Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Her name was Mrs. Carberry, but her readers knew her as Mary Margaret. Two months earlier, she suffered a debilitating stroke that took away her vibrant life. Previously a prolific writer of advice columns and opinion pieces, the blockage of blood to her brain dammed the steady flow of wisdom to her innumerable fans. They never again would benefit from the words of this intelligent, feisty, and self‐proclaimed Cranky Catholic. Unfortunately, I would not know Mary Margaret for her words, but only her numbers: her vital signs, her urine output, her tube feed residuals.

Not able to communicate with us, we wondered did Mrs. Carberry want this tracheostomy that was placed? Did she want this peg tube that fed her continuously? And even if she would have initially agreed to them, would she still want them now? Especially given she was not improving and had little hope for a meaningful recovery.

We posed these difficult questions to her two sons. One son believed that his mother would want an end to these aggressive measures. The other son disagreed; he said his mother would want to make every effort to stay alive.

In the end, Mary Margaret's voice found its way to us and provided us with the answer. She did not tell us in the conventional manner via a lawyer or a living will. Her friends did not come forth and let us know about serious conversations during their afternoon lunches. Instead, Mary Margaret penned it to her audience of devoted readers in a newspaper column written 14 years earlier. Mary Margaret's poignant words were revealed to her doctors by her son who understood its undeniable significance.

Mary Margaret was an essayist in Chicago whose pieces filled many major newspapers and magazines. She had strong opinions on matters large and small, writing articles addressing topics ranging from her Catholic beliefs to gender‐based inequities in the workplace. One article in particular addressed sickness and death and provided her sons the answer they sought. Having witnessed illness strike two loved ones, it was only natural for Mary Margaret to write about it. Her very personal essay was entitled Tough Questions on Life, Death and a Dog Named Bamboo. The words, resurfacing years later, and now having direct meaning to her own life and death, may have been some of the most profound and prophetic words of her career:

Tough Questions on Life, Death and a Dog Named Bamboo

I sat with her that evening while she was dyingrubbing her back, smoothing her head, whispering that I loved her, trying to be of some small comfort as she snuggled closer, looking up with her mysteriously accepting, somehow understanding brown eyes.

Adjusting herself once more, she half rose, then toppled sideways and simply stopped breathing. She died as a lady ought to be able to diequietly, as easily as possible, in her own bed. In my bed actually. She was Bamboo, my Shar‐pei, and it is difficult to write this even several months later without tears starting to roll.

It was not just that last day, of course. For a bit more than a week, Bamboo had been giving signs of a serious problema heavy doggie cough indicating severe congestion and a firm, stubborn decision not to eat. The kitchen offered a parade of small bowls of her favorite people foods with which I hoped to restore her appetite when she determinedly ignored her regular dog food. She had her choice of cottage cheese, scrambled eggs, ground sirloin, cheddar chunks, ice cream, buttered rice and morea virtual buffet for ants.

After I set each dish out, she would go over to look and sniff admiringly, even wag her tail, but then rather reluctantly return to her favorite resting place, a small rug at the top of the stairs to the front door.

She would only drink a lot of water, bowl after bowl, in which she did also get her medicine, mashed and melted. Late on that last afternoon, however she stopped the drinking, too. I couldn't get her to sip even when I brought the water dish to her or offered the ice cubes she once loved to lick. In her own way, she was saying No.

Lately I have been reflecting again on the experience as a result of having heard some discussion about the death of a woman with whom I once shared friendly commuter chitchat as we trained together into the Loop.

Following a stroke, she had been unconscious, vegetative, tragically for almost as long as I had enjoyed the eight years of Bamboo's delightful companionship. Her husband, I learned, had ultimately gone to court and had been granted permission to remove the feeding tube and let nature take its course. A counteraction to prevent this was filed by some well‐intentioned people; but what I believe as good human and legal sense prevailed. So without the tube feeding, this nice long‐suffering woman finally slipped away to God.

People who oppose the dying being released this way argue that they are being starved to death without the feeding tubes. But I don't buy that, especially after having watched Bamboo decide by some deep natural instinct that it was time for her, first, to stop eating even the treats she loved and, finally, to stop drinking while she waited patiently for what was to come, what was inevitable.

There used to be an advertising slogan: It's not nice to fool Mother Nature. If you believe in God and the promise of eternity, perhaps it is equally not nice to fool dying human bodies into a semblance of living when nature is poised to move them beyond the rim of this life. Nature or God, I mean, and absolutely never, of course, a manipulative Dr. Death.

I don't think my puppy was starving those last few days so much as simply stopping. Simply letting herself be folded into an immutable process. At least this is something to ponder in terms of the will of God overwhelming the hopes of man. I am awed and rather apprehensive and yet somehow comfortable with this conclusion.

A couple of months tops with the tubes and no other reasonable hope, I think I'll tell my kids.

Mary Margaret's words struck a cord with both her sons. Her wishes, neatly laid out in a dusty newspaper, were respected. Mary Margaret entered hospice and died peacefully 2 weeks later.

(Tough Questions on Life, Death and a Dog Named Bamboo originally appeared in the The Catholic New World on July 16, 1993. The article was reprinted with their permission.)

Postscript: The author of the essay (my mother) passed away after a week in hospice care and 7 weeks in hospitals following a stroke. She was a published writer for more than 60 years. For her 61st birthday, my brother and I decided to buy her a wrinkly little puppy to keep her company and bark at anyone who came to her house. It ended up being a terrific watchdog as well as my mom's best friend. The last days with her puppy were translated into the essay, which also helped guide me during my mother's final days. My hope is that she and Bamboo are enjoying the promise of eternity in each other's company.

Patrick Carberry

Her name was Mrs. Carberry, but her readers knew her as Mary Margaret. Two months earlier, she suffered a debilitating stroke that took away her vibrant life. Previously a prolific writer of advice columns and opinion pieces, the blockage of blood to her brain dammed the steady flow of wisdom to her innumerable fans. They never again would benefit from the words of this intelligent, feisty, and self‐proclaimed Cranky Catholic. Unfortunately, I would not know Mary Margaret for her words, but only her numbers: her vital signs, her urine output, her tube feed residuals.

Not able to communicate with us, we wondered did Mrs. Carberry want this tracheostomy that was placed? Did she want this peg tube that fed her continuously? And even if she would have initially agreed to them, would she still want them now? Especially given she was not improving and had little hope for a meaningful recovery.

We posed these difficult questions to her two sons. One son believed that his mother would want an end to these aggressive measures. The other son disagreed; he said his mother would want to make every effort to stay alive.

In the end, Mary Margaret's voice found its way to us and provided us with the answer. She did not tell us in the conventional manner via a lawyer or a living will. Her friends did not come forth and let us know about serious conversations during their afternoon lunches. Instead, Mary Margaret penned it to her audience of devoted readers in a newspaper column written 14 years earlier. Mary Margaret's poignant words were revealed to her doctors by her son who understood its undeniable significance.

Mary Margaret was an essayist in Chicago whose pieces filled many major newspapers and magazines. She had strong opinions on matters large and small, writing articles addressing topics ranging from her Catholic beliefs to gender‐based inequities in the workplace. One article in particular addressed sickness and death and provided her sons the answer they sought. Having witnessed illness strike two loved ones, it was only natural for Mary Margaret to write about it. Her very personal essay was entitled Tough Questions on Life, Death and a Dog Named Bamboo. The words, resurfacing years later, and now having direct meaning to her own life and death, may have been some of the most profound and prophetic words of her career:

Tough Questions on Life, Death and a Dog Named Bamboo

I sat with her that evening while she was dyingrubbing her back, smoothing her head, whispering that I loved her, trying to be of some small comfort as she snuggled closer, looking up with her mysteriously accepting, somehow understanding brown eyes.

Adjusting herself once more, she half rose, then toppled sideways and simply stopped breathing. She died as a lady ought to be able to diequietly, as easily as possible, in her own bed. In my bed actually. She was Bamboo, my Shar‐pei, and it is difficult to write this even several months later without tears starting to roll.

It was not just that last day, of course. For a bit more than a week, Bamboo had been giving signs of a serious problema heavy doggie cough indicating severe congestion and a firm, stubborn decision not to eat. The kitchen offered a parade of small bowls of her favorite people foods with which I hoped to restore her appetite when she determinedly ignored her regular dog food. She had her choice of cottage cheese, scrambled eggs, ground sirloin, cheddar chunks, ice cream, buttered rice and morea virtual buffet for ants.

After I set each dish out, she would go over to look and sniff admiringly, even wag her tail, but then rather reluctantly return to her favorite resting place, a small rug at the top of the stairs to the front door.

She would only drink a lot of water, bowl after bowl, in which she did also get her medicine, mashed and melted. Late on that last afternoon, however she stopped the drinking, too. I couldn't get her to sip even when I brought the water dish to her or offered the ice cubes she once loved to lick. In her own way, she was saying No.

Lately I have been reflecting again on the experience as a result of having heard some discussion about the death of a woman with whom I once shared friendly commuter chitchat as we trained together into the Loop.

Following a stroke, she had been unconscious, vegetative, tragically for almost as long as I had enjoyed the eight years of Bamboo's delightful companionship. Her husband, I learned, had ultimately gone to court and had been granted permission to remove the feeding tube and let nature take its course. A counteraction to prevent this was filed by some well‐intentioned people; but what I believe as good human and legal sense prevailed. So without the tube feeding, this nice long‐suffering woman finally slipped away to God.

People who oppose the dying being released this way argue that they are being starved to death without the feeding tubes. But I don't buy that, especially after having watched Bamboo decide by some deep natural instinct that it was time for her, first, to stop eating even the treats she loved and, finally, to stop drinking while she waited patiently for what was to come, what was inevitable.

There used to be an advertising slogan: It's not nice to fool Mother Nature. If you believe in God and the promise of eternity, perhaps it is equally not nice to fool dying human bodies into a semblance of living when nature is poised to move them beyond the rim of this life. Nature or God, I mean, and absolutely never, of course, a manipulative Dr. Death.

I don't think my puppy was starving those last few days so much as simply stopping. Simply letting herself be folded into an immutable process. At least this is something to ponder in terms of the will of God overwhelming the hopes of man. I am awed and rather apprehensive and yet somehow comfortable with this conclusion.

A couple of months tops with the tubes and no other reasonable hope, I think I'll tell my kids.

Mary Margaret's words struck a cord with both her sons. Her wishes, neatly laid out in a dusty newspaper, were respected. Mary Margaret entered hospice and died peacefully 2 weeks later.

(Tough Questions on Life, Death and a Dog Named Bamboo originally appeared in the The Catholic New World on July 16, 1993. The article was reprinted with their permission.)

Postscript: The author of the essay (my mother) passed away after a week in hospice care and 7 weeks in hospitals following a stroke. She was a published writer for more than 60 years. For her 61st birthday, my brother and I decided to buy her a wrinkly little puppy to keep her company and bark at anyone who came to her house. It ended up being a terrific watchdog as well as my mom's best friend. The last days with her puppy were translated into the essay, which also helped guide me during my mother's final days. My hope is that she and Bamboo are enjoying the promise of eternity in each other's company.

Patrick Carberry

Her name was Mrs. Carberry, but her readers knew her as Mary Margaret. Two months earlier, she suffered a debilitating stroke that took away her vibrant life. Previously a prolific writer of advice columns and opinion pieces, the blockage of blood to her brain dammed the steady flow of wisdom to her innumerable fans. They never again would benefit from the words of this intelligent, feisty, and self‐proclaimed Cranky Catholic. Unfortunately, I would not know Mary Margaret for her words, but only her numbers: her vital signs, her urine output, her tube feed residuals.

Not able to communicate with us, we wondered did Mrs. Carberry want this tracheostomy that was placed? Did she want this peg tube that fed her continuously? And even if she would have initially agreed to them, would she still want them now? Especially given she was not improving and had little hope for a meaningful recovery.

We posed these difficult questions to her two sons. One son believed that his mother would want an end to these aggressive measures. The other son disagreed; he said his mother would want to make every effort to stay alive.

In the end, Mary Margaret's voice found its way to us and provided us with the answer. She did not tell us in the conventional manner via a lawyer or a living will. Her friends did not come forth and let us know about serious conversations during their afternoon lunches. Instead, Mary Margaret penned it to her audience of devoted readers in a newspaper column written 14 years earlier. Mary Margaret's poignant words were revealed to her doctors by her son who understood its undeniable significance.

Mary Margaret was an essayist in Chicago whose pieces filled many major newspapers and magazines. She had strong opinions on matters large and small, writing articles addressing topics ranging from her Catholic beliefs to gender‐based inequities in the workplace. One article in particular addressed sickness and death and provided her sons the answer they sought. Having witnessed illness strike two loved ones, it was only natural for Mary Margaret to write about it. Her very personal essay was entitled Tough Questions on Life, Death and a Dog Named Bamboo. The words, resurfacing years later, and now having direct meaning to her own life and death, may have been some of the most profound and prophetic words of her career:

Tough Questions on Life, Death and a Dog Named Bamboo

I sat with her that evening while she was dyingrubbing her back, smoothing her head, whispering that I loved her, trying to be of some small comfort as she snuggled closer, looking up with her mysteriously accepting, somehow understanding brown eyes.

Adjusting herself once more, she half rose, then toppled sideways and simply stopped breathing. She died as a lady ought to be able to diequietly, as easily as possible, in her own bed. In my bed actually. She was Bamboo, my Shar‐pei, and it is difficult to write this even several months later without tears starting to roll.

It was not just that last day, of course. For a bit more than a week, Bamboo had been giving signs of a serious problema heavy doggie cough indicating severe congestion and a firm, stubborn decision not to eat. The kitchen offered a parade of small bowls of her favorite people foods with which I hoped to restore her appetite when she determinedly ignored her regular dog food. She had her choice of cottage cheese, scrambled eggs, ground sirloin, cheddar chunks, ice cream, buttered rice and morea virtual buffet for ants.

After I set each dish out, she would go over to look and sniff admiringly, even wag her tail, but then rather reluctantly return to her favorite resting place, a small rug at the top of the stairs to the front door.

She would only drink a lot of water, bowl after bowl, in which she did also get her medicine, mashed and melted. Late on that last afternoon, however she stopped the drinking, too. I couldn't get her to sip even when I brought the water dish to her or offered the ice cubes she once loved to lick. In her own way, she was saying No.

Lately I have been reflecting again on the experience as a result of having heard some discussion about the death of a woman with whom I once shared friendly commuter chitchat as we trained together into the Loop.

Following a stroke, she had been unconscious, vegetative, tragically for almost as long as I had enjoyed the eight years of Bamboo's delightful companionship. Her husband, I learned, had ultimately gone to court and had been granted permission to remove the feeding tube and let nature take its course. A counteraction to prevent this was filed by some well‐intentioned people; but what I believe as good human and legal sense prevailed. So without the tube feeding, this nice long‐suffering woman finally slipped away to God.

People who oppose the dying being released this way argue that they are being starved to death without the feeding tubes. But I don't buy that, especially after having watched Bamboo decide by some deep natural instinct that it was time for her, first, to stop eating even the treats she loved and, finally, to stop drinking while she waited patiently for what was to come, what was inevitable.

There used to be an advertising slogan: It's not nice to fool Mother Nature. If you believe in God and the promise of eternity, perhaps it is equally not nice to fool dying human bodies into a semblance of living when nature is poised to move them beyond the rim of this life. Nature or God, I mean, and absolutely never, of course, a manipulative Dr. Death.

I don't think my puppy was starving those last few days so much as simply stopping. Simply letting herself be folded into an immutable process. At least this is something to ponder in terms of the will of God overwhelming the hopes of man. I am awed and rather apprehensive and yet somehow comfortable with this conclusion.

A couple of months tops with the tubes and no other reasonable hope, I think I'll tell my kids.

Mary Margaret's words struck a cord with both her sons. Her wishes, neatly laid out in a dusty newspaper, were respected. Mary Margaret entered hospice and died peacefully 2 weeks later.

(Tough Questions on Life, Death and a Dog Named Bamboo originally appeared in the The Catholic New World on July 16, 1993. The article was reprinted with their permission.)

Postscript: The author of the essay (my mother) passed away after a week in hospice care and 7 weeks in hospitals following a stroke. She was a published writer for more than 60 years. For her 61st birthday, my brother and I decided to buy her a wrinkly little puppy to keep her company and bark at anyone who came to her house. It ended up being a terrific watchdog as well as my mom's best friend. The last days with her puppy were translated into the essay, which also helped guide me during my mother's final days. My hope is that she and Bamboo are enjoying the promise of eternity in each other's company.

Patrick Carberry

More than 53,000 children 19 years of age or younger died in 2004,1 and more than 40% of these children died while hospitalized.25 Recently, pediatric end‐of‐life (EOL) issues have gained clinical and research attention, primarily focused on children with chronic conditions, ethical dilemmas surrounding childhood death and dying, and the need for interdisciplinary palliative care efforts for dying children and their families.2, 3, 69

Much remains unknown about patterns of EOL hospital care at the national level for all children, both with and without complex chronic conditions. Because a large proportion of childhood mortality occurs during hospitalization, the inpatient setting is a crucial arena for patients and families facing EOL issues. However, little is known about how insurance status and interhospital transfer are associated with patterns of hospitalization and mortality for children while hospitalized, or about hospital charges and lengths of stay for children who die as inpatients versus those who survive to discharge. In addition, although spending on EOL health care in the United States has attracted considerable attention in recent years, the published literature focuses almost exclusively on adult populations.1012

Illuminating the patterns of childhood mortality in hospital settings may inform expanding institutional efforts to address death and dying for children and their families. We conducted an analysis of national patterns of hospitalization over a span of a decade (19922002), in order to characterize sociodemographic and health care factors associated with inpatient mortality, and to examine patterns of hospital resource use related to EOL care. We hypothesized that resource use would be higher for children who died versus those who survived, and would be higher for uninsured versus insured children.13 We also hypothesized that children admitted upon transfer from another hospital would have higher risk of mortality.14

METHODS

Our data source was the National Inpatient Sample (NIS), which is a component of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality. The HCUP is a set of databases developed through partnership among health care institutions and federal and state governments.15 The NIS is the largest publicly available all‐payer inpatient database in the United States, and contains de‐identified, patient‐level clinical data included in a typical discharge abstract. For each year, these data reflect hospital stays from between 800 and 1000 institutions sampled to approximate a 20% stratified sample of nonfederal community hospitals, including public hospitals, children's hospitals, and academic medical centers but excluding long‐term hospitals, psychiatric hospitals, and chemical dependency treatment facilities.

We chose the NIS for this analysis because we were interested in the most common diagnoses for hospitalized children. An alternative database, such as the KID (Kids Inpatient Database), is optimal for less commonly seen discharge diagnoses and did not permit a full decade of retrospective analysis.

In order to characterize changes in mortality and health resource utilization related to our research questions, we conducted a comparative cross‐sectional analysis of 3 years of the NIS over the years 1992, 1997, and 2002. For each year of NIS data, discharge‐level weights were provided to permit calculation of national estimates of hospitalization rates standardized to the concurrent national population.15 All inpatient hospital stays of children aged 17 years and younger were selected.

Discharge data were analyzed based on age, sex, payer status, and transfer status on admission. Although transfer status is not often considered in studies of mortality, we expected that it would be associated with mortality, as a potential indicator of disease severity.14 We included only interhospital transfers, and excluded patients transferred from other locations such as long‐term care facilities. We categorized discharges into 5 age groups: newborns, whose hospitalization began at birth; infants up to 1 year of age who were not born during hospitalization; 15 years; 610 years; and 1117 years. This stratification allowed us to separate infants who were admitted from home or from another hospital versus those who were born during hospitalization. Payer groups included Medicaid, private insurance, and uninsured. Medicare and other payers were analyzed, but were present in very small numbers and are not reported.

Outcomes included weighted inpatient mortality rate, weighted mean of length of stay (in days), and weighted mean total hospital charges. For nationally weighted data, lengths of stay and hospital charges are typically reported as means because weighted medians cannot be estimated.16 We compared mortality patterns for patients who were transferred between hospitals versus those who were not, using multivariable logistic regression to identify factors associated with in‐hospital mortality. Of note, transfer status was evaluated from the standpoint of the receiving hospital as children who were admitted upon transfer from another hospital. Thus, our estimates likely underestimate the effects attributed to interhospital transfer, because this evaluation is unilateral and does not include the transferring hospital. The 5 most common principal Diagnosis‐Related Groups (DRGs) upon discharge were compiled for each of the study years for both survivors and decedents. In order to interpret the analyses of discharge‐related hospital charges in constant dollars, we standardized all hospital charges to 2002 US dollars using the Consumer Price Index.17

Statistical analyses included bivariate comparisons of sociodemographic characteristics and the study outcomes, for each of the study years. We also conducted multivariable regression analyses of mortality, comparing effects of sociodemographic variables and transfer status. We conducted all analyses using Stata, version 8 (Stata Corp., College Station, TX), with which we incorporated sample weights to account for the complex stratified sampling of hospitals that comprise the NIS, and to generate variance estimates with which we derived 95% confidence intervals (95% CI). NIS samples included weighted data for 6.2 million discharges in 1992, 7.1 million discharges in 1997, and 7.9 million discharges in 2002. All results are presented using weighted values. The study was funded internally and all analyses were conducted by the authors. The authors had no financial interest in the outcome. The study was exempt from human subjects review as an analysis of de‐identified secondary data.

RESULTS

DISCUSSION

CONCLUSION

This national study of inpatient mortality patterns among US children over the span of a decade presents a new framework of challenges to clinicians and investigators regarding EOL care for children. As health care providers and institutions expand their efforts to meet the needs of severely ill children and their families, such efforts must be cognizant of the high burden of mortality among the youngest children, as well as those who are transferred between hospitals, and children without insurance coverage. These children and their families may require expanded EOL care and support services, beyond those typically available in most hospitals and communities.

More than 53,000 children 19 years of age or younger died in 2004,1 and more than 40% of these children died while hospitalized.25 Recently, pediatric end‐of‐life (EOL) issues have gained clinical and research attention, primarily focused on children with chronic conditions, ethical dilemmas surrounding childhood death and dying, and the need for interdisciplinary palliative care efforts for dying children and their families.2, 3, 69

Much remains unknown about patterns of EOL hospital care at the national level for all children, both with and without complex chronic conditions. Because a large proportion of childhood mortality occurs during hospitalization, the inpatient setting is a crucial arena for patients and families facing EOL issues. However, little is known about how insurance status and interhospital transfer are associated with patterns of hospitalization and mortality for children while hospitalized, or about hospital charges and lengths of stay for children who die as inpatients versus those who survive to discharge. In addition, although spending on EOL health care in the United States has attracted considerable attention in recent years, the published literature focuses almost exclusively on adult populations.1012

Illuminating the patterns of childhood mortality in hospital settings may inform expanding institutional efforts to address death and dying for children and their families. We conducted an analysis of national patterns of hospitalization over a span of a decade (19922002), in order to characterize sociodemographic and health care factors associated with inpatient mortality, and to examine patterns of hospital resource use related to EOL care. We hypothesized that resource use would be higher for children who died versus those who survived, and would be higher for uninsured versus insured children.13 We also hypothesized that children admitted upon transfer from another hospital would have higher risk of mortality.14

METHODS

Our data source was the National Inpatient Sample (NIS), which is a component of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality. The HCUP is a set of databases developed through partnership among health care institutions and federal and state governments.15 The NIS is the largest publicly available all‐payer inpatient database in the United States, and contains de‐identified, patient‐level clinical data included in a typical discharge abstract. For each year, these data reflect hospital stays from between 800 and 1000 institutions sampled to approximate a 20% stratified sample of nonfederal community hospitals, including public hospitals, children's hospitals, and academic medical centers but excluding long‐term hospitals, psychiatric hospitals, and chemical dependency treatment facilities.

We chose the NIS for this analysis because we were interested in the most common diagnoses for hospitalized children. An alternative database, such as the KID (Kids Inpatient Database), is optimal for less commonly seen discharge diagnoses and did not permit a full decade of retrospective analysis.

In order to characterize changes in mortality and health resource utilization related to our research questions, we conducted a comparative cross‐sectional analysis of 3 years of the NIS over the years 1992, 1997, and 2002. For each year of NIS data, discharge‐level weights were provided to permit calculation of national estimates of hospitalization rates standardized to the concurrent national population.15 All inpatient hospital stays of children aged 17 years and younger were selected.

Discharge data were analyzed based on age, sex, payer status, and transfer status on admission. Although transfer status is not often considered in studies of mortality, we expected that it would be associated with mortality, as a potential indicator of disease severity.14 We included only interhospital transfers, and excluded patients transferred from other locations such as long‐term care facilities. We categorized discharges into 5 age groups: newborns, whose hospitalization began at birth; infants up to 1 year of age who were not born during hospitalization; 15 years; 610 years; and 1117 years. This stratification allowed us to separate infants who were admitted from home or from another hospital versus those who were born during hospitalization. Payer groups included Medicaid, private insurance, and uninsured. Medicare and other payers were analyzed, but were present in very small numbers and are not reported.

Outcomes included weighted inpatient mortality rate, weighted mean of length of stay (in days), and weighted mean total hospital charges. For nationally weighted data, lengths of stay and hospital charges are typically reported as means because weighted medians cannot be estimated.16 We compared mortality patterns for patients who were transferred between hospitals versus those who were not, using multivariable logistic regression to identify factors associated with in‐hospital mortality. Of note, transfer status was evaluated from the standpoint of the receiving hospital as children who were admitted upon transfer from another hospital. Thus, our estimates likely underestimate the effects attributed to interhospital transfer, because this evaluation is unilateral and does not include the transferring hospital. The 5 most common principal Diagnosis‐Related Groups (DRGs) upon discharge were compiled for each of the study years for both survivors and decedents. In order to interpret the analyses of discharge‐related hospital charges in constant dollars, we standardized all hospital charges to 2002 US dollars using the Consumer Price Index.17

Statistical analyses included bivariate comparisons of sociodemographic characteristics and the study outcomes, for each of the study years. We also conducted multivariable regression analyses of mortality, comparing effects of sociodemographic variables and transfer status. We conducted all analyses using Stata, version 8 (Stata Corp., College Station, TX), with which we incorporated sample weights to account for the complex stratified sampling of hospitals that comprise the NIS, and to generate variance estimates with which we derived 95% confidence intervals (95% CI). NIS samples included weighted data for 6.2 million discharges in 1992, 7.1 million discharges in 1997, and 7.9 million discharges in 2002. All results are presented using weighted values. The study was funded internally and all analyses were conducted by the authors. The authors had no financial interest in the outcome. The study was exempt from human subjects review as an analysis of de‐identified secondary data.

RESULTS

DISCUSSION

CONCLUSION

This national study of inpatient mortality patterns among US children over the span of a decade presents a new framework of challenges to clinicians and investigators regarding EOL care for children. As health care providers and institutions expand their efforts to meet the needs of severely ill children and their families, such efforts must be cognizant of the high burden of mortality among the youngest children, as well as those who are transferred between hospitals, and children without insurance coverage. These children and their families may require expanded EOL care and support services, beyond those typically available in most hospitals and communities.

More than 53,000 children 19 years of age or younger died in 2004,1 and more than 40% of these children died while hospitalized.25 Recently, pediatric end‐of‐life (EOL) issues have gained clinical and research attention, primarily focused on children with chronic conditions, ethical dilemmas surrounding childhood death and dying, and the need for interdisciplinary palliative care efforts for dying children and their families.2, 3, 69

Much remains unknown about patterns of EOL hospital care at the national level for all children, both with and without complex chronic conditions. Because a large proportion of childhood mortality occurs during hospitalization, the inpatient setting is a crucial arena for patients and families facing EOL issues. However, little is known about how insurance status and interhospital transfer are associated with patterns of hospitalization and mortality for children while hospitalized, or about hospital charges and lengths of stay for children who die as inpatients versus those who survive to discharge. In addition, although spending on EOL health care in the United States has attracted considerable attention in recent years, the published literature focuses almost exclusively on adult populations.1012

Illuminating the patterns of childhood mortality in hospital settings may inform expanding institutional efforts to address death and dying for children and their families. We conducted an analysis of national patterns of hospitalization over a span of a decade (19922002), in order to characterize sociodemographic and health care factors associated with inpatient mortality, and to examine patterns of hospital resource use related to EOL care. We hypothesized that resource use would be higher for children who died versus those who survived, and would be higher for uninsured versus insured children.13 We also hypothesized that children admitted upon transfer from another hospital would have higher risk of mortality.14

METHODS

Our data source was the National Inpatient Sample (NIS), which is a component of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality. The HCUP is a set of databases developed through partnership among health care institutions and federal and state governments.15 The NIS is the largest publicly available all‐payer inpatient database in the United States, and contains de‐identified, patient‐level clinical data included in a typical discharge abstract. For each year, these data reflect hospital stays from between 800 and 1000 institutions sampled to approximate a 20% stratified sample of nonfederal community hospitals, including public hospitals, children's hospitals, and academic medical centers but excluding long‐term hospitals, psychiatric hospitals, and chemical dependency treatment facilities.

We chose the NIS for this analysis because we were interested in the most common diagnoses for hospitalized children. An alternative database, such as the KID (Kids Inpatient Database), is optimal for less commonly seen discharge diagnoses and did not permit a full decade of retrospective analysis.

In order to characterize changes in mortality and health resource utilization related to our research questions, we conducted a comparative cross‐sectional analysis of 3 years of the NIS over the years 1992, 1997, and 2002. For each year of NIS data, discharge‐level weights were provided to permit calculation of national estimates of hospitalization rates standardized to the concurrent national population.15 All inpatient hospital stays of children aged 17 years and younger were selected.

Discharge data were analyzed based on age, sex, payer status, and transfer status on admission. Although transfer status is not often considered in studies of mortality, we expected that it would be associated with mortality, as a potential indicator of disease severity.14 We included only interhospital transfers, and excluded patients transferred from other locations such as long‐term care facilities. We categorized discharges into 5 age groups: newborns, whose hospitalization began at birth; infants up to 1 year of age who were not born during hospitalization; 15 years; 610 years; and 1117 years. This stratification allowed us to separate infants who were admitted from home or from another hospital versus those who were born during hospitalization. Payer groups included Medicaid, private insurance, and uninsured. Medicare and other payers were analyzed, but were present in very small numbers and are not reported.

Outcomes included weighted inpatient mortality rate, weighted mean of length of stay (in days), and weighted mean total hospital charges. For nationally weighted data, lengths of stay and hospital charges are typically reported as means because weighted medians cannot be estimated.16 We compared mortality patterns for patients who were transferred between hospitals versus those who were not, using multivariable logistic regression to identify factors associated with in‐hospital mortality. Of note, transfer status was evaluated from the standpoint of the receiving hospital as children who were admitted upon transfer from another hospital. Thus, our estimates likely underestimate the effects attributed to interhospital transfer, because this evaluation is unilateral and does not include the transferring hospital. The 5 most common principal Diagnosis‐Related Groups (DRGs) upon discharge were compiled for each of the study years for both survivors and decedents. In order to interpret the analyses of discharge‐related hospital charges in constant dollars, we standardized all hospital charges to 2002 US dollars using the Consumer Price Index.17

Statistical analyses included bivariate comparisons of sociodemographic characteristics and the study outcomes, for each of the study years. We also conducted multivariable regression analyses of mortality, comparing effects of sociodemographic variables and transfer status. We conducted all analyses using Stata, version 8 (Stata Corp., College Station, TX), with which we incorporated sample weights to account for the complex stratified sampling of hospitals that comprise the NIS, and to generate variance estimates with which we derived 95% confidence intervals (95% CI). NIS samples included weighted data for 6.2 million discharges in 1992, 7.1 million discharges in 1997, and 7.9 million discharges in 2002. All results are presented using weighted values. The study was funded internally and all analyses were conducted by the authors. The authors had no financial interest in the outcome. The study was exempt from human subjects review as an analysis of de‐identified secondary data.

RESULTS

DISCUSSION

CONCLUSION

This national study of inpatient mortality patterns among US children over the span of a decade presents a new framework of challenges to clinicians and investigators regarding EOL care for children. As health care providers and institutions expand their efforts to meet the needs of severely ill children and their families, such efforts must be cognizant of the high burden of mortality among the youngest children, as well as those who are transferred between hospitals, and children without insurance coverage. These children and their families may require expanded EOL care and support services, beyond those typically available in most hospitals and communities.

It is ironic that our specialty of hospital‐based medicine grew out of the soil of managed care and a renewed emphasis on generalism.2 Historical precedence clearly confirms the virtue of specialization and multidisciplinary care. Taken in this context, hospitalists have been comanagers from the very start, working with primary care physicians. The unprecedented growth of hospitalists in the United States has been accelerated by forces that pulled generalists out of the hospital and off the hospital wardsnamely the expensive inefficiency of trying to be in 2 places at 1 time. Faced with an expanding scope of practice and increasing outpatient volumes coupled with declining reimbursements, primary care physicians (PCPs) recognized the need to share their patients with inpatient comanagers.

Today, the surgeon is faced with many of the same pressures experienced by PCPs. Surgical productivity, efficiency, and quality are highly valued, yet require the surgeon to be in 2 places at 1 time. In the past, many surgeons in teaching hospitals relied on surgical residents to manage uncomplicated presurgical and postsurgical care and collaborated with internists for more difficult problems. Now, surgical residents are limited by work‐hour restrictions imposed by the Accreditation Council for Graduate Medical Education,3 reducing their ability to respond to patients outside the operating room. Perhaps more importantly, surgical patients today continue to increase in age and complexity, with a projected 50% rise in surgery‐related costs and a 100% rise in surgical complications in the next 2 decades.4 An experienced comanager of surgical patients that does not rely on PCPs or the surgical education system makes great practical and economic sense, and is a natural evolution of the hospitalist concept and skill set. Hospital medicine core competencies highlight perioperative medicine as a body of knowledge and practice germane to hospitalists. In fact, it specifically states that hospitalists should strive to engage in efforts to improve the efficiency and quality of care through innovative models, which may include comanagement of surgical patients in the perioperative period.5

CONSULTATION VERSUS COMANAGEMENT

Historically, in academic settings surgeons and medical practitioners have collaborated via the framework of consultation. If a surgeon needed assistance with uncontrolled diabetes or blood pressure, he or she called the internist to make recommendations on appropriate treatment. If the internist was faced with a potential surgical issue, he or she consulted the surgeon for their evaluation and opinion. In today's chaotic hospital environment, this collaborative framework has obvious inefficiencies. By definition, the consultation involves a formal request, which demands seamless communication that often does not exist. Next, the consultant reviews the chart, evaluates the patient, reviews pertinent clinical data, and provides an assessment with recommendations for management and care. How and whether these recommendations are enacted may be explicitly defined by the requesting service, but often it is not, and a delay in execution of recommendations potentially ensues. An observational cohort study showed that patients receiving medical consultation were no more likely to have tight glycemic control, perioperative beta‐blockers administration, or venous thromboembolism (VTE) prophylaxis; however, patients receiving consultation had a longer length of stay and higher costs of care.6 Comanagement represents a patient care referral, not consultation. A comanager is requested at the outset, but subsequently plays a much more active role, which may involve daily or twice daily visits, writing progress notes and orders, assessing and managing acute issues, and facilitating discharge planning and care transitions. Despite the ability to facilitate care, the basis for comanagement should be the same as for specialty consultation.

In contrast to academic settings, comanagement by PCPs and medical subspecialists occurs routinely in community hospitals. This model works best for patients with few problems who are followed closely by a single comanager, typically the PCP. However, complex patients with multiple comorbidities may decompensate without an attentive and experienced PCP, or wind up with numerous subspecialists making recommendations and writing orders in a disorganized fashion. The extreme of this situation is an unsystematic and inefficient management by committee, where medical specialists pick and choose an area of comanagement, without clear boundaries between the various team members. This approach is fraught with pitfalls in communication and may lead to conflicting recommendations or false assumptions among team members, further increasing patient morbidity.

In both academic and community settings, comanagement by a hospitalist offers advantages of consistent availability and proactive perioperative expertise, both in diagnosing and treating relevant problems and in recognizing the need for subspecialty involvement, thus improving efficiency of care. Although some health care systems may consider automatic patient care referrals to hospitalists for all surgical patients, this approach should be discouraged unless the patient population demands specialty involvement. Best practice would identify comorbid surgical patients during the outpatient preoperative process and then hardwire the patient care referral to the hospitalist upon surgical admission.

COMANAGEMENT MAKES SENSE

The multidisciplinary nature of comanagement can streamline individual patient care from the moment the decision for surgery is made. Preoperative assessment and management by the hospitalist can uncover risks from known conditions requiring optimization; identify new, undiagnosed conditions affecting the perioperative period; and initiate prophylactic and therapeutic regimens that reduce the chances for postoperative complications. Specific examples may include beta‐blockers in higher risk patients, anticoagulation management, and VTE prophylaxis.

The comanaging hospitalist ensures that these strategies are implemented, tailors them to the individual patient, and diagnoses and treats complications promptly when they occur. In addition, hospitalist comanagers can be more involved to facilitate patient transitions to posthospital care venues; this might involve communication with patients, families, case managers, and PCPs, among others. Ultimately, the investment of the comanaging hospitalist in the surgical patient is much greater in both scope and time. This may be expected to improve patient care efficiency, reduce length of stay, and may decrease overall complications. In addition, this investment is often recognized by the other important members of the care team, including nursing, case management, and patients and families, thus improving both patient and nursing satisfaction ratings.

AVAILABLE DATA ON THE BENEFITS OF COMANAGEMENT

Early studies on comanagement focused on orthopedic surgery and geriatric collaboration. Zuckerman et al.7 studied the effects of an interdisciplinary team approach to the hip fracture patient, entitled the Geriatric Hip Fracture Program (GHFP), in the mid‐1980s. They compared 431 patients admitted under the care of the GHFP for surgical repair of hip fracture between 1985 and 1988 with 60 historical controls at the same institution prior to the inception of the program. GHFP patients were evaluated by an orthopedic surgeon and a consulting internist or geriatrician. In addition to therapy service evaluations, each patient was screened by an ophthalmologist for visual impairment, a psychiatrist for preexisting cognitive dysfunction and depression, a social worker, and a case manager. GHFP patients had fewer postoperative complications, fewer intensive care unit transfers for acute medical issues, better ambulatory status and distance ambulated at discharge, and nonsignificant trends toward decreased length of stay and increased likelihood of return to home. A more recent prospective observational study of patients with hip fracture in Australia8 compared a 4‐year period of geriatric comanagement of 447 patients with hip fracture with 3 years of historical control patients (n = 504) prior to the institution of the comanagement service. Postoperative medical complications, mortality, and 6‐month readmission rates were significantly lower in the geriatric comanagement cohort. No differences in median length of hospital stay or in discharge destination were noted. The proportion of patients receiving anti‐osteoporotic therapy (calcium, vitamin D, and bisphosphonates) increased from 12% to 93% after the institution of comanagement. Also, the proportion of patients prescribed pharmacologic VTE prophylaxis increased from 63% to 94%, and symptomatic VTE events (deep vein thrombosis or PE) decreased from 4.6% to 1.3% after implementation. In another geriatrician comanagement study, Marcantonio et al.9 performed a randomized trial in patients with hip fracture comparing geriatric comanagement with a structured treatment care protocol to usual care. Although length of stay was unchanged and costs of care were not reported, geriatric comanagement significantly reduced the number and severity of episodes of delirium.

Macpherson et al.10 studied the effect of internist comanagement of 165 cardiothoracic surgery patients in the Minneaoplis Veteran's Affairs Medical Center in 1990. They found that, compared with the prior year, the implementation of internist comanagement was associated with hospital stays of 6 days shorter length, lower use of resources such as lab and radiology, and a trend toward decreased mortality. Huddleston et al.11 conducted a randomized controlled trial of 526 patients undergoing elective total hip or knee arthroplasty, comparing a comanagement hospitalist‐orthopedic team with standard orthopedic surgery care and internal medicine consultation as needed. Despite comparison to the standard of tightly managed care protocols in elective hip and knee arthroplasty, patients comanaged by hospitalists were more likely to be discharged without postoperative complications, and were ready for discharge half a day sooner when adjusting for skilled facility bed availability. No difference in mortality rates or total cost of care was noted between the 2 models. However, nurses and surgeons both strongly preferred the comanagement model, with providers reporting that care was prompt and coordinated, and there was an enhanced ease of providing care. In a second study, the authors from the same institution12 studied 466 patients over 65 years of age admitted for surgical repair of hip fracture. Patients in the comanagement group went to surgery faster, were discharged sooner after surgery, and had an overall lower length of stay. No differences were noted in inpatient mortality, 30‐day readmission rates, or complication rates. Delirium was diagnosed more often in the comanagement group, but a diagnosis of delirium was associated with an earlier discharge after surgery. This may reflect greater attention to the presence of delirium, better documentation, and more prompt treatment.

Preoperative testing centers staffed by anesthesiologists have been shown to positively impact surgical care.1315 However, there has been little study to specifically evaluate the role of medical comanagement in the preoperative setting. Jaffer et al.16 demonstrated a reduction in postoperative pulmonary complications in a mixed surgical population by utilizing a structured preoperative assessment and management program of hospitalists.

COMANAGEMENT SATISFACTION

Surgical comanagement has been reported to improve surgeon and nurse satisfaction ratings.11 Salerno et al.,17 in their study of consultation preferences of surgeons, internists and family physicians, confirmed that surgeons, especially orthopedic surgeons, favor the comanagement model more than the traditional consultation model. This is not surprising as surgeons in the comanagement model may be expected to spend more time in the operating room as opposed to the hospital floors, thus improving patient access to timely surgery and reducing cancellations and delays. Ultimately, the comanagement model may result in a competitive advantage over traditional care. Improved patient access and throughput may improve patient satisfaction with their surgical experience, which could lead to increased surgical referrals, both patient and PCP initiated. Satisfaction and positive learning experiences of surgical residents with this system of care may improve the likelihood of them joining such a practice, which will then foster the cultural evolution of comanagement. In addition, because of the increased scrutiny and potential financial ties (ie, pay for performance) to quality and safety issues, a comanagement model involving hospitalists is ideally poised to systematically account for these issues. Finally, because of nurse staffing shortages, care processes that promote workplace satisfaction and respect may promote nurse recruitment and retention, thus improving the competitive advantage even further.

CONCLUSION

Surgical comanagement has many distinct advantages for all parties involved, including the surgeon, hospitalist, house staff, nurses, case manager, patient and family, and the health care system overall. As hospitalists have been comanaging medical inpatients with primary care physicians for years, the concept of surgical comanagement is truly a natural evolution of the scope of hospitalist practice.

It is ironic that our specialty of hospital‐based medicine grew out of the soil of managed care and a renewed emphasis on generalism.2 Historical precedence clearly confirms the virtue of specialization and multidisciplinary care. Taken in this context, hospitalists have been comanagers from the very start, working with primary care physicians. The unprecedented growth of hospitalists in the United States has been accelerated by forces that pulled generalists out of the hospital and off the hospital wardsnamely the expensive inefficiency of trying to be in 2 places at 1 time. Faced with an expanding scope of practice and increasing outpatient volumes coupled with declining reimbursements, primary care physicians (PCPs) recognized the need to share their patients with inpatient comanagers.

Today, the surgeon is faced with many of the same pressures experienced by PCPs. Surgical productivity, efficiency, and quality are highly valued, yet require the surgeon to be in 2 places at 1 time. In the past, many surgeons in teaching hospitals relied on surgical residents to manage uncomplicated presurgical and postsurgical care and collaborated with internists for more difficult problems. Now, surgical residents are limited by work‐hour restrictions imposed by the Accreditation Council for Graduate Medical Education,3 reducing their ability to respond to patients outside the operating room. Perhaps more importantly, surgical patients today continue to increase in age and complexity, with a projected 50% rise in surgery‐related costs and a 100% rise in surgical complications in the next 2 decades.4 An experienced comanager of surgical patients that does not rely on PCPs or the surgical education system makes great practical and economic sense, and is a natural evolution of the hospitalist concept and skill set. Hospital medicine core competencies highlight perioperative medicine as a body of knowledge and practice germane to hospitalists. In fact, it specifically states that hospitalists should strive to engage in efforts to improve the efficiency and quality of care through innovative models, which may include comanagement of surgical patients in the perioperative period.5

CONSULTATION VERSUS COMANAGEMENT

Historically, in academic settings surgeons and medical practitioners have collaborated via the framework of consultation. If a surgeon needed assistance with uncontrolled diabetes or blood pressure, he or she called the internist to make recommendations on appropriate treatment. If the internist was faced with a potential surgical issue, he or she consulted the surgeon for their evaluation and opinion. In today's chaotic hospital environment, this collaborative framework has obvious inefficiencies. By definition, the consultation involves a formal request, which demands seamless communication that often does not exist. Next, the consultant reviews the chart, evaluates the patient, reviews pertinent clinical data, and provides an assessment with recommendations for management and care. How and whether these recommendations are enacted may be explicitly defined by the requesting service, but often it is not, and a delay in execution of recommendations potentially ensues. An observational cohort study showed that patients receiving medical consultation were no more likely to have tight glycemic control, perioperative beta‐blockers administration, or venous thromboembolism (VTE) prophylaxis; however, patients receiving consultation had a longer length of stay and higher costs of care.6 Comanagement represents a patient care referral, not consultation. A comanager is requested at the outset, but subsequently plays a much more active role, which may involve daily or twice daily visits, writing progress notes and orders, assessing and managing acute issues, and facilitating discharge planning and care transitions. Despite the ability to facilitate care, the basis for comanagement should be the same as for specialty consultation.

In contrast to academic settings, comanagement by PCPs and medical subspecialists occurs routinely in community hospitals. This model works best for patients with few problems who are followed closely by a single comanager, typically the PCP. However, complex patients with multiple comorbidities may decompensate without an attentive and experienced PCP, or wind up with numerous subspecialists making recommendations and writing orders in a disorganized fashion. The extreme of this situation is an unsystematic and inefficient management by committee, where medical specialists pick and choose an area of comanagement, without clear boundaries between the various team members. This approach is fraught with pitfalls in communication and may lead to conflicting recommendations or false assumptions among team members, further increasing patient morbidity.

In both academic and community settings, comanagement by a hospitalist offers advantages of consistent availability and proactive perioperative expertise, both in diagnosing and treating relevant problems and in recognizing the need for subspecialty involvement, thus improving efficiency of care. Although some health care systems may consider automatic patient care referrals to hospitalists for all surgical patients, this approach should be discouraged unless the patient population demands specialty involvement. Best practice would identify comorbid surgical patients during the outpatient preoperative process and then hardwire the patient care referral to the hospitalist upon surgical admission.

COMANAGEMENT MAKES SENSE

The multidisciplinary nature of comanagement can streamline individual patient care from the moment the decision for surgery is made. Preoperative assessment and management by the hospitalist can uncover risks from known conditions requiring optimization; identify new, undiagnosed conditions affecting the perioperative period; and initiate prophylactic and therapeutic regimens that reduce the chances for postoperative complications. Specific examples may include beta‐blockers in higher risk patients, anticoagulation management, and VTE prophylaxis.

The comanaging hospitalist ensures that these strategies are implemented, tailors them to the individual patient, and diagnoses and treats complications promptly when they occur. In addition, hospitalist comanagers can be more involved to facilitate patient transitions to posthospital care venues; this might involve communication with patients, families, case managers, and PCPs, among others. Ultimately, the investment of the comanaging hospitalist in the surgical patient is much greater in both scope and time. This may be expected to improve patient care efficiency, reduce length of stay, and may decrease overall complications. In addition, this investment is often recognized by the other important members of the care team, including nursing, case management, and patients and families, thus improving both patient and nursing satisfaction ratings.

AVAILABLE DATA ON THE BENEFITS OF COMANAGEMENT

Early studies on comanagement focused on orthopedic surgery and geriatric collaboration. Zuckerman et al.7 studied the effects of an interdisciplinary team approach to the hip fracture patient, entitled the Geriatric Hip Fracture Program (GHFP), in the mid‐1980s. They compared 431 patients admitted under the care of the GHFP for surgical repair of hip fracture between 1985 and 1988 with 60 historical controls at the same institution prior to the inception of the program. GHFP patients were evaluated by an orthopedic surgeon and a consulting internist or geriatrician. In addition to therapy service evaluations, each patient was screened by an ophthalmologist for visual impairment, a psychiatrist for preexisting cognitive dysfunction and depression, a social worker, and a case manager. GHFP patients had fewer postoperative complications, fewer intensive care unit transfers for acute medical issues, better ambulatory status and distance ambulated at discharge, and nonsignificant trends toward decreased length of stay and increased likelihood of return to home. A more recent prospective observational study of patients with hip fracture in Australia8 compared a 4‐year period of geriatric comanagement of 447 patients with hip fracture with 3 years of historical control patients (n = 504) prior to the institution of the comanagement service. Postoperative medical complications, mortality, and 6‐month readmission rates were significantly lower in the geriatric comanagement cohort. No differences in median length of hospital stay or in discharge destination were noted. The proportion of patients receiving anti‐osteoporotic therapy (calcium, vitamin D, and bisphosphonates) increased from 12% to 93% after the institution of comanagement. Also, the proportion of patients prescribed pharmacologic VTE prophylaxis increased from 63% to 94%, and symptomatic VTE events (deep vein thrombosis or PE) decreased from 4.6% to 1.3% after implementation. In another geriatrician comanagement study, Marcantonio et al.9 performed a randomized trial in patients with hip fracture comparing geriatric comanagement with a structured treatment care protocol to usual care. Although length of stay was unchanged and costs of care were not reported, geriatric comanagement significantly reduced the number and severity of episodes of delirium.

Macpherson et al.10 studied the effect of internist comanagement of 165 cardiothoracic surgery patients in the Minneaoplis Veteran's Affairs Medical Center in 1990. They found that, compared with the prior year, the implementation of internist comanagement was associated with hospital stays of 6 days shorter length, lower use of resources such as lab and radiology, and a trend toward decreased mortality. Huddleston et al.11 conducted a randomized controlled trial of 526 patients undergoing elective total hip or knee arthroplasty, comparing a comanagement hospitalist‐orthopedic team with standard orthopedic surgery care and internal medicine consultation as needed. Despite comparison to the standard of tightly managed care protocols in elective hip and knee arthroplasty, patients comanaged by hospitalists were more likely to be discharged without postoperative complications, and were ready for discharge half a day sooner when adjusting for skilled facility bed availability. No difference in mortality rates or total cost of care was noted between the 2 models. However, nurses and surgeons both strongly preferred the comanagement model, with providers reporting that care was prompt and coordinated, and there was an enhanced ease of providing care. In a second study, the authors from the same institution12 studied 466 patients over 65 years of age admitted for surgical repair of hip fracture. Patients in the comanagement group went to surgery faster, were discharged sooner after surgery, and had an overall lower length of stay. No differences were noted in inpatient mortality, 30‐day readmission rates, or complication rates. Delirium was diagnosed more often in the comanagement group, but a diagnosis of delirium was associated with an earlier discharge after surgery. This may reflect greater attention to the presence of delirium, better documentation, and more prompt treatment.

Preoperative testing centers staffed by anesthesiologists have been shown to positively impact surgical care.1315 However, there has been little study to specifically evaluate the role of medical comanagement in the preoperative setting. Jaffer et al.16 demonstrated a reduction in postoperative pulmonary complications in a mixed surgical population by utilizing a structured preoperative assessment and management program of hospitalists.

COMANAGEMENT SATISFACTION

Surgical comanagement has been reported to improve surgeon and nurse satisfaction ratings.11 Salerno et al.,17 in their study of consultation preferences of surgeons, internists and family physicians, confirmed that surgeons, especially orthopedic surgeons, favor the comanagement model more than the traditional consultation model. This is not surprising as surgeons in the comanagement model may be expected to spend more time in the operating room as opposed to the hospital floors, thus improving patient access to timely surgery and reducing cancellations and delays. Ultimately, the comanagement model may result in a competitive advantage over traditional care. Improved patient access and throughput may improve patient satisfaction with their surgical experience, which could lead to increased surgical referrals, both patient and PCP initiated. Satisfaction and positive learning experiences of surgical residents with this system of care may improve the likelihood of them joining such a practice, which will then foster the cultural evolution of comanagement. In addition, because of the increased scrutiny and potential financial ties (ie, pay for performance) to quality and safety issues, a comanagement model involving hospitalists is ideally poised to systematically account for these issues. Finally, because of nurse staffing shortages, care processes that promote workplace satisfaction and respect may promote nurse recruitment and retention, thus improving the competitive advantage even further.

CONCLUSION

Surgical comanagement has many distinct advantages for all parties involved, including the surgeon, hospitalist, house staff, nurses, case manager, patient and family, and the health care system overall. As hospitalists have been comanaging medical inpatients with primary care physicians for years, the concept of surgical comanagement is truly a natural evolution of the scope of hospitalist practice.

It is ironic that our specialty of hospital‐based medicine grew out of the soil of managed care and a renewed emphasis on generalism.2 Historical precedence clearly confirms the virtue of specialization and multidisciplinary care. Taken in this context, hospitalists have been comanagers from the very start, working with primary care physicians. The unprecedented growth of hospitalists in the United States has been accelerated by forces that pulled generalists out of the hospital and off the hospital wardsnamely the expensive inefficiency of trying to be in 2 places at 1 time. Faced with an expanding scope of practice and increasing outpatient volumes coupled with declining reimbursements, primary care physicians (PCPs) recognized the need to share their patients with inpatient comanagers.

Today, the surgeon is faced with many of the same pressures experienced by PCPs. Surgical productivity, efficiency, and quality are highly valued, yet require the surgeon to be in 2 places at 1 time. In the past, many surgeons in teaching hospitals relied on surgical residents to manage uncomplicated presurgical and postsurgical care and collaborated with internists for more difficult problems. Now, surgical residents are limited by work‐hour restrictions imposed by the Accreditation Council for Graduate Medical Education,3 reducing their ability to respond to patients outside the operating room. Perhaps more importantly, surgical patients today continue to increase in age and complexity, with a projected 50% rise in surgery‐related costs and a 100% rise in surgical complications in the next 2 decades.4 An experienced comanager of surgical patients that does not rely on PCPs or the surgical education system makes great practical and economic sense, and is a natural evolution of the hospitalist concept and skill set. Hospital medicine core competencies highlight perioperative medicine as a body of knowledge and practice germane to hospitalists. In fact, it specifically states that hospitalists should strive to engage in efforts to improve the efficiency and quality of care through innovative models, which may include comanagement of surgical patients in the perioperative period.5

CONSULTATION VERSUS COMANAGEMENT

Historically, in academic settings surgeons and medical practitioners have collaborated via the framework of consultation. If a surgeon needed assistance with uncontrolled diabetes or blood pressure, he or she called the internist to make recommendations on appropriate treatment. If the internist was faced with a potential surgical issue, he or she consulted the surgeon for their evaluation and opinion. In today's chaotic hospital environment, this collaborative framework has obvious inefficiencies. By definition, the consultation involves a formal request, which demands seamless communication that often does not exist. Next, the consultant reviews the chart, evaluates the patient, reviews pertinent clinical data, and provides an assessment with recommendations for management and care. How and whether these recommendations are enacted may be explicitly defined by the requesting service, but often it is not, and a delay in execution of recommendations potentially ensues. An observational cohort study showed that patients receiving medical consultation were no more likely to have tight glycemic control, perioperative beta‐blockers administration, or venous thromboembolism (VTE) prophylaxis; however, patients receiving consultation had a longer length of stay and higher costs of care.6 Comanagement represents a patient care referral, not consultation. A comanager is requested at the outset, but subsequently plays a much more active role, which may involve daily or twice daily visits, writing progress notes and orders, assessing and managing acute issues, and facilitating discharge planning and care transitions. Despite the ability to facilitate care, the basis for comanagement should be the same as for specialty consultation.

In contrast to academic settings, comanagement by PCPs and medical subspecialists occurs routinely in community hospitals. This model works best for patients with few problems who are followed closely by a single comanager, typically the PCP. However, complex patients with multiple comorbidities may decompensate without an attentive and experienced PCP, or wind up with numerous subspecialists making recommendations and writing orders in a disorganized fashion. The extreme of this situation is an unsystematic and inefficient management by committee, where medical specialists pick and choose an area of comanagement, without clear boundaries between the various team members. This approach is fraught with pitfalls in communication and may lead to conflicting recommendations or false assumptions among team members, further increasing patient morbidity.

In both academic and community settings, comanagement by a hospitalist offers advantages of consistent availability and proactive perioperative expertise, both in diagnosing and treating relevant problems and in recognizing the need for subspecialty involvement, thus improving efficiency of care. Although some health care systems may consider automatic patient care referrals to hospitalists for all surgical patients, this approach should be discouraged unless the patient population demands specialty involvement. Best practice would identify comorbid surgical patients during the outpatient preoperative process and then hardwire the patient care referral to the hospitalist upon surgical admission.

COMANAGEMENT MAKES SENSE

The multidisciplinary nature of comanagement can streamline individual patient care from the moment the decision for surgery is made. Preoperative assessment and management by the hospitalist can uncover risks from known conditions requiring optimization; identify new, undiagnosed conditions affecting the perioperative period; and initiate prophylactic and therapeutic regimens that reduce the chances for postoperative complications. Specific examples may include beta‐blockers in higher risk patients, anticoagulation management, and VTE prophylaxis.

The comanaging hospitalist ensures that these strategies are implemented, tailors them to the individual patient, and diagnoses and treats complications promptly when they occur. In addition, hospitalist comanagers can be more involved to facilitate patient transitions to posthospital care venues; this might involve communication with patients, families, case managers, and PCPs, among others. Ultimately, the investment of the comanaging hospitalist in the surgical patient is much greater in both scope and time. This may be expected to improve patient care efficiency, reduce length of stay, and may decrease overall complications. In addition, this investment is often recognized by the other important members of the care team, including nursing, case management, and patients and families, thus improving both patient and nursing satisfaction ratings.

AVAILABLE DATA ON THE BENEFITS OF COMANAGEMENT

Early studies on comanagement focused on orthopedic surgery and geriatric collaboration. Zuckerman et al.7 studied the effects of an interdisciplinary team approach to the hip fracture patient, entitled the Geriatric Hip Fracture Program (GHFP), in the mid‐1980s. They compared 431 patients admitted under the care of the GHFP for surgical repair of hip fracture between 1985 and 1988 with 60 historical controls at the same institution prior to the inception of the program. GHFP patients were evaluated by an orthopedic surgeon and a consulting internist or geriatrician. In addition to therapy service evaluations, each patient was screened by an ophthalmologist for visual impairment, a psychiatrist for preexisting cognitive dysfunction and depression, a social worker, and a case manager. GHFP patients had fewer postoperative complications, fewer intensive care unit transfers for acute medical issues, better ambulatory status and distance ambulated at discharge, and nonsignificant trends toward decreased length of stay and increased likelihood of return to home. A more recent prospective observational study of patients with hip fracture in Australia8 compared a 4‐year period of geriatric comanagement of 447 patients with hip fracture with 3 years of historical control patients (n = 504) prior to the institution of the comanagement service. Postoperative medical complications, mortality, and 6‐month readmission rates were significantly lower in the geriatric comanagement cohort. No differences in median length of hospital stay or in discharge destination were noted. The proportion of patients receiving anti‐osteoporotic therapy (calcium, vitamin D, and bisphosphonates) increased from 12% to 93% after the institution of comanagement. Also, the proportion of patients prescribed pharmacologic VTE prophylaxis increased from 63% to 94%, and symptomatic VTE events (deep vein thrombosis or PE) decreased from 4.6% to 1.3% after implementation. In another geriatrician comanagement study, Marcantonio et al.9 performed a randomized trial in patients with hip fracture comparing geriatric comanagement with a structured treatment care protocol to usual care. Although length of stay was unchanged and costs of care were not reported, geriatric comanagement significantly reduced the number and severity of episodes of delirium.

Macpherson et al.10 studied the effect of internist comanagement of 165 cardiothoracic surgery patients in the Minneaoplis Veteran's Affairs Medical Center in 1990. They found that, compared with the prior year, the implementation of internist comanagement was associated with hospital stays of 6 days shorter length, lower use of resources such as lab and radiology, and a trend toward decreased mortality. Huddleston et al.11 conducted a randomized controlled trial of 526 patients undergoing elective total hip or knee arthroplasty, comparing a comanagement hospitalist‐orthopedic team with standard orthopedic surgery care and internal medicine consultation as needed. Despite comparison to the standard of tightly managed care protocols in elective hip and knee arthroplasty, patients comanaged by hospitalists were more likely to be discharged without postoperative complications, and were ready for discharge half a day sooner when adjusting for skilled facility bed availability. No difference in mortality rates or total cost of care was noted between the 2 models. However, nurses and surgeons both strongly preferred the comanagement model, with providers reporting that care was prompt and coordinated, and there was an enhanced ease of providing care. In a second study, the authors from the same institution12 studied 466 patients over 65 years of age admitted for surgical repair of hip fracture. Patients in the comanagement group went to surgery faster, were discharged sooner after surgery, and had an overall lower length of stay. No differences were noted in inpatient mortality, 30‐day readmission rates, or complication rates. Delirium was diagnosed more often in the comanagement group, but a diagnosis of delirium was associated with an earlier discharge after surgery. This may reflect greater attention to the presence of delirium, better documentation, and more prompt treatment.

Preoperative testing centers staffed by anesthesiologists have been shown to positively impact surgical care.1315 However, there has been little study to specifically evaluate the role of medical comanagement in the preoperative setting. Jaffer et al.16 demonstrated a reduction in postoperative pulmonary complications in a mixed surgical population by utilizing a structured preoperative assessment and management program of hospitalists.

COMANAGEMENT SATISFACTION

Surgical comanagement has been reported to improve surgeon and nurse satisfaction ratings.11 Salerno et al.,17 in their study of consultation preferences of surgeons, internists and family physicians, confirmed that surgeons, especially orthopedic surgeons, favor the comanagement model more than the traditional consultation model. This is not surprising as surgeons in the comanagement model may be expected to spend more time in the operating room as opposed to the hospital floors, thus improving patient access to timely surgery and reducing cancellations and delays. Ultimately, the comanagement model may result in a competitive advantage over traditional care. Improved patient access and throughput may improve patient satisfaction with their surgical experience, which could lead to increased surgical referrals, both patient and PCP initiated. Satisfaction and positive learning experiences of surgical residents with this system of care may improve the likelihood of them joining such a practice, which will then foster the cultural evolution of comanagement. In addition, because of the increased scrutiny and potential financial ties (ie, pay for performance) to quality and safety issues, a comanagement model involving hospitalists is ideally poised to systematically account for these issues. Finally, because of nurse staffing shortages, care processes that promote workplace satisfaction and respect may promote nurse recruitment and retention, thus improving the competitive advantage even further.

CONCLUSION

Surgical comanagement has many distinct advantages for all parties involved, including the surgeon, hospitalist, house staff, nurses, case manager, patient and family, and the health care system overall. As hospitalists have been comanaging medical inpatients with primary care physicians for years, the concept of surgical comanagement is truly a natural evolution of the scope of hospitalist practice.

Ventilator‐associated pneumonia (VAP) is a serious and common complication for patients in the intensive care unit (ICU).1 VAP is defined as a pulmonary infection occurring after hospital admission in a mechanically‐ventilated patient with a tracheostomy or endotracheal tube.2, 3 With an attributable mortality that may exceed 20% and an estimated cost of $5000‐$20,000 per episode,49 the management of VAP is an important issue for both patient safety and cost of care.

The diagnosis of VAP is a controversial topic in critical care, primarily because of the difficulty distinguishing between airway colonization, upper respiratory tract infection (eg, tracheobronchitis), and early‐onset pneumonia. Some clinicians insist that an invasive sampling technique (eg, bronchoalveolar lavage) with quantitative cultures is essential for determining the presence of VAP.10 However, other clinicians suggest that a noninvasive approach using qualitative cultures (eg, tracheal suctioning) is an acceptable alternative.11 Regardless, nearly all experts agree that a specimen for microbiologic culture should be obtained prior to initiating antibiotics. Subsequent therapy should then be adjusted according to culture results.

Studies from both Europe and North America have demonstrated considerable variation in the diagnostic approaches used for patients with suspected VAP.12, 13 This variation is likely a result of several factors including controversy about the best diagnostic approach, variation in clinician knowledge and experience, and variation in ICU management protocols. Such practice variability is common for many ICU behaviors.1416 Quality‐of‐care proponents view this variation as an important opportunity for improvement.17

During a recent national collaborative aimed at reducing health careassociated infections in the ICU, we discovered many participants were uncertain about how to diagnose and manage VAP, and considerable practice variability existed among participating hospitals. This uncertainty provided an important opportunity for developing consensus on VAP management. On the basis of diagnostic criteria outlined by the Centers for Disease Control and Prevention (CDC), we developed algorithms as tools for diagnosing VAP in 4 ICU populations: infant, pediatric, immunocompromised, and adult ICU patients. We also developed an algorithm for initial VAP treatment. An interdisciplinary team of experts reviewed the current literature and developed these evidence‐based consensus guidelines. Our intent is that the algorithms provide guidance to clinicians looking for a standardized approach to the diagnosis and management of this complicated clinical situation.

METHODS

Our primary goal was to develop practical algorithms that assist ICU clinicians in the diagnosis and management of VAP during daily practice. To improve the quality and credibility of these algorithms, the development process used a stepwise approach that included assembling an interdisciplinary team of experts, appraising the published evidence, and formulating the algorithms through a consensus process.18

RESULTS

DISCUSSION

In this article, we introduce algorithms for diagnosing and managing VAP in infant, pediatric, immunocompromised, and adult ICU patients. We developed 4 algorithms because the hospitals in our system care for a wide range of patients. Our definitions for VAP were based on criteria outlined by the CDC because these rigorously developed criteria have been widely disseminated as components of the Institute for Healthcare Improvement's ventilator bundle.120 Clinicians should be able to easily incorporate these practical algorithms into their current practice.

The algorithms were developed during a collaborative across a large national health care system. We undertook this task because many clinicians were uncertain how to integrate the enormous volume of VAP literature into their daily practice, and we suspected there was large variation in practice in our ICUs. Recent studies from other health care systems provided empiric evidence to support this notion.12, 13

We offer these algorithms as practical tools to assist ICU clinicians and not as proscriptive mandates. We realize that the algorithms may need modification based on a hospital's unique bacteriology and patient populations. We also anticipate that the algorithms will adapt to future changes in VAP epidemiology, preventive strategies, emerging pathogens, and new antibiotics.

Numerous resources are available to learn more about VAP management. An excellent guideline from the Infectious Diseases Society of America and the American Thoracic Society discusses VAP issues in detail,5 although this guideline only focuses on immunocompetent adult patients. The journal Respiratory Care organized an international conference with numerous VAP experts in 2005 and subsequently devoted an entire issue to this topic.81 The Canadian Critical Care Trials Group and the Canadian Critical Care Society conducted systematic reviews and developed separate guidelines for the prevention, diagnosis, and treatment of VAP.80, 121

In summary, we present diagnostic and treatment algorithms for VAP. Our intent is that these algorithms may provide evidence‐based practical guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem.

Ventilator‐associated pneumonia (VAP) is a serious and common complication for patients in the intensive care unit (ICU).1 VAP is defined as a pulmonary infection occurring after hospital admission in a mechanically‐ventilated patient with a tracheostomy or endotracheal tube.2, 3 With an attributable mortality that may exceed 20% and an estimated cost of $5000‐$20,000 per episode,49 the management of VAP is an important issue for both patient safety and cost of care.

The diagnosis of VAP is a controversial topic in critical care, primarily because of the difficulty distinguishing between airway colonization, upper respiratory tract infection (eg, tracheobronchitis), and early‐onset pneumonia. Some clinicians insist that an invasive sampling technique (eg, bronchoalveolar lavage) with quantitative cultures is essential for determining the presence of VAP.10 However, other clinicians suggest that a noninvasive approach using qualitative cultures (eg, tracheal suctioning) is an acceptable alternative.11 Regardless, nearly all experts agree that a specimen for microbiologic culture should be obtained prior to initiating antibiotics. Subsequent therapy should then be adjusted according to culture results.

Studies from both Europe and North America have demonstrated considerable variation in the diagnostic approaches used for patients with suspected VAP.12, 13 This variation is likely a result of several factors including controversy about the best diagnostic approach, variation in clinician knowledge and experience, and variation in ICU management protocols. Such practice variability is common for many ICU behaviors.1416 Quality‐of‐care proponents view this variation as an important opportunity for improvement.17

During a recent national collaborative aimed at reducing health careassociated infections in the ICU, we discovered many participants were uncertain about how to diagnose and manage VAP, and considerable practice variability existed among participating hospitals. This uncertainty provided an important opportunity for developing consensus on VAP management. On the basis of diagnostic criteria outlined by the Centers for Disease Control and Prevention (CDC), we developed algorithms as tools for diagnosing VAP in 4 ICU populations: infant, pediatric, immunocompromised, and adult ICU patients. We also developed an algorithm for initial VAP treatment. An interdisciplinary team of experts reviewed the current literature and developed these evidence‐based consensus guidelines. Our intent is that the algorithms provide guidance to clinicians looking for a standardized approach to the diagnosis and management of this complicated clinical situation.

METHODS

Our primary goal was to develop practical algorithms that assist ICU clinicians in the diagnosis and management of VAP during daily practice. To improve the quality and credibility of these algorithms, the development process used a stepwise approach that included assembling an interdisciplinary team of experts, appraising the published evidence, and formulating the algorithms through a consensus process.18

RESULTS

DISCUSSION

In this article, we introduce algorithms for diagnosing and managing VAP in infant, pediatric, immunocompromised, and adult ICU patients. We developed 4 algorithms because the hospitals in our system care for a wide range of patients. Our definitions for VAP were based on criteria outlined by the CDC because these rigorously developed criteria have been widely disseminated as components of the Institute for Healthcare Improvement's ventilator bundle.120 Clinicians should be able to easily incorporate these practical algorithms into their current practice.

The algorithms were developed during a collaborative across a large national health care system. We undertook this task because many clinicians were uncertain how to integrate the enormous volume of VAP literature into their daily practice, and we suspected there was large variation in practice in our ICUs. Recent studies from other health care systems provided empiric evidence to support this notion.12, 13

We offer these algorithms as practical tools to assist ICU clinicians and not as proscriptive mandates. We realize that the algorithms may need modification based on a hospital's unique bacteriology and patient populations. We also anticipate that the algorithms will adapt to future changes in VAP epidemiology, preventive strategies, emerging pathogens, and new antibiotics.

Numerous resources are available to learn more about VAP management. An excellent guideline from the Infectious Diseases Society of America and the American Thoracic Society discusses VAP issues in detail,5 although this guideline only focuses on immunocompetent adult patients. The journal Respiratory Care organized an international conference with numerous VAP experts in 2005 and subsequently devoted an entire issue to this topic.81 The Canadian Critical Care Trials Group and the Canadian Critical Care Society conducted systematic reviews and developed separate guidelines for the prevention, diagnosis, and treatment of VAP.80, 121

In summary, we present diagnostic and treatment algorithms for VAP. Our intent is that these algorithms may provide evidence‐based practical guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem.

Ventilator‐associated pneumonia (VAP) is a serious and common complication for patients in the intensive care unit (ICU).1 VAP is defined as a pulmonary infection occurring after hospital admission in a mechanically‐ventilated patient with a tracheostomy or endotracheal tube.2, 3 With an attributable mortality that may exceed 20% and an estimated cost of $5000‐$20,000 per episode,49 the management of VAP is an important issue for both patient safety and cost of care.

The diagnosis of VAP is a controversial topic in critical care, primarily because of the difficulty distinguishing between airway colonization, upper respiratory tract infection (eg, tracheobronchitis), and early‐onset pneumonia. Some clinicians insist that an invasive sampling technique (eg, bronchoalveolar lavage) with quantitative cultures is essential for determining the presence of VAP.10 However, other clinicians suggest that a noninvasive approach using qualitative cultures (eg, tracheal suctioning) is an acceptable alternative.11 Regardless, nearly all experts agree that a specimen for microbiologic culture should be obtained prior to initiating antibiotics. Subsequent therapy should then be adjusted according to culture results.

Studies from both Europe and North America have demonstrated considerable variation in the diagnostic approaches used for patients with suspected VAP.12, 13 This variation is likely a result of several factors including controversy about the best diagnostic approach, variation in clinician knowledge and experience, and variation in ICU management protocols. Such practice variability is common for many ICU behaviors.1416 Quality‐of‐care proponents view this variation as an important opportunity for improvement.17

During a recent national collaborative aimed at reducing health careassociated infections in the ICU, we discovered many participants were uncertain about how to diagnose and manage VAP, and considerable practice variability existed among participating hospitals. This uncertainty provided an important opportunity for developing consensus on VAP management. On the basis of diagnostic criteria outlined by the Centers for Disease Control and Prevention (CDC), we developed algorithms as tools for diagnosing VAP in 4 ICU populations: infant, pediatric, immunocompromised, and adult ICU patients. We also developed an algorithm for initial VAP treatment. An interdisciplinary team of experts reviewed the current literature and developed these evidence‐based consensus guidelines. Our intent is that the algorithms provide guidance to clinicians looking for a standardized approach to the diagnosis and management of this complicated clinical situation.

METHODS

Our primary goal was to develop practical algorithms that assist ICU clinicians in the diagnosis and management of VAP during daily practice. To improve the quality and credibility of these algorithms, the development process used a stepwise approach that included assembling an interdisciplinary team of experts, appraising the published evidence, and formulating the algorithms through a consensus process.18

RESULTS