vertebral augmentation is similar to the fracture rate seen in patients not treated with osteoporosis therapy.44

Assessment of the impact of vertebral augmentation procedures on the cost of care is limited by the lack of high‐quality clinical studies.45, 46 Randomized controlled trials evaluating the benefit and risk of these procedures compared to conservative management are underway.4749 Pending further evidence, these procedures are best reserved for patients who fail to benefit from other measures to control pain and improve mobility.

Long Term

A comprehensive discussion of the long‐term management of osteoporosis is beyond the scope of this work. However, the inpatient setting presents an opportune time to initiate long‐term medical therapy. Studies show that the majority of patients who sustain osteoporotic fractures do not receive pharmacologic treatment for osteoporosis.5053 Hospitalists have the opportunity to start medications that can reduce the risk for subsequent fracture by nearly 50%.5458 A total calcium intake of 1200 to 1500 mg per day and vitamin D of 400 to 800 IU per day are recommended for all postmenopausal women. Patients who smoke should receive smoking cessation counseling and be considered for pharmacologic treatment for tobacco dependence. All patients should be assessed for fall risk, including a review of medications and assessment of alcohol intake.

Before considering pharmacologic treatment for osteoporosis, secondary causes of low bone mass must be excluded. Bisphosphonates are generally considered first‐line pharmacologic therapy for osteoporosis. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) have been shown in randomized trials to increase bone density and reduce the risk of osteoporotic fractures.55, 56, 59 Daily, weekly, and monthly preparations of bisphosphonates now exist. Pill‐induced esophagitis is a potential adverse effect of bisphosphonate therapy, but is extremely rare if proper precautions are taken. Patients should take oral bisphosphonates on an empty stomach, with a full glass of water, sitting upright, and have nothing to eat or drink for at least one half hour. If compliance with oral bisphosphonates is not possible, or esophageal abnormalities preclude oral bisphosphonate use, one may consider the use of intravenous ibandronate or zoledronic acid (Reclast). A 3‐year randomized controlled trial of yearly zoledronic acid improved bone density and reduced the incidence of osteoporotic fractures.60 Bisphosphonates are generally not recommended when creatinine clearance is less than 30 mL/minute. Other pharmacologic options for the treatment of osteoporosis include selective estrogen receptor modulators and anabolic agents. The reader is referred to an excellent review by Rosen61 for additional discussion of these therapies. The American College of Rheumatology clinical guidelines for the management of glucocorticoid induced osteoporosis are also worthy of review.62

Hospitalists are naturally suited to improve the quality of care for patients hospitalized with vertebral fractures. Most patients who currently sustain osteoporotic fractures do not receive appropriate evaluation and treatment. One study used an interdisciplinary team to identify, assess, and begin treatment for appropriate patients hospitalized with osteoporotic fractures.63 The intervention resulted in significantly more patients taking osteoporosis treatment medications 6 months after the incident fracture.

Conclusions

Acute vertebral fracture is a common clinical problem associated with significant morbidity and increased risk of mortality. Treatment of vertebral fracture should include analgesics and physical therapy. Percutaneous augmentation procedures may be considered in patients who fail optimal medical therapy. Because most vertebral fractures are due to osteoporosis and the healthcare system currently fails to appropriately assess and treat most patients who have sustained osteoporotic fractures, hospitalists are in an optimal position to initiate long‐term preventative treatment for these patients.

An 89‐year‐old female presents to the Emergency Department with lower back pain for the past 5 days. The patient has a past medical history of polymyalgia rheumatica and hypothyroidism. Her medications include prednisone 10 mg daily and levothyroxine 50 g daily. Aside from tenderness over the third lumbar vertebra, her physical exam is unremarkable. An x‐ray shows a fracture of the third lumbar vertebra. Basic laboratory studies, including calcium and creatinine are normal.

The Clinical Problem and Impact

Vertebral fractures (often termed vertebral compression fractures) affect approximately 25% of all postmenopausal women.1, 2 Only one‐third of vertebral fractures are brought to medical attention.3, 4 In the remaining two‐thirds, patients are either asymptomatic or do not seek medical attention. The lifetime risk of a clinical vertebral fracture is approximately 16% and 5% in white women and men, respectively.1 The risk of vertebral fracture increases with age, lower bone mineral density (BMD), and prior vertebral fracture.1, 5 Women with a preexisting vertebral fracture have a 5‐fold increased risk for a new vertebral fracture relative to those without a history of vertebral fracture.5, 6 Approximately 20% of women who sustain a vertebral fracture will have a new vertebral fracture in the subsequent year.5, 6 Vertebral fractures are frequently overlooked on chest x‐rays and hence there is a need for increased awareness and improved recognition of radiographically‐demonstrated fractures.7 Hospitalists must appreciate that a vertebral fracture is often the first clue to underlying osteoporosis. At least 90% of vertebral and hip fractures are attributable to osteoporosis.5

Typically, the pain related to an acute vertebral fracture improves over 4 to 6 weeks.8, 9 However, pain can persist, resulting in functional impairment, and a decline in the quality of life.1013 Vertebral fractures may lead to kyphosis and reduced lung function. This, in turn, may increase the risk for pneumonia, the most common cause of death in patients with osteoporosis.4 Both clinical and subclinical vertebral fractures are, in fact, independently associated with increased mortality,4, 14, 15 particularly in the period immediately following the event.16 The economic impact of osteoporosis and its related fractures is substantial.1719 In 1995, the annual direct medical cost for the inpatient care of vertebral fractures was estimated to be $575 million.19

Evidence‐Based Approach to the Hospitalized Patient

Management

Short Term

Short‐term management goals include the relief of pain and recovery of mobility. Nonsteroidal antiinflammatory drugs (NSAIDs) and low‐dose opioid medications should be used first in an effort to relieve pain. Beyond its potential effect on bone density, calcitonin (Miacalcin, Fortical) has long been used in acute vertebral fractures for analgesia. A systematic review of 5 randomized controlled trials concluded that calcitonin significantly reduced the pain from acute vertebral fractures.27 Calcitonin improved pain as early as 1 week into treatment and the benefit was persistent at 4 weeks. The analgesic mechanism of action for calcitonin is not entirely clear. Proposed mechanisms include increased ‐endorphin release, an antiinflammatory effect, and a direct effect on specific receptors in the central nervous system.27, 28

Pamidronate (Aredia) also has shown efficacy at reducing acute fracture pain. In a double‐blinded trial, Armigeat et al.29 evaluated pamidronate 30 mg daily for 3 days as compared to placebo in 32 patients. Pain scores were improved at 7 and 30 days with pamidronate. The mechanism of analgesia is unclear. Bisphosphonates are known to inhibit osteoclast activity, but may also work by blocking the effect of inflammatory cytokines.29

Early pain relief is critical in order to encourage physical activity. Bed rest should be avoided, as immobility may increase the risk for pressure ulcers, venous thromboembolism, and pneumonia.3033 Although bracing is frequently used in acute vertebral fracture, the modality has not been formally studied. Although also not well studied in the acute setting, physical therapy has been shown to reduce pain and improve functioning for patients with chronic pain from vertebral fracture,34 and is generally recommended.35

Percutaneous vertebral augmentation procedures include vertebroplasty and kyphoplasty. In vertebroplasty, polymethylmethacrylate cement is injected through a needle under fluoroscopic guidance into the collapsed vertebral body. With kyphoplasty, balloon tamps are used to elevate vertebral endplates prior to injection of cement (Figure 1).36 The proposed mechanism of action for both procedures is stabilization of the fracture by the hardened polymethylmethacrylate cement. These procedures are commonly performed by interventional radiologists without the need for general anesthesia; however, depending on the institution, they may be done by orthopedic surgeons, neurosurgeons, or anesthesiologists. The procedure can be performed as an outpatient, if indicated. Although the volume of these procedures has grown dramatically in recent years,37, 38 the quality of evidence supporting their use is relatively weak.3941 Only 1 randomized controlled trial has been published evaluating the potential benefit of vertebroplasty over conservative management.42 Voormolen et al.42 evaluated patients with vertebral fractures and pain refractive to 6 weeks of optimal medical therapy. Patients were treated with vertebroplasty or continuation of medical therapy. Vertebroplasty significantly improved pain initially, but not after 2 weeks. Like the study by Voormolen et al.,42 most studies evaluating percutaneous vertebral augmentation procedures have been conducted on patients with long‐term pain refractory to medical management. One notable exception is a nonrandomized trial published by Diamond et al.6 In that study, 55 patients were treated with vertebroplasty while 24 were treated conservatively. Pain at 24 hours was significantly improved in patients treated with vertebroplasty. At 6 weeks, however, there was no difference among the 2 groups.

Figure 1

The risk of short‐term complications from vertebral augmentation procedures is difficult to assess in light of the small sample sizes and methodological limitations of existing studies. Cement leakage occurs in 40% to 41% of patients treated with vertebroplasty, as compared with 8% to 9% with kyphoplasty.39, 41 Pulmonary emboli occur in 0.6% and 0.01% of patients treated with vertebroplasty and kyphoplasty, respectively, while neurologic complications occur in 0.6% and 0.03% of patients.41 Concern exists about whether percutaneous vertebral augmentation procedures might increase the risk for subsequent fractures,43, 44 as the incidence of new fractures appears to be elevated in the period immediately following the procedure and approximately two‐thirds of new fractures occur in vertebrae adjacent to the augmented vertebra.39, 41, 44 However, the 20% incidence of new vertebral fractures in the year following vertebral augmentation is similar to the fracture rate seen in patients not treated with osteoporosis therapy.44

Assessment of the impact of vertebral augmentation procedures on the cost of care is limited by the lack of high‐quality clinical studies.45, 46 Randomized controlled trials evaluating the benefit and risk of these procedures compared to conservative management are underway.4749 Pending further evidence, these procedures are best reserved for patients who fail to benefit from other measures to control pain and improve mobility.

Long Term

A comprehensive discussion of the long‐term management of osteoporosis is beyond the scope of this work. However, the inpatient setting presents an opportune time to initiate long‐term medical therapy. Studies show that the majority of patients who sustain osteoporotic fractures do not receive pharmacologic treatment for osteoporosis.5053 Hospitalists have the opportunity to start medications that can reduce the risk for subsequent fracture by nearly 50%.5458 A total calcium intake of 1200 to 1500 mg per day and vitamin D of 400 to 800 IU per day are recommended for all postmenopausal women. Patients who smoke should receive smoking cessation counseling and be considered for pharmacologic treatment for tobacco dependence. All patients should be assessed for fall risk, including a review of medications and assessment of alcohol intake.

Before considering pharmacologic treatment for osteoporosis, secondary causes of low bone mass must be excluded. Bisphosphonates are generally considered first‐line pharmacologic therapy for osteoporosis. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) have been shown in randomized trials to increase bone density and reduce the risk of osteoporotic fractures.55, 56, 59 Daily, weekly, and monthly preparations of bisphosphonates now exist. Pill‐induced esophagitis is a potential adverse effect of bisphosphonate therapy, but is extremely rare if proper precautions are taken. Patients should take oral bisphosphonates on an empty stomach, with a full glass of water, sitting upright, and have nothing to eat or drink for at least one half hour. If compliance with oral bisphosphonates is not possible, or esophageal abnormalities preclude oral bisphosphonate use, one may consider the use of intravenous ibandronate or zoledronic acid (Reclast). A 3‐year randomized controlled trial of yearly zoledronic acid improved bone density and reduced the incidence of osteoporotic fractures.60 Bisphosphonates are generally not recommended when creatinine clearance is less than 30 mL/minute. Other pharmacologic options for the treatment of osteoporosis include selective estrogen receptor modulators and anabolic agents. The reader is referred to an excellent review by Rosen61 for additional discussion of these therapies. The American College of Rheumatology clinical guidelines for the management of glucocorticoid induced osteoporosis are also worthy of review.62

Hospitalists are naturally suited to improve the quality of care for patients hospitalized with vertebral fractures. Most patients who currently sustain osteoporotic fractures do not receive appropriate evaluation and treatment. One study used an interdisciplinary team to identify, assess, and begin treatment for appropriate patients hospitalized with osteoporotic fractures.63 The intervention resulted in significantly more patients taking osteoporosis treatment medications 6 months after the incident fracture.

Conclusions

Acute vertebral fracture is a common clinical problem associated with significant morbidity and increased risk of mortality. Treatment of vertebral fracture should include analgesics and physical therapy. Percutaneous augmentation procedures may be considered in patients who fail optimal medical therapy. Because most vertebral fractures are due to osteoporosis and the healthcare system currently fails to appropriately assess and treat most patients who have sustained osteoporotic fractures, hospitalists are in an optimal position to initiate long‐term preventative treatment for these patients.

An 89‐year‐old female presents to the Emergency Department with lower back pain for the past 5 days. The patient has a past medical history of polymyalgia rheumatica and hypothyroidism. Her medications include prednisone 10 mg daily and levothyroxine 50 g daily. Aside from tenderness over the third lumbar vertebra, her physical exam is unremarkable. An x‐ray shows a fracture of the third lumbar vertebra. Basic laboratory studies, including calcium and creatinine are normal.

The Clinical Problem and Impact

Vertebral fractures (often termed vertebral compression fractures) affect approximately 25% of all postmenopausal women.1, 2 Only one‐third of vertebral fractures are brought to medical attention.3, 4 In the remaining two‐thirds, patients are either asymptomatic or do not seek medical attention. The lifetime risk of a clinical vertebral fracture is approximately 16% and 5% in white women and men, respectively.1 The risk of vertebral fracture increases with age, lower bone mineral density (BMD), and prior vertebral fracture.1, 5 Women with a preexisting vertebral fracture have a 5‐fold increased risk for a new vertebral fracture relative to those without a history of vertebral fracture.5, 6 Approximately 20% of women who sustain a vertebral fracture will have a new vertebral fracture in the subsequent year.5, 6 Vertebral fractures are frequently overlooked on chest x‐rays and hence there is a need for increased awareness and improved recognition of radiographically‐demonstrated fractures.7 Hospitalists must appreciate that a vertebral fracture is often the first clue to underlying osteoporosis. At least 90% of vertebral and hip fractures are attributable to osteoporosis.5

Typically, the pain related to an acute vertebral fracture improves over 4 to 6 weeks.8, 9 However, pain can persist, resulting in functional impairment, and a decline in the quality of life.1013 Vertebral fractures may lead to kyphosis and reduced lung function. This, in turn, may increase the risk for pneumonia, the most common cause of death in patients with osteoporosis.4 Both clinical and subclinical vertebral fractures are, in fact, independently associated with increased mortality,4, 14, 15 particularly in the period immediately following the event.16 The economic impact of osteoporosis and its related fractures is substantial.1719 In 1995, the annual direct medical cost for the inpatient care of vertebral fractures was estimated to be $575 million.19

Evidence‐Based Approach to the Hospitalized Patient

Management

Short Term

Short‐term management goals include the relief of pain and recovery of mobility. Nonsteroidal antiinflammatory drugs (NSAIDs) and low‐dose opioid medications should be used first in an effort to relieve pain. Beyond its potential effect on bone density, calcitonin (Miacalcin, Fortical) has long been used in acute vertebral fractures for analgesia. A systematic review of 5 randomized controlled trials concluded that calcitonin significantly reduced the pain from acute vertebral fractures.27 Calcitonin improved pain as early as 1 week into treatment and the benefit was persistent at 4 weeks. The analgesic mechanism of action for calcitonin is not entirely clear. Proposed mechanisms include increased ‐endorphin release, an antiinflammatory effect, and a direct effect on specific receptors in the central nervous system.27, 28

Pamidronate (Aredia) also has shown efficacy at reducing acute fracture pain. In a double‐blinded trial, Armigeat et al.29 evaluated pamidronate 30 mg daily for 3 days as compared to placebo in 32 patients. Pain scores were improved at 7 and 30 days with pamidronate. The mechanism of analgesia is unclear. Bisphosphonates are known to inhibit osteoclast activity, but may also work by blocking the effect of inflammatory cytokines.29

Early pain relief is critical in order to encourage physical activity. Bed rest should be avoided, as immobility may increase the risk for pressure ulcers, venous thromboembolism, and pneumonia.3033 Although bracing is frequently used in acute vertebral fracture, the modality has not been formally studied. Although also not well studied in the acute setting, physical therapy has been shown to reduce pain and improve functioning for patients with chronic pain from vertebral fracture,34 and is generally recommended.35

Percutaneous vertebral augmentation procedures include vertebroplasty and kyphoplasty. In vertebroplasty, polymethylmethacrylate cement is injected through a needle under fluoroscopic guidance into the collapsed vertebral body. With kyphoplasty, balloon tamps are used to elevate vertebral endplates prior to injection of cement (Figure 1).36 The proposed mechanism of action for both procedures is stabilization of the fracture by the hardened polymethylmethacrylate cement. These procedures are commonly performed by interventional radiologists without the need for general anesthesia; however, depending on the institution, they may be done by orthopedic surgeons, neurosurgeons, or anesthesiologists. The procedure can be performed as an outpatient, if indicated. Although the volume of these procedures has grown dramatically in recent years,37, 38 the quality of evidence supporting their use is relatively weak.3941 Only 1 randomized controlled trial has been published evaluating the potential benefit of vertebroplasty over conservative management.42 Voormolen et al.42 evaluated patients with vertebral fractures and pain refractive to 6 weeks of optimal medical therapy. Patients were treated with vertebroplasty or continuation of medical therapy. Vertebroplasty significantly improved pain initially, but not after 2 weeks. Like the study by Voormolen et al.,42 most studies evaluating percutaneous vertebral augmentation procedures have been conducted on patients with long‐term pain refractory to medical management. One notable exception is a nonrandomized trial published by Diamond et al.6 In that study, 55 patients were treated with vertebroplasty while 24 were treated conservatively. Pain at 24 hours was significantly improved in patients treated with vertebroplasty. At 6 weeks, however, there was no difference among the 2 groups.

Figure 1

The risk of short‐term complications from vertebral augmentation procedures is difficult to assess in light of the small sample sizes and methodological limitations of existing studies. Cement leakage occurs in 40% to 41% of patients treated with vertebroplasty, as compared with 8% to 9% with kyphoplasty.39, 41 Pulmonary emboli occur in 0.6% and 0.01% of patients treated with vertebroplasty and kyphoplasty, respectively, while neurologic complications occur in 0.6% and 0.03% of patients.41 Concern exists about whether percutaneous vertebral augmentation procedures might increase the risk for subsequent fractures,43, 44 as the incidence of new fractures appears to be elevated in the period immediately following the procedure and approximately two‐thirds of new fractures occur in vertebrae adjacent to the augmented vertebra.39, 41, 44 However, the 20% incidence of new vertebral fractures in the year following vertebral augmentation is similar to the fracture rate seen in patients not treated with osteoporosis therapy.44

Assessment of the impact of vertebral augmentation procedures on the cost of care is limited by the lack of high‐quality clinical studies.45, 46 Randomized controlled trials evaluating the benefit and risk of these procedures compared to conservative management are underway.4749 Pending further evidence, these procedures are best reserved for patients who fail to benefit from other measures to control pain and improve mobility.

Long Term

A comprehensive discussion of the long‐term management of osteoporosis is beyond the scope of this work. However, the inpatient setting presents an opportune time to initiate long‐term medical therapy. Studies show that the majority of patients who sustain osteoporotic fractures do not receive pharmacologic treatment for osteoporosis.5053 Hospitalists have the opportunity to start medications that can reduce the risk for subsequent fracture by nearly 50%.5458 A total calcium intake of 1200 to 1500 mg per day and vitamin D of 400 to 800 IU per day are recommended for all postmenopausal women. Patients who smoke should receive smoking cessation counseling and be considered for pharmacologic treatment for tobacco dependence. All patients should be assessed for fall risk, including a review of medications and assessment of alcohol intake.

Before considering pharmacologic treatment for osteoporosis, secondary causes of low bone mass must be excluded. Bisphosphonates are generally considered first‐line pharmacologic therapy for osteoporosis. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) have been shown in randomized trials to increase bone density and reduce the risk of osteoporotic fractures.55, 56, 59 Daily, weekly, and monthly preparations of bisphosphonates now exist. Pill‐induced esophagitis is a potential adverse effect of bisphosphonate therapy, but is extremely rare if proper precautions are taken. Patients should take oral bisphosphonates on an empty stomach, with a full glass of water, sitting upright, and have nothing to eat or drink for at least one half hour. If compliance with oral bisphosphonates is not possible, or esophageal abnormalities preclude oral bisphosphonate use, one may consider the use of intravenous ibandronate or zoledronic acid (Reclast). A 3‐year randomized controlled trial of yearly zoledronic acid improved bone density and reduced the incidence of osteoporotic fractures.60 Bisphosphonates are generally not recommended when creatinine clearance is less than 30 mL/minute. Other pharmacologic options for the treatment of osteoporosis include selective estrogen receptor modulators and anabolic agents. The reader is referred to an excellent review by Rosen61 for additional discussion of these therapies. The American College of Rheumatology clinical guidelines for the management of glucocorticoid induced osteoporosis are also worthy of review.62

Hospitalists are naturally suited to improve the quality of care for patients hospitalized with vertebral fractures. Most patients who currently sustain osteoporotic fractures do not receive appropriate evaluation and treatment. One study used an interdisciplinary team to identify, assess, and begin treatment for appropriate patients hospitalized with osteoporotic fractures.63 The intervention resulted in significantly more patients taking osteoporosis treatment medications 6 months after the incident fracture.

Conclusions

Acute vertebral fracture is a common clinical problem associated with significant morbidity and increased risk of mortality. Treatment of vertebral fracture should include analgesics and physical therapy. Percutaneous augmentation procedures may be considered in patients who fail optimal medical therapy. Because most vertebral fractures are due to osteoporosis and the healthcare system currently fails to appropriately assess and treat most patients who have sustained osteoporotic fractures, hospitalists are in an optimal position to initiate long‐term preventative treatment for these patients.

Preserving continuity of care and assuring patient safety are core values of the hospitalist movement.1 Communicating clinical information to the patient, the primary care provider (PCP), and hospital‐based providers has been recognized in the hospitalist literature as an important domain of quality assurance.29 Correctly identifying a patient's inpatient physician during admission and later in the hospital course is essential to achieve these goals. This initial step has not been specifically addressed in the literature, though the complexity of this process can create significant challenges for larger hospitalist programs.

Rochester General Hospital (RGH) is a 528‐bed community teaching hospital. Our hospitalist program evolved from the general medicine unit (GMU) faculty that traditionally cared for most unreferred patients; ie, those whose PCPs had no admitting privileges. In 2004, we began covering patients of privilege‐holder partnering PCPs. Within 3 years, more than 120 privileged PCPs decided to refer all their admissions to us, though unreferred cases still make up the majority of our 10,000 annual admissions. GMU hospitalists either round as teaching attendings or attend patients on nonteaching services. Many PCPs continue to admit their own patients.

As our program began to work with numerous partnering PCPs, it became difficult to decide which patients the hospitalist team should be called to admit, and which should be admitted to the PCP. Having the emergency department (ED) providers page the PCPs or their call partners of the PCPs for attending service decisions proved infeasible and unreliable. Additionally, similar challenges emerged later in the hospitalization when patients were transferred from one service, floor, or provider to another, especially from the intensive care unit (ICU) to the medical service.

Errors regarding admissions to the hospitalist service can be classified as:

• Type‐I errors: The PCP provides inpatient care but the patient is erroneously admitted to a hospitalist, creating discontinuity of care and dissatisfaction.

• Type‐II errors: The PCP refers to the hospitalists but is erroneously identified as the inpatient attending physician. As the hospitalist team is not notified about these cases, admitted patients may go without physician services for a period of time.

Methods

RGH has a widely used, clinically focused EHR system that does not offer full CPOE functionality. The EHR includes a database of physicians with admitting privileges, so we decided to store information on the system regarding PCPs' hospitalist coverage. Initially, we simply uploaded a list of our partnering PCPs. However, looking up information from files proved too cumbersome for busy ED providers and hospitalists. Additionally, this solution lacked a feedback loop to alert for errors.

Therefore, we designed a system with 3 main functional elements to identify and display each patient's:

• 1

  candidacy for hospitalist coverage;

• 2

  actual hospitalist coverage; and

• 3

  mismatches between the above statuses.

These steps are explained below, followed by a description of the system's actual utilization. In addition to the text, we demonstrate the concept of and provide detailed information on our system in Figure 1 and Table 1.

Figure 1

First, to identify a patient's candidacy for hospitalist coverage, we created a PCP color coding algorithm, based on whether the PCP has admitting privileges at RGH and/or has arranged hospitalist coverage for her/his patients. Whether or not hospitalist coverage is expected for a given patient's PCP is displayed on the EHR.

Second, a data field called GMU‐dr was created to describe whether the patient is actually assigned to a hospitalist. The GMU on‐call physician assigns a GMU‐dr to all appropriate patients (ie, updates the field's value). This step acknowledges hospitalist coverage for a given patient and also identifies the hospitalist physician. It simultaneously adds the patient to the appropriate rounding censuses. The GMU‐dr data field is updated every time the rounding physician changes (eg, for weekend coverage).

Third, the EHR's assignment monitor algorithm compares the expected and actual hospitalist coverage (based on PCP color coding, GMU‐dr, admission type, location, time of day, etc.) and displays mismatches on the assignment monitor census. We created this special‐function census to include patients with the more dangerous type‐II coverage errors that would not show up on our rounding censuses.

The assignment monitor census is regularly reviewed by the call physicians and should be cleared of patients. Unaccounted patients showing up on this census are handled with urgency equal to that of an unseen admission. Most patients on the assignment monitor census have missing or incorrect information: correcting that information removes the patient from this alert list. However, some patients with correct information are captured due to an unusual relationship with the hospitalist program; eg, consultation or individual exceptions from coverage arrangements. The GMU‐status field was created to explain such situations and remove these patients from the alert list.

Results

According to a survey that was distributed to the 19 eligible hospitalists and returned by 17 (89%), this system greatly improved our admission and patient distribution process, with the following results:

• PCP color coding prevents type‐I and type‐II coverage identification errors more than once a week according to 94.1% and 88.2% of hospitalists, respectively. Ninety‐four percent agreed (absolutely or strongly) that color coding is a convenient tool to identify PCP referral status.

• The assignment monitor identifies patients more than once a month that would have been lost in the preintervention era, according to 94.1% of the hospitalists. All hospitalists surveyed believed that this alert list had several times prevented potentially life‐threatening complications, and that the system is more useful than burdensome.

• The GMU‐dr data field correctly identifies the hospitalist while the attending is misassigned in the core EHR system more than once a week, according to 93.7% of surveyed hospitalists (80% of these stated it happens daily). None believed the system would provide incorrect information with that frequency. Every hospitalist agreed that the GMU‐dr and GMU‐status tools are efficient methods for distributing patients, keeping track of attending designations, and maintaining a unit census and personal rounding censuses: cumulatively 85.7% absolutely agreed, while 12.7% strongly agreed.

We also assessed how promptly the call team responded to the assignment monitor alerts by correcting the information in the system (the census is recorded every 4 hours). Due to the intensity of the ED call, physicians often just scan this alert list (and take clinical action on the captured patients as needed) without updating the EHR fields until the end of their shifts. Measuring the speed of clearing patients from the census may grossly underestimate the actual usage of the list, though this data is useful to access a worst‐case scenario.

During the first week of September 2007 we cared for 270 patients: 52 were captured on the assignment monitor before a GMU‐dr was assigned or the patient was deemed non‐GMU. No patient was recaptured on the list more than 8 hours after the initial appearance.

Discussion

Since we enhanced a widely‐used program, our intervention required minimal training. As our innovation was designed and underwent trial by hospitalists, immediate feedback assured user‐friendly implementation, good acceptance, and improved workflow.

• Color coding eliminated the time‐intensive and error‐prone lookup of coverage arrangements.

• Updating GMU‐dr and GMU‐status in the EHR takes very little time and provides immediate benefits (eg, clearly defined rounding censuses). This task has been integrated into our signout tool, making these functions even more intuitive.

• Using the assignment monitor census is fundamental for patient safety, but correcting EHR information creates some additional work for busy call physicians. Implementing this step required active change‐management: writing policies, designing metrics, and considering incentives. The call physicians (3 shifts per day) are officially responsible for patient distribution, including clearing the screening census before passing the call pager to the next shift.

We identified some potential limitations, though these issues generally apply to any information technology (IT) implementation: Setting up the program requires an adaptable EHR and close collaboration with the IT department. The system's accuracy depends on correctly identifying the patient's PCP in the EHR. Maintaining and coordinating the data regarding PCP privileges and hospitalist coverage requires a central database has been created.

Meanwhile, we found these tools very useful in solving problems beyond patient distribution:

• PCP color coding can export information to other applications about hospitalist coverage and assist ED and nonmedical services to contact the proper medical service for admissions and consults.

• GMU‐dr and GMU‐status can be used to create personal rounding censuses, provide billing lists to third‐party applications, and support proprietary applications, thus assisting patient distribution decisions and guiding hospital staff to call the patient's correct provider 24/7.

• Special function censuses (defined by algorithms) are now used as alert lists for different patient issues (eg, observational patients staying beyond their allotted time) and by nonhospitalist services.

We presented hospitalist‐specific EHR concepts (patient coverage algorithms, special‐function censuses, and patient tracking by provider‐entered information) and their specific applications in our hospital. We believe our tools can be implemented in various locations and EHRs. Though the challenges may differ from setting to setting (eg, patient distribution between coexistent hospitalist programs, or responding to limitations of resident duty hours), these solutions are highly adaptable and have the potential of providing additional benefits beyond hospitalist coverage issues.

Preserving continuity of care and assuring patient safety are core values of the hospitalist movement.1 Communicating clinical information to the patient, the primary care provider (PCP), and hospital‐based providers has been recognized in the hospitalist literature as an important domain of quality assurance.29 Correctly identifying a patient's inpatient physician during admission and later in the hospital course is essential to achieve these goals. This initial step has not been specifically addressed in the literature, though the complexity of this process can create significant challenges for larger hospitalist programs.

Rochester General Hospital (RGH) is a 528‐bed community teaching hospital. Our hospitalist program evolved from the general medicine unit (GMU) faculty that traditionally cared for most unreferred patients; ie, those whose PCPs had no admitting privileges. In 2004, we began covering patients of privilege‐holder partnering PCPs. Within 3 years, more than 120 privileged PCPs decided to refer all their admissions to us, though unreferred cases still make up the majority of our 10,000 annual admissions. GMU hospitalists either round as teaching attendings or attend patients on nonteaching services. Many PCPs continue to admit their own patients.

As our program began to work with numerous partnering PCPs, it became difficult to decide which patients the hospitalist team should be called to admit, and which should be admitted to the PCP. Having the emergency department (ED) providers page the PCPs or their call partners of the PCPs for attending service decisions proved infeasible and unreliable. Additionally, similar challenges emerged later in the hospitalization when patients were transferred from one service, floor, or provider to another, especially from the intensive care unit (ICU) to the medical service.

Errors regarding admissions to the hospitalist service can be classified as:

• Type‐I errors: The PCP provides inpatient care but the patient is erroneously admitted to a hospitalist, creating discontinuity of care and dissatisfaction.

• Type‐II errors: The PCP refers to the hospitalists but is erroneously identified as the inpatient attending physician. As the hospitalist team is not notified about these cases, admitted patients may go without physician services for a period of time.

Methods

RGH has a widely used, clinically focused EHR system that does not offer full CPOE functionality. The EHR includes a database of physicians with admitting privileges, so we decided to store information on the system regarding PCPs' hospitalist coverage. Initially, we simply uploaded a list of our partnering PCPs. However, looking up information from files proved too cumbersome for busy ED providers and hospitalists. Additionally, this solution lacked a feedback loop to alert for errors.

Therefore, we designed a system with 3 main functional elements to identify and display each patient's:

• 1

  candidacy for hospitalist coverage;

• 2

  actual hospitalist coverage; and

• 3

  mismatches between the above statuses.

These steps are explained below, followed by a description of the system's actual utilization. In addition to the text, we demonstrate the concept of and provide detailed information on our system in Figure 1 and Table 1.

Figure 1

First, to identify a patient's candidacy for hospitalist coverage, we created a PCP color coding algorithm, based on whether the PCP has admitting privileges at RGH and/or has arranged hospitalist coverage for her/his patients. Whether or not hospitalist coverage is expected for a given patient's PCP is displayed on the EHR.

Second, a data field called GMU‐dr was created to describe whether the patient is actually assigned to a hospitalist. The GMU on‐call physician assigns a GMU‐dr to all appropriate patients (ie, updates the field's value). This step acknowledges hospitalist coverage for a given patient and also identifies the hospitalist physician. It simultaneously adds the patient to the appropriate rounding censuses. The GMU‐dr data field is updated every time the rounding physician changes (eg, for weekend coverage).

Third, the EHR's assignment monitor algorithm compares the expected and actual hospitalist coverage (based on PCP color coding, GMU‐dr, admission type, location, time of day, etc.) and displays mismatches on the assignment monitor census. We created this special‐function census to include patients with the more dangerous type‐II coverage errors that would not show up on our rounding censuses.

The assignment monitor census is regularly reviewed by the call physicians and should be cleared of patients. Unaccounted patients showing up on this census are handled with urgency equal to that of an unseen admission. Most patients on the assignment monitor census have missing or incorrect information: correcting that information removes the patient from this alert list. However, some patients with correct information are captured due to an unusual relationship with the hospitalist program; eg, consultation or individual exceptions from coverage arrangements. The GMU‐status field was created to explain such situations and remove these patients from the alert list.

Results

According to a survey that was distributed to the 19 eligible hospitalists and returned by 17 (89%), this system greatly improved our admission and patient distribution process, with the following results:

• PCP color coding prevents type‐I and type‐II coverage identification errors more than once a week according to 94.1% and 88.2% of hospitalists, respectively. Ninety‐four percent agreed (absolutely or strongly) that color coding is a convenient tool to identify PCP referral status.

• The assignment monitor identifies patients more than once a month that would have been lost in the preintervention era, according to 94.1% of the hospitalists. All hospitalists surveyed believed that this alert list had several times prevented potentially life‐threatening complications, and that the system is more useful than burdensome.

• The GMU‐dr data field correctly identifies the hospitalist while the attending is misassigned in the core EHR system more than once a week, according to 93.7% of surveyed hospitalists (80% of these stated it happens daily). None believed the system would provide incorrect information with that frequency. Every hospitalist agreed that the GMU‐dr and GMU‐status tools are efficient methods for distributing patients, keeping track of attending designations, and maintaining a unit census and personal rounding censuses: cumulatively 85.7% absolutely agreed, while 12.7% strongly agreed.

We also assessed how promptly the call team responded to the assignment monitor alerts by correcting the information in the system (the census is recorded every 4 hours). Due to the intensity of the ED call, physicians often just scan this alert list (and take clinical action on the captured patients as needed) without updating the EHR fields until the end of their shifts. Measuring the speed of clearing patients from the census may grossly underestimate the actual usage of the list, though this data is useful to access a worst‐case scenario.

During the first week of September 2007 we cared for 270 patients: 52 were captured on the assignment monitor before a GMU‐dr was assigned or the patient was deemed non‐GMU. No patient was recaptured on the list more than 8 hours after the initial appearance.

Discussion

Since we enhanced a widely‐used program, our intervention required minimal training. As our innovation was designed and underwent trial by hospitalists, immediate feedback assured user‐friendly implementation, good acceptance, and improved workflow.

• Color coding eliminated the time‐intensive and error‐prone lookup of coverage arrangements.

• Updating GMU‐dr and GMU‐status in the EHR takes very little time and provides immediate benefits (eg, clearly defined rounding censuses). This task has been integrated into our signout tool, making these functions even more intuitive.

• Using the assignment monitor census is fundamental for patient safety, but correcting EHR information creates some additional work for busy call physicians. Implementing this step required active change‐management: writing policies, designing metrics, and considering incentives. The call physicians (3 shifts per day) are officially responsible for patient distribution, including clearing the screening census before passing the call pager to the next shift.

We identified some potential limitations, though these issues generally apply to any information technology (IT) implementation: Setting up the program requires an adaptable EHR and close collaboration with the IT department. The system's accuracy depends on correctly identifying the patient's PCP in the EHR. Maintaining and coordinating the data regarding PCP privileges and hospitalist coverage requires a central database has been created.

Meanwhile, we found these tools very useful in solving problems beyond patient distribution:

• PCP color coding can export information to other applications about hospitalist coverage and assist ED and nonmedical services to contact the proper medical service for admissions and consults.

• GMU‐dr and GMU‐status can be used to create personal rounding censuses, provide billing lists to third‐party applications, and support proprietary applications, thus assisting patient distribution decisions and guiding hospital staff to call the patient's correct provider 24/7.

• Special function censuses (defined by algorithms) are now used as alert lists for different patient issues (eg, observational patients staying beyond their allotted time) and by nonhospitalist services.

We presented hospitalist‐specific EHR concepts (patient coverage algorithms, special‐function censuses, and patient tracking by provider‐entered information) and their specific applications in our hospital. We believe our tools can be implemented in various locations and EHRs. Though the challenges may differ from setting to setting (eg, patient distribution between coexistent hospitalist programs, or responding to limitations of resident duty hours), these solutions are highly adaptable and have the potential of providing additional benefits beyond hospitalist coverage issues.

Preserving continuity of care and assuring patient safety are core values of the hospitalist movement.1 Communicating clinical information to the patient, the primary care provider (PCP), and hospital‐based providers has been recognized in the hospitalist literature as an important domain of quality assurance.29 Correctly identifying a patient's inpatient physician during admission and later in the hospital course is essential to achieve these goals. This initial step has not been specifically addressed in the literature, though the complexity of this process can create significant challenges for larger hospitalist programs.

Rochester General Hospital (RGH) is a 528‐bed community teaching hospital. Our hospitalist program evolved from the general medicine unit (GMU) faculty that traditionally cared for most unreferred patients; ie, those whose PCPs had no admitting privileges. In 2004, we began covering patients of privilege‐holder partnering PCPs. Within 3 years, more than 120 privileged PCPs decided to refer all their admissions to us, though unreferred cases still make up the majority of our 10,000 annual admissions. GMU hospitalists either round as teaching attendings or attend patients on nonteaching services. Many PCPs continue to admit their own patients.

As our program began to work with numerous partnering PCPs, it became difficult to decide which patients the hospitalist team should be called to admit, and which should be admitted to the PCP. Having the emergency department (ED) providers page the PCPs or their call partners of the PCPs for attending service decisions proved infeasible and unreliable. Additionally, similar challenges emerged later in the hospitalization when patients were transferred from one service, floor, or provider to another, especially from the intensive care unit (ICU) to the medical service.

Errors regarding admissions to the hospitalist service can be classified as:

• Type‐I errors: The PCP provides inpatient care but the patient is erroneously admitted to a hospitalist, creating discontinuity of care and dissatisfaction.

• Type‐II errors: The PCP refers to the hospitalists but is erroneously identified as the inpatient attending physician. As the hospitalist team is not notified about these cases, admitted patients may go without physician services for a period of time.

Methods

RGH has a widely used, clinically focused EHR system that does not offer full CPOE functionality. The EHR includes a database of physicians with admitting privileges, so we decided to store information on the system regarding PCPs' hospitalist coverage. Initially, we simply uploaded a list of our partnering PCPs. However, looking up information from files proved too cumbersome for busy ED providers and hospitalists. Additionally, this solution lacked a feedback loop to alert for errors.

Therefore, we designed a system with 3 main functional elements to identify and display each patient's:

• 1

  candidacy for hospitalist coverage;

• 2

  actual hospitalist coverage; and

• 3

  mismatches between the above statuses.

These steps are explained below, followed by a description of the system's actual utilization. In addition to the text, we demonstrate the concept of and provide detailed information on our system in Figure 1 and Table 1.

Figure 1

First, to identify a patient's candidacy for hospitalist coverage, we created a PCP color coding algorithm, based on whether the PCP has admitting privileges at RGH and/or has arranged hospitalist coverage for her/his patients. Whether or not hospitalist coverage is expected for a given patient's PCP is displayed on the EHR.

Second, a data field called GMU‐dr was created to describe whether the patient is actually assigned to a hospitalist. The GMU on‐call physician assigns a GMU‐dr to all appropriate patients (ie, updates the field's value). This step acknowledges hospitalist coverage for a given patient and also identifies the hospitalist physician. It simultaneously adds the patient to the appropriate rounding censuses. The GMU‐dr data field is updated every time the rounding physician changes (eg, for weekend coverage).

Third, the EHR's assignment monitor algorithm compares the expected and actual hospitalist coverage (based on PCP color coding, GMU‐dr, admission type, location, time of day, etc.) and displays mismatches on the assignment monitor census. We created this special‐function census to include patients with the more dangerous type‐II coverage errors that would not show up on our rounding censuses.

The assignment monitor census is regularly reviewed by the call physicians and should be cleared of patients. Unaccounted patients showing up on this census are handled with urgency equal to that of an unseen admission. Most patients on the assignment monitor census have missing or incorrect information: correcting that information removes the patient from this alert list. However, some patients with correct information are captured due to an unusual relationship with the hospitalist program; eg, consultation or individual exceptions from coverage arrangements. The GMU‐status field was created to explain such situations and remove these patients from the alert list.

Results

According to a survey that was distributed to the 19 eligible hospitalists and returned by 17 (89%), this system greatly improved our admission and patient distribution process, with the following results:

• PCP color coding prevents type‐I and type‐II coverage identification errors more than once a week according to 94.1% and 88.2% of hospitalists, respectively. Ninety‐four percent agreed (absolutely or strongly) that color coding is a convenient tool to identify PCP referral status.

• The assignment monitor identifies patients more than once a month that would have been lost in the preintervention era, according to 94.1% of the hospitalists. All hospitalists surveyed believed that this alert list had several times prevented potentially life‐threatening complications, and that the system is more useful than burdensome.

• The GMU‐dr data field correctly identifies the hospitalist while the attending is misassigned in the core EHR system more than once a week, according to 93.7% of surveyed hospitalists (80% of these stated it happens daily). None believed the system would provide incorrect information with that frequency. Every hospitalist agreed that the GMU‐dr and GMU‐status tools are efficient methods for distributing patients, keeping track of attending designations, and maintaining a unit census and personal rounding censuses: cumulatively 85.7% absolutely agreed, while 12.7% strongly agreed.

We also assessed how promptly the call team responded to the assignment monitor alerts by correcting the information in the system (the census is recorded every 4 hours). Due to the intensity of the ED call, physicians often just scan this alert list (and take clinical action on the captured patients as needed) without updating the EHR fields until the end of their shifts. Measuring the speed of clearing patients from the census may grossly underestimate the actual usage of the list, though this data is useful to access a worst‐case scenario.

During the first week of September 2007 we cared for 270 patients: 52 were captured on the assignment monitor before a GMU‐dr was assigned or the patient was deemed non‐GMU. No patient was recaptured on the list more than 8 hours after the initial appearance.

Discussion

Since we enhanced a widely‐used program, our intervention required minimal training. As our innovation was designed and underwent trial by hospitalists, immediate feedback assured user‐friendly implementation, good acceptance, and improved workflow.

• Color coding eliminated the time‐intensive and error‐prone lookup of coverage arrangements.

• Updating GMU‐dr and GMU‐status in the EHR takes very little time and provides immediate benefits (eg, clearly defined rounding censuses). This task has been integrated into our signout tool, making these functions even more intuitive.

• Using the assignment monitor census is fundamental for patient safety, but correcting EHR information creates some additional work for busy call physicians. Implementing this step required active change‐management: writing policies, designing metrics, and considering incentives. The call physicians (3 shifts per day) are officially responsible for patient distribution, including clearing the screening census before passing the call pager to the next shift.

We identified some potential limitations, though these issues generally apply to any information technology (IT) implementation: Setting up the program requires an adaptable EHR and close collaboration with the IT department. The system's accuracy depends on correctly identifying the patient's PCP in the EHR. Maintaining and coordinating the data regarding PCP privileges and hospitalist coverage requires a central database has been created.

Meanwhile, we found these tools very useful in solving problems beyond patient distribution:

• PCP color coding can export information to other applications about hospitalist coverage and assist ED and nonmedical services to contact the proper medical service for admissions and consults.

• GMU‐dr and GMU‐status can be used to create personal rounding censuses, provide billing lists to third‐party applications, and support proprietary applications, thus assisting patient distribution decisions and guiding hospital staff to call the patient's correct provider 24/7.

• Special function censuses (defined by algorithms) are now used as alert lists for different patient issues (eg, observational patients staying beyond their allotted time) and by nonhospitalist services.

We presented hospitalist‐specific EHR concepts (patient coverage algorithms, special‐function censuses, and patient tracking by provider‐entered information) and their specific applications in our hospital. We believe our tools can be implemented in various locations and EHRs. Though the challenges may differ from setting to setting (eg, patient distribution between coexistent hospitalist programs, or responding to limitations of resident duty hours), these solutions are highly adaptable and have the potential of providing additional benefits beyond hospitalist coverage issues.

Short‐stay units (SSUs) are common alternatives to traditional inpatient services.1 When defined broadly to include observation units for low‐risk chest pain patients, SSUs exist in one‐third of hospitals in the United States.2 Amidst growing demands for inpatient services, SSUs have recently developed beyond observation medicine to provide more complex inpatient services in locations commonly adjacent to emergency departments (EDs).1 Hospitalists are well‐positioned to staff these emerging SSUs because of their expertise in managing complex inpatient services.3

Despite this, we found only 3 reports of hospitalist‐run SSUs designed for general medical inpatients (2 from Spain and 1 from Canada).46 Whereas these early reports introduce hospitalist‐run SSUs, they provide limited data to make firm conclusions about their usefulness or appropriate design. For example, none of these reports assessed patients' characteristics upon admission. Nor did they provide details about the services that the SSUs provided. Yet evaluation of both types of patient‐level datadescriptions of patients' needs upon admission and how these needs are met during their staysdetermine whether or not hospitalist‐run SSUs meet their potential to efficiently care for backlogs of patients who otherwise await admission to traditional inpatient services.

In order to further explore these issues, we first sought to characterize our SSU patients upon admission and record what services they received during their stays. To help interpret our results, we then investigated associations between these characteristics and measures of successfully caring for patients in our SSU.

Patients and Methods

Design and Setting

In this prospective cohort study, we included all patients admitted to the hospitalist‐run SSU of Cook County Hospital, a 500‐bed public teaching hospital in Chicago, Illinois, from January through April of 2006. Our 14‐bed SSU opened in 2002 to reduce overcrowding on the traditional inpatient wards by admitting adult patients who require inpatient care but might be eligible for discharge within 3 days. The unit is geographically part of the ED but is staffed by resident physicians and a rotating group of hospitalist attending physicians from the Department of Medicine. At least 1 attending and resident physician are available throughout the day, including weekend days and holidays; evenings are covered by a resident who presents overnight admissions to an attending physician the following morning.

ED physicians admit general medical patients to the SSU 24 hours per day, 7 days per week. Though admissions do not require prior approval from SSU physicians, the Departments of Medicine and Emergency Medicine have collaboratively promoted 5 suggested admission‐location guidelines to admitting ED physicians (Figure 1). For candidate SSU patients, these 5 guidelines are not intended to be restrictive but to provide a framework for the complex decision‐making process that our ED physicians encounter, particularly during periods of extreme overcrowding.7 First, patients should have an anticipated stay shorter than 72 hours. Second, patients should not have an eventual need for admission to traditional inpatient services such as the general medicine wards or intensive care units; this guideline is intended to improve patient safety by reducing unnecessary handoffs between physicians.8 Third, patients with provisional cardiovascular diagnoses should be preferentially admitted to the SSU over the general medical wards; this guideline is intended to improve hospital‐wide efficiency because our SSU is equipped with continuous telemetry monitors, an exercise treadmill testing (ETT) laboratory, and other reserved cardiac tests (see Admission Characteristics and Services Received section, below). Fourth, patients' risk should be no higher than intermediate level. Admitting ED physicians are encouraged to use posted risk estimators for patients with provisional diagnoses of possible acute coronary syndrome (ACS), decompensated heart failure, asthma exacerbation, and out‐of‐control diabetes. Finally, patients should not need advanced ancillary services; these include bedside procedures (eg, central venous catheter insertions), time‐intensive nursing (eg, regular dressing changes), and complex social‐services (eg, long‐term care facility placements).

Figure 1

Data Collection

After receiving approval from the institutional review board, attending physician investigators conducted an interview, physical examination, and review of medical records for each enrolled patient within 12 hours of admission to the SSU. When ED attending physicians' provisional primary diagnoses included possible ACS or decompensated heart failure, which we knew from earlier pilot data were our 2 most common provisional diagnoses, investigators gathered patient data to be applied in validated models of risk after the study period (Figure 2).9, 10 Some of the clinical predictors required for these models are based on patients' findings on presentation to the ED. For example, Goldman's risk model for major cardiac events uses patients' initial systolic blood pressures on presentation to the ED.9 In such cases, investigators gathered needed data from electronic and paper charts generated in the ED. Upon discharge from the SSU, investigators reviewed patients' medical records a second time. All data were entered by investigators and instantly committed into an online database.

Figure 2

Results

SSU Success

The median LOS for all patients was 42 hours (interquartile range [IRQ] 22‐63) and 156 patients (21% of 738) had unsuccessful SSU stays (Table 3). The most common reason for an unsuccessful stay was a stay longer than 72 hours (71% of 156). Among the 66 patients who required admission to traditional inpatient services, nearly one‐half (48%) were admitted expressly to receive treatments not available in the SSU after having a specialty consult.

Patients' provisional diagnoses were associated with unsuccessful stays in bivariate analyses (Table 3). In addition, when patients were grouped into 3 risk stratums (very‐low, low, and intermediate‐and‐high), unsuccessful stays increased with increasing risk. For example, in patients with possible ACS, the proportion of unsuccessful stays increased from 17% of 306 very‐low risk patients to 27% of 55 intermediate‐and‐high risk patients (P value for trend = 0.012. Similarly, in patients with heart failure, the proportion of unsuccessful stays increased from 25% of 181 very‐low risk patients to 100% of 3 intermediate‐and‐high risk patients (P value for trend = 0.004).

However, in multiple variable models that simultaneously included patients' characteristics upon admission with services received during their SSU stay, only the provisional diagnosis of heart failure was associated with unsuccessful stays (OR, 1.9; 95% CI, 1.12‐3.18); risk assessments for possible ACS (P = 0.29) and heart failure (P = 0.32) were unimportant predictors of unsuccessful stays (Table 4). On the other hand, whether or not patients received diagnostic tests, acute care treatments, or specialty consultations were important predictors. In particular, patients who received specialty consultations were much more likely to require admission to traditional inpatient services than those patients who did not (OR, 13.1; 95% CI, 6.9‐24.9) and had a 52% chance of having an unsuccessful stay (95% CI, 42‐61%; Figure 3). In addition, the accessibility of a diagnostic test was inversely proportional to the chance of having a long stay; patients who received an open access test had a 12% chance of a long stay (95% CI, 8‐16%) whereas those who received a limited access test had a 29% chance of a long stay (95% CI, 20‐39%). Receiving acute care treatments was also a significant, though less important, predictor of an unsuccessful stay (Table 4).

Figure 3

Discussion

We found that the types of services received by patients during their SSU stays were stronger predictors of long stays and eventual admissions to traditional inpatient services than patients' characteristics upon admission to the SSU. This suggests that SSUs should be focused toward matching patients' anticipated needs with readily accessible services. For example, in our SSU, which cares for over 2,250 patients annually, more than 1,200 patients will receive diagnostic tests in a given year. Among these patients, those who receive a limited access test will be more than twice as likely to have long stays than those who receive an open access test (Figure 3). Though our conclusions may not be applicable to other settings, this study is the most comprehensive description of patients admitted to a hospitalist‐run SSU. In addition, our study is the first to demonstrate that diagnostic and consultative services are the most important predictors of successful stays in SSUs. This promotes the practical strategy that hospitalists who staff SSUs should focus administratively toward gaining access to these services.

Very few of our SSU patients did not fulfill the suggested requirements of our admission location guidelines. For example, only 2% of 691 patients with either possible ACS or heart failure were high risk (Figure 2). Despite this, 21% of our patients had stays longer than 72 hours or were admitted to traditional inpatient services. The paradoxically high proportion of unsuccessful stays among mostly very‐low and low risk patients simply reflects how the clinical risk models that we used were not designed to predict unsuccessful stays. Moreover, as our multiple variable models suggest, improvements in the selection process of candidate SSU patients are more likely to come from an ability to incorporate assessments of what services patients will receive rather than from assessments of their clinical risk (Table 4). Therefore, the immediate plans of the accepting SSU physicians, the physicians who will determine what services patients eventually receive, should be incorporated in the admission‐location decision process.

Three of our findings highlight how input from accepting SSU physiciansconveyed to ED physicians before their final admission‐location decisions are mademay improve the SSU patient selection process. First, 23% of our patients were discharged home after brief stays with no advanced tests, specialty consultations, or acute care treatments (Table 3). Though some of these patients may have required inpatient services other than the ones we recorded, most were admitted with very‐low risk possible ACS; if they required overnight stays at all, many of them may have been better cared for in the ED observation unit (Figure 1). Second, 74% of the patients who required admission to traditional inpatient services were admitted for services not readily available to patients in the SSU (Table 3). Among these patients, nearly one‐third (21/66) received no advanced diagnostic tests in the SSU. This suggests that these patients should have been admitted directly to the general medical wards; doing so may have improved efficiency and quality of care by reducing unnecessary handoffs between physicians. Both types of patientsthose with minimal inpatient needs and those with more needs than the SSU can providehighlight how incorporating accepting SSU physicians' plans may improve the SSU patient selection process. After all, those best equipped to determine if the SSU will meet (or exceed) the needs of candidate patients are the SSU physicians themselves.

Third, we found that whether or not SSU physicians required assistance from specialists was the strongest predictor of unsuccessful stays: when an accepting physician determined that a patient should receive a specialty consultation, that patient's chance of having an unsuccessful stay was over 50% (Figure 3). Our study was not designed to determine how specialty consultations were associated with unsuccessful stays. We did not, for example, record whether or not hospitalists changed their diagnostic, treatment, or admission plans because of specialists' recommendations.12 Therefore, we cannot conclude that specialty consultations actually caused long stays or traditional admissions. Nevertheless, when our SSU physicians did not manage patients independent of specialty consultations, we observed a high likelihood of unsuccessful stays. Because accepting SSU physicians are the ones who will determine whether or not they need assistance from specialists, weighing their immediate plans for specialty consultations into the admission‐location decision process may improve the efficiency of SSUs. Others have recognized the importance of specialty consultations in SSUs by directly incorporating specialists as coattending physicians.13

Our study had several limitations. First, we studied mostly patients with cardiovascular diagnoses. Predictors of success in SSUs that admit patients with different diagnostic profiles may be different. In particular, SSUs that admit patients with a wide array of diagnoses may find that matching patients' needs with readily accessible services is impractical, because these needs may be too wide‐ranging. Second, our study design was observational. However, other than seasonal variations in admission patterns, there was little room for selection bias because we enrolled all consecutive admissions over the 4‐month study period, which gives us more confidence in our results. Third, our study did not record whether or not ED physicians knowingly overrode the suggested admission‐location guidelines because of limited bed availability. Yet, if shortages of beds on traditional inpatient services were driving patients who were otherwise candidates for the general medical wards in to the SSU, then we would have expected higher‐risk patients and greater needs for limited access tests. Finally, our descriptions of patients' needs were based on what diagnostic, consultative, and treatment services patients actually received; yet these needs did not include diagnostic tests that were ordered but never performed. However, any missed needs would bias our results toward no association with unsuccessful stays, because unsuccessful stays would generally increase while patients await needed services.

Future research could address these limitations through an experimental trial of traditional admissions versus admission to a hospitalist‐run SSU. And, because hospitals are complex systems of health care delivery where changes in one patient care unit often affect others in unanticipated ways,14 the impact of SSUs on other patient care units that are closely connected to SSUs, such as EDs and the general medical wards (Figure 1), should be simultaneously observed. For example, though our findings suggest that the accessibility of diagnostic tests should parallel ordering SSU physicians' needs for those tests, making all diagnostic tests open to SSU physicians may result in shortsightedly lengthening the stays of patients in other care units. Future research should also observe the decision‐making process of both the physicians who make admission‐location decisions (ED physicians) and those who determine the eventual plans for patients in the SSU (hospitalists). Accepting physicians from other patient care units have found improved outcomes of efficiency when they were involved in the complex process of deciding where to admit patients.15, 16 After an initial evaluation of a candidate SSU patient in the ED, a hospitalist who staffs both the general medical wards and the SSU would be uniquely well‐positioned to help an ED physician decide where a patient's needs would be best met. Although ED physicians will rightly be concerned that consulting SSU hospitalists may slow patient flow, hands‐on consultations of candidate SSU patients, who have a narrow range of diagnoses and low‐risk profiles, would likely be brief. In addition, because many SSUs are conveniently adjacent to EDs, the burden of communication may be minor.1 To address these questions, hospitalists who staff SSUs must continue the observed trend of working collaboratively with ED physicians.15, 17, 18