Approximately 13 out of every 1,000 hospitalized patients are infected with Clostridium difficile (C. diff), a new study reports.

The study, by the Association for Professionals in Infection Control and Epidemiology (APIC), surveyed 12,000 patients in 648 medical facilities. Nearly 1,500 patients (12.5%) were identified with C. diff, a bacterium that causes diarrhea and more serious intestinal conditions. The occurrence rate was between 6.5 and 20 times higher than previous estimates.

Infection control is a part of hospitalist training, however, preventive efforts have been stagnant, says William Ford, MD, section chief of hospital medicine for Temple University Hospital in Philadelphia. Temple already has begun answering APIC's call for intensified infection control with a hand washing outreach protocol. Over a two-month period, hospitalists volunteered to administer five-minute PowerPoint presentations to the nursing staff during all shifts, reminding staff of the importance of washing their hands for at least 30 seconds with warm water and soap, and using friction when doing so.

The hospital has implemented a poster campaign with photos and step-by-step instructions regarding the proper hand-washing technique.

Although some disagree, hand washing has been shown to decrease the transmission of nosocomial infections, Dr. Ford says. "Hand washing," he says, "is the first line of defense for C. diff infections."

The study will be published in the January issue of American Journal of Infection Control.

Approximately 13 out of every 1,000 hospitalized patients are infected with Clostridium difficile (C. diff), a new study reports.

The study, by the Association for Professionals in Infection Control and Epidemiology (APIC), surveyed 12,000 patients in 648 medical facilities. Nearly 1,500 patients (12.5%) were identified with C. diff, a bacterium that causes diarrhea and more serious intestinal conditions. The occurrence rate was between 6.5 and 20 times higher than previous estimates.

Infection control is a part of hospitalist training, however, preventive efforts have been stagnant, says William Ford, MD, section chief of hospital medicine for Temple University Hospital in Philadelphia. Temple already has begun answering APIC's call for intensified infection control with a hand washing outreach protocol. Over a two-month period, hospitalists volunteered to administer five-minute PowerPoint presentations to the nursing staff during all shifts, reminding staff of the importance of washing their hands for at least 30 seconds with warm water and soap, and using friction when doing so.

The hospital has implemented a poster campaign with photos and step-by-step instructions regarding the proper hand-washing technique.

Although some disagree, hand washing has been shown to decrease the transmission of nosocomial infections, Dr. Ford says. "Hand washing," he says, "is the first line of defense for C. diff infections."

The study will be published in the January issue of American Journal of Infection Control.

Approximately 13 out of every 1,000 hospitalized patients are infected with Clostridium difficile (C. diff), a new study reports.

The study, by the Association for Professionals in Infection Control and Epidemiology (APIC), surveyed 12,000 patients in 648 medical facilities. Nearly 1,500 patients (12.5%) were identified with C. diff, a bacterium that causes diarrhea and more serious intestinal conditions. The occurrence rate was between 6.5 and 20 times higher than previous estimates.

Infection control is a part of hospitalist training, however, preventive efforts have been stagnant, says William Ford, MD, section chief of hospital medicine for Temple University Hospital in Philadelphia. Temple already has begun answering APIC's call for intensified infection control with a hand washing outreach protocol. Over a two-month period, hospitalists volunteered to administer five-minute PowerPoint presentations to the nursing staff during all shifts, reminding staff of the importance of washing their hands for at least 30 seconds with warm water and soap, and using friction when doing so.

The hospital has implemented a poster campaign with photos and step-by-step instructions regarding the proper hand-washing technique.

Although some disagree, hand washing has been shown to decrease the transmission of nosocomial infections, Dr. Ford says. "Hand washing," he says, "is the first line of defense for C. diff infections."

The study will be published in the January issue of American Journal of Infection Control.

Better patient outcomes have been seen in hospitals that employ the hospitalist model of care, reports a new study in Human Resource Management (2008;47(4):729—755).

"This study will resonate among hospitalists as something to reinforce what their intuitions have told them," says Joe Miller, study co-author and SHM's executive advisor to the CEO. Although a lot of other studies have shown hospitalists to be more efficient, this is the first to try to understand why, he says.

The study attributes the success of the hospitalist model to a concept known as relational coordination, in which members of the healthcare team are assessed based on their coordination with other team members. In the study, performance outcomes were analyzed in more than 6,000 cases at Newton-Wellesley Hospital in Newton, Mass. between July 2001 and July 2003. On the days when the attending physician was a hospitalist, as opposed to a primary care physician, the relational coordination between the care team—meaning the strength of the communication and relationships between physicians and the other care providers—was statistically significantly higher. This translated into decreased length of hospital stay, reduced hospital costs by $655 per patient, a 41.8% reduction in the risk of patient readmittance, and a 13.2% improvement in coordination.

"Hospitals are being asked to share their performance results and it's being acknowledged that delivering their service requires coordination and cooperation among the various players." Miller says. "I think this study may stimulate more research, and it may stimulate hospital executives to examine the hospitalist program within their organization to achieve these types of results."

Better patient outcomes have been seen in hospitals that employ the hospitalist model of care, reports a new study in Human Resource Management (2008;47(4):729—755).

"This study will resonate among hospitalists as something to reinforce what their intuitions have told them," says Joe Miller, study co-author and SHM's executive advisor to the CEO. Although a lot of other studies have shown hospitalists to be more efficient, this is the first to try to understand why, he says.

The study attributes the success of the hospitalist model to a concept known as relational coordination, in which members of the healthcare team are assessed based on their coordination with other team members. In the study, performance outcomes were analyzed in more than 6,000 cases at Newton-Wellesley Hospital in Newton, Mass. between July 2001 and July 2003. On the days when the attending physician was a hospitalist, as opposed to a primary care physician, the relational coordination between the care team—meaning the strength of the communication and relationships between physicians and the other care providers—was statistically significantly higher. This translated into decreased length of hospital stay, reduced hospital costs by $655 per patient, a 41.8% reduction in the risk of patient readmittance, and a 13.2% improvement in coordination.

"Hospitals are being asked to share their performance results and it's being acknowledged that delivering their service requires coordination and cooperation among the various players." Miller says. "I think this study may stimulate more research, and it may stimulate hospital executives to examine the hospitalist program within their organization to achieve these types of results."

Better patient outcomes have been seen in hospitals that employ the hospitalist model of care, reports a new study in Human Resource Management (2008;47(4):729—755).

"This study will resonate among hospitalists as something to reinforce what their intuitions have told them," says Joe Miller, study co-author and SHM's executive advisor to the CEO. Although a lot of other studies have shown hospitalists to be more efficient, this is the first to try to understand why, he says.

The study attributes the success of the hospitalist model to a concept known as relational coordination, in which members of the healthcare team are assessed based on their coordination with other team members. In the study, performance outcomes were analyzed in more than 6,000 cases at Newton-Wellesley Hospital in Newton, Mass. between July 2001 and July 2003. On the days when the attending physician was a hospitalist, as opposed to a primary care physician, the relational coordination between the care team—meaning the strength of the communication and relationships between physicians and the other care providers—was statistically significantly higher. This translated into decreased length of hospital stay, reduced hospital costs by $655 per patient, a 41.8% reduction in the risk of patient readmittance, and a 13.2% improvement in coordination.

"Hospitals are being asked to share their performance results and it's being acknowledged that delivering their service requires coordination and cooperation among the various players." Miller says. "I think this study may stimulate more research, and it may stimulate hospital executives to examine the hospitalist program within their organization to achieve these types of results."

With a new survey reporting more than 150,000 primary care doctors are expected to reduce the number of patients they see or stop practicing altogether within the next three years, hospitalist programs need to focus on their retention rates, one hospital medicine group leader says.

"In this industry, we need to do more to make sure people realize that this is a career platform, and not just a placeholder for them to move on to another job," says Adam Singer, MD, CEO and CMO of IPC: The Hospitalist Company. "We're seeing a lot of this in hospitals. A lot of people use this as a one-year job in order to get a fellowship, and so we are seeing that a large percentage of the doctors that actually come, leave in order to go on to another career."

To increase retention, HM programs need to make sure young doctors in residency are better educated about the benefits of hospital medicine, such as higher incomes and the exciting short-term, high-impact relationships that appeal to young physicians, Dr. Singer says. Additionally, HM needs to advocate more medical school slots to assist in the creation of more physicians, he says.

The survey, "The Physicians' Perspective: Medical Practice in 2008," was released Nov. 18 by The Physician's Foundation. Additional findings include:

• 76% of physicians said they are either at "full capacity" or "overextended and overworked;"

• 45% said they would retire today if they had the financial means; and

• 60% would not recommend medicine as a career to young people.

For more information on the survey, visit http://www.physiciansfoundations.org.

With a new survey reporting more than 150,000 primary care doctors are expected to reduce the number of patients they see or stop practicing altogether within the next three years, hospitalist programs need to focus on their retention rates, one hospital medicine group leader says.

"In this industry, we need to do more to make sure people realize that this is a career platform, and not just a placeholder for them to move on to another job," says Adam Singer, MD, CEO and CMO of IPC: The Hospitalist Company. "We're seeing a lot of this in hospitals. A lot of people use this as a one-year job in order to get a fellowship, and so we are seeing that a large percentage of the doctors that actually come, leave in order to go on to another career."

To increase retention, HM programs need to make sure young doctors in residency are better educated about the benefits of hospital medicine, such as higher incomes and the exciting short-term, high-impact relationships that appeal to young physicians, Dr. Singer says. Additionally, HM needs to advocate more medical school slots to assist in the creation of more physicians, he says.

The survey, "The Physicians' Perspective: Medical Practice in 2008," was released Nov. 18 by The Physician's Foundation. Additional findings include:

• 76% of physicians said they are either at "full capacity" or "overextended and overworked;"

• 45% said they would retire today if they had the financial means; and

• 60% would not recommend medicine as a career to young people.

For more information on the survey, visit http://www.physiciansfoundations.org.

With a new survey reporting more than 150,000 primary care doctors are expected to reduce the number of patients they see or stop practicing altogether within the next three years, hospitalist programs need to focus on their retention rates, one hospital medicine group leader says.

"In this industry, we need to do more to make sure people realize that this is a career platform, and not just a placeholder for them to move on to another job," says Adam Singer, MD, CEO and CMO of IPC: The Hospitalist Company. "We're seeing a lot of this in hospitals. A lot of people use this as a one-year job in order to get a fellowship, and so we are seeing that a large percentage of the doctors that actually come, leave in order to go on to another career."

To increase retention, HM programs need to make sure young doctors in residency are better educated about the benefits of hospital medicine, such as higher incomes and the exciting short-term, high-impact relationships that appeal to young physicians, Dr. Singer says. Additionally, HM needs to advocate more medical school slots to assist in the creation of more physicians, he says.

The survey, "The Physicians' Perspective: Medical Practice in 2008," was released Nov. 18 by The Physician's Foundation. Additional findings include:

• 76% of physicians said they are either at "full capacity" or "overextended and overworked;"

• 45% said they would retire today if they had the financial means; and

• 60% would not recommend medicine as a career to young people.

For more information on the survey, visit http://www.physiciansfoundations.org.

Literature at a Glance

• Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.
• Intensive glucose-lowering therapy in diabetic patients at high risk for cardiovascular events increased mortality.
• Targeting normal glycated hemoglobin levels with a gliclazide-based regimen does not have an effect on preventing major macrovascular events.
• Non-invasive ventilation has no effect on short-term mortality or rates of tracheal intubation and admission to ICU
• Routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes.
• No clinical benefit exists in employing intensive renal replacement over a conventional approach in critically ill patients.
• Initial UFH bolus and infusion dosing used for NSTE ACS often exceeds recommended weight-adjusted dosing.
• High BNP or NT-pro-BNP levels can differentiate patients who are at a higher risk of complicated hospital course and short-term mortality.
• Use of a silver-coated ET tube reduces the incidence of VAP, as well as delays time to VAP occurrence.

Tight Glucose Control in the Intensive Care Unit (ICU) Setting Does Not Reduce Short-Term Mortality

Clinical question: Does tight glucose control for critically ill patients affect mortality?

Background: Intensive glucose control for adult ICU patients has been advocated by numerous professional societies and adopted worldwide as a means to reduce mortality of critically ill patients. Evidence from multiple randomized controlled trials of tight glucose control in the ICU setting, however, shows mixed results.

Study Design: Meta-analysis of randomized controlled trials.

Setting: 29 studies involving 8,432 critically ill patients.

Synopsis: This study evaluated 29 trials involving critically ill adult patients randomized to tight glucose control versus usual care. Comparing these patients, there was no significant difference in short-term mortality (<30 days). Stratification of trials by level of glucose control (very tight <110 mg/dL versus moderately tight <150 mg/dL) and by ICU setting (surgical, medical, or mixed medical-surgical) did not affect mortality.

Tight glucose control was associated with a reduced risk of septicemia, but only in surgical patients. There was no association between tight control and a new need for dialysis, consistent across all ICU settings, as well as with both levels of glucose control. Finally, there was an increased risk of hypoglycemia (<40 mg/dL) with tight control, higher in patients who received very tight control versus those who received moderately tight control.

Limitations of the studies evaluated in this meta-analysis include difficulties with consistently maintaining tight glucose control. Twenty one percent of the trials did not achieve a mean glucose level within 5 mg/dL of the goal. This, along with a lack of standardization in reporting glucose control, makes study comparison problematic.

Bottom Line: Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.

Citation: Wiener, RS, Wiener DC, Larson, RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300:933-944.

Intensive Glucose-Lowering Therapy Increases Mortality in High-Risk Diabetic Patients

Clinical Question: Does intensive glucose-lowering therapy reduce cardiac events in high-risk diabetic patients?

Background: Epidemiologic studies have suggested the risk of cardiovascular disease increases with higher levels of glycated hemoglobin in patients with type-2 diabetes. No definitive data from randomized trials exist to test the effect of intensive glucose-lowering therapy on the rate of cardiovascular events in high-risk diabetic patients.

Study Design: Multicenter randomized controlled trial led by the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group.

Setting: 77 clinical centers in the U.S. and Canada.

Synopsis: 10,251 diabetic patients with established cardiovascular disease or additional cardiovascular risk factors, and median glycated hemoglobin level of 8.1%, received either intensive therapy (targeting glycated hemoglobin level <6.0%) or standard therapy (targeting level from 7.0% to 7.9%). The primary outcome was a composite of non-fatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes.

Data indicated intensive therapy did decrease the rate of non-fatal myocardial infarctions, however, it did not significantly reduce the primary composite of major cardiovascular events. Moreover, intensive therapy resulted in a significant increase in death from cardiovascular causes, as well as a relative increase of 22% of death from any cause, during follow up of three and a half years. Due to this finding, the intensive therapy regimen was discontinued 17 months before the scheduled end of the study.

Analysis of the data has not identified a cause for the unexpected increased mortality in the intensive therapy group, and has not shown any medication or combination of medications to be responsible.

Bottom Line: Intensive glucose-lowering therapy in diabetic patients at high risk for cardiovascular events increased mortality and did not significantly reduce major cardiovascular events.

Citation: Action to control cardiovascular risk in diabetes study group. Effects of intensive glucose lowering in type-2 diabetes. N Engl J Med. 2008;358:2545-2559.

Intensive Glucose Control Reduces Nephropathy but Has No Effect on Major Cardiovascular Events

Clinical Question: Does intensive glucose-lowering therapy decrease major macrovascular and microvascular events in high-risk diabetic patients?

Background: Prospective studies show a direct association between elevated glycated hemoglobin levels in diabetics and increased risk of vascular events. However, definitive evidence from randomized trials about the role of intensive glucose control in preventing vascular disease in diabetics is lacking.

Study Design: Multicenter randomized controlled trial led by the ADVANCE Collaborative Group.

Setting: 215 clinical centers in 20 countries from Asia, Australia, Europe, and North America.

Synopsis: 11,140 diabetic patients received either standard glucose therapy or intensive glucose therapy using gliclazide, as well as other drugs, to reach a targeted glycated hemoglobin of 6.5% or less. The primary outcome was a composite of major macrovascular and microvascular events, including nonfatal myocardial infarction (MI), nonfatal stroke, death from cardiovascular causes, nephropathy, and retinopathy.

Intensive glucose-lowering therapy, as compared to standard therapy, resulted in a 21% relative reduction of new or worsening nephropathy. There was no significant effect on the rate of MI, strokes, death from cardiovascular causes, or retinopathy. Furthermore, intensive glucose control was associated with an increased risk of severe hypoglycemia and increased rate of hospitalization. In contrast to the ACCORD study, intensive therapy did not result in an increase in mortality.

Bottom Line: While targeting normal glycated hemoglobin levels with a gliclazide-based regimen reduced the rate of nephropathy, this strategy did not have an effect on preventing major macrovascular events.

Citation: ADVANCE collaborative group. Intensive blood glucose control and vascular outcomes in patients with type-2 diabetes. N Eng J Med. 2008;358:2560-2572.

Non-invasive Ventilation Does Not Improve Short-Term Mortality in Patients with Acute Cardiogenic Pulmonary Edema

Clinical Question: Does non-invasive ventilation improve survival for patients with acute cardiogenic pulmonary edema?

Background: Acute cardiogenic pulmonary edema is a common medical emergency, but only small trials address outcomes of non-invasive methods of ventilation.

Study Design: A prospective, randomized control study.

Setting: 26 emergency rooms and hospitals in the United Kingdom.

Synopsis: 1,069 patients with a clinical diagnosis of acute cardiogenic pulmonary edema in the emergency room were randomized to one of three treatment strategies: standard oxygen therapy, continuous positive airway pressure (CPAP), or non-invasive intermittent positive pressure ventilation (NIPPV).

There was no significant difference in the seven-day mortality between patients receiving standard oxygen therapy (9.8%) and those treated with non-invasive ventilation (9.5%). Additionally, there was no significant difference in the combined end point of death or intubation within seven days between patients receiving CPAP and NIPPV—the primary end points of the study.

While non-invasive ventilation was associated with greater reductions in dyspnea, heart rate, acidosis, and hypercapnia than was standard oxygen therapy, rates of other secondary outcomes—including tracheal intubation, admission to the critical care unit, myocardial infarction, and 30-day mortality—were similar.

Bottom Line: Although non-invasive ventilation rapidly improves respiratory distress and metabolic disturbances for patients with acute cardiogenic pulmonary edema, it has no effect on short-term mortality or rates of tracheal intubation and admission to ICU.

Citation: Gray A, Goodacre S, Newby D, et al. Non-invasive ventilation in acute cardiogenic pulmonary edema. N Eng J Med. 2008;359:142-151.

Rhythm Control in Patients with Atrial Fibrillation and CHF Does Not Improve Mortality

Clinical Question: Does the restoration of sinus rhythm in patients with atrial fibrillation and heart failure reduce mortality from cardiovascular causes?

Background: Recent data show rhythm control provides no benefit over rate control among patients with atrial fibrillation, but limited information is available regarding its applicability to patients with heart failure.

Study Design: Multicenter, prospective, double-blind, randomized trial.

Settings: 123 medical centers worldwide.

Synopsis:1,376 patients with a left ventricular ejection fraction of 35% or less, symptoms of heart failure, and a history of atrial fibrillation were randomized (allocation not concealed) either to a rhythm-control (e.g., conversion to sinus rhythm) or rate-control strategy. The primary outcome measured was the time to death from cardiovascular causes. Secondary outcomes included death from any cause, stroke, worsening heart failure, hospitalization, quality of life, cost of therapy, and a composite of death from cardiovascular causes, stroke or worsening heart failure.

Study follow up succeeded with 94% of enrolled patients completing follow up (median=47 months for survivors) or dying. Amiodarone was the drug used most often in the rhythm-control group. Ninety percent of patients received angiotensin converting enzyme inhibitors or angiotensin II receptor blocker, and 90% received anticoagulation.

Among patients with atrial fibrillation and congestive heart failure, the number of deaths from cardiovascular causes was similar in the rate (25%) and rhythm-control group (27%). Furthermore, there were no significant differences in important secondary outcomes, including death from any cause, worsening heart failure, or stroke.

Bottom Line: For patients with heart failure from systolic dysfunction and atrial fibrillation, the routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes as compared with a rate-control strategy.

Citation: Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667-2677.

No Benefit from Intensive Renal Replacement Therapy in Critically Ill Patients with Acute Kidney Injury (AKI)

Clinical Question: Does intensive renal replacement therapy, as compared with a conventional treatment strategy, affect outcomes in critically ill patients?

Background: The optimal timing for the initiation, method, and dosing of renal replacement therapy among patients with AKI remains uncertain. Previous single-center studies limited to single methods of renal replacement therapy have suggested more intensive therapy is associated with improved survival. These results, however, have been inconsistent.

Study Design: Randomized controlled trial.

Setting: Veterans Affairs hospitals and university affiliated medical centers.

Synopsis: This study randomized 1,124 of 4,340 eligible critically ill adults with AKI to receive either intensive renal replacement therapy or a less intensive, more conventional approach. The primary end point of death at day 60 from any cause was 53.6% with intensive therapy and 51.5 % with less intensive therapy (odds ratio, 1.09; 95% CI 0.86 to 1.40; p=0.47). No significant differences were found in secondary end points, including rate of recovery of kidney function, duration of renal-replacement therapy, or evolution of non-renal organ failure.

This study demonstrates providing hemodialysis more frequently than three times per week to hemodynamically stable patients, or providing continuous renal replacement therapy at an effluent flow rate of more than 20 ml/kg/hour to hemodynamically unstable patients, does not improve outcomes. It should be noted, however, the less-intensive treatment strategy in this study provides a dose of renal replacement therapy exceeding the normal dose given in usual care.

Bottom Line: No clinical benefit exists in employing intensive renal replacement over a conventional approach in critically ill patients.

Citation: Palevsky PM, Zhang JH, O’Connor TZ, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359(1):7-20.

Elderly Patients and Females with Acute Coronary Syndrome (ACS) Often Receive Excess Doses of Heparin

Clinical Question: What initial dosing of unfractionated heparin (UFH) for patients with non-ST-segment elevation (NSTE) acute coronary syndrome is most frequently used and how does it affect risk of bleeding?

Background: UFH is commonly used in clinical practice for NSTE ACS, but a wide variability continues to exist in dosing protocols. Clinical studies have shown UFH dosing based on weight provides more effective early anticoagulation. However, the relationship between increasing weight-adjusted doses of UFH and the risk of bleeding has not been well described.

Study Design: Retrospective cohort study.

Setting: 420 U.S. hospitals involved in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation) initiative.

Synopsis: This study used data from patients enrolled in the CRUSADE initiative to investigate UFH dosing amongst 24,021 patients presenting with NSTE ACS. The study showed despite a recommendation to use weight-adjusted UFH dosing for NSTE ACS, there is a continued preference for a fixed dosing regimen of 5,000 U bolus and 1,000 U/hr initial infusion.

This fixed dose means women and the elderly are more likely to receive an excess UFH dose due to their lower body weight. The study found 35% of the group received excess weight-adjusted doses of UFH.

A clear relationship is present between excess weight-adjusted UFH doses and major bleeding, with the risk of major bleeding increasing particularly when UFH dose exceeds the recommended dosing of 70 U/kg bolus and 15 U/kg per hour infusion.

These observations support the need to follow guidelines on weight-adjusted UFH dosing in order to minimize the risk of bleeding in patients with NSTE ACS.

Bottom line: The initial UFH bolus and infusion dosing used for NSTE ACS often exceeds recommended weight-adjusted dosing, leading to higher rates of bleeding, particularly among women and the elderly.

Citation: Melloni C, Alexander KP, Chen AY et al. Unfractionated heparin dosing and risk of major bleeding in non-ST-segment elevation acute coronary syndromes. Am Heart J. 2008;156(2):209-215.

Elevated BNP Level Is a Marker for Higher Risk of Adverse Outcomes in Patients with Pulmonary Embolism

Clinical Question: Can elevated BNP levels predict adverse outcomes in patients with acute pulmonary embolism (PE)?

Background: Plasma brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) often are elevated in patients with PE and right ventricular (RV) dysfunction. The finding of RV dysfunction on echocardiography is an indicator of poor outcome in these patients. The role of BNP levels to differentiate patients with PE who are at higher risk of adverse events and poor clinical outcomes has not been determined.

Study Design: Meta analysis of prospective studies.

Settings: 13 studies involving 1,132 patients.

Synopsis: Elevated levels of BNP or NT-pro-BNP were noted in 51% of patients with acute PE. These patients had a higher rate of complicated inpatient course, as well as a higher risk of 30-day mortality (odds ratio 6.8; 95% CI 4.4-10; odds-ratio 7.6; 95% CI 3.4-17). Additionally, increased BNP levels were significantly associated with RV dysfunction (p<0.0001).

While elevated BNP levels may serve as a marker for increased risk of adverse outcomes, the investigators stress these levels alone should not be used to pursue more aggressive treatment strategies. Elevation of these markers is nonspecific and can be secondary to pre-existing heart, lung, or kidney disease, or older age. Further studies are needed to determine the role of BNP in risk stratifying patients with acute PE to different forms of therapy.

Bottom Line: High BNP or NT-pro-BNP levels can differentiate patients with PE who are at a higher risk of complicated hospital course and short-term mortality.

Citation: Klok FA, Mos IC, Huisman MV. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med 2008;178:425-430.

Silver-Coated Endotracheal Tubes Reduce Incidence of Ventilator-Associated Pneumonia (VAP)

Clinical Question: Can silver-coated endotracheal tubes reduce the incidence of VAP?

Background: Given the high morbidity linked to VAP, prevention strategies have been sought. Silver has broad-spectrum antimicrobial activity in vitro. Thus, a silver-coated endotracheal tube (ET) was designed to help prevent biofilm formation and bacterial colonization.

Study Design: A prospective, randomized, single-blind, controlled study.

Settings: 54 centers in North America.

Synopsis: Out of 9,417 potentially eligible patients, 2,003 patients expected to require mechanical ventilation for 24 hours or longer were randomized to undergo intubation with endotracheal tubes with and without silver coating. The primary outcome was incidence of VAP based on quantitative culture of bronchoalveolar lavage fluid.

The rate of microbiologically confirmed VAP in patients intubated for 24 hours or longer with the silver-coated ET tube was 4.8%, as compared to 7.5% in the control group. Using silver-coated ET tubes resulted in a 35.9% relative risk reduction of VAP incidence. Furthermore, the silver-coated ET tube was associated with a delayed time to VAP occurrence. Other outcomes, including length of intubation, duration of hospital stay, mortality, and frequency of adverse events, however, did not show statistically significant differences between the two groups.

Bottom Line: Using a silver-coated ET tube reduces the incidence of VAP, as well as delays time to VAP occurrence.

Citation: Kollef MH, Afessa B, Anzueta A, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805-813.

Literature at a Glance

• Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.
• Intensive glucose-lowering therapy in diabetic patients at high risk for cardiovascular events increased mortality.
• Targeting normal glycated hemoglobin levels with a gliclazide-based regimen does not have an effect on preventing major macrovascular events.
• Non-invasive ventilation has no effect on short-term mortality or rates of tracheal intubation and admission to ICU
• Routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes.
• No clinical benefit exists in employing intensive renal replacement over a conventional approach in critically ill patients.
• Initial UFH bolus and infusion dosing used for NSTE ACS often exceeds recommended weight-adjusted dosing.
• High BNP or NT-pro-BNP levels can differentiate patients who are at a higher risk of complicated hospital course and short-term mortality.
• Use of a silver-coated ET tube reduces the incidence of VAP, as well as delays time to VAP occurrence.

Tight Glucose Control in the Intensive Care Unit (ICU) Setting Does Not Reduce Short-Term Mortality

Clinical question: Does tight glucose control for critically ill patients affect mortality?

Background: Intensive glucose control for adult ICU patients has been advocated by numerous professional societies and adopted worldwide as a means to reduce mortality of critically ill patients. Evidence from multiple randomized controlled trials of tight glucose control in the ICU setting, however, shows mixed results.

Study Design: Meta-analysis of randomized controlled trials.

Setting: 29 studies involving 8,432 critically ill patients.

Synopsis: This study evaluated 29 trials involving critically ill adult patients randomized to tight glucose control versus usual care. Comparing these patients, there was no significant difference in short-term mortality (<30 days). Stratification of trials by level of glucose control (very tight <110 mg/dL versus moderately tight <150 mg/dL) and by ICU setting (surgical, medical, or mixed medical-surgical) did not affect mortality.

Tight glucose control was associated with a reduced risk of septicemia, but only in surgical patients. There was no association between tight control and a new need for dialysis, consistent across all ICU settings, as well as with both levels of glucose control. Finally, there was an increased risk of hypoglycemia (<40 mg/dL) with tight control, higher in patients who received very tight control versus those who received moderately tight control.

Limitations of the studies evaluated in this meta-analysis include difficulties with consistently maintaining tight glucose control. Twenty one percent of the trials did not achieve a mean glucose level within 5 mg/dL of the goal. This, along with a lack of standardization in reporting glucose control, makes study comparison problematic.

Bottom Line: Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.

Citation: Wiener, RS, Wiener DC, Larson, RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300:933-944.

Intensive Glucose-Lowering Therapy Increases Mortality in High-Risk Diabetic Patients

Clinical Question: Does intensive glucose-lowering therapy reduce cardiac events in high-risk diabetic patients?

Background: Epidemiologic studies have suggested the risk of cardiovascular disease increases with higher levels of glycated hemoglobin in patients with type-2 diabetes. No definitive data from randomized trials exist to test the effect of intensive glucose-lowering therapy on the rate of cardiovascular events in high-risk diabetic patients.

Study Design: Multicenter randomized controlled trial led by the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group.

Setting: 77 clinical centers in the U.S. and Canada.

Synopsis: 10,251 diabetic patients with established cardiovascular disease or additional cardiovascular risk factors, and median glycated hemoglobin level of 8.1%, received either intensive therapy (targeting glycated hemoglobin level <6.0%) or standard therapy (targeting level from 7.0% to 7.9%). The primary outcome was a composite of non-fatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes.

Data indicated intensive therapy did decrease the rate of non-fatal myocardial infarctions, however, it did not significantly reduce the primary composite of major cardiovascular events. Moreover, intensive therapy resulted in a significant increase in death from cardiovascular causes, as well as a relative increase of 22% of death from any cause, during follow up of three and a half years. Due to this finding, the intensive therapy regimen was discontinued 17 months before the scheduled end of the study.

Analysis of the data has not identified a cause for the unexpected increased mortality in the intensive therapy group, and has not shown any medication or combination of medications to be responsible.

Bottom Line: Intensive glucose-lowering therapy in diabetic patients at high risk for cardiovascular events increased mortality and did not significantly reduce major cardiovascular events.

Citation: Action to control cardiovascular risk in diabetes study group. Effects of intensive glucose lowering in type-2 diabetes. N Engl J Med. 2008;358:2545-2559.

Intensive Glucose Control Reduces Nephropathy but Has No Effect on Major Cardiovascular Events

Clinical Question: Does intensive glucose-lowering therapy decrease major macrovascular and microvascular events in high-risk diabetic patients?

Background: Prospective studies show a direct association between elevated glycated hemoglobin levels in diabetics and increased risk of vascular events. However, definitive evidence from randomized trials about the role of intensive glucose control in preventing vascular disease in diabetics is lacking.

Study Design: Multicenter randomized controlled trial led by the ADVANCE Collaborative Group.

Setting: 215 clinical centers in 20 countries from Asia, Australia, Europe, and North America.

Synopsis: 11,140 diabetic patients received either standard glucose therapy or intensive glucose therapy using gliclazide, as well as other drugs, to reach a targeted glycated hemoglobin of 6.5% or less. The primary outcome was a composite of major macrovascular and microvascular events, including nonfatal myocardial infarction (MI), nonfatal stroke, death from cardiovascular causes, nephropathy, and retinopathy.

Intensive glucose-lowering therapy, as compared to standard therapy, resulted in a 21% relative reduction of new or worsening nephropathy. There was no significant effect on the rate of MI, strokes, death from cardiovascular causes, or retinopathy. Furthermore, intensive glucose control was associated with an increased risk of severe hypoglycemia and increased rate of hospitalization. In contrast to the ACCORD study, intensive therapy did not result in an increase in mortality.

Bottom Line: While targeting normal glycated hemoglobin levels with a gliclazide-based regimen reduced the rate of nephropathy, this strategy did not have an effect on preventing major macrovascular events.

Citation: ADVANCE collaborative group. Intensive blood glucose control and vascular outcomes in patients with type-2 diabetes. N Eng J Med. 2008;358:2560-2572.

Non-invasive Ventilation Does Not Improve Short-Term Mortality in Patients with Acute Cardiogenic Pulmonary Edema

Clinical Question: Does non-invasive ventilation improve survival for patients with acute cardiogenic pulmonary edema?

Background: Acute cardiogenic pulmonary edema is a common medical emergency, but only small trials address outcomes of non-invasive methods of ventilation.

Study Design: A prospective, randomized control study.

Setting: 26 emergency rooms and hospitals in the United Kingdom.

Synopsis: 1,069 patients with a clinical diagnosis of acute cardiogenic pulmonary edema in the emergency room were randomized to one of three treatment strategies: standard oxygen therapy, continuous positive airway pressure (CPAP), or non-invasive intermittent positive pressure ventilation (NIPPV).

There was no significant difference in the seven-day mortality between patients receiving standard oxygen therapy (9.8%) and those treated with non-invasive ventilation (9.5%). Additionally, there was no significant difference in the combined end point of death or intubation within seven days between patients receiving CPAP and NIPPV—the primary end points of the study.

While non-invasive ventilation was associated with greater reductions in dyspnea, heart rate, acidosis, and hypercapnia than was standard oxygen therapy, rates of other secondary outcomes—including tracheal intubation, admission to the critical care unit, myocardial infarction, and 30-day mortality—were similar.

Bottom Line: Although non-invasive ventilation rapidly improves respiratory distress and metabolic disturbances for patients with acute cardiogenic pulmonary edema, it has no effect on short-term mortality or rates of tracheal intubation and admission to ICU.

Citation: Gray A, Goodacre S, Newby D, et al. Non-invasive ventilation in acute cardiogenic pulmonary edema. N Eng J Med. 2008;359:142-151.

Rhythm Control in Patients with Atrial Fibrillation and CHF Does Not Improve Mortality

Clinical Question: Does the restoration of sinus rhythm in patients with atrial fibrillation and heart failure reduce mortality from cardiovascular causes?

Background: Recent data show rhythm control provides no benefit over rate control among patients with atrial fibrillation, but limited information is available regarding its applicability to patients with heart failure.

Study Design: Multicenter, prospective, double-blind, randomized trial.

Settings: 123 medical centers worldwide.

Synopsis:1,376 patients with a left ventricular ejection fraction of 35% or less, symptoms of heart failure, and a history of atrial fibrillation were randomized (allocation not concealed) either to a rhythm-control (e.g., conversion to sinus rhythm) or rate-control strategy. The primary outcome measured was the time to death from cardiovascular causes. Secondary outcomes included death from any cause, stroke, worsening heart failure, hospitalization, quality of life, cost of therapy, and a composite of death from cardiovascular causes, stroke or worsening heart failure.

Study follow up succeeded with 94% of enrolled patients completing follow up (median=47 months for survivors) or dying. Amiodarone was the drug used most often in the rhythm-control group. Ninety percent of patients received angiotensin converting enzyme inhibitors or angiotensin II receptor blocker, and 90% received anticoagulation.

Among patients with atrial fibrillation and congestive heart failure, the number of deaths from cardiovascular causes was similar in the rate (25%) and rhythm-control group (27%). Furthermore, there were no significant differences in important secondary outcomes, including death from any cause, worsening heart failure, or stroke.

Bottom Line: For patients with heart failure from systolic dysfunction and atrial fibrillation, the routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes as compared with a rate-control strategy.

Citation: Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667-2677.

No Benefit from Intensive Renal Replacement Therapy in Critically Ill Patients with Acute Kidney Injury (AKI)

Clinical Question: Does intensive renal replacement therapy, as compared with a conventional treatment strategy, affect outcomes in critically ill patients?

Background: The optimal timing for the initiation, method, and dosing of renal replacement therapy among patients with AKI remains uncertain. Previous single-center studies limited to single methods of renal replacement therapy have suggested more intensive therapy is associated with improved survival. These results, however, have been inconsistent.

Study Design: Randomized controlled trial.

Setting: Veterans Affairs hospitals and university affiliated medical centers.

Synopsis: This study randomized 1,124 of 4,340 eligible critically ill adults with AKI to receive either intensive renal replacement therapy or a less intensive, more conventional approach. The primary end point of death at day 60 from any cause was 53.6% with intensive therapy and 51.5 % with less intensive therapy (odds ratio, 1.09; 95% CI 0.86 to 1.40; p=0.47). No significant differences were found in secondary end points, including rate of recovery of kidney function, duration of renal-replacement therapy, or evolution of non-renal organ failure.

This study demonstrates providing hemodialysis more frequently than three times per week to hemodynamically stable patients, or providing continuous renal replacement therapy at an effluent flow rate of more than 20 ml/kg/hour to hemodynamically unstable patients, does not improve outcomes. It should be noted, however, the less-intensive treatment strategy in this study provides a dose of renal replacement therapy exceeding the normal dose given in usual care.

Bottom Line: No clinical benefit exists in employing intensive renal replacement over a conventional approach in critically ill patients.

Citation: Palevsky PM, Zhang JH, O’Connor TZ, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359(1):7-20.

Elderly Patients and Females with Acute Coronary Syndrome (ACS) Often Receive Excess Doses of Heparin

Clinical Question: What initial dosing of unfractionated heparin (UFH) for patients with non-ST-segment elevation (NSTE) acute coronary syndrome is most frequently used and how does it affect risk of bleeding?

Background: UFH is commonly used in clinical practice for NSTE ACS, but a wide variability continues to exist in dosing protocols. Clinical studies have shown UFH dosing based on weight provides more effective early anticoagulation. However, the relationship between increasing weight-adjusted doses of UFH and the risk of bleeding has not been well described.

Study Design: Retrospective cohort study.

Setting: 420 U.S. hospitals involved in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation) initiative.

Synopsis: This study used data from patients enrolled in the CRUSADE initiative to investigate UFH dosing amongst 24,021 patients presenting with NSTE ACS. The study showed despite a recommendation to use weight-adjusted UFH dosing for NSTE ACS, there is a continued preference for a fixed dosing regimen of 5,000 U bolus and 1,000 U/hr initial infusion.

This fixed dose means women and the elderly are more likely to receive an excess UFH dose due to their lower body weight. The study found 35% of the group received excess weight-adjusted doses of UFH.

A clear relationship is present between excess weight-adjusted UFH doses and major bleeding, with the risk of major bleeding increasing particularly when UFH dose exceeds the recommended dosing of 70 U/kg bolus and 15 U/kg per hour infusion.

These observations support the need to follow guidelines on weight-adjusted UFH dosing in order to minimize the risk of bleeding in patients with NSTE ACS.

Bottom line: The initial UFH bolus and infusion dosing used for NSTE ACS often exceeds recommended weight-adjusted dosing, leading to higher rates of bleeding, particularly among women and the elderly.

Citation: Melloni C, Alexander KP, Chen AY et al. Unfractionated heparin dosing and risk of major bleeding in non-ST-segment elevation acute coronary syndromes. Am Heart J. 2008;156(2):209-215.

Elevated BNP Level Is a Marker for Higher Risk of Adverse Outcomes in Patients with Pulmonary Embolism

Clinical Question: Can elevated BNP levels predict adverse outcomes in patients with acute pulmonary embolism (PE)?

Background: Plasma brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) often are elevated in patients with PE and right ventricular (RV) dysfunction. The finding of RV dysfunction on echocardiography is an indicator of poor outcome in these patients. The role of BNP levels to differentiate patients with PE who are at higher risk of adverse events and poor clinical outcomes has not been determined.

Study Design: Meta analysis of prospective studies.

Settings: 13 studies involving 1,132 patients.

Synopsis: Elevated levels of BNP or NT-pro-BNP were noted in 51% of patients with acute PE. These patients had a higher rate of complicated inpatient course, as well as a higher risk of 30-day mortality (odds ratio 6.8; 95% CI 4.4-10; odds-ratio 7.6; 95% CI 3.4-17). Additionally, increased BNP levels were significantly associated with RV dysfunction (p<0.0001).

While elevated BNP levels may serve as a marker for increased risk of adverse outcomes, the investigators stress these levels alone should not be used to pursue more aggressive treatment strategies. Elevation of these markers is nonspecific and can be secondary to pre-existing heart, lung, or kidney disease, or older age. Further studies are needed to determine the role of BNP in risk stratifying patients with acute PE to different forms of therapy.

Bottom Line: High BNP or NT-pro-BNP levels can differentiate patients with PE who are at a higher risk of complicated hospital course and short-term mortality.

Citation: Klok FA, Mos IC, Huisman MV. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med 2008;178:425-430.

Silver-Coated Endotracheal Tubes Reduce Incidence of Ventilator-Associated Pneumonia (VAP)

Clinical Question: Can silver-coated endotracheal tubes reduce the incidence of VAP?

Background: Given the high morbidity linked to VAP, prevention strategies have been sought. Silver has broad-spectrum antimicrobial activity in vitro. Thus, a silver-coated endotracheal tube (ET) was designed to help prevent biofilm formation and bacterial colonization.

Study Design: A prospective, randomized, single-blind, controlled study.

Settings: 54 centers in North America.

Synopsis: Out of 9,417 potentially eligible patients, 2,003 patients expected to require mechanical ventilation for 24 hours or longer were randomized to undergo intubation with endotracheal tubes with and without silver coating. The primary outcome was incidence of VAP based on quantitative culture of bronchoalveolar lavage fluid.

The rate of microbiologically confirmed VAP in patients intubated for 24 hours or longer with the silver-coated ET tube was 4.8%, as compared to 7.5% in the control group. Using silver-coated ET tubes resulted in a 35.9% relative risk reduction of VAP incidence. Furthermore, the silver-coated ET tube was associated with a delayed time to VAP occurrence. Other outcomes, including length of intubation, duration of hospital stay, mortality, and frequency of adverse events, however, did not show statistically significant differences between the two groups.

Bottom Line: Using a silver-coated ET tube reduces the incidence of VAP, as well as delays time to VAP occurrence.

Citation: Kollef MH, Afessa B, Anzueta A, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805-813.

Literature at a Glance

• Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.
• Intensive glucose-lowering therapy in diabetic patients at high risk for cardiovascular events increased mortality.
• Targeting normal glycated hemoglobin levels with a gliclazide-based regimen does not have an effect on preventing major macrovascular events.
• Non-invasive ventilation has no effect on short-term mortality or rates of tracheal intubation and admission to ICU
• Routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes.
• No clinical benefit exists in employing intensive renal replacement over a conventional approach in critically ill patients.
• Initial UFH bolus and infusion dosing used for NSTE ACS often exceeds recommended weight-adjusted dosing.
• High BNP or NT-pro-BNP levels can differentiate patients who are at a higher risk of complicated hospital course and short-term mortality.
• Use of a silver-coated ET tube reduces the incidence of VAP, as well as delays time to VAP occurrence.

Tight Glucose Control in the Intensive Care Unit (ICU) Setting Does Not Reduce Short-Term Mortality

Clinical question: Does tight glucose control for critically ill patients affect mortality?

Background: Intensive glucose control for adult ICU patients has been advocated by numerous professional societies and adopted worldwide as a means to reduce mortality of critically ill patients. Evidence from multiple randomized controlled trials of tight glucose control in the ICU setting, however, shows mixed results.

Study Design: Meta-analysis of randomized controlled trials.

Setting: 29 studies involving 8,432 critically ill patients.

Synopsis: This study evaluated 29 trials involving critically ill adult patients randomized to tight glucose control versus usual care. Comparing these patients, there was no significant difference in short-term mortality (<30 days). Stratification of trials by level of glucose control (very tight <110 mg/dL versus moderately tight <150 mg/dL) and by ICU setting (surgical, medical, or mixed medical-surgical) did not affect mortality.

Tight glucose control was associated with a reduced risk of septicemia, but only in surgical patients. There was no association between tight control and a new need for dialysis, consistent across all ICU settings, as well as with both levels of glucose control. Finally, there was an increased risk of hypoglycemia (<40 mg/dL) with tight control, higher in patients who received very tight control versus those who received moderately tight control.

Limitations of the studies evaluated in this meta-analysis include difficulties with consistently maintaining tight glucose control. Twenty one percent of the trials did not achieve a mean glucose level within 5 mg/dL of the goal. This, along with a lack of standardization in reporting glucose control, makes study comparison problematic.

Bottom Line: Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.

Citation: Wiener, RS, Wiener DC, Larson, RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300:933-944.

Intensive Glucose-Lowering Therapy Increases Mortality in High-Risk Diabetic Patients

Clinical Question: Does intensive glucose-lowering therapy reduce cardiac events in high-risk diabetic patients?

Background: Epidemiologic studies have suggested the risk of cardiovascular disease increases with higher levels of glycated hemoglobin in patients with type-2 diabetes. No definitive data from randomized trials exist to test the effect of intensive glucose-lowering therapy on the rate of cardiovascular events in high-risk diabetic patients.

Study Design: Multicenter randomized controlled trial led by the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group.

Setting: 77 clinical centers in the U.S. and Canada.

Synopsis: 10,251 diabetic patients with established cardiovascular disease or additional cardiovascular risk factors, and median glycated hemoglobin level of 8.1%, received either intensive therapy (targeting glycated hemoglobin level <6.0%) or standard therapy (targeting level from 7.0% to 7.9%). The primary outcome was a composite of non-fatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes.

Data indicated intensive therapy did decrease the rate of non-fatal myocardial infarctions, however, it did not significantly reduce the primary composite of major cardiovascular events. Moreover, intensive therapy resulted in a significant increase in death from cardiovascular causes, as well as a relative increase of 22% of death from any cause, during follow up of three and a half years. Due to this finding, the intensive therapy regimen was discontinued 17 months before the scheduled end of the study.

Analysis of the data has not identified a cause for the unexpected increased mortality in the intensive therapy group, and has not shown any medication or combination of medications to be responsible.

Bottom Line: Intensive glucose-lowering therapy in diabetic patients at high risk for cardiovascular events increased mortality and did not significantly reduce major cardiovascular events.

Citation: Action to control cardiovascular risk in diabetes study group. Effects of intensive glucose lowering in type-2 diabetes. N Engl J Med. 2008;358:2545-2559.

Intensive Glucose Control Reduces Nephropathy but Has No Effect on Major Cardiovascular Events

Clinical Question: Does intensive glucose-lowering therapy decrease major macrovascular and microvascular events in high-risk diabetic patients?

Background: Prospective studies show a direct association between elevated glycated hemoglobin levels in diabetics and increased risk of vascular events. However, definitive evidence from randomized trials about the role of intensive glucose control in preventing vascular disease in diabetics is lacking.

Study Design: Multicenter randomized controlled trial led by the ADVANCE Collaborative Group.

Setting: 215 clinical centers in 20 countries from Asia, Australia, Europe, and North America.

Synopsis: 11,140 diabetic patients received either standard glucose therapy or intensive glucose therapy using gliclazide, as well as other drugs, to reach a targeted glycated hemoglobin of 6.5% or less. The primary outcome was a composite of major macrovascular and microvascular events, including nonfatal myocardial infarction (MI), nonfatal stroke, death from cardiovascular causes, nephropathy, and retinopathy.

Intensive glucose-lowering therapy, as compared to standard therapy, resulted in a 21% relative reduction of new or worsening nephropathy. There was no significant effect on the rate of MI, strokes, death from cardiovascular causes, or retinopathy. Furthermore, intensive glucose control was associated with an increased risk of severe hypoglycemia and increased rate of hospitalization. In contrast to the ACCORD study, intensive therapy did not result in an increase in mortality.

Bottom Line: While targeting normal glycated hemoglobin levels with a gliclazide-based regimen reduced the rate of nephropathy, this strategy did not have an effect on preventing major macrovascular events.

Citation: ADVANCE collaborative group. Intensive blood glucose control and vascular outcomes in patients with type-2 diabetes. N Eng J Med. 2008;358:2560-2572.

Non-invasive Ventilation Does Not Improve Short-Term Mortality in Patients with Acute Cardiogenic Pulmonary Edema

Clinical Question: Does non-invasive ventilation improve survival for patients with acute cardiogenic pulmonary edema?

Background: Acute cardiogenic pulmonary edema is a common medical emergency, but only small trials address outcomes of non-invasive methods of ventilation.

Study Design: A prospective, randomized control study.

Setting: 26 emergency rooms and hospitals in the United Kingdom.

Synopsis: 1,069 patients with a clinical diagnosis of acute cardiogenic pulmonary edema in the emergency room were randomized to one of three treatment strategies: standard oxygen therapy, continuous positive airway pressure (CPAP), or non-invasive intermittent positive pressure ventilation (NIPPV).

There was no significant difference in the seven-day mortality between patients receiving standard oxygen therapy (9.8%) and those treated with non-invasive ventilation (9.5%). Additionally, there was no significant difference in the combined end point of death or intubation within seven days between patients receiving CPAP and NIPPV—the primary end points of the study.

While non-invasive ventilation was associated with greater reductions in dyspnea, heart rate, acidosis, and hypercapnia than was standard oxygen therapy, rates of other secondary outcomes—including tracheal intubation, admission to the critical care unit, myocardial infarction, and 30-day mortality—were similar.

Bottom Line: Although non-invasive ventilation rapidly improves respiratory distress and metabolic disturbances for patients with acute cardiogenic pulmonary edema, it has no effect on short-term mortality or rates of tracheal intubation and admission to ICU.

Citation: Gray A, Goodacre S, Newby D, et al. Non-invasive ventilation in acute cardiogenic pulmonary edema. N Eng J Med. 2008;359:142-151.

Rhythm Control in Patients with Atrial Fibrillation and CHF Does Not Improve Mortality

Clinical Question: Does the restoration of sinus rhythm in patients with atrial fibrillation and heart failure reduce mortality from cardiovascular causes?

Background: Recent data show rhythm control provides no benefit over rate control among patients with atrial fibrillation, but limited information is available regarding its applicability to patients with heart failure.

Study Design: Multicenter, prospective, double-blind, randomized trial.

Settings: 123 medical centers worldwide.

Synopsis:1,376 patients with a left ventricular ejection fraction of 35% or less, symptoms of heart failure, and a history of atrial fibrillation were randomized (allocation not concealed) either to a rhythm-control (e.g., conversion to sinus rhythm) or rate-control strategy. The primary outcome measured was the time to death from cardiovascular causes. Secondary outcomes included death from any cause, stroke, worsening heart failure, hospitalization, quality of life, cost of therapy, and a composite of death from cardiovascular causes, stroke or worsening heart failure.

Study follow up succeeded with 94% of enrolled patients completing follow up (median=47 months for survivors) or dying. Amiodarone was the drug used most often in the rhythm-control group. Ninety percent of patients received angiotensin converting enzyme inhibitors or angiotensin II receptor blocker, and 90% received anticoagulation.

Among patients with atrial fibrillation and congestive heart failure, the number of deaths from cardiovascular causes was similar in the rate (25%) and rhythm-control group (27%). Furthermore, there were no significant differences in important secondary outcomes, including death from any cause, worsening heart failure, or stroke.

Bottom Line: For patients with heart failure from systolic dysfunction and atrial fibrillation, the routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes as compared with a rate-control strategy.

Citation: Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667-2677.

No Benefit from Intensive Renal Replacement Therapy in Critically Ill Patients with Acute Kidney Injury (AKI)

Clinical Question: Does intensive renal replacement therapy, as compared with a conventional treatment strategy, affect outcomes in critically ill patients?

Background: The optimal timing for the initiation, method, and dosing of renal replacement therapy among patients with AKI remains uncertain. Previous single-center studies limited to single methods of renal replacement therapy have suggested more intensive therapy is associated with improved survival. These results, however, have been inconsistent.

Study Design: Randomized controlled trial.

Setting: Veterans Affairs hospitals and university affiliated medical centers.

Synopsis: This study randomized 1,124 of 4,340 eligible critically ill adults with AKI to receive either intensive renal replacement therapy or a less intensive, more conventional approach. The primary end point of death at day 60 from any cause was 53.6% with intensive therapy and 51.5 % with less intensive therapy (odds ratio, 1.09; 95% CI 0.86 to 1.40; p=0.47). No significant differences were found in secondary end points, including rate of recovery of kidney function, duration of renal-replacement therapy, or evolution of non-renal organ failure.

This study demonstrates providing hemodialysis more frequently than three times per week to hemodynamically stable patients, or providing continuous renal replacement therapy at an effluent flow rate of more than 20 ml/kg/hour to hemodynamically unstable patients, does not improve outcomes. It should be noted, however, the less-intensive treatment strategy in this study provides a dose of renal replacement therapy exceeding the normal dose given in usual care.

Bottom Line: No clinical benefit exists in employing intensive renal replacement over a conventional approach in critically ill patients.

Citation: Palevsky PM, Zhang JH, O’Connor TZ, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359(1):7-20.

Elderly Patients and Females with Acute Coronary Syndrome (ACS) Often Receive Excess Doses of Heparin

Clinical Question: What initial dosing of unfractionated heparin (UFH) for patients with non-ST-segment elevation (NSTE) acute coronary syndrome is most frequently used and how does it affect risk of bleeding?

Background: UFH is commonly used in clinical practice for NSTE ACS, but a wide variability continues to exist in dosing protocols. Clinical studies have shown UFH dosing based on weight provides more effective early anticoagulation. However, the relationship between increasing weight-adjusted doses of UFH and the risk of bleeding has not been well described.

Study Design: Retrospective cohort study.

Setting: 420 U.S. hospitals involved in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation) initiative.

Synopsis: This study used data from patients enrolled in the CRUSADE initiative to investigate UFH dosing amongst 24,021 patients presenting with NSTE ACS. The study showed despite a recommendation to use weight-adjusted UFH dosing for NSTE ACS, there is a continued preference for a fixed dosing regimen of 5,000 U bolus and 1,000 U/hr initial infusion.

This fixed dose means women and the elderly are more likely to receive an excess UFH dose due to their lower body weight. The study found 35% of the group received excess weight-adjusted doses of UFH.

A clear relationship is present between excess weight-adjusted UFH doses and major bleeding, with the risk of major bleeding increasing particularly when UFH dose exceeds the recommended dosing of 70 U/kg bolus and 15 U/kg per hour infusion.

These observations support the need to follow guidelines on weight-adjusted UFH dosing in order to minimize the risk of bleeding in patients with NSTE ACS.

Bottom line: The initial UFH bolus and infusion dosing used for NSTE ACS often exceeds recommended weight-adjusted dosing, leading to higher rates of bleeding, particularly among women and the elderly.

Citation: Melloni C, Alexander KP, Chen AY et al. Unfractionated heparin dosing and risk of major bleeding in non-ST-segment elevation acute coronary syndromes. Am Heart J. 2008;156(2):209-215.

Elevated BNP Level Is a Marker for Higher Risk of Adverse Outcomes in Patients with Pulmonary Embolism

Clinical Question: Can elevated BNP levels predict adverse outcomes in patients with acute pulmonary embolism (PE)?

Background: Plasma brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) often are elevated in patients with PE and right ventricular (RV) dysfunction. The finding of RV dysfunction on echocardiography is an indicator of poor outcome in these patients. The role of BNP levels to differentiate patients with PE who are at higher risk of adverse events and poor clinical outcomes has not been determined.

Study Design: Meta analysis of prospective studies.

Settings: 13 studies involving 1,132 patients.

Synopsis: Elevated levels of BNP or NT-pro-BNP were noted in 51% of patients with acute PE. These patients had a higher rate of complicated inpatient course, as well as a higher risk of 30-day mortality (odds ratio 6.8; 95% CI 4.4-10; odds-ratio 7.6; 95% CI 3.4-17). Additionally, increased BNP levels were significantly associated with RV dysfunction (p<0.0001).

While elevated BNP levels may serve as a marker for increased risk of adverse outcomes, the investigators stress these levels alone should not be used to pursue more aggressive treatment strategies. Elevation of these markers is nonspecific and can be secondary to pre-existing heart, lung, or kidney disease, or older age. Further studies are needed to determine the role of BNP in risk stratifying patients with acute PE to different forms of therapy.

Bottom Line: High BNP or NT-pro-BNP levels can differentiate patients with PE who are at a higher risk of complicated hospital course and short-term mortality.

Citation: Klok FA, Mos IC, Huisman MV. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med 2008;178:425-430.

Silver-Coated Endotracheal Tubes Reduce Incidence of Ventilator-Associated Pneumonia (VAP)

Clinical Question: Can silver-coated endotracheal tubes reduce the incidence of VAP?

Background: Given the high morbidity linked to VAP, prevention strategies have been sought. Silver has broad-spectrum antimicrobial activity in vitro. Thus, a silver-coated endotracheal tube (ET) was designed to help prevent biofilm formation and bacterial colonization.

Study Design: A prospective, randomized, single-blind, controlled study.

Settings: 54 centers in North America.

Synopsis: Out of 9,417 potentially eligible patients, 2,003 patients expected to require mechanical ventilation for 24 hours or longer were randomized to undergo intubation with endotracheal tubes with and without silver coating. The primary outcome was incidence of VAP based on quantitative culture of bronchoalveolar lavage fluid.

The rate of microbiologically confirmed VAP in patients intubated for 24 hours or longer with the silver-coated ET tube was 4.8%, as compared to 7.5% in the control group. Using silver-coated ET tubes resulted in a 35.9% relative risk reduction of VAP incidence. Furthermore, the silver-coated ET tube was associated with a delayed time to VAP occurrence. Other outcomes, including length of intubation, duration of hospital stay, mortality, and frequency of adverse events, however, did not show statistically significant differences between the two groups.

Bottom Line: Using a silver-coated ET tube reduces the incidence of VAP, as well as delays time to VAP occurrence.

Citation: Kollef MH, Afessa B, Anzueta A, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805-813.

Healthcare quality and patient safety is a hot topic in hospitals across the country, as well as here at The Society of Hospital Medicine (SHM). It seems like every day we hear of new regulatory requirements from the Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and state health departments, or requirements from other health care organizations, including insurance companies. It’s hard to keep up with it all.

To help hospitals with their quality initiatives, SHM recently beefed up its Quality Initiatives Department by adding three new staff members, including myself. I’d like to introduce you to our newest members. My name is Jane Kelly-Cummings, and I joined SHM in July as the senior director of Quality Initiatives. I’m responsible for the strategic planning, development and implementation of quality initiatives for the society and the staff liaison for the Hospital Quality and Patient Safety Committee. I’ve been a registered nurse (RN) for more than 20 years and have been working in the quality world for more than a decade.

Linda Boclair joined SHM in June as director of Quality Initiatives. She is responsible for proposal/grant writing, managing select quality initiative projects, and department operations. She has a background in medical technology and industrial relations/organizational behavior. Linda currently is working on a medication reconciliation project, an advisory panel on pharmacoeconomics, and she is working on the new co-management taskforce.

Lauren Valentino also joined SHM in June as the departments project coordinator. She is responsible for supporting the Quality Initiatives department through project planning and implementation. Lauren also is a support resource for the society, providing documentation and coordination to the committees, task forces, and various special interest groups.

The new staffers join Joy M. Wittnebert-Barnosky, senior project manager; Tina Budnitz, senior advisor for Quality Initiatives; and Kathleen Kerr, project manager of QI Mentored Implementation in rounding out SHM’s new Quality Initiatives Department.

In order to best meet the quality initiatives needs of our members, we have been developing SHM’s quality initiatives strategic plan. We had the chance to share the plan with SHM board members at the bi-annual board meeting in October. The board received the strategic plan well, and the group is looking forward to an update at the January board meeting. SHM’s strategic quality initiative planning began in October 2007, when a group of SHM leaders met to begin the process of developing a 10-year strategic plan for quality initiatives. The output of this meeting led to six areas of focus, which we refer to as core strategies:

• Develop education programs and technical support tools in quality improvement or patient safety;
• Advance a national quality agenda for hospitals and hospitalists;
• Facilitate cultural change and develop initiatives to promote hospital medicine’s role in quality initiatives within the C-suite at our nation’s hospitals;
• Evaluate effectiveness of current offerings in quality improvement or patient safety;
• Promote adoption of health information technologies to advance patient safety and quality improvement; and
• Promote and support the new science of QI (i.e., develop a research agenda).

Linking these focus areas with SHM’s Core Competencies in Hospital Medicine and current national industry quality initiatives, such as The Joint Commission’s National Patient Safety Goals and Core Measures, is the basic foundation for SHM’s strategic quality plan. This plan will allow SHM to become more proactive in our approach to quality initiatives for the next one, three, five, and 10 years. It will help us focus on the areas identified as needs for hospitalists and hospital medicine.

Plan Breakdown

I would like to tell you about some of the newest quality initiatives currently underway. First is an advisory board on pharmacoeconomics. We are pulling together 11 industry leaders, including CEOs, chief financial officers, chief medical officers, pharmacists, and thought leaders in quality. This advisory board will be evaluating the standard operating procedures in hospitals across the country regarding the use of pharmacoeconomics in decisions to utilize medications, especially newer and more expensive agents, using venous thromboembolism (VTE) prevention as a case example.

We have assembled another advisory board, which is just underway, to look at complicated skin and skin structure infections (cSSSI). This board will include hospitalists, infection control physicians, emergency room physicians, pharmacists, wound care nurses, and quality improvement experts.

Lastly, we have a second VTE project charged with the development of an automated, electronic query for a major commercial clinical information system. The project team is tasked to develop and demonstrate how a system can dramatically increase the prevalence of VTE prophylaxis in hospitals where it will be piloted.

Collaborative Efforts

I also would like to share a few of the other exciting activities the quality department has been up to recently. SHM is in the process of collaborating on a book with the Joint Commission Resources on Hospitalists and Patient Safety. The book is scheduled for release this spring, so be on the lookout. We also are writing an article for the The Physician Executive, which is the journal of the American College of Physician Executives. The article focuses on how quality, patient safety, and patient satisfaction are becoming priorities for physician executives, and how hospitalists are a critical element of a strategy to address this priority. We also are talking with other organizations, such as the American Hospital Association and United Health Group, about potential collaborative work in the future.

So, you can see things at SHM headquarters are anything but dull. The entire QI department—both the veterans and new staff—are looking forward to helping you make your quality and patient safety initiatives more successful and improve the care of patients throughout the country. TH

Healthcare quality and patient safety is a hot topic in hospitals across the country, as well as here at The Society of Hospital Medicine (SHM). It seems like every day we hear of new regulatory requirements from the Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and state health departments, or requirements from other health care organizations, including insurance companies. It’s hard to keep up with it all.

To help hospitals with their quality initiatives, SHM recently beefed up its Quality Initiatives Department by adding three new staff members, including myself. I’d like to introduce you to our newest members. My name is Jane Kelly-Cummings, and I joined SHM in July as the senior director of Quality Initiatives. I’m responsible for the strategic planning, development and implementation of quality initiatives for the society and the staff liaison for the Hospital Quality and Patient Safety Committee. I’ve been a registered nurse (RN) for more than 20 years and have been working in the quality world for more than a decade.

Linda Boclair joined SHM in June as director of Quality Initiatives. She is responsible for proposal/grant writing, managing select quality initiative projects, and department operations. She has a background in medical technology and industrial relations/organizational behavior. Linda currently is working on a medication reconciliation project, an advisory panel on pharmacoeconomics, and she is working on the new co-management taskforce.

Lauren Valentino also joined SHM in June as the departments project coordinator. She is responsible for supporting the Quality Initiatives department through project planning and implementation. Lauren also is a support resource for the society, providing documentation and coordination to the committees, task forces, and various special interest groups.

The new staffers join Joy M. Wittnebert-Barnosky, senior project manager; Tina Budnitz, senior advisor for Quality Initiatives; and Kathleen Kerr, project manager of QI Mentored Implementation in rounding out SHM’s new Quality Initiatives Department.

In order to best meet the quality initiatives needs of our members, we have been developing SHM’s quality initiatives strategic plan. We had the chance to share the plan with SHM board members at the bi-annual board meeting in October. The board received the strategic plan well, and the group is looking forward to an update at the January board meeting. SHM’s strategic quality initiative planning began in October 2007, when a group of SHM leaders met to begin the process of developing a 10-year strategic plan for quality initiatives. The output of this meeting led to six areas of focus, which we refer to as core strategies:

• Develop education programs and technical support tools in quality improvement or patient safety;
• Advance a national quality agenda for hospitals and hospitalists;
• Facilitate cultural change and develop initiatives to promote hospital medicine’s role in quality initiatives within the C-suite at our nation’s hospitals;
• Evaluate effectiveness of current offerings in quality improvement or patient safety;
• Promote adoption of health information technologies to advance patient safety and quality improvement; and
• Promote and support the new science of QI (i.e., develop a research agenda).

Linking these focus areas with SHM’s Core Competencies in Hospital Medicine and current national industry quality initiatives, such as The Joint Commission’s National Patient Safety Goals and Core Measures, is the basic foundation for SHM’s strategic quality plan. This plan will allow SHM to become more proactive in our approach to quality initiatives for the next one, three, five, and 10 years. It will help us focus on the areas identified as needs for hospitalists and hospital medicine.

Plan Breakdown

I would like to tell you about some of the newest quality initiatives currently underway. First is an advisory board on pharmacoeconomics. We are pulling together 11 industry leaders, including CEOs, chief financial officers, chief medical officers, pharmacists, and thought leaders in quality. This advisory board will be evaluating the standard operating procedures in hospitals across the country regarding the use of pharmacoeconomics in decisions to utilize medications, especially newer and more expensive agents, using venous thromboembolism (VTE) prevention as a case example.

We have assembled another advisory board, which is just underway, to look at complicated skin and skin structure infections (cSSSI). This board will include hospitalists, infection control physicians, emergency room physicians, pharmacists, wound care nurses, and quality improvement experts.

Lastly, we have a second VTE project charged with the development of an automated, electronic query for a major commercial clinical information system. The project team is tasked to develop and demonstrate how a system can dramatically increase the prevalence of VTE prophylaxis in hospitals where it will be piloted.

Collaborative Efforts

I also would like to share a few of the other exciting activities the quality department has been up to recently. SHM is in the process of collaborating on a book with the Joint Commission Resources on Hospitalists and Patient Safety. The book is scheduled for release this spring, so be on the lookout. We also are writing an article for the The Physician Executive, which is the journal of the American College of Physician Executives. The article focuses on how quality, patient safety, and patient satisfaction are becoming priorities for physician executives, and how hospitalists are a critical element of a strategy to address this priority. We also are talking with other organizations, such as the American Hospital Association and United Health Group, about potential collaborative work in the future.

So, you can see things at SHM headquarters are anything but dull. The entire QI department—both the veterans and new staff—are looking forward to helping you make your quality and patient safety initiatives more successful and improve the care of patients throughout the country. TH

Healthcare quality and patient safety is a hot topic in hospitals across the country, as well as here at The Society of Hospital Medicine (SHM). It seems like every day we hear of new regulatory requirements from the Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and state health departments, or requirements from other health care organizations, including insurance companies. It’s hard to keep up with it all.

To help hospitals with their quality initiatives, SHM recently beefed up its Quality Initiatives Department by adding three new staff members, including myself. I’d like to introduce you to our newest members. My name is Jane Kelly-Cummings, and I joined SHM in July as the senior director of Quality Initiatives. I’m responsible for the strategic planning, development and implementation of quality initiatives for the society and the staff liaison for the Hospital Quality and Patient Safety Committee. I’ve been a registered nurse (RN) for more than 20 years and have been working in the quality world for more than a decade.

Linda Boclair joined SHM in June as director of Quality Initiatives. She is responsible for proposal/grant writing, managing select quality initiative projects, and department operations. She has a background in medical technology and industrial relations/organizational behavior. Linda currently is working on a medication reconciliation project, an advisory panel on pharmacoeconomics, and she is working on the new co-management taskforce.

Lauren Valentino also joined SHM in June as the departments project coordinator. She is responsible for supporting the Quality Initiatives department through project planning and implementation. Lauren also is a support resource for the society, providing documentation and coordination to the committees, task forces, and various special interest groups.

The new staffers join Joy M. Wittnebert-Barnosky, senior project manager; Tina Budnitz, senior advisor for Quality Initiatives; and Kathleen Kerr, project manager of QI Mentored Implementation in rounding out SHM’s new Quality Initiatives Department.

In order to best meet the quality initiatives needs of our members, we have been developing SHM’s quality initiatives strategic plan. We had the chance to share the plan with SHM board members at the bi-annual board meeting in October. The board received the strategic plan well, and the group is looking forward to an update at the January board meeting. SHM’s strategic quality initiative planning began in October 2007, when a group of SHM leaders met to begin the process of developing a 10-year strategic plan for quality initiatives. The output of this meeting led to six areas of focus, which we refer to as core strategies:

• Develop education programs and technical support tools in quality improvement or patient safety;
• Advance a national quality agenda for hospitals and hospitalists;
• Facilitate cultural change and develop initiatives to promote hospital medicine’s role in quality initiatives within the C-suite at our nation’s hospitals;
• Evaluate effectiveness of current offerings in quality improvement or patient safety;
• Promote adoption of health information technologies to advance patient safety and quality improvement; and
• Promote and support the new science of QI (i.e., develop a research agenda).

Linking these focus areas with SHM’s Core Competencies in Hospital Medicine and current national industry quality initiatives, such as The Joint Commission’s National Patient Safety Goals and Core Measures, is the basic foundation for SHM’s strategic quality plan. This plan will allow SHM to become more proactive in our approach to quality initiatives for the next one, three, five, and 10 years. It will help us focus on the areas identified as needs for hospitalists and hospital medicine.

Plan Breakdown

I would like to tell you about some of the newest quality initiatives currently underway. First is an advisory board on pharmacoeconomics. We are pulling together 11 industry leaders, including CEOs, chief financial officers, chief medical officers, pharmacists, and thought leaders in quality. This advisory board will be evaluating the standard operating procedures in hospitals across the country regarding the use of pharmacoeconomics in decisions to utilize medications, especially newer and more expensive agents, using venous thromboembolism (VTE) prevention as a case example.

We have assembled another advisory board, which is just underway, to look at complicated skin and skin structure infections (cSSSI). This board will include hospitalists, infection control physicians, emergency room physicians, pharmacists, wound care nurses, and quality improvement experts.

Lastly, we have a second VTE project charged with the development of an automated, electronic query for a major commercial clinical information system. The project team is tasked to develop and demonstrate how a system can dramatically increase the prevalence of VTE prophylaxis in hospitals where it will be piloted.

Collaborative Efforts

I also would like to share a few of the other exciting activities the quality department has been up to recently. SHM is in the process of collaborating on a book with the Joint Commission Resources on Hospitalists and Patient Safety. The book is scheduled for release this spring, so be on the lookout. We also are writing an article for the The Physician Executive, which is the journal of the American College of Physician Executives. The article focuses on how quality, patient safety, and patient satisfaction are becoming priorities for physician executives, and how hospitalists are a critical element of a strategy to address this priority. We also are talking with other organizations, such as the American Hospital Association and United Health Group, about potential collaborative work in the future.

So, you can see things at SHM headquarters are anything but dull. The entire QI department—both the veterans and new staff—are looking forward to helping you make your quality and patient safety initiatives more successful and improve the care of patients throughout the country. TH

Most hospitalists vividly recall Congress overriding President Bush’s July veto to avert a hefty, 10.6% cut in Medicare Part B payments to physicians. That memorable, last-minute save (instead of a pay cut, Congress increased Part B payments by 1.1%) was just a tiny part of some important legislation. The Medicare Improvements for Patients and Providers Act (MIPPA) includes myriad provisions addressing Medicare benefits, protections for low-income beneficiaries, changes for providers, data collection requirements for correcting healthcare disparities, and much more.

Hospitalists will be particularly interested in a handful of the provisions outlined in MIPPA, some of which impact them directly and others that will affect hospitals and clinical care, and still more whose outcomes remain to be seen.

For example, MIPPA is the legislation that extends the Physician Quality Reporting Initiative (PQRI) for two years, offering a bonus payment in 2009 and 2010 of 2% (up from 1.5%) of total Medicare allowed charges. It also directs the Centers for Medicare and Medicaid Services (CMS) to publicly post the list of providers who participate in the PQRI. (See “A Permanent PQRI” in the October 2008 issue of The Hospitalist.)

MIPPA also requires CMS to establish a program to promote widespread adoption of electronic prescribing, as outlined in “e-Prescription for Success?” in the September 2008 issue of The Hospitalist. Reporting on e-prescribing is not likely to apply to hospitalists, says Bradley Flansbaum, DO, MPH, chief of hospitalist section at Lenox Hill Hospital in New York City and a member of SHM’s Public Policy Committee. “Of course, it depends on whether the hospital uses it, but no one can say whether a hospitalist will get a benefit for reporting on e-prescribing,” he says.

Lucrative Changes to E&M Codes

One provision directly impacting hospitalists is MIPPA’s changes to payments for inpatient evaluation and management codes (E&M codes). According to Laura Allendorf, SHM’s senior advisor for advocacy and government affairs, this change will result in an estimated 3% average gain in total Medicare payments to hospitalists, or $5,000 to $6,000 annually—on top of the 1.1% payment update. (It’s important to note the final 2009 physician fee schedule, published in November, could change the overall impact for individual members.) E&M payments from some private payers also could increase, since many base their fees on Medicare’s fee schedule.

Quality Research Initiatives

MIPPA requires the establishment or continuation of several quality research initiatives, designed to help CMS determine new models of efficiency of care and cost efficiency.

One of these initiatives is Patient-Centered Medical Home (PCMH), a care model that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. MIPPA grants new funding and expanded authority for CMS’ Medical Home Demonstration Project—if certain quality and/or savings targets are achieved.

“We’ve talked a bit about Patient-Centered Medical Home,” says Dr. Flansbaum of SHM’s Public Policy Committee. “From a political standpoint, it’s a feel-good agenda item with a lot of bipartisan support. The notion of this is here, but operationalizing it—getting it to work—is an entirely different story.” By definition, PCMH will revolve around primary care physicians, and the role and responsibilities of any hospitalists involved is yet unknown—as is the reimbursement model. “This is so far away right now, it’s a notion that needs to be turned into a theory that needs to be turned into a paradigm, to paraphrase Woody Allen,” Dr. Flansbaum says.

Another initiative greenlighted by MIPPA is comparative effectiveness research, or CER. It examines the effectiveness of different therapies for a specific medical condition, or for a specific set of patients, to determine the best option. It may involve comparing competing medications, or may analyze different treatment approaches such as surgery, devices, and drug therapies. MIPPA requires the Institute of Medicine report on best practices for the review of comparative effectiveness research and the development of clinical protocols.

“Obviously, the medical device companies and the pharmaceutical companies are against this,” Dr. Flansbaum says. “But it would be helpful for physicians, because it would give some guidance in certain gray-area treatments, such as: Is this drug appropriate in treating an end-stage cancer patient?” And as far as the nation’s health care system goes, he explains, “I think we need comparative effectiveness. We can’t continue as we are—on the net, we’re going broke—our current healthcare system can’t afford to keep going.”

Not the Only Game in Town

One interesting provision of MIPPA revokes “the unique authority of the Joint Commission to deem hospitals in compliance with the Medicare Conditions of Participation,” meaning hospital compliance is an open market—subject to approval from CMS, of course.

“The Joint Commission has been the gold standard for hospitals for a long, long time,” Dr. Flansbaum points out. “Now that they’ve opened that up, DNV (Det Norske Veritas Healthcare, Inc.) [for example], can compete with the Joint Commission to certify hospitals.”

What will this mean for hospitals? Probably not much in the short term. “I believe only 15 hospitals have DNV certifications, and that all of those also have a Joint Commission certification,” Dr. Flansbaum says, adding “[DNV and the Joint Commission] have a different approach; it’s like the ACT and the SAT. Both are used for college entrance exams, but the SAT is still mostly the gold standard, like the Joint Commission. But who knows? That could change … and if it does, well, competition is good.”

Some of the MIPPA provisions, such as the quality research initiatives, could end up shaping the future of healthcare. Others, such as the continuation of PQRI, may lead to new payment models for physicians.

Only time will tell which provisions will truly improve efficiency and costs—and which will impact hospital medicine in particular. TH

Jane Jerrard is a medical writer based in Chicago.

Most hospitalists vividly recall Congress overriding President Bush’s July veto to avert a hefty, 10.6% cut in Medicare Part B payments to physicians. That memorable, last-minute save (instead of a pay cut, Congress increased Part B payments by 1.1%) was just a tiny part of some important legislation. The Medicare Improvements for Patients and Providers Act (MIPPA) includes myriad provisions addressing Medicare benefits, protections for low-income beneficiaries, changes for providers, data collection requirements for correcting healthcare disparities, and much more.

Hospitalists will be particularly interested in a handful of the provisions outlined in MIPPA, some of which impact them directly and others that will affect hospitals and clinical care, and still more whose outcomes remain to be seen.

For example, MIPPA is the legislation that extends the Physician Quality Reporting Initiative (PQRI) for two years, offering a bonus payment in 2009 and 2010 of 2% (up from 1.5%) of total Medicare allowed charges. It also directs the Centers for Medicare and Medicaid Services (CMS) to publicly post the list of providers who participate in the PQRI. (See “A Permanent PQRI” in the October 2008 issue of The Hospitalist.)

MIPPA also requires CMS to establish a program to promote widespread adoption of electronic prescribing, as outlined in “e-Prescription for Success?” in the September 2008 issue of The Hospitalist. Reporting on e-prescribing is not likely to apply to hospitalists, says Bradley Flansbaum, DO, MPH, chief of hospitalist section at Lenox Hill Hospital in New York City and a member of SHM’s Public Policy Committee. “Of course, it depends on whether the hospital uses it, but no one can say whether a hospitalist will get a benefit for reporting on e-prescribing,” he says.

Lucrative Changes to E&M Codes

One provision directly impacting hospitalists is MIPPA’s changes to payments for inpatient evaluation and management codes (E&M codes). According to Laura Allendorf, SHM’s senior advisor for advocacy and government affairs, this change will result in an estimated 3% average gain in total Medicare payments to hospitalists, or $5,000 to $6,000 annually—on top of the 1.1% payment update. (It’s important to note the final 2009 physician fee schedule, published in November, could change the overall impact for individual members.) E&M payments from some private payers also could increase, since many base their fees on Medicare’s fee schedule.

Quality Research Initiatives

MIPPA requires the establishment or continuation of several quality research initiatives, designed to help CMS determine new models of efficiency of care and cost efficiency.

One of these initiatives is Patient-Centered Medical Home (PCMH), a care model that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. MIPPA grants new funding and expanded authority for CMS’ Medical Home Demonstration Project—if certain quality and/or savings targets are achieved.

“We’ve talked a bit about Patient-Centered Medical Home,” says Dr. Flansbaum of SHM’s Public Policy Committee. “From a political standpoint, it’s a feel-good agenda item with a lot of bipartisan support. The notion of this is here, but operationalizing it—getting it to work—is an entirely different story.” By definition, PCMH will revolve around primary care physicians, and the role and responsibilities of any hospitalists involved is yet unknown—as is the reimbursement model. “This is so far away right now, it’s a notion that needs to be turned into a theory that needs to be turned into a paradigm, to paraphrase Woody Allen,” Dr. Flansbaum says.

Another initiative greenlighted by MIPPA is comparative effectiveness research, or CER. It examines the effectiveness of different therapies for a specific medical condition, or for a specific set of patients, to determine the best option. It may involve comparing competing medications, or may analyze different treatment approaches such as surgery, devices, and drug therapies. MIPPA requires the Institute of Medicine report on best practices for the review of comparative effectiveness research and the development of clinical protocols.

“Obviously, the medical device companies and the pharmaceutical companies are against this,” Dr. Flansbaum says. “But it would be helpful for physicians, because it would give some guidance in certain gray-area treatments, such as: Is this drug appropriate in treating an end-stage cancer patient?” And as far as the nation’s health care system goes, he explains, “I think we need comparative effectiveness. We can’t continue as we are—on the net, we’re going broke—our current healthcare system can’t afford to keep going.”

Not the Only Game in Town

One interesting provision of MIPPA revokes “the unique authority of the Joint Commission to deem hospitals in compliance with the Medicare Conditions of Participation,” meaning hospital compliance is an open market—subject to approval from CMS, of course.

“The Joint Commission has been the gold standard for hospitals for a long, long time,” Dr. Flansbaum points out. “Now that they’ve opened that up, DNV (Det Norske Veritas Healthcare, Inc.) [for example], can compete with the Joint Commission to certify hospitals.”

What will this mean for hospitals? Probably not much in the short term. “I believe only 15 hospitals have DNV certifications, and that all of those also have a Joint Commission certification,” Dr. Flansbaum says, adding “[DNV and the Joint Commission] have a different approach; it’s like the ACT and the SAT. Both are used for college entrance exams, but the SAT is still mostly the gold standard, like the Joint Commission. But who knows? That could change … and if it does, well, competition is good.”

Some of the MIPPA provisions, such as the quality research initiatives, could end up shaping the future of healthcare. Others, such as the continuation of PQRI, may lead to new payment models for physicians.

Only time will tell which provisions will truly improve efficiency and costs—and which will impact hospital medicine in particular. TH

Jane Jerrard is a medical writer based in Chicago.

Most hospitalists vividly recall Congress overriding President Bush’s July veto to avert a hefty, 10.6% cut in Medicare Part B payments to physicians. That memorable, last-minute save (instead of a pay cut, Congress increased Part B payments by 1.1%) was just a tiny part of some important legislation. The Medicare Improvements for Patients and Providers Act (MIPPA) includes myriad provisions addressing Medicare benefits, protections for low-income beneficiaries, changes for providers, data collection requirements for correcting healthcare disparities, and much more.

Hospitalists will be particularly interested in a handful of the provisions outlined in MIPPA, some of which impact them directly and others that will affect hospitals and clinical care, and still more whose outcomes remain to be seen.

For example, MIPPA is the legislation that extends the Physician Quality Reporting Initiative (PQRI) for two years, offering a bonus payment in 2009 and 2010 of 2% (up from 1.5%) of total Medicare allowed charges. It also directs the Centers for Medicare and Medicaid Services (CMS) to publicly post the list of providers who participate in the PQRI. (See “A Permanent PQRI” in the October 2008 issue of The Hospitalist.)

MIPPA also requires CMS to establish a program to promote widespread adoption of electronic prescribing, as outlined in “e-Prescription for Success?” in the September 2008 issue of The Hospitalist. Reporting on e-prescribing is not likely to apply to hospitalists, says Bradley Flansbaum, DO, MPH, chief of hospitalist section at Lenox Hill Hospital in New York City and a member of SHM’s Public Policy Committee. “Of course, it depends on whether the hospital uses it, but no one can say whether a hospitalist will get a benefit for reporting on e-prescribing,” he says.

Lucrative Changes to E&M Codes

One provision directly impacting hospitalists is MIPPA’s changes to payments for inpatient evaluation and management codes (E&M codes). According to Laura Allendorf, SHM’s senior advisor for advocacy and government affairs, this change will result in an estimated 3% average gain in total Medicare payments to hospitalists, or $5,000 to $6,000 annually—on top of the 1.1% payment update. (It’s important to note the final 2009 physician fee schedule, published in November, could change the overall impact for individual members.) E&M payments from some private payers also could increase, since many base their fees on Medicare’s fee schedule.

Quality Research Initiatives

MIPPA requires the establishment or continuation of several quality research initiatives, designed to help CMS determine new models of efficiency of care and cost efficiency.

One of these initiatives is Patient-Centered Medical Home (PCMH), a care model that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. MIPPA grants new funding and expanded authority for CMS’ Medical Home Demonstration Project—if certain quality and/or savings targets are achieved.

“We’ve talked a bit about Patient-Centered Medical Home,” says Dr. Flansbaum of SHM’s Public Policy Committee. “From a political standpoint, it’s a feel-good agenda item with a lot of bipartisan support. The notion of this is here, but operationalizing it—getting it to work—is an entirely different story.” By definition, PCMH will revolve around primary care physicians, and the role and responsibilities of any hospitalists involved is yet unknown—as is the reimbursement model. “This is so far away right now, it’s a notion that needs to be turned into a theory that needs to be turned into a paradigm, to paraphrase Woody Allen,” Dr. Flansbaum says.

Another initiative greenlighted by MIPPA is comparative effectiveness research, or CER. It examines the effectiveness of different therapies for a specific medical condition, or for a specific set of patients, to determine the best option. It may involve comparing competing medications, or may analyze different treatment approaches such as surgery, devices, and drug therapies. MIPPA requires the Institute of Medicine report on best practices for the review of comparative effectiveness research and the development of clinical protocols.

“Obviously, the medical device companies and the pharmaceutical companies are against this,” Dr. Flansbaum says. “But it would be helpful for physicians, because it would give some guidance in certain gray-area treatments, such as: Is this drug appropriate in treating an end-stage cancer patient?” And as far as the nation’s health care system goes, he explains, “I think we need comparative effectiveness. We can’t continue as we are—on the net, we’re going broke—our current healthcare system can’t afford to keep going.”

Not the Only Game in Town

One interesting provision of MIPPA revokes “the unique authority of the Joint Commission to deem hospitals in compliance with the Medicare Conditions of Participation,” meaning hospital compliance is an open market—subject to approval from CMS, of course.

“The Joint Commission has been the gold standard for hospitals for a long, long time,” Dr. Flansbaum points out. “Now that they’ve opened that up, DNV (Det Norske Veritas Healthcare, Inc.) [for example], can compete with the Joint Commission to certify hospitals.”

What will this mean for hospitals? Probably not much in the short term. “I believe only 15 hospitals have DNV certifications, and that all of those also have a Joint Commission certification,” Dr. Flansbaum says, adding “[DNV and the Joint Commission] have a different approach; it’s like the ACT and the SAT. Both are used for college entrance exams, but the SAT is still mostly the gold standard, like the Joint Commission. But who knows? That could change … and if it does, well, competition is good.”

Some of the MIPPA provisions, such as the quality research initiatives, could end up shaping the future of healthcare. Others, such as the continuation of PQRI, may lead to new payment models for physicians.

Only time will tell which provisions will truly improve efficiency and costs—and which will impact hospital medicine in particular. TH

Jane Jerrard is a medical writer based in Chicago.

A distraught daughter demands you place a feeding tube in her father, your patient, who has not eaten in three days. The patient’s advanced dementia, anti-coagulation therapy, and other co-morbidities suggest such a move may not be in his best interest. How do you respond?

Ethical dilemmas rarely are simple or clear cut. They often involve revisiting the same issues time and again. That’s where an ethics committee comes in, says Maj. Heather Cereste, MD, U.S. Air Force, co-director of the geriatric medicine service and chair of the bioethics committee at Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas.

Ethics committees provide oversight and assist the institution in creating policies to guide staff through ethical dilemmas, Dr. Cereste says.

“Our job at the ethics committee—and we try to make this very clear—is not to solve people’s problems or dictate care,” she says. “Our job is to provide a perspective and a way of thinking about an issue to better equip people to get through it.”

Though it seems straightforward, the notion is fraught with myriad complications.

A Range of Issues

Pediatric Hospitalist Sheldon Berkowitz, MD, medical director, Minneapolis Children’s Clinic (MCC), Children’s Hospital and Clinics of Minnesota, has been involved with ethics issues for 24 years. He currently is the ethics committee chair at MCC. In his experience, he says “most [ethics committee] consults come from intensive care settings, relating to life-and-death issues.”

The issues become trickier for patients from cultures with specific traditions and beliefs surrounding death. Anita Gandhy, MD, a hospitalist board certified in hospice and palliative care, works at Saint Francis Memorial Hospital in San Francisco. The family of a patient she was treating wanted to continue care for its loved one despite the fact the patient was dying. “I later found out that a baby had recently been born into the family,” Dr. Gandhy says. “In the Chinese culture, if someone dies around the time that a baby is born, that spirit will follow the baby. So the family’s desire to prolong care was consistent with their cultural beliefs.”

Ethical dilemmas surface in a variety of situations—not just related to end-of-life treatment—and between a variety of parties: patient surrogates and medical staff, members of the care team, patients and family, or among family members themselves. Physicians will face many types of conflicts:

• Who makes decisions regarding the rights and preferences of unidentified patients without designated surrogates or advance directives;
• Whether to allow medical training on the newly dead;
• Whether to agree to requests for exorbitant or unorthodox treatments;
• Whether family members can ably deliver home care for a patient who is being discharged; or
• Whether to grant sterilization requests from families of adolescent children with Down syndrome.1

Underutilized Service?

With such a wide swath of potential ethical dilemmas, it would seem intuitive for physicians to use an ethics committee when one is available. Yet, a 2005 survey of 600 U.S. hospitals by The National Center for Ethics in Health Care tells a different story. The survey found 81% of the general hospitals responding to the survey had ethics consultation services, and 100% of hospitals with more than 400 beds had such services. However, the staff sought the ethics consultation services a median of only three times in the year prior to the survey.2

Hospitalist Olivia Wendy Zachary, MD, has worked for two years at California Pacific Medical Center in San Francisco. In that time, she has requested a total of four ethics consults. One recent consultation helped her determine the source of durable power of attorney for a patient who was a prisoner and who, because he was a felon and a ward of the state prison system, could not make his own healthcare decisions.

There are other situations, however, when Dr. Zachary refrains from asking for an ethics consult. For example, as a geriatrician conversant in the potential adverse outcomes of tube feeding patients with dementia, she makes the judgment calls in these instances.

“I feel very comfortable giving family members the data, in a way that they can understand, on the conflicts of tube feeding in demented patients,” Dr. Zachary says. “The role of the ethics committee, in my opinion, should be to answer conflicts for which you do not have the answers. … If that’s beyond your expertise—if you don’t know the studies and aren’t a geriatrician—then in that case, it might be appropriate.”

In other words, don’t call the ethics committee because you don’t have the time to clearly communicate with the family.

Call on the Committee

Medical ethics dilemmas aren’t always as straightforward as knowing the possible negative consequences of placing a feeding tube in a dementia patient. So when should you call on the ethics committee? Physicians at St. Joseph’s Hospital in St. Paul, Minn., fill out an ethics consultation request form to help the hospital determine the need for the consult.

Robert C. Moravec, MD, medical director, director of hospital medicine, and chair of the ethics committee at St. Joseph’s, says the form was created to prevent physicians from requesting consults prematurely, before they have attempted a family care conference or fully understand the issue at hand. For example, providers occasionally request ethics consults when the problem really is poor communication.

“Sometimes, when our ethics committee is consulted, we discover that there is so much emotional energy going into the issue that the participants are simply not communicating,” Dr. Cereste says. “We can help them identify that.”

Other times, the issue lies in a conflict between the physician and the patient’s family. The physician may want to move from aggressive care to a pain and palliative care approach. The family, of course, wants to stay the aggressive course. It’s not the committee’s job to resolve this conflict, Dr. Berkowitz cautions. “The role of the ethics committee should be helping to identify, delineate, and resolve ethics issues,” he explains. “The committee should not be there simply to help the attending physician accomplish their goals.”

Committee Credibility

Even if physicians know when to ask for help from an ethics committee, they only will do so if they trust the enterprise, Dr. Moravec says. Using a multidisciplinary approach has worked at St. Joseph’s, where the ethics committee is comprised of nursing clinical directors, physicians, social workers, chaplains, hospice and palliative care directors, and even dietitians, who meet monthly.

When the St. Joseph’s ethics committee convenes, members fill out a multi-page record for each patient. In addition to a summary of the patient’s medical history, goals of treatment, preferences, and expected quality of life with proposed treatments (or withdrawal thereof), the record documents the committee’s conclusions, Dr. Moravec says. One copy of the document gets incorporated into the patient’s chart, one is sent to hospital administration, and a third gets channeled to the hospital system’s organization-wide ethics committee. This reporting through the medical staff fosters physician buy-in, Dr. Moravec says.

Physicians are less likely to use the consultation services if they feel the ethics committee doesn’t have teeth, says Rachel George, MD, MBA, hospitalist at Aurora St. Luke’s Hospital in Milwaukee, and regional director of five west coast hospitalist programs for Cogent Healthcare, Inc.

The same is true for one Southern California hospitalist who preferred to remain anonymous. “I rarely call for an ethics consult because they’re rarely helpful,” she says. “Generally, the issues we bring to the ethics committee are those where the family is pushing us to provide care we think is futile, and the ethics committee really doesn’t make a decision. You don’t get the backup you need, and you end up very frustrated.”

Sometimes, the California hospitalist continues, the family needs permission from the hospital to halt futile care. Without a durable power of attorney, the care team may find itself bowing to the wishes of one family member—the outlier—who insists the patient be kept alive with aggressive measures. The inpatient palliative care team often fills the ethics gap, helping the medical team discuss end-of-life issues, goals, and desires with the family. Hospitalists, she says, sometimes need an authoritative body to say, “It is no longer ethical to do this to this patient.”

“Having a hospital committee say it’s OK to withdraw a feeding tube or stop dialysis gives a comfort level to physicians,” Dr. Moravec says, “especially if the committee involves clergy, as well as administration. That is powerful support for that doctor.”

Med Students & Residents

The key to making ethics committees more effectively and widely used is education, Dr. George says. “We need to be educating our medical students and residents a lot more aggressively than we are right now,” she asserts. “How to talk with families about end-of-life issues, what is appropriate or inappropriate care, how should you be using your ethics committees—none of that is taught.”

At Children’s Hospital and Clinics, Dr. Berkowitz meets with residents and medical students every six weeks to discuss cases with ethical dilemmas. He says house staffers have little background or experience with ethics. The American Medical Association’s Liaison Committee on Medical Education 2007-2008 survey of 126 U.S. medical colleges found medical ethics was included in one required course at all 126 colleges, and was an elective course in 61. For some perspective, a course in end-of-life care was required at 124 schools and was an elective at 69. A course in palliative care was required at 120 schools, and was an elective in 60.3

Dr. Berkowitz agrees outreach is one solution. “The longer you have an ethics committee available and doing consultations in an institution, the more you expand the knowledge about how to handle problems,” he says. “People who may have previously requested an ethics consult may now have the skills and ability to handle these issues on their own, without needing to call a consult.”

Dr. Gandhy, of Saint Francis Memorial, believes such additional knowledge helps her focus on a patient’s family, not her own plan. “If the family is not ready to withdraw the care, I realize that forcing my agenda on them can also cause suffering,” she says. “When I change my focus to ask, ‘What is going to help the patient and the family?’ sometimes I don’t even need the ethics committee, because I am then able to address the family’s concerns.”

And that’s when everybody gains. TH

Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.

References

1. Snyder L, Leffler C;, for the Ethics and Human Rights Committee, American College of Physicians. Ethics Manual. 5th ed.,2005.

2. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007 Feb;7(2):13-25.

3. Barzansky B, Etze SI. 2007-2008 annual medical school questionnaire part II. JAMA 2008;300(10):1221.

A distraught daughter demands you place a feeding tube in her father, your patient, who has not eaten in three days. The patient’s advanced dementia, anti-coagulation therapy, and other co-morbidities suggest such a move may not be in his best interest. How do you respond?

Ethical dilemmas rarely are simple or clear cut. They often involve revisiting the same issues time and again. That’s where an ethics committee comes in, says Maj. Heather Cereste, MD, U.S. Air Force, co-director of the geriatric medicine service and chair of the bioethics committee at Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas.

Ethics committees provide oversight and assist the institution in creating policies to guide staff through ethical dilemmas, Dr. Cereste says.

“Our job at the ethics committee—and we try to make this very clear—is not to solve people’s problems or dictate care,” she says. “Our job is to provide a perspective and a way of thinking about an issue to better equip people to get through it.”

Though it seems straightforward, the notion is fraught with myriad complications.

A Range of Issues

Pediatric Hospitalist Sheldon Berkowitz, MD, medical director, Minneapolis Children’s Clinic (MCC), Children’s Hospital and Clinics of Minnesota, has been involved with ethics issues for 24 years. He currently is the ethics committee chair at MCC. In his experience, he says “most [ethics committee] consults come from intensive care settings, relating to life-and-death issues.”

The issues become trickier for patients from cultures with specific traditions and beliefs surrounding death. Anita Gandhy, MD, a hospitalist board certified in hospice and palliative care, works at Saint Francis Memorial Hospital in San Francisco. The family of a patient she was treating wanted to continue care for its loved one despite the fact the patient was dying. “I later found out that a baby had recently been born into the family,” Dr. Gandhy says. “In the Chinese culture, if someone dies around the time that a baby is born, that spirit will follow the baby. So the family’s desire to prolong care was consistent with their cultural beliefs.”

Ethical dilemmas surface in a variety of situations—not just related to end-of-life treatment—and between a variety of parties: patient surrogates and medical staff, members of the care team, patients and family, or among family members themselves. Physicians will face many types of conflicts:

• Who makes decisions regarding the rights and preferences of unidentified patients without designated surrogates or advance directives;
• Whether to allow medical training on the newly dead;
• Whether to agree to requests for exorbitant or unorthodox treatments;
• Whether family members can ably deliver home care for a patient who is being discharged; or
• Whether to grant sterilization requests from families of adolescent children with Down syndrome.1

Underutilized Service?

With such a wide swath of potential ethical dilemmas, it would seem intuitive for physicians to use an ethics committee when one is available. Yet, a 2005 survey of 600 U.S. hospitals by The National Center for Ethics in Health Care tells a different story. The survey found 81% of the general hospitals responding to the survey had ethics consultation services, and 100% of hospitals with more than 400 beds had such services. However, the staff sought the ethics consultation services a median of only three times in the year prior to the survey.2

Hospitalist Olivia Wendy Zachary, MD, has worked for two years at California Pacific Medical Center in San Francisco. In that time, she has requested a total of four ethics consults. One recent consultation helped her determine the source of durable power of attorney for a patient who was a prisoner and who, because he was a felon and a ward of the state prison system, could not make his own healthcare decisions.

There are other situations, however, when Dr. Zachary refrains from asking for an ethics consult. For example, as a geriatrician conversant in the potential adverse outcomes of tube feeding patients with dementia, she makes the judgment calls in these instances.

“I feel very comfortable giving family members the data, in a way that they can understand, on the conflicts of tube feeding in demented patients,” Dr. Zachary says. “The role of the ethics committee, in my opinion, should be to answer conflicts for which you do not have the answers. … If that’s beyond your expertise—if you don’t know the studies and aren’t a geriatrician—then in that case, it might be appropriate.”

In other words, don’t call the ethics committee because you don’t have the time to clearly communicate with the family.

Call on the Committee

Medical ethics dilemmas aren’t always as straightforward as knowing the possible negative consequences of placing a feeding tube in a dementia patient. So when should you call on the ethics committee? Physicians at St. Joseph’s Hospital in St. Paul, Minn., fill out an ethics consultation request form to help the hospital determine the need for the consult.

Robert C. Moravec, MD, medical director, director of hospital medicine, and chair of the ethics committee at St. Joseph’s, says the form was created to prevent physicians from requesting consults prematurely, before they have attempted a family care conference or fully understand the issue at hand. For example, providers occasionally request ethics consults when the problem really is poor communication.

“Sometimes, when our ethics committee is consulted, we discover that there is so much emotional energy going into the issue that the participants are simply not communicating,” Dr. Cereste says. “We can help them identify that.”

Other times, the issue lies in a conflict between the physician and the patient’s family. The physician may want to move from aggressive care to a pain and palliative care approach. The family, of course, wants to stay the aggressive course. It’s not the committee’s job to resolve this conflict, Dr. Berkowitz cautions. “The role of the ethics committee should be helping to identify, delineate, and resolve ethics issues,” he explains. “The committee should not be there simply to help the attending physician accomplish their goals.”

Committee Credibility

Even if physicians know when to ask for help from an ethics committee, they only will do so if they trust the enterprise, Dr. Moravec says. Using a multidisciplinary approach has worked at St. Joseph’s, where the ethics committee is comprised of nursing clinical directors, physicians, social workers, chaplains, hospice and palliative care directors, and even dietitians, who meet monthly.

When the St. Joseph’s ethics committee convenes, members fill out a multi-page record for each patient. In addition to a summary of the patient’s medical history, goals of treatment, preferences, and expected quality of life with proposed treatments (or withdrawal thereof), the record documents the committee’s conclusions, Dr. Moravec says. One copy of the document gets incorporated into the patient’s chart, one is sent to hospital administration, and a third gets channeled to the hospital system’s organization-wide ethics committee. This reporting through the medical staff fosters physician buy-in, Dr. Moravec says.

Physicians are less likely to use the consultation services if they feel the ethics committee doesn’t have teeth, says Rachel George, MD, MBA, hospitalist at Aurora St. Luke’s Hospital in Milwaukee, and regional director of five west coast hospitalist programs for Cogent Healthcare, Inc.

The same is true for one Southern California hospitalist who preferred to remain anonymous. “I rarely call for an ethics consult because they’re rarely helpful,” she says. “Generally, the issues we bring to the ethics committee are those where the family is pushing us to provide care we think is futile, and the ethics committee really doesn’t make a decision. You don’t get the backup you need, and you end up very frustrated.”

Sometimes, the California hospitalist continues, the family needs permission from the hospital to halt futile care. Without a durable power of attorney, the care team may find itself bowing to the wishes of one family member—the outlier—who insists the patient be kept alive with aggressive measures. The inpatient palliative care team often fills the ethics gap, helping the medical team discuss end-of-life issues, goals, and desires with the family. Hospitalists, she says, sometimes need an authoritative body to say, “It is no longer ethical to do this to this patient.”

“Having a hospital committee say it’s OK to withdraw a feeding tube or stop dialysis gives a comfort level to physicians,” Dr. Moravec says, “especially if the committee involves clergy, as well as administration. That is powerful support for that doctor.”

Med Students & Residents

The key to making ethics committees more effectively and widely used is education, Dr. George says. “We need to be educating our medical students and residents a lot more aggressively than we are right now,” she asserts. “How to talk with families about end-of-life issues, what is appropriate or inappropriate care, how should you be using your ethics committees—none of that is taught.”

At Children’s Hospital and Clinics, Dr. Berkowitz meets with residents and medical students every six weeks to discuss cases with ethical dilemmas. He says house staffers have little background or experience with ethics. The American Medical Association’s Liaison Committee on Medical Education 2007-2008 survey of 126 U.S. medical colleges found medical ethics was included in one required course at all 126 colleges, and was an elective course in 61. For some perspective, a course in end-of-life care was required at 124 schools and was an elective at 69. A course in palliative care was required at 120 schools, and was an elective in 60.3

Dr. Berkowitz agrees outreach is one solution. “The longer you have an ethics committee available and doing consultations in an institution, the more you expand the knowledge about how to handle problems,” he says. “People who may have previously requested an ethics consult may now have the skills and ability to handle these issues on their own, without needing to call a consult.”

Dr. Gandhy, of Saint Francis Memorial, believes such additional knowledge helps her focus on a patient’s family, not her own plan. “If the family is not ready to withdraw the care, I realize that forcing my agenda on them can also cause suffering,” she says. “When I change my focus to ask, ‘What is going to help the patient and the family?’ sometimes I don’t even need the ethics committee, because I am then able to address the family’s concerns.”

And that’s when everybody gains. TH

Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.

References

1. Snyder L, Leffler C;, for the Ethics and Human Rights Committee, American College of Physicians. Ethics Manual. 5th ed.,2005.

2. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007 Feb;7(2):13-25.

3. Barzansky B, Etze SI. 2007-2008 annual medical school questionnaire part II. JAMA 2008;300(10):1221.

A distraught daughter demands you place a feeding tube in her father, your patient, who has not eaten in three days. The patient’s advanced dementia, anti-coagulation therapy, and other co-morbidities suggest such a move may not be in his best interest. How do you respond?

Ethical dilemmas rarely are simple or clear cut. They often involve revisiting the same issues time and again. That’s where an ethics committee comes in, says Maj. Heather Cereste, MD, U.S. Air Force, co-director of the geriatric medicine service and chair of the bioethics committee at Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas.

Ethics committees provide oversight and assist the institution in creating policies to guide staff through ethical dilemmas, Dr. Cereste says.

“Our job at the ethics committee—and we try to make this very clear—is not to solve people’s problems or dictate care,” she says. “Our job is to provide a perspective and a way of thinking about an issue to better equip people to get through it.”

Though it seems straightforward, the notion is fraught with myriad complications.

A Range of Issues

Pediatric Hospitalist Sheldon Berkowitz, MD, medical director, Minneapolis Children’s Clinic (MCC), Children’s Hospital and Clinics of Minnesota, has been involved with ethics issues for 24 years. He currently is the ethics committee chair at MCC. In his experience, he says “most [ethics committee] consults come from intensive care settings, relating to life-and-death issues.”

The issues become trickier for patients from cultures with specific traditions and beliefs surrounding death. Anita Gandhy, MD, a hospitalist board certified in hospice and palliative care, works at Saint Francis Memorial Hospital in San Francisco. The family of a patient she was treating wanted to continue care for its loved one despite the fact the patient was dying. “I later found out that a baby had recently been born into the family,” Dr. Gandhy says. “In the Chinese culture, if someone dies around the time that a baby is born, that spirit will follow the baby. So the family’s desire to prolong care was consistent with their cultural beliefs.”

Ethical dilemmas surface in a variety of situations—not just related to end-of-life treatment—and between a variety of parties: patient surrogates and medical staff, members of the care team, patients and family, or among family members themselves. Physicians will face many types of conflicts:

• Who makes decisions regarding the rights and preferences of unidentified patients without designated surrogates or advance directives;
• Whether to allow medical training on the newly dead;
• Whether to agree to requests for exorbitant or unorthodox treatments;
• Whether family members can ably deliver home care for a patient who is being discharged; or
• Whether to grant sterilization requests from families of adolescent children with Down syndrome.1

Underutilized Service?

With such a wide swath of potential ethical dilemmas, it would seem intuitive for physicians to use an ethics committee when one is available. Yet, a 2005 survey of 600 U.S. hospitals by The National Center for Ethics in Health Care tells a different story. The survey found 81% of the general hospitals responding to the survey had ethics consultation services, and 100% of hospitals with more than 400 beds had such services. However, the staff sought the ethics consultation services a median of only three times in the year prior to the survey.2

Hospitalist Olivia Wendy Zachary, MD, has worked for two years at California Pacific Medical Center in San Francisco. In that time, she has requested a total of four ethics consults. One recent consultation helped her determine the source of durable power of attorney for a patient who was a prisoner and who, because he was a felon and a ward of the state prison system, could not make his own healthcare decisions.

There are other situations, however, when Dr. Zachary refrains from asking for an ethics consult. For example, as a geriatrician conversant in the potential adverse outcomes of tube feeding patients with dementia, she makes the judgment calls in these instances.

“I feel very comfortable giving family members the data, in a way that they can understand, on the conflicts of tube feeding in demented patients,” Dr. Zachary says. “The role of the ethics committee, in my opinion, should be to answer conflicts for which you do not have the answers. … If that’s beyond your expertise—if you don’t know the studies and aren’t a geriatrician—then in that case, it might be appropriate.”

In other words, don’t call the ethics committee because you don’t have the time to clearly communicate with the family.

Call on the Committee

Medical ethics dilemmas aren’t always as straightforward as knowing the possible negative consequences of placing a feeding tube in a dementia patient. So when should you call on the ethics committee? Physicians at St. Joseph’s Hospital in St. Paul, Minn., fill out an ethics consultation request form to help the hospital determine the need for the consult.

Robert C. Moravec, MD, medical director, director of hospital medicine, and chair of the ethics committee at St. Joseph’s, says the form was created to prevent physicians from requesting consults prematurely, before they have attempted a family care conference or fully understand the issue at hand. For example, providers occasionally request ethics consults when the problem really is poor communication.

“Sometimes, when our ethics committee is consulted, we discover that there is so much emotional energy going into the issue that the participants are simply not communicating,” Dr. Cereste says. “We can help them identify that.”

Other times, the issue lies in a conflict between the physician and the patient’s family. The physician may want to move from aggressive care to a pain and palliative care approach. The family, of course, wants to stay the aggressive course. It’s not the committee’s job to resolve this conflict, Dr. Berkowitz cautions. “The role of the ethics committee should be helping to identify, delineate, and resolve ethics issues,” he explains. “The committee should not be there simply to help the attending physician accomplish their goals.”

Committee Credibility

Even if physicians know when to ask for help from an ethics committee, they only will do so if they trust the enterprise, Dr. Moravec says. Using a multidisciplinary approach has worked at St. Joseph’s, where the ethics committee is comprised of nursing clinical directors, physicians, social workers, chaplains, hospice and palliative care directors, and even dietitians, who meet monthly.

When the St. Joseph’s ethics committee convenes, members fill out a multi-page record for each patient. In addition to a summary of the patient’s medical history, goals of treatment, preferences, and expected quality of life with proposed treatments (or withdrawal thereof), the record documents the committee’s conclusions, Dr. Moravec says. One copy of the document gets incorporated into the patient’s chart, one is sent to hospital administration, and a third gets channeled to the hospital system’s organization-wide ethics committee. This reporting through the medical staff fosters physician buy-in, Dr. Moravec says.

Physicians are less likely to use the consultation services if they feel the ethics committee doesn’t have teeth, says Rachel George, MD, MBA, hospitalist at Aurora St. Luke’s Hospital in Milwaukee, and regional director of five west coast hospitalist programs for Cogent Healthcare, Inc.

The same is true for one Southern California hospitalist who preferred to remain anonymous. “I rarely call for an ethics consult because they’re rarely helpful,” she says. “Generally, the issues we bring to the ethics committee are those where the family is pushing us to provide care we think is futile, and the ethics committee really doesn’t make a decision. You don’t get the backup you need, and you end up very frustrated.”

Sometimes, the California hospitalist continues, the family needs permission from the hospital to halt futile care. Without a durable power of attorney, the care team may find itself bowing to the wishes of one family member—the outlier—who insists the patient be kept alive with aggressive measures. The inpatient palliative care team often fills the ethics gap, helping the medical team discuss end-of-life issues, goals, and desires with the family. Hospitalists, she says, sometimes need an authoritative body to say, “It is no longer ethical to do this to this patient.”

“Having a hospital committee say it’s OK to withdraw a feeding tube or stop dialysis gives a comfort level to physicians,” Dr. Moravec says, “especially if the committee involves clergy, as well as administration. That is powerful support for that doctor.”

Med Students & Residents

The key to making ethics committees more effectively and widely used is education, Dr. George says. “We need to be educating our medical students and residents a lot more aggressively than we are right now,” she asserts. “How to talk with families about end-of-life issues, what is appropriate or inappropriate care, how should you be using your ethics committees—none of that is taught.”

At Children’s Hospital and Clinics, Dr. Berkowitz meets with residents and medical students every six weeks to discuss cases with ethical dilemmas. He says house staffers have little background or experience with ethics. The American Medical Association’s Liaison Committee on Medical Education 2007-2008 survey of 126 U.S. medical colleges found medical ethics was included in one required course at all 126 colleges, and was an elective course in 61. For some perspective, a course in end-of-life care was required at 124 schools and was an elective at 69. A course in palliative care was required at 120 schools, and was an elective in 60.3

Dr. Berkowitz agrees outreach is one solution. “The longer you have an ethics committee available and doing consultations in an institution, the more you expand the knowledge about how to handle problems,” he says. “People who may have previously requested an ethics consult may now have the skills and ability to handle these issues on their own, without needing to call a consult.”

Dr. Gandhy, of Saint Francis Memorial, believes such additional knowledge helps her focus on a patient’s family, not her own plan. “If the family is not ready to withdraw the care, I realize that forcing my agenda on them can also cause suffering,” she says. “When I change my focus to ask, ‘What is going to help the patient and the family?’ sometimes I don’t even need the ethics committee, because I am then able to address the family’s concerns.”

And that’s when everybody gains. TH

Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.

References

1. Snyder L, Leffler C;, for the Ethics and Human Rights Committee, American College of Physicians. Ethics Manual. 5th ed.,2005.

2. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007 Feb;7(2):13-25.

3. Barzansky B, Etze SI. 2007-2008 annual medical school questionnaire part II. JAMA 2008;300(10):1221.

What are hospitalist leaders reading these days? What books, journals, and Web sites do they turn to—or recommend—for honing management skills, keeping up with industry trends, or generally staying sharp? In the January 2008 issue of The Hospitalist, four hospitalists in management positions shared their picks; here, three other leaders in the industry offer their “recommended reads.”

The President’s Picks

SHM President Patrick Cawley, MD, chief medical officer of the University of South Carolina Medical Center in Charleston, recommends a variety of resources for hospitalists in leadership positions and those who aspire to lead.

You're in Charge, Now What? The 8 Point Plan by Thomas J. Neff and James M. Citrin

“For any leader moving into a new position, this is an invaluable guide for the first six months,” Dr. Cawley says. “It was originally written for CEOs, but it works for any leadership role. Every time I have taken on a new leadership position, I have re-read it and learned something new.”

Competitive Advantage by Michael E. Porter

“This business reference classic details the underpinnings of today’s MBA programs,” Dr. Cawley explains. “The concepts of competitive advantage, value creation, and value chain are absolutes to anyone involved in strategic planning, and certainly for any hospitalist program which requires financial support.”

A Sense of Urgency by John P. Kotter

The newest book by a leading expert in change management, this book focuses on the first step of successful change. “All hospitalists who are interested in improving quality must understand the difference between false urgency and true urgency, since it is key to knowing which events can be used to successfully drive change,” Dr. Cawley states.

Getting Things Done by David Allen

“I’m always on a quest for better personal organization and time management skills,” Dr. Cawley admits. “GTD is one such method. Combine the book with the Microsoft Outlook tips and you’ll never look back.”

Harvard Business Review

“This is one of the few magazines I read cover to cover each month—Harvard Business Review is the business community’s equivalent of the New England Journal of Medicine,” Dr. Cawley says.

Hardwiring Excellence by Quint Studer

“Many hospitals across the nation have engaged the Studer Group to help improve leadership accountability and performance,” Dr. Cawley explains. “This book is the hospital version of Good to Great.”

Dr. Cawley adds, “for something really different … .”

The Prince by Machiavelli and The Politics of Life: 25 Rules for Survival in a Brutal and Manipulative World by Craig Crawford

“For any hospitalist who is part of a larger organization, and certainly for any leader, politics are a constant,” Dr. Cawley points out. “If you’re serious about understanding such motivations, you need to become not only a student of leadership, but one of politics, as well. The place to start is The Prince. Strive for the deeper understanding of Machiavelli and not the often quoted ‘ends justifies the means’ superficiality. Crawford’s book is the modern equivalent.”

A Pediatric Hospitalist Recommends…

Jack Percelay, MD, MPH, FAAP, E.L.M.O. Pediatrics, New York, also serves on SHM’s board of directors. He recommends reading these five resources:

Getting to Yes: Negotiating Agreement Without Giving In by Roger Fisher and William L. Ury

Dr. Percelay calls this book required reading, saying, “This is not new—it’s a core requirement for hospital medicine group leaders, hospitalists, or anyone who needs to negotiate for themselves.”

Hospitalists: A Guide to Building and Sustaining a Successful Program by Joseph A. Miller, John Nelson, MD, and Winthrop F. Whitcomb, MD

“This is a tremendously useful resource, if you’re having problems with your administration—if the C-suite doesn’t really ‘get’ hospitalists,” Dr. Percelay says. “It helps readers understand the philosophy behind a highly successful hospital medicine program. If you were going to convert a hospital executive to hospital medicine with one book, this is the book to give them. It’s very useful to know about for this reason.”

Crucial Conversations: Tools for Talking When Stakes are High and Crucial Confrontations by Kerry Patterson, Joseph Grenny, Ron McMillan and Al Switzler

“These books are more advanced and are targeted for those interested in developing their conflict resolution and leadership skills,” Dr. Percelay says. “They were recommended on the SHM practice management list serve, and they’re for both your personal and your professional life. These are the most useful leadership books I have read this year.”

The Cincinnati Children’s Hospital Pediatric Grand Rounds available at www.cincinnatichildrens. org/ed/cme/streaming-media/library/pgr/default.htm

“This is a pediatrics resource. Cincinnati Children’s Hospital has all of its grand rounds on the Web,” Dr. Percelay says. “For someone like me, who works in a community hospital and doesn’t have access to the latest and greatest research, this site provides free access to cutting edge, high-quality presentations. Some are very relevant to pediatric hospital medicine, and some presentations even offer free continuing medical education. Other hospitals do this, as well, but the Cincinnati site is the most user-friendly site I’ve found.”

Teaching Tools

Sylvia Cheney McKean, MD, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist Service in Boston and SHM board member, uses several resources for dual purposes: to find the latest clinical information and to enhance and support her teaching.

PubMed available at www.ncbi.nlm. nih.gov/pubmed

The U.S. National Library of Medicine and the National Institutes of Health administer the PubMed site, which includes more than 18 million citations from MEDLINE and other life science journals for biomedical articles dating back to the 1950s. The site includes links to full text articles and other related resources.

“I find that most of my reading is through PubMed,” Dr. McKean says. “I get the latest, most up-to-date information. ... I generally proceed by first framing the question that needs to be answered and then looking for the best evidence. The key thing is to ask the right questions.”

American College of Physicians’ Medical Knowledge Self-Assessment Program (MKSAP) is available at www.acponline.org/products_services/ mksap/14.

“I find the ACP’s MKSAP syllabus very helpful for teaching and remaining updated,” Dr. McKean explains. “People use this to study for their boards, but it’s very helpful to teach residents ... and for viewing clinical problems.”

The Journal of Hospital Medicine

“I look at each issue cover to cover,” Dr. McKean says, “because it’s the most relevant journal of any out there. It has new research, professional development articles, and articles based on the Core Competencies of Hospital Medicine.”

SHM online research rooms available at www.hospitalmedicine.org

“SHM provides valuable resources that are being regularly updated for new hospitalists, hospitalist leaders and practicing hospitalists with the Core Competencies in Hospital Medicine as a framework,” Dr. McKean says. “There are new resource rooms coming out all the time, while the old ones are constantly updated. What I find most valuable is the quality improvement primer, a downloadable workbook which crosses all QI topics and gives physicians who have not had training in QI projects a framework to start their own … in their hospital.” TH

Jane Jerrard is a medical writer based in Chicago. She also writes “Public Policy” for The Hospitalist.

What are hospitalist leaders reading these days? What books, journals, and Web sites do they turn to—or recommend—for honing management skills, keeping up with industry trends, or generally staying sharp? In the January 2008 issue of The Hospitalist, four hospitalists in management positions shared their picks; here, three other leaders in the industry offer their “recommended reads.”

The President’s Picks

SHM President Patrick Cawley, MD, chief medical officer of the University of South Carolina Medical Center in Charleston, recommends a variety of resources for hospitalists in leadership positions and those who aspire to lead.

You're in Charge, Now What? The 8 Point Plan by Thomas J. Neff and James M. Citrin

“For any leader moving into a new position, this is an invaluable guide for the first six months,” Dr. Cawley says. “It was originally written for CEOs, but it works for any leadership role. Every time I have taken on a new leadership position, I have re-read it and learned something new.”

Competitive Advantage by Michael E. Porter

“This business reference classic details the underpinnings of today’s MBA programs,” Dr. Cawley explains. “The concepts of competitive advantage, value creation, and value chain are absolutes to anyone involved in strategic planning, and certainly for any hospitalist program which requires financial support.”

A Sense of Urgency by John P. Kotter

The newest book by a leading expert in change management, this book focuses on the first step of successful change. “All hospitalists who are interested in improving quality must understand the difference between false urgency and true urgency, since it is key to knowing which events can be used to successfully drive change,” Dr. Cawley states.

Getting Things Done by David Allen

“I’m always on a quest for better personal organization and time management skills,” Dr. Cawley admits. “GTD is one such method. Combine the book with the Microsoft Outlook tips and you’ll never look back.”

Harvard Business Review

“This is one of the few magazines I read cover to cover each month—Harvard Business Review is the business community’s equivalent of the New England Journal of Medicine,” Dr. Cawley says.

Hardwiring Excellence by Quint Studer

“Many hospitals across the nation have engaged the Studer Group to help improve leadership accountability and performance,” Dr. Cawley explains. “This book is the hospital version of Good to Great.”

Dr. Cawley adds, “for something really different … .”

The Prince by Machiavelli and The Politics of Life: 25 Rules for Survival in a Brutal and Manipulative World by Craig Crawford

“For any hospitalist who is part of a larger organization, and certainly for any leader, politics are a constant,” Dr. Cawley points out. “If you’re serious about understanding such motivations, you need to become not only a student of leadership, but one of politics, as well. The place to start is The Prince. Strive for the deeper understanding of Machiavelli and not the often quoted ‘ends justifies the means’ superficiality. Crawford’s book is the modern equivalent.”

A Pediatric Hospitalist Recommends…

Jack Percelay, MD, MPH, FAAP, E.L.M.O. Pediatrics, New York, also serves on SHM’s board of directors. He recommends reading these five resources:

Getting to Yes: Negotiating Agreement Without Giving In by Roger Fisher and William L. Ury

Dr. Percelay calls this book required reading, saying, “This is not new—it’s a core requirement for hospital medicine group leaders, hospitalists, or anyone who needs to negotiate for themselves.”

Hospitalists: A Guide to Building and Sustaining a Successful Program by Joseph A. Miller, John Nelson, MD, and Winthrop F. Whitcomb, MD

“This is a tremendously useful resource, if you’re having problems with your administration—if the C-suite doesn’t really ‘get’ hospitalists,” Dr. Percelay says. “It helps readers understand the philosophy behind a highly successful hospital medicine program. If you were going to convert a hospital executive to hospital medicine with one book, this is the book to give them. It’s very useful to know about for this reason.”

Crucial Conversations: Tools for Talking When Stakes are High and Crucial Confrontations by Kerry Patterson, Joseph Grenny, Ron McMillan and Al Switzler

“These books are more advanced and are targeted for those interested in developing their conflict resolution and leadership skills,” Dr. Percelay says. “They were recommended on the SHM practice management list serve, and they’re for both your personal and your professional life. These are the most useful leadership books I have read this year.”

The Cincinnati Children’s Hospital Pediatric Grand Rounds available at www.cincinnatichildrens. org/ed/cme/streaming-media/library/pgr/default.htm

“This is a pediatrics resource. Cincinnati Children’s Hospital has all of its grand rounds on the Web,” Dr. Percelay says. “For someone like me, who works in a community hospital and doesn’t have access to the latest and greatest research, this site provides free access to cutting edge, high-quality presentations. Some are very relevant to pediatric hospital medicine, and some presentations even offer free continuing medical education. Other hospitals do this, as well, but the Cincinnati site is the most user-friendly site I’ve found.”

Teaching Tools

Sylvia Cheney McKean, MD, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist Service in Boston and SHM board member, uses several resources for dual purposes: to find the latest clinical information and to enhance and support her teaching.

PubMed available at www.ncbi.nlm. nih.gov/pubmed

The U.S. National Library of Medicine and the National Institutes of Health administer the PubMed site, which includes more than 18 million citations from MEDLINE and other life science journals for biomedical articles dating back to the 1950s. The site includes links to full text articles and other related resources.

“I find that most of my reading is through PubMed,” Dr. McKean says. “I get the latest, most up-to-date information. ... I generally proceed by first framing the question that needs to be answered and then looking for the best evidence. The key thing is to ask the right questions.”

American College of Physicians’ Medical Knowledge Self-Assessment Program (MKSAP) is available at www.acponline.org/products_services/ mksap/14.

“I find the ACP’s MKSAP syllabus very helpful for teaching and remaining updated,” Dr. McKean explains. “People use this to study for their boards, but it’s very helpful to teach residents ... and for viewing clinical problems.”

The Journal of Hospital Medicine

“I look at each issue cover to cover,” Dr. McKean says, “because it’s the most relevant journal of any out there. It has new research, professional development articles, and articles based on the Core Competencies of Hospital Medicine.”

SHM online research rooms available at www.hospitalmedicine.org

“SHM provides valuable resources that are being regularly updated for new hospitalists, hospitalist leaders and practicing hospitalists with the Core Competencies in Hospital Medicine as a framework,” Dr. McKean says. “There are new resource rooms coming out all the time, while the old ones are constantly updated. What I find most valuable is the quality improvement primer, a downloadable workbook which crosses all QI topics and gives physicians who have not had training in QI projects a framework to start their own … in their hospital.” TH

Jane Jerrard is a medical writer based in Chicago. She also writes “Public Policy” for The Hospitalist.

What are hospitalist leaders reading these days? What books, journals, and Web sites do they turn to—or recommend—for honing management skills, keeping up with industry trends, or generally staying sharp? In the January 2008 issue of The Hospitalist, four hospitalists in management positions shared their picks; here, three other leaders in the industry offer their “recommended reads.”

The President’s Picks

SHM President Patrick Cawley, MD, chief medical officer of the University of South Carolina Medical Center in Charleston, recommends a variety of resources for hospitalists in leadership positions and those who aspire to lead.

You're in Charge, Now What? The 8 Point Plan by Thomas J. Neff and James M. Citrin

“For any leader moving into a new position, this is an invaluable guide for the first six months,” Dr. Cawley says. “It was originally written for CEOs, but it works for any leadership role. Every time I have taken on a new leadership position, I have re-read it and learned something new.”

Competitive Advantage by Michael E. Porter

“This business reference classic details the underpinnings of today’s MBA programs,” Dr. Cawley explains. “The concepts of competitive advantage, value creation, and value chain are absolutes to anyone involved in strategic planning, and certainly for any hospitalist program which requires financial support.”

A Sense of Urgency by John P. Kotter

The newest book by a leading expert in change management, this book focuses on the first step of successful change. “All hospitalists who are interested in improving quality must understand the difference between false urgency and true urgency, since it is key to knowing which events can be used to successfully drive change,” Dr. Cawley states.

Getting Things Done by David Allen

“I’m always on a quest for better personal organization and time management skills,” Dr. Cawley admits. “GTD is one such method. Combine the book with the Microsoft Outlook tips and you’ll never look back.”

Harvard Business Review

“This is one of the few magazines I read cover to cover each month—Harvard Business Review is the business community’s equivalent of the New England Journal of Medicine,” Dr. Cawley says.

Hardwiring Excellence by Quint Studer

“Many hospitals across the nation have engaged the Studer Group to help improve leadership accountability and performance,” Dr. Cawley explains. “This book is the hospital version of Good to Great.”

Dr. Cawley adds, “for something really different … .”

The Prince by Machiavelli and The Politics of Life: 25 Rules for Survival in a Brutal and Manipulative World by Craig Crawford

“For any hospitalist who is part of a larger organization, and certainly for any leader, politics are a constant,” Dr. Cawley points out. “If you’re serious about understanding such motivations, you need to become not only a student of leadership, but one of politics, as well. The place to start is The Prince. Strive for the deeper understanding of Machiavelli and not the often quoted ‘ends justifies the means’ superficiality. Crawford’s book is the modern equivalent.”

A Pediatric Hospitalist Recommends…

Jack Percelay, MD, MPH, FAAP, E.L.M.O. Pediatrics, New York, also serves on SHM’s board of directors. He recommends reading these five resources:

Getting to Yes: Negotiating Agreement Without Giving In by Roger Fisher and William L. Ury

Dr. Percelay calls this book required reading, saying, “This is not new—it’s a core requirement for hospital medicine group leaders, hospitalists, or anyone who needs to negotiate for themselves.”

Hospitalists: A Guide to Building and Sustaining a Successful Program by Joseph A. Miller, John Nelson, MD, and Winthrop F. Whitcomb, MD

“This is a tremendously useful resource, if you’re having problems with your administration—if the C-suite doesn’t really ‘get’ hospitalists,” Dr. Percelay says. “It helps readers understand the philosophy behind a highly successful hospital medicine program. If you were going to convert a hospital executive to hospital medicine with one book, this is the book to give them. It’s very useful to know about for this reason.”

Crucial Conversations: Tools for Talking When Stakes are High and Crucial Confrontations by Kerry Patterson, Joseph Grenny, Ron McMillan and Al Switzler

“These books are more advanced and are targeted for those interested in developing their conflict resolution and leadership skills,” Dr. Percelay says. “They were recommended on the SHM practice management list serve, and they’re for both your personal and your professional life. These are the most useful leadership books I have read this year.”

The Cincinnati Children’s Hospital Pediatric Grand Rounds available at www.cincinnatichildrens. org/ed/cme/streaming-media/library/pgr/default.htm

“This is a pediatrics resource. Cincinnati Children’s Hospital has all of its grand rounds on the Web,” Dr. Percelay says. “For someone like me, who works in a community hospital and doesn’t have access to the latest and greatest research, this site provides free access to cutting edge, high-quality presentations. Some are very relevant to pediatric hospital medicine, and some presentations even offer free continuing medical education. Other hospitals do this, as well, but the Cincinnati site is the most user-friendly site I’ve found.”

Teaching Tools

Sylvia Cheney McKean, MD, medical director, Brigham and Women’s Hospital/Faulkner Hospitalist Service in Boston and SHM board member, uses several resources for dual purposes: to find the latest clinical information and to enhance and support her teaching.

PubMed available at www.ncbi.nlm. nih.gov/pubmed

The U.S. National Library of Medicine and the National Institutes of Health administer the PubMed site, which includes more than 18 million citations from MEDLINE and other life science journals for biomedical articles dating back to the 1950s. The site includes links to full text articles and other related resources.

“I find that most of my reading is through PubMed,” Dr. McKean says. “I get the latest, most up-to-date information. ... I generally proceed by first framing the question that needs to be answered and then looking for the best evidence. The key thing is to ask the right questions.”

American College of Physicians’ Medical Knowledge Self-Assessment Program (MKSAP) is available at www.acponline.org/products_services/ mksap/14.

“I find the ACP’s MKSAP syllabus very helpful for teaching and remaining updated,” Dr. McKean explains. “People use this to study for their boards, but it’s very helpful to teach residents ... and for viewing clinical problems.”

The Journal of Hospital Medicine

“I look at each issue cover to cover,” Dr. McKean says, “because it’s the most relevant journal of any out there. It has new research, professional development articles, and articles based on the Core Competencies of Hospital Medicine.”

SHM online research rooms available at www.hospitalmedicine.org

“SHM provides valuable resources that are being regularly updated for new hospitalists, hospitalist leaders and practicing hospitalists with the Core Competencies in Hospital Medicine as a framework,” Dr. McKean says. “There are new resource rooms coming out all the time, while the old ones are constantly updated. What I find most valuable is the quality improvement primer, a downloadable workbook which crosses all QI topics and gives physicians who have not had training in QI projects a framework to start their own … in their hospital.” TH

Jane Jerrard is a medical writer based in Chicago. She also writes “Public Policy” for The Hospitalist.

Got a job offer? Congratulations! The hard part of finding your first job after residency is complete. This also is a time to sit down and think about what’s important to you, as you want the details of your job to be stated in a contract. Here are some tips about contract negotiation.

Get It in Writing

Just as in practice, where we are always told, “it didn’t happen if it’s not documented in the chart,” the same holds true for your workplace contract. This is the time to prioritize what elements are important to you in order to have a satisfying and rewarding career, both professionally and financially. If a particular aspect of your employment agreement is important to you, be it salary, schedule, or malpractice insurance coverage, be sure its stated in writing in your contract. Verbal statements from your employer, such as “we’ll discuss this after you start your job,” should raise a red flag.

Know What Is Negotiable

Some residents are relieved just to secure their first job offer and they immediately accept the initial offer as-is, without attempting to negotiate. Although it’s probably unreasonable to negotiate everything, after you read the initial contract, if anything important is not to your satisfaction, it is practical to have a discussion with your employer. Employers expect this of their hires and, if done politely and professionally, this is a time to build bridges with your future supervisor. Moreover, they begin to better understand your needs and you theirs.

You may find it helpful to talk to associates in the group about what parts of their contracts were negotiable. For example, particularly in academic settings, you may find salary and benefits are not negotiable; however, other benefits, such as office space or protected research time, may be negotiable. Basically, the best time to negotiate is the “honeymoon” period, right after a job offer has been made, as the employer will be doing its best to entice a prospective employee.

Consider a Legal Opinion

In general, the more complex your contract, the more important it will be to solicit the help of an attorney experienced in healthcare. Even if your contract is very simple, contains a standardized salary and benefit structure, has no restrictive covenants, and partnership is not an issue, it may be helpful to have your contract reviewed by an attorney. Understand what is written in your contract and, if there is any doubt, hire a lawyer.

Ultimately, you will be signing the contract, not your lawyer, so be sure you understand what is in it and don’t get mired in “legalese.” Some firms offer third-party contract negotiation; they will assign an attorney to step in as an intermediary. Then again, most experts recommend against hiring a third-party negotiator, as this may increase the distance between you and your employer at a time probably best spent getting to know each other.

Maintain a Keen Eye

Specifics to look for in your new contract:

Work requirements. The employment agreement should visibly define your job responsibilities. Things to look for in your contract include the obligations of the physician, number of shifts or hours or weeks per year you are expected to work, call responsibilities, a census cap (if applicable), allotted vacation time, and continuing medical education time.

Compensation. The contract clearly should delineate how you will be paid. Some hospitalists are compensated solely via a salary; others are paid based on billing/productivity, while the majority are paid based on a combination of these methods (a base salary plus incentives). Be sure you understand the incentive and/or bonus structure of your salary. Practices basing incentives on physician productivity will incorporate your own billing practices and often is measured in relative value units (RVUs). In some settings, group incentives are based on quality targets set by the administration, such as the Joint Commission on the Accreditation of Healthcare Organi-­zations (JCAHO) core measure compliance, dictation timeliness, or patient/primary care physician satisfaction.

Benefits. In addition to your salary, you should see that your benefits are spelled out. The obvious benefits include medical, dental, and vision insurance, as well as a retirement savings plan. As discussed in the July 2008 issue of The Hospitalist, as demand for hospitalists continues to exceed supply, look for signing bonuses, coverage of relocation expenses, and the possibility of student loan payoff. Other important benefits include coverage of professional dues, CME allocation, and licensing and board examination fees.

Malpractice Insurance. This can be a complicated topic. In general, there are two major classes of malpractice insurance: an occurrence policy and a claims-made policy. In respect to an occurrence policy, any malpractice incident arising while the coverage was in place, regardless of when the claim was filed, will be covered even after you have stopped practicing under that policy. A claims-made policy, on the other hand, protects physicians for any covered claim, if they are insured when the claim is made. It does not cover malpractice claims filed after the physician cancels the malpractice policy, even if the claim is about an event that occurred while the physician was insured.

If you are offered a claims-made policy, require your employer to add tail coverage, which covers you after leaving the practice for any events occurred during employment. If you are unclear about any part of the group’s malpractice coverage, consider seeking legal advice.

Restrictive covenants. These are non-compete clauses often setting geographic and time restrictions of where and when a physician can practice in the event they leave the group. Though you never know what the future holds, this becomes relevant if you were to change jobs and work at an adjacent local facility or one in a nearby county. In general, hospitalists rarely carry a panel of patients, so an employer probably should not be concerned about hospitalists taking patients with them if/when they leave the practice. Be cautious of restrictive covenants found in your contract.

Ownership/Partnership. In some private groups, partnership will be offered after a preliminary employment period, usually one to two years. Look for your contract to state when and how partnership might be offered, and what the criteria to join are. This also is the time to ask others in the group to get a sense of how many associates are offered partnership and when this might happen.

Allowable Activities. Look for any restrictions regarding your activities outside normal clinical duties, such as teaching, research, or consulting for other firms. If such restrictions are in your contract, there may be specifications about whether income from such activities is yours or whether it is shared with the rest of the practice. TH

Bryan Huang, MD, assistant clinical professor, division of hospital medicine, University of California-San Diego Department of Medicine, Bhavin Patel, MD, hospitalist at Regions Hospital, HealthPartners Medical Group, St. Paul, Minn., Bijo Chacko, MD, hospitalist program medical director, Preferred Health Partners, New York City, and chair of SHM’s Young Physician Committee.

Got a job offer? Congratulations! The hard part of finding your first job after residency is complete. This also is a time to sit down and think about what’s important to you, as you want the details of your job to be stated in a contract. Here are some tips about contract negotiation.

Get It in Writing

Just as in practice, where we are always told, “it didn’t happen if it’s not documented in the chart,” the same holds true for your workplace contract. This is the time to prioritize what elements are important to you in order to have a satisfying and rewarding career, both professionally and financially. If a particular aspect of your employment agreement is important to you, be it salary, schedule, or malpractice insurance coverage, be sure its stated in writing in your contract. Verbal statements from your employer, such as “we’ll discuss this after you start your job,” should raise a red flag.

Know What Is Negotiable

Some residents are relieved just to secure their first job offer and they immediately accept the initial offer as-is, without attempting to negotiate. Although it’s probably unreasonable to negotiate everything, after you read the initial contract, if anything important is not to your satisfaction, it is practical to have a discussion with your employer. Employers expect this of their hires and, if done politely and professionally, this is a time to build bridges with your future supervisor. Moreover, they begin to better understand your needs and you theirs.

You may find it helpful to talk to associates in the group about what parts of their contracts were negotiable. For example, particularly in academic settings, you may find salary and benefits are not negotiable; however, other benefits, such as office space or protected research time, may be negotiable. Basically, the best time to negotiate is the “honeymoon” period, right after a job offer has been made, as the employer will be doing its best to entice a prospective employee.

Consider a Legal Opinion

In general, the more complex your contract, the more important it will be to solicit the help of an attorney experienced in healthcare. Even if your contract is very simple, contains a standardized salary and benefit structure, has no restrictive covenants, and partnership is not an issue, it may be helpful to have your contract reviewed by an attorney. Understand what is written in your contract and, if there is any doubt, hire a lawyer.

Ultimately, you will be signing the contract, not your lawyer, so be sure you understand what is in it and don’t get mired in “legalese.” Some firms offer third-party contract negotiation; they will assign an attorney to step in as an intermediary. Then again, most experts recommend against hiring a third-party negotiator, as this may increase the distance between you and your employer at a time probably best spent getting to know each other.

Maintain a Keen Eye

Specifics to look for in your new contract:

Work requirements. The employment agreement should visibly define your job responsibilities. Things to look for in your contract include the obligations of the physician, number of shifts or hours or weeks per year you are expected to work, call responsibilities, a census cap (if applicable), allotted vacation time, and continuing medical education time.

Compensation. The contract clearly should delineate how you will be paid. Some hospitalists are compensated solely via a salary; others are paid based on billing/productivity, while the majority are paid based on a combination of these methods (a base salary plus incentives). Be sure you understand the incentive and/or bonus structure of your salary. Practices basing incentives on physician productivity will incorporate your own billing practices and often is measured in relative value units (RVUs). In some settings, group incentives are based on quality targets set by the administration, such as the Joint Commission on the Accreditation of Healthcare Organi-­zations (JCAHO) core measure compliance, dictation timeliness, or patient/primary care physician satisfaction.

Benefits. In addition to your salary, you should see that your benefits are spelled out. The obvious benefits include medical, dental, and vision insurance, as well as a retirement savings plan. As discussed in the July 2008 issue of The Hospitalist, as demand for hospitalists continues to exceed supply, look for signing bonuses, coverage of relocation expenses, and the possibility of student loan payoff. Other important benefits include coverage of professional dues, CME allocation, and licensing and board examination fees.

Malpractice Insurance. This can be a complicated topic. In general, there are two major classes of malpractice insurance: an occurrence policy and a claims-made policy. In respect to an occurrence policy, any malpractice incident arising while the coverage was in place, regardless of when the claim was filed, will be covered even after you have stopped practicing under that policy. A claims-made policy, on the other hand, protects physicians for any covered claim, if they are insured when the claim is made. It does not cover malpractice claims filed after the physician cancels the malpractice policy, even if the claim is about an event that occurred while the physician was insured.

If you are offered a claims-made policy, require your employer to add tail coverage, which covers you after leaving the practice for any events occurred during employment. If you are unclear about any part of the group’s malpractice coverage, consider seeking legal advice.

Restrictive covenants. These are non-compete clauses often setting geographic and time restrictions of where and when a physician can practice in the event they leave the group. Though you never know what the future holds, this becomes relevant if you were to change jobs and work at an adjacent local facility or one in a nearby county. In general, hospitalists rarely carry a panel of patients, so an employer probably should not be concerned about hospitalists taking patients with them if/when they leave the practice. Be cautious of restrictive covenants found in your contract.

Ownership/Partnership. In some private groups, partnership will be offered after a preliminary employment period, usually one to two years. Look for your contract to state when and how partnership might be offered, and what the criteria to join are. This also is the time to ask others in the group to get a sense of how many associates are offered partnership and when this might happen.

Allowable Activities. Look for any restrictions regarding your activities outside normal clinical duties, such as teaching, research, or consulting for other firms. If such restrictions are in your contract, there may be specifications about whether income from such activities is yours or whether it is shared with the rest of the practice. TH

Bryan Huang, MD, assistant clinical professor, division of hospital medicine, University of California-San Diego Department of Medicine, Bhavin Patel, MD, hospitalist at Regions Hospital, HealthPartners Medical Group, St. Paul, Minn., Bijo Chacko, MD, hospitalist program medical director, Preferred Health Partners, New York City, and chair of SHM’s Young Physician Committee.

Got a job offer? Congratulations! The hard part of finding your first job after residency is complete. This also is a time to sit down and think about what’s important to you, as you want the details of your job to be stated in a contract. Here are some tips about contract negotiation.

Get It in Writing

Just as in practice, where we are always told, “it didn’t happen if it’s not documented in the chart,” the same holds true for your workplace contract. This is the time to prioritize what elements are important to you in order to have a satisfying and rewarding career, both professionally and financially. If a particular aspect of your employment agreement is important to you, be it salary, schedule, or malpractice insurance coverage, be sure its stated in writing in your contract. Verbal statements from your employer, such as “we’ll discuss this after you start your job,” should raise a red flag.

Know What Is Negotiable

Some residents are relieved just to secure their first job offer and they immediately accept the initial offer as-is, without attempting to negotiate. Although it’s probably unreasonable to negotiate everything, after you read the initial contract, if anything important is not to your satisfaction, it is practical to have a discussion with your employer. Employers expect this of their hires and, if done politely and professionally, this is a time to build bridges with your future supervisor. Moreover, they begin to better understand your needs and you theirs.

You may find it helpful to talk to associates in the group about what parts of their contracts were negotiable. For example, particularly in academic settings, you may find salary and benefits are not negotiable; however, other benefits, such as office space or protected research time, may be negotiable. Basically, the best time to negotiate is the “honeymoon” period, right after a job offer has been made, as the employer will be doing its best to entice a prospective employee.

Consider a Legal Opinion

In general, the more complex your contract, the more important it will be to solicit the help of an attorney experienced in healthcare. Even if your contract is very simple, contains a standardized salary and benefit structure, has no restrictive covenants, and partnership is not an issue, it may be helpful to have your contract reviewed by an attorney. Understand what is written in your contract and, if there is any doubt, hire a lawyer.

Ultimately, you will be signing the contract, not your lawyer, so be sure you understand what is in it and don’t get mired in “legalese.” Some firms offer third-party contract negotiation; they will assign an attorney to step in as an intermediary. Then again, most experts recommend against hiring a third-party negotiator, as this may increase the distance between you and your employer at a time probably best spent getting to know each other.

Maintain a Keen Eye

Specifics to look for in your new contract:

Work requirements. The employment agreement should visibly define your job responsibilities. Things to look for in your contract include the obligations of the physician, number of shifts or hours or weeks per year you are expected to work, call responsibilities, a census cap (if applicable), allotted vacation time, and continuing medical education time.

Compensation. The contract clearly should delineate how you will be paid. Some hospitalists are compensated solely via a salary; others are paid based on billing/productivity, while the majority are paid based on a combination of these methods (a base salary plus incentives). Be sure you understand the incentive and/or bonus structure of your salary. Practices basing incentives on physician productivity will incorporate your own billing practices and often is measured in relative value units (RVUs). In some settings, group incentives are based on quality targets set by the administration, such as the Joint Commission on the Accreditation of Healthcare Organi-­zations (JCAHO) core measure compliance, dictation timeliness, or patient/primary care physician satisfaction.

Benefits. In addition to your salary, you should see that your benefits are spelled out. The obvious benefits include medical, dental, and vision insurance, as well as a retirement savings plan. As discussed in the July 2008 issue of The Hospitalist, as demand for hospitalists continues to exceed supply, look for signing bonuses, coverage of relocation expenses, and the possibility of student loan payoff. Other important benefits include coverage of professional dues, CME allocation, and licensing and board examination fees.

Malpractice Insurance. This can be a complicated topic. In general, there are two major classes of malpractice insurance: an occurrence policy and a claims-made policy. In respect to an occurrence policy, any malpractice incident arising while the coverage was in place, regardless of when the claim was filed, will be covered even after you have stopped practicing under that policy. A claims-made policy, on the other hand, protects physicians for any covered claim, if they are insured when the claim is made. It does not cover malpractice claims filed after the physician cancels the malpractice policy, even if the claim is about an event that occurred while the physician was insured.

If you are offered a claims-made policy, require your employer to add tail coverage, which covers you after leaving the practice for any events occurred during employment. If you are unclear about any part of the group’s malpractice coverage, consider seeking legal advice.

Restrictive covenants. These are non-compete clauses often setting geographic and time restrictions of where and when a physician can practice in the event they leave the group. Though you never know what the future holds, this becomes relevant if you were to change jobs and work at an adjacent local facility or one in a nearby county. In general, hospitalists rarely carry a panel of patients, so an employer probably should not be concerned about hospitalists taking patients with them if/when they leave the practice. Be cautious of restrictive covenants found in your contract.

Ownership/Partnership. In some private groups, partnership will be offered after a preliminary employment period, usually one to two years. Look for your contract to state when and how partnership might be offered, and what the criteria to join are. This also is the time to ask others in the group to get a sense of how many associates are offered partnership and when this might happen.

Allowable Activities. Look for any restrictions regarding your activities outside normal clinical duties, such as teaching, research, or consulting for other firms. If such restrictions are in your contract, there may be specifications about whether income from such activities is yours or whether it is shared with the rest of the practice. TH

Bryan Huang, MD, assistant clinical professor, division of hospital medicine, University of California-San Diego Department of Medicine, Bhavin Patel, MD, hospitalist at Regions Hospital, HealthPartners Medical Group, St. Paul, Minn., Bijo Chacko, MD, hospitalist program medical director, Preferred Health Partners, New York City, and chair of SHM’s Young Physician Committee.

The elderly constitute the fastest-growing segment of the U.S. population. According to one estimate, nearly one in five Americans will be 65 years old or older by 2050.1 Geriatric medicine has produced a plethora of information regarding older patients’ special needs, but when it comes to teaching medical students and residents, most curricular materials focus on the care and management of older outpatients, rather than inpatients. In an effort to fill this gap, faculty at the University of Chicago School of Medicine developed the Curriculum for the Hospitalized Aging Medical Patient (CHAMP). It is designed to help instructors teach the management of elderly inpatients. In this month’s issue of the Journal of Hospital Medicine, lead author Paula Podrazik, MD, associate professor in the section of geriatrics, department of medicine, University of Chicago, and her co-authors explain CHAMP as it was perceived by a targeted group of faculty learners.

CHAMP incorporates knowledge gleaned from first-hand experience and a review of the literature and existing models of care. “Our goal was to improve patient care and systems of hospital care through education by faculty development,” Dr. Podrazik tells The Hospitalist. The CHAMP program emphasizes issues of particular importance in geriatric hospital medicine, including frailty, avoiding hazards of hospitalization, palliation, and care transitions.

For example, “hospitalists need to know certain aspects of dementia care, such as how to recognize it and screen for it,” she explains. “They have to determine whether a particular patient is able to make decisions, and they have to understand what it is about this condition that puts these patients at higher risk in the hospital.” Another example includes medication review and “communicating medication changes when transitioning the patient to a skilled nursing facility, home, or a rehabilitation center.”

Dr. Podrazik and her colleagues hope CHAMP might entice more medical students and residents to consider entering geriatric medicine. “Half of the [hospital] beds in the U.S. are filled with patients who are at least 65 years old. Many students and residents base their career decisions on what they see during their hospital rotation, so this was a great opportunity for us, as geriatricians, to influence that decision.”

The program consists of learning modules presented in 12, four-hour sessions. The modules address four basic themes:

• Identification of the frail or vulnerable elderly patient;
• Recognition and avoidance of hospitalization hazards, such as falls and dementia;
• Palliative care and end-of-life issues; and
• Improving transitions of care.

Each module has specific learning objectives and an evaluation process based on the standard precepts of curriculum design. The first part of each session covers topics on geriatric inpatient medicine, such as high-risk medications, medication reconciliation, restraint use, care transitions, and other aspects of mandates from The Joint Commission, which have particular relevance to the care of elderly people. Faculty participants listen to 30- to 90-minute lectures on each topic, with an emphasis on applying the content during bedside teaching rounds.

Modules presented in the second half of the session cover teaching techniques, such as the Stanford Faculty Development Program for Medical Teachers, which uses case scenarios and practice sessions to polish participants’ teaching skills. Another component specifically developed for CHAMP is a mini-course called “Teaching on Today’s Wards.” It is designed to help non-geriatric faculty put more geriatrics content in their bedside rounds, and to improve bedside teaching techniques in the inpatient wards.

The CHAMP curriculum also addresses the core competencies designated by the Accreditation Council for Graduate Medical Education (ACGME), namely professionalism, communication, systems-based practice, and practice-based learning and improvement.

The basic principles of geriatric care already exist, Dr. Podrazik says. “It was our job to pull it all together,” she explains. “A program of this size and magnitude couldn’t have been done without the participation of people in a multitude of areas, including hospitalists, geriatricians, internists, and PhD educators. We had multiple champions who took different areas and just ran with them.”

With eight faculty scholars volunteering to serve as guinea pigs, Dr. Podrazik and her colleagues pilot-tested the program in the spring of 2004. By 2006, another 21 faculty members had participated in CHAMP, including nearly half of the university’s general medicine faculty and most of its hospitalists. The response was enthusiastic, she says, with learners praising the presentation of geriatric issues and concrete suggestions for incorporating the information in their own teaching sessions. Upon completion of the CHAMP series, participants reported feeling significantly more knowledgeable about geriatric content, had more positive attitudes toward older patients, and felt more confident in their ability to care for older patients and teach geriatric medicine.

A major challenge was “providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes,” the authors wrote. To solve this problem, they added objective structural teaching evaluations (OSTEs), so participants could test their teaching skills and mastery of geriatric content. Practice-oriented games, exercises, and tutorials, and ongoing contact with CHAMP alumnae and faculty are provided, as well as access to support materials online. Efforts are under way to incorporate core CHAMP faculty members into hospitalist and general medicine lecture series. Also being considered is having a CHAMP core faculty member attend during inpatient ward rounds.

It appears as though CHAMP is starting to pay off, in terms of patient care, Dr. Podrazik says. Although she cautioned the findings are “really preliminary,” and data analysis is ongoing, clinical data “do show a beneficial effect on a number of patient care outcomes.” TH

Norra MacReady is a medical writer based in California.

Reference

1. Passel JS, Cohn D. U.S. population projections: 2005-2050. Pew Research Center. http://pewhispanic.org/reports/report.php?ReportID=85. Published February 11, 2008. Accessed Thursday, October 23, 2008.

The elderly constitute the fastest-growing segment of the U.S. population. According to one estimate, nearly one in five Americans will be 65 years old or older by 2050.1 Geriatric medicine has produced a plethora of information regarding older patients’ special needs, but when it comes to teaching medical students and residents, most curricular materials focus on the care and management of older outpatients, rather than inpatients. In an effort to fill this gap, faculty at the University of Chicago School of Medicine developed the Curriculum for the Hospitalized Aging Medical Patient (CHAMP). It is designed to help instructors teach the management of elderly inpatients. In this month’s issue of the Journal of Hospital Medicine, lead author Paula Podrazik, MD, associate professor in the section of geriatrics, department of medicine, University of Chicago, and her co-authors explain CHAMP as it was perceived by a targeted group of faculty learners.

CHAMP incorporates knowledge gleaned from first-hand experience and a review of the literature and existing models of care. “Our goal was to improve patient care and systems of hospital care through education by faculty development,” Dr. Podrazik tells The Hospitalist. The CHAMP program emphasizes issues of particular importance in geriatric hospital medicine, including frailty, avoiding hazards of hospitalization, palliation, and care transitions.

For example, “hospitalists need to know certain aspects of dementia care, such as how to recognize it and screen for it,” she explains. “They have to determine whether a particular patient is able to make decisions, and they have to understand what it is about this condition that puts these patients at higher risk in the hospital.” Another example includes medication review and “communicating medication changes when transitioning the patient to a skilled nursing facility, home, or a rehabilitation center.”

Dr. Podrazik and her colleagues hope CHAMP might entice more medical students and residents to consider entering geriatric medicine. “Half of the [hospital] beds in the U.S. are filled with patients who are at least 65 years old. Many students and residents base their career decisions on what they see during their hospital rotation, so this was a great opportunity for us, as geriatricians, to influence that decision.”

The program consists of learning modules presented in 12, four-hour sessions. The modules address four basic themes:

• Identification of the frail or vulnerable elderly patient;
• Recognition and avoidance of hospitalization hazards, such as falls and dementia;
• Palliative care and end-of-life issues; and
• Improving transitions of care.

Each module has specific learning objectives and an evaluation process based on the standard precepts of curriculum design. The first part of each session covers topics on geriatric inpatient medicine, such as high-risk medications, medication reconciliation, restraint use, care transitions, and other aspects of mandates from The Joint Commission, which have particular relevance to the care of elderly people. Faculty participants listen to 30- to 90-minute lectures on each topic, with an emphasis on applying the content during bedside teaching rounds.

Modules presented in the second half of the session cover teaching techniques, such as the Stanford Faculty Development Program for Medical Teachers, which uses case scenarios and practice sessions to polish participants’ teaching skills. Another component specifically developed for CHAMP is a mini-course called “Teaching on Today’s Wards.” It is designed to help non-geriatric faculty put more geriatrics content in their bedside rounds, and to improve bedside teaching techniques in the inpatient wards.

The CHAMP curriculum also addresses the core competencies designated by the Accreditation Council for Graduate Medical Education (ACGME), namely professionalism, communication, systems-based practice, and practice-based learning and improvement.

The basic principles of geriatric care already exist, Dr. Podrazik says. “It was our job to pull it all together,” she explains. “A program of this size and magnitude couldn’t have been done without the participation of people in a multitude of areas, including hospitalists, geriatricians, internists, and PhD educators. We had multiple champions who took different areas and just ran with them.”

With eight faculty scholars volunteering to serve as guinea pigs, Dr. Podrazik and her colleagues pilot-tested the program in the spring of 2004. By 2006, another 21 faculty members had participated in CHAMP, including nearly half of the university’s general medicine faculty and most of its hospitalists. The response was enthusiastic, she says, with learners praising the presentation of geriatric issues and concrete suggestions for incorporating the information in their own teaching sessions. Upon completion of the CHAMP series, participants reported feeling significantly more knowledgeable about geriatric content, had more positive attitudes toward older patients, and felt more confident in their ability to care for older patients and teach geriatric medicine.

A major challenge was “providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes,” the authors wrote. To solve this problem, they added objective structural teaching evaluations (OSTEs), so participants could test their teaching skills and mastery of geriatric content. Practice-oriented games, exercises, and tutorials, and ongoing contact with CHAMP alumnae and faculty are provided, as well as access to support materials online. Efforts are under way to incorporate core CHAMP faculty members into hospitalist and general medicine lecture series. Also being considered is having a CHAMP core faculty member attend during inpatient ward rounds.

It appears as though CHAMP is starting to pay off, in terms of patient care, Dr. Podrazik says. Although she cautioned the findings are “really preliminary,” and data analysis is ongoing, clinical data “do show a beneficial effect on a number of patient care outcomes.” TH

Norra MacReady is a medical writer based in California.

Reference

1. Passel JS, Cohn D. U.S. population projections: 2005-2050. Pew Research Center. http://pewhispanic.org/reports/report.php?ReportID=85. Published February 11, 2008. Accessed Thursday, October 23, 2008.

The elderly constitute the fastest-growing segment of the U.S. population. According to one estimate, nearly one in five Americans will be 65 years old or older by 2050.1 Geriatric medicine has produced a plethora of information regarding older patients’ special needs, but when it comes to teaching medical students and residents, most curricular materials focus on the care and management of older outpatients, rather than inpatients. In an effort to fill this gap, faculty at the University of Chicago School of Medicine developed the Curriculum for the Hospitalized Aging Medical Patient (CHAMP). It is designed to help instructors teach the management of elderly inpatients. In this month’s issue of the Journal of Hospital Medicine, lead author Paula Podrazik, MD, associate professor in the section of geriatrics, department of medicine, University of Chicago, and her co-authors explain CHAMP as it was perceived by a targeted group of faculty learners.

CHAMP incorporates knowledge gleaned from first-hand experience and a review of the literature and existing models of care. “Our goal was to improve patient care and systems of hospital care through education by faculty development,” Dr. Podrazik tells The Hospitalist. The CHAMP program emphasizes issues of particular importance in geriatric hospital medicine, including frailty, avoiding hazards of hospitalization, palliation, and care transitions.

For example, “hospitalists need to know certain aspects of dementia care, such as how to recognize it and screen for it,” she explains. “They have to determine whether a particular patient is able to make decisions, and they have to understand what it is about this condition that puts these patients at higher risk in the hospital.” Another example includes medication review and “communicating medication changes when transitioning the patient to a skilled nursing facility, home, or a rehabilitation center.”

Dr. Podrazik and her colleagues hope CHAMP might entice more medical students and residents to consider entering geriatric medicine. “Half of the [hospital] beds in the U.S. are filled with patients who are at least 65 years old. Many students and residents base their career decisions on what they see during their hospital rotation, so this was a great opportunity for us, as geriatricians, to influence that decision.”

The program consists of learning modules presented in 12, four-hour sessions. The modules address four basic themes:

• Identification of the frail or vulnerable elderly patient;
• Recognition and avoidance of hospitalization hazards, such as falls and dementia;
• Palliative care and end-of-life issues; and
• Improving transitions of care.

Each module has specific learning objectives and an evaluation process based on the standard precepts of curriculum design. The first part of each session covers topics on geriatric inpatient medicine, such as high-risk medications, medication reconciliation, restraint use, care transitions, and other aspects of mandates from The Joint Commission, which have particular relevance to the care of elderly people. Faculty participants listen to 30- to 90-minute lectures on each topic, with an emphasis on applying the content during bedside teaching rounds.

Modules presented in the second half of the session cover teaching techniques, such as the Stanford Faculty Development Program for Medical Teachers, which uses case scenarios and practice sessions to polish participants’ teaching skills. Another component specifically developed for CHAMP is a mini-course called “Teaching on Today’s Wards.” It is designed to help non-geriatric faculty put more geriatrics content in their bedside rounds, and to improve bedside teaching techniques in the inpatient wards.

The CHAMP curriculum also addresses the core competencies designated by the Accreditation Council for Graduate Medical Education (ACGME), namely professionalism, communication, systems-based practice, and practice-based learning and improvement.

The basic principles of geriatric care already exist, Dr. Podrazik says. “It was our job to pull it all together,” she explains. “A program of this size and magnitude couldn’t have been done without the participation of people in a multitude of areas, including hospitalists, geriatricians, internists, and PhD educators. We had multiple champions who took different areas and just ran with them.”

With eight faculty scholars volunteering to serve as guinea pigs, Dr. Podrazik and her colleagues pilot-tested the program in the spring of 2004. By 2006, another 21 faculty members had participated in CHAMP, including nearly half of the university’s general medicine faculty and most of its hospitalists. The response was enthusiastic, she says, with learners praising the presentation of geriatric issues and concrete suggestions for incorporating the information in their own teaching sessions. Upon completion of the CHAMP series, participants reported feeling significantly more knowledgeable about geriatric content, had more positive attitudes toward older patients, and felt more confident in their ability to care for older patients and teach geriatric medicine.

A major challenge was “providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes,” the authors wrote. To solve this problem, they added objective structural teaching evaluations (OSTEs), so participants could test their teaching skills and mastery of geriatric content. Practice-oriented games, exercises, and tutorials, and ongoing contact with CHAMP alumnae and faculty are provided, as well as access to support materials online. Efforts are under way to incorporate core CHAMP faculty members into hospitalist and general medicine lecture series. Also being considered is having a CHAMP core faculty member attend during inpatient ward rounds.

It appears as though CHAMP is starting to pay off, in terms of patient care, Dr. Podrazik says. Although she cautioned the findings are “really preliminary,” and data analysis is ongoing, clinical data “do show a beneficial effect on a number of patient care outcomes.” TH

Norra MacReady is a medical writer based in California.

Reference

1. Passel JS, Cohn D. U.S. population projections: 2005-2050. Pew Research Center. http://pewhispanic.org/reports/report.php?ReportID=85. Published February 11, 2008. Accessed Thursday, October 23, 2008.