Case

A 66-year-old female with a pack-a-day smoking habit is admitted to orthopedics with a hip fracture following a fall in her home. You are consulted to perform a pre-operative risk assessment and manage her heart failure. The following day, she undergoes an open reduction and internal fixation and does well following the surgery. She is scheduled to be discharged for rehabilitation in two days. She will continue taking her cardiac medications and the narcotics (as needed) for pain. What else can you recommend to reduce her chances of suffering another hip fracture?

Overview

Approximately 300,000 hip fractures occur each year in the United States.¹ The lifetime risk of sustaining a hip fracture is 18% for a woman and 6% for a man.2 One-year mortality after a hip fracture is 20% to 25%, and up to half of patients who live independently prior to their fracture cannot gain independence afterward.

In the late 1990s, inpatient care, nursing home care, and outpatient services associated with hip fractures totaled approximately $14 billion annually. These costs are predicted to reach $50 billion by the year 2040.3 Not surprisingly, second hip fractures are common, with up to 12% of patients suffering another fracture within one year of follow up.1 Risk of morbidity and mortality are even higher after a second hip fracture.

In most experts’ opinions, a fragility fracture indicates osteoporosis and warrants treatment—regardless of bone densitometry findings. Still, multiple studies have shown patients who sustain a hip fracture frequently are not diagnosed, evaluated, or treated for osteoporosis.4 This is analogous to treating an acute coronary syndrome without initiating treatment for a patient’s hypertension and hyperlipidemia prior to discharge. As such, providers clearly are missing an opportunity to begin effective measures at a critical stage in the disease.

Data Review

Physiology of bone strength: Bone minerals—in particular calcium hydroxyapatite—contribute to bone strength by making bone a hard tissue. Collagen adds flexibility and gives bone the ability to absorb energy. The degree of bone mineralization and the number of collagen crosslinks help determine how much stress a bone can tolerate before it breaks. Further, in response to daily stressors, bone accumulates microcracks. Remodeling is then accomplished by bone resorption and formation.5

Estrogen plays an important role in normal remodeling by controlling osteoclast action. Thus, estrogen deficiency leads to prolonged osteoclast activity and increased rates of bone resorption. This explains why bone remodeling typically favors bone resorption later in life and why women are at greatest risk for fracture.5

Vitamin D and calcium: Vitamin D, produced by the skin or ingested, is transported in the circulation by a binding protein to the liver, where it is converted to 25-hydroxyvitamin D. This form is inactive and must be converted by the kidneys to the active form, 1,25-dihydroxyvitamin D. The active form is needed for absorption of renal and intestinal calcium.6

Without vitamin D only 10% to 15% of dietary calcium is absorbed. In one study, serum levels of 25-hydroxyvitamin D directly were related to bone mineral density. When the level was 30 ng/mL or less, there was a significant decrease in intestinal calcium absorption and bone mineral density.6

Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.

Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.

click for large version

Management

Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.

In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.

Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.

Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8

Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7

Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9

Physicians Don’t Recognize Osteoporosis

In 2000, Kamel et al. retrospectively studied the charts of 170 patients age 65 and older who were hospitalized with a hip fracture, and found that fewer than 5% had been diagnosed with or treated for osteoporosis.7 Follin et al., noted similar results in 2003, reporting that only 14% of the patients were diagnosed with osteoporosis prior to discharge and 75% of patients received no therapy.10

Follin et al., also noted patients who received a diagnosis of osteoporosis prior to discharge were more likely to receive therapy. Sixty-five percent of patients diagnosed with osteoporosis received treatment as opposed to 20% of those not diagnosed. They surmised the lack of treatment may relate to the lack of recognition that a fragility fracture often means osteoporosis.10

Hospitalist Consult, Treatment of Osteoporosis in Hip Fracture Patients

A 2003 retrospective analysis from a university-based academic hospital aimed to determine whether hospitalist consultation during admission for a hip fracture resulted in improved treatment of osteoporosis. The results indicated 29% of patients received treatment for osteoporosis at the time of discharge. Twenty percent received calcium, and only 7% received a bisphosphonate. Those who received hospitalist consultation did not have a significant improvement in osteoporosis treatment, thus representing a huge missed opportunity.11

Back to the Case

You recognize that, because your patient has sustained a fragility fracture, she has osteoporosis and you wish to initiate treatment before she leaves the hospital. Her 25-hydroxyvitamin D level is 18 ng/mL. You commence 50,000 units of vitamin D once weekly and advise that she have her vitamin D level checked again in three months by her primary care provider. She has no contraindications, thus you also initiate a bisphosphonate and remind her to take 1,200 mg of calcium daily.

You encourage smoking cessation, decreased alcohol use, a simplified medication regimen, and weight-bearing exercises in the future. In addition, you ensure she has the proper gait stability items at discharge. You arrange a visiting nurse/therapist to assess her home for fall risks. Lastly, you schedule an outpatient bone mineral density scan and arrange a follow-up with her primary care provider. TH

Dr. Baker is a hospitalist at Ohio State University. Dr McDermott is professor of medicine and clinical pharmacy and endocrinology and diabetes practice director, University of Colorado Denver.

References

1. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women. The Framingham Study. Arch Intern Med. 2007;167(18):1971-1976.
2. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporosis Int. 2002;13:205-210.
3. Gardner MJ, Brophy RH, Demetrakopoulos D, et al. Interventions to improve osteoporosis treatment following hip fracture. The Journal of Bone and Joint Surgery. 2005;87-A(1):3-7.
4. Gardner MJ, Flik KR, Mooar P, Lane JM.Improve-ment in the undertreatment of osteoporosis following hip fracture. The Journal of Bone and Joint Surgery. 2002;84-A(8):1342-1348.
5. Seeman E, Delmas PD. Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354(21):2250-2261.
6. Holick, MF. Vitamin D Deficiency. N Engl J Med. 2007;357(3):266-281.
7. Glauser T. Practical strategies for managing osteoporosis: An evidence-based approach to risk assessment and treatment. Dialogues in Clinical Practice. 2007.
8. Morin S, Rahme E, Behlouli H, Tenenhouse A, Goltzman D, Pilote L. Effectiveness of antiresorptive agents in the prevention of recurrent hip fractures. Osteoporosis Int. 2007;18:1625-1632.
9. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zolendronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
10. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy.2003;23(2):190-198.
11. Jachna CM, Whittle J, Lukert B, Graves L, Bhargava T. Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients. Osteoporosis Int. 2003;14:665-671.

Case

A 66-year-old female with a pack-a-day smoking habit is admitted to orthopedics with a hip fracture following a fall in her home. You are consulted to perform a pre-operative risk assessment and manage her heart failure. The following day, she undergoes an open reduction and internal fixation and does well following the surgery. She is scheduled to be discharged for rehabilitation in two days. She will continue taking her cardiac medications and the narcotics (as needed) for pain. What else can you recommend to reduce her chances of suffering another hip fracture?

Overview

Approximately 300,000 hip fractures occur each year in the United States.¹ The lifetime risk of sustaining a hip fracture is 18% for a woman and 6% for a man.2 One-year mortality after a hip fracture is 20% to 25%, and up to half of patients who live independently prior to their fracture cannot gain independence afterward.

In the late 1990s, inpatient care, nursing home care, and outpatient services associated with hip fractures totaled approximately $14 billion annually. These costs are predicted to reach $50 billion by the year 2040.3 Not surprisingly, second hip fractures are common, with up to 12% of patients suffering another fracture within one year of follow up.1 Risk of morbidity and mortality are even higher after a second hip fracture.

In most experts’ opinions, a fragility fracture indicates osteoporosis and warrants treatment—regardless of bone densitometry findings. Still, multiple studies have shown patients who sustain a hip fracture frequently are not diagnosed, evaluated, or treated for osteoporosis.4 This is analogous to treating an acute coronary syndrome without initiating treatment for a patient’s hypertension and hyperlipidemia prior to discharge. As such, providers clearly are missing an opportunity to begin effective measures at a critical stage in the disease.

Data Review

Physiology of bone strength: Bone minerals—in particular calcium hydroxyapatite—contribute to bone strength by making bone a hard tissue. Collagen adds flexibility and gives bone the ability to absorb energy. The degree of bone mineralization and the number of collagen crosslinks help determine how much stress a bone can tolerate before it breaks. Further, in response to daily stressors, bone accumulates microcracks. Remodeling is then accomplished by bone resorption and formation.5

Estrogen plays an important role in normal remodeling by controlling osteoclast action. Thus, estrogen deficiency leads to prolonged osteoclast activity and increased rates of bone resorption. This explains why bone remodeling typically favors bone resorption later in life and why women are at greatest risk for fracture.5

Vitamin D and calcium: Vitamin D, produced by the skin or ingested, is transported in the circulation by a binding protein to the liver, where it is converted to 25-hydroxyvitamin D. This form is inactive and must be converted by the kidneys to the active form, 1,25-dihydroxyvitamin D. The active form is needed for absorption of renal and intestinal calcium.6

Without vitamin D only 10% to 15% of dietary calcium is absorbed. In one study, serum levels of 25-hydroxyvitamin D directly were related to bone mineral density. When the level was 30 ng/mL or less, there was a significant decrease in intestinal calcium absorption and bone mineral density.6

Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.

Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.

click for large version

Management

Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.

In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.

Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.

Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8

Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7

Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9

Physicians Don’t Recognize Osteoporosis

In 2000, Kamel et al. retrospectively studied the charts of 170 patients age 65 and older who were hospitalized with a hip fracture, and found that fewer than 5% had been diagnosed with or treated for osteoporosis.7 Follin et al., noted similar results in 2003, reporting that only 14% of the patients were diagnosed with osteoporosis prior to discharge and 75% of patients received no therapy.10

Follin et al., also noted patients who received a diagnosis of osteoporosis prior to discharge were more likely to receive therapy. Sixty-five percent of patients diagnosed with osteoporosis received treatment as opposed to 20% of those not diagnosed. They surmised the lack of treatment may relate to the lack of recognition that a fragility fracture often means osteoporosis.10

Hospitalist Consult, Treatment of Osteoporosis in Hip Fracture Patients

A 2003 retrospective analysis from a university-based academic hospital aimed to determine whether hospitalist consultation during admission for a hip fracture resulted in improved treatment of osteoporosis. The results indicated 29% of patients received treatment for osteoporosis at the time of discharge. Twenty percent received calcium, and only 7% received a bisphosphonate. Those who received hospitalist consultation did not have a significant improvement in osteoporosis treatment, thus representing a huge missed opportunity.11

Back to the Case

You recognize that, because your patient has sustained a fragility fracture, she has osteoporosis and you wish to initiate treatment before she leaves the hospital. Her 25-hydroxyvitamin D level is 18 ng/mL. You commence 50,000 units of vitamin D once weekly and advise that she have her vitamin D level checked again in three months by her primary care provider. She has no contraindications, thus you also initiate a bisphosphonate and remind her to take 1,200 mg of calcium daily.

You encourage smoking cessation, decreased alcohol use, a simplified medication regimen, and weight-bearing exercises in the future. In addition, you ensure she has the proper gait stability items at discharge. You arrange a visiting nurse/therapist to assess her home for fall risks. Lastly, you schedule an outpatient bone mineral density scan and arrange a follow-up with her primary care provider. TH

Dr. Baker is a hospitalist at Ohio State University. Dr McDermott is professor of medicine and clinical pharmacy and endocrinology and diabetes practice director, University of Colorado Denver.

References

1. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women. The Framingham Study. Arch Intern Med. 2007;167(18):1971-1976.
2. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporosis Int. 2002;13:205-210.
3. Gardner MJ, Brophy RH, Demetrakopoulos D, et al. Interventions to improve osteoporosis treatment following hip fracture. The Journal of Bone and Joint Surgery. 2005;87-A(1):3-7.
4. Gardner MJ, Flik KR, Mooar P, Lane JM.Improve-ment in the undertreatment of osteoporosis following hip fracture. The Journal of Bone and Joint Surgery. 2002;84-A(8):1342-1348.
5. Seeman E, Delmas PD. Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354(21):2250-2261.
6. Holick, MF. Vitamin D Deficiency. N Engl J Med. 2007;357(3):266-281.
7. Glauser T. Practical strategies for managing osteoporosis: An evidence-based approach to risk assessment and treatment. Dialogues in Clinical Practice. 2007.
8. Morin S, Rahme E, Behlouli H, Tenenhouse A, Goltzman D, Pilote L. Effectiveness of antiresorptive agents in the prevention of recurrent hip fractures. Osteoporosis Int. 2007;18:1625-1632.
9. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zolendronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
10. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy.2003;23(2):190-198.
11. Jachna CM, Whittle J, Lukert B, Graves L, Bhargava T. Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients. Osteoporosis Int. 2003;14:665-671.

Case

A 66-year-old female with a pack-a-day smoking habit is admitted to orthopedics with a hip fracture following a fall in her home. You are consulted to perform a pre-operative risk assessment and manage her heart failure. The following day, she undergoes an open reduction and internal fixation and does well following the surgery. She is scheduled to be discharged for rehabilitation in two days. She will continue taking her cardiac medications and the narcotics (as needed) for pain. What else can you recommend to reduce her chances of suffering another hip fracture?

Overview

Approximately 300,000 hip fractures occur each year in the United States.¹ The lifetime risk of sustaining a hip fracture is 18% for a woman and 6% for a man.2 One-year mortality after a hip fracture is 20% to 25%, and up to half of patients who live independently prior to their fracture cannot gain independence afterward.

In the late 1990s, inpatient care, nursing home care, and outpatient services associated with hip fractures totaled approximately $14 billion annually. These costs are predicted to reach $50 billion by the year 2040.3 Not surprisingly, second hip fractures are common, with up to 12% of patients suffering another fracture within one year of follow up.1 Risk of morbidity and mortality are even higher after a second hip fracture.

In most experts’ opinions, a fragility fracture indicates osteoporosis and warrants treatment—regardless of bone densitometry findings. Still, multiple studies have shown patients who sustain a hip fracture frequently are not diagnosed, evaluated, or treated for osteoporosis.4 This is analogous to treating an acute coronary syndrome without initiating treatment for a patient’s hypertension and hyperlipidemia prior to discharge. As such, providers clearly are missing an opportunity to begin effective measures at a critical stage in the disease.

Data Review

Physiology of bone strength: Bone minerals—in particular calcium hydroxyapatite—contribute to bone strength by making bone a hard tissue. Collagen adds flexibility and gives bone the ability to absorb energy. The degree of bone mineralization and the number of collagen crosslinks help determine how much stress a bone can tolerate before it breaks. Further, in response to daily stressors, bone accumulates microcracks. Remodeling is then accomplished by bone resorption and formation.5

Estrogen plays an important role in normal remodeling by controlling osteoclast action. Thus, estrogen deficiency leads to prolonged osteoclast activity and increased rates of bone resorption. This explains why bone remodeling typically favors bone resorption later in life and why women are at greatest risk for fracture.5

Vitamin D and calcium: Vitamin D, produced by the skin or ingested, is transported in the circulation by a binding protein to the liver, where it is converted to 25-hydroxyvitamin D. This form is inactive and must be converted by the kidneys to the active form, 1,25-dihydroxyvitamin D. The active form is needed for absorption of renal and intestinal calcium.6

Without vitamin D only 10% to 15% of dietary calcium is absorbed. In one study, serum levels of 25-hydroxyvitamin D directly were related to bone mineral density. When the level was 30 ng/mL or less, there was a significant decrease in intestinal calcium absorption and bone mineral density.6

Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.

Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.

click for large version

Management

Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.

In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.

Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.

Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8

Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7

Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9

Physicians Don’t Recognize Osteoporosis

In 2000, Kamel et al. retrospectively studied the charts of 170 patients age 65 and older who were hospitalized with a hip fracture, and found that fewer than 5% had been diagnosed with or treated for osteoporosis.7 Follin et al., noted similar results in 2003, reporting that only 14% of the patients were diagnosed with osteoporosis prior to discharge and 75% of patients received no therapy.10

Follin et al., also noted patients who received a diagnosis of osteoporosis prior to discharge were more likely to receive therapy. Sixty-five percent of patients diagnosed with osteoporosis received treatment as opposed to 20% of those not diagnosed. They surmised the lack of treatment may relate to the lack of recognition that a fragility fracture often means osteoporosis.10

Hospitalist Consult, Treatment of Osteoporosis in Hip Fracture Patients

A 2003 retrospective analysis from a university-based academic hospital aimed to determine whether hospitalist consultation during admission for a hip fracture resulted in improved treatment of osteoporosis. The results indicated 29% of patients received treatment for osteoporosis at the time of discharge. Twenty percent received calcium, and only 7% received a bisphosphonate. Those who received hospitalist consultation did not have a significant improvement in osteoporosis treatment, thus representing a huge missed opportunity.11

Back to the Case

You recognize that, because your patient has sustained a fragility fracture, she has osteoporosis and you wish to initiate treatment before she leaves the hospital. Her 25-hydroxyvitamin D level is 18 ng/mL. You commence 50,000 units of vitamin D once weekly and advise that she have her vitamin D level checked again in three months by her primary care provider. She has no contraindications, thus you also initiate a bisphosphonate and remind her to take 1,200 mg of calcium daily.

You encourage smoking cessation, decreased alcohol use, a simplified medication regimen, and weight-bearing exercises in the future. In addition, you ensure she has the proper gait stability items at discharge. You arrange a visiting nurse/therapist to assess her home for fall risks. Lastly, you schedule an outpatient bone mineral density scan and arrange a follow-up with her primary care provider. TH

Dr. Baker is a hospitalist at Ohio State University. Dr McDermott is professor of medicine and clinical pharmacy and endocrinology and diabetes practice director, University of Colorado Denver.

References

1. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women. The Framingham Study. Arch Intern Med. 2007;167(18):1971-1976.
2. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporosis Int. 2002;13:205-210.
3. Gardner MJ, Brophy RH, Demetrakopoulos D, et al. Interventions to improve osteoporosis treatment following hip fracture. The Journal of Bone and Joint Surgery. 2005;87-A(1):3-7.
4. Gardner MJ, Flik KR, Mooar P, Lane JM.Improve-ment in the undertreatment of osteoporosis following hip fracture. The Journal of Bone and Joint Surgery. 2002;84-A(8):1342-1348.
5. Seeman E, Delmas PD. Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354(21):2250-2261.
6. Holick, MF. Vitamin D Deficiency. N Engl J Med. 2007;357(3):266-281.
7. Glauser T. Practical strategies for managing osteoporosis: An evidence-based approach to risk assessment and treatment. Dialogues in Clinical Practice. 2007.
8. Morin S, Rahme E, Behlouli H, Tenenhouse A, Goltzman D, Pilote L. Effectiveness of antiresorptive agents in the prevention of recurrent hip fractures. Osteoporosis Int. 2007;18:1625-1632.
9. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zolendronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
10. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy.2003;23(2):190-198.
11. Jachna CM, Whittle J, Lukert B, Graves L, Bhargava T. Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients. Osteoporosis Int. 2003;14:665-671.

Observation care provides a mechanism to evaluate and treat patients without the resource utilization and financial responsibility associated with an inpatient admission. Hospitalists may not understand the billing compliance risk and corresponding revenue implications when observation services (OBS) are not captured correctly.

Are OBS best reported with observation care codes (99218-99220, 99234-99236), office visit codes (99201-99215), or initial hospital care codes (99221-99223)? Code selection depends upon the patient’s registered status, the nature of the provided service, and the length of stay. Review the following information before reporting OBS to ensure an accurate claim submission.

Attending Physician Responsibilities

The physician-documented reason for observation substantiates the medical necessity for the OBS admission. Contractors often evaluate medical records to determine the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient), and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay.

Certain diagnoses and procedures generally do not support an inpatient admission and fall within the definitions of outpatient observation. Uncomplicated presentations of chest pain (rule out MI), mild asthma/COPD, mild CHF, syncope and decreased responsiveness, atrial arrhythmias, and renal colic all frequently are associated with the expectation of a brief (less than 24-hour) stay unless serious pathology is uncovered.2 Situations that do not meet the criteria for observation care are considered “not medically necessary” and separate payment is not permitted. Examples of circumstances that lack medical necessity include:

• Outpatient blood administration;
• Lack of/delay in patient transportation;
• Provision of a medical exam for patients who do not require skilled support;
• Routine preparation prior to and recovery after diagnostic testing;
• Routine recovery and post-operative care after ambulatory surgery;
• When used for the convenience of the physician, patient or patient’s family;
• While awaiting transfer to another facility;
• Duration of care exceeding 48 hours;
• When an overnight stay is planned prior to diagnostic testing;
• Standing orders following outpatient surgery;
• Services that would normally require inpatient stay;
• No physicians order to admit to observation;
• Observation following an uncomplicated treatment or procedure;
• Services that are not reasonable and necessary for care of the patient;
• Services provided concurrently with chemotherapy; and
• Inpatients discharged to outpatient observation status.3

The attending physician of record assumes responsibility for the patient’s admission to observation and is permitted to report observation care codes. In addition to the reason for admission, a medical record involving the observation stay must include dated and timed physician admitting orders outlining the care plan, physician progress notes, and discharge orders. This documentation must be added to any other record prepared as a result of an emergency department or outpatient clinic encounter. If physicians other than the admitting physician/group (i.e., physicians in different specialties) provide services to the patient during observation, they must use the appropriate outpatient visit (e.g., 99214) or consultation code (e.g., 99244).

Length of Stay⁴

In general, the duration of observation care services typically does not exceed 24 hours, although in some circumstances patients may require a second day. Observation care for greater than 48 hours without inpatient admission is not considered medically necessary but may be payable after medical review. When the stay spans two calendar days, physician billing is straightforward: Select an initial observation care code (99218-99220) for calendar day one and the observation discharge code (99217) for day two. Only the admitting physician/group may report the discharge service, when applicable. Documentation must demonstrate a face-to-face encounter by the physician for each date of service.

Should the stay only constitute one calendar day, the duration of care becomes a crucial factor in determining the code category. Standard OBS codes (99218-99220) are applicable if the patient stay is less than eight hours on any given date. The OBS discharge code (99217) is not reported in this instance, although the documentation should reflect the attending physician’s written order and appropriate discharge plan. Alternately, same day admit/discharge codes (99234-99236) apply to single-day stays lasting more than eight hours. The OBS discharge code (99217) also is not reported in this instance. Documentation must identify, at a minimum:

• Duration of the stay;
• Presence by the billing physician; and
• Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

Sometimes the patient requires inpatient admission after initially being placed in observation. If the inpatient admission occurs on the same day as the OBS admission, only one service is reported (e.g., 99222). The physician need not redocument a complete history and physical (H&P) but merely write the new order for admission and update the OBS assessment with any relevant, new information.

Should the inpatient admission occur on the second calendar day of the OBS stay, the physician is able to report the initial observation care code (e.g., 99219) on day one, and the initial inpatient care code (e.g., 99223) on day two. However, the physician must meet the documentation guidelines for initial hospital care and redocument the H&P associated with the reported visit level. In the case of 99223, the physician must document a comprehensive history (only referring to the previous review of systems and histories, while rewriting the history of present illness) and high complexity decision making. If the physician chooses not to document to this extent, a subsequent hospital care code (99231-99233) is reasonable because the episode of care is a continuation from the observation phase.

Beware that some insurers may change the patient’s status for the entire episode of care. In other words, the conversion to inpatient status occurs on day two of the patient stay, but the insurer may convert the entire stay, including day one, to an inpatient status. Should this happen, the physician is responsible for reporting the visit category that corresponds with the patient’s status. Inpatient services codes are required for claim submission when the patient stay qualifies as an inpatient admission. Because these conversions occur with some frequency, it is advisable to hold claims intended for observation patients until the correct patient status can be confirmed by the utilization review team, and communicated to the physician. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References

1. 1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
2. 2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.
3. 3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.
4. 4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.
5. 5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.
6. 6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

Observation care provides a mechanism to evaluate and treat patients without the resource utilization and financial responsibility associated with an inpatient admission. Hospitalists may not understand the billing compliance risk and corresponding revenue implications when observation services (OBS) are not captured correctly.

Are OBS best reported with observation care codes (99218-99220, 99234-99236), office visit codes (99201-99215), or initial hospital care codes (99221-99223)? Code selection depends upon the patient’s registered status, the nature of the provided service, and the length of stay. Review the following information before reporting OBS to ensure an accurate claim submission.

Attending Physician Responsibilities

The physician-documented reason for observation substantiates the medical necessity for the OBS admission. Contractors often evaluate medical records to determine the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient), and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay.

Certain diagnoses and procedures generally do not support an inpatient admission and fall within the definitions of outpatient observation. Uncomplicated presentations of chest pain (rule out MI), mild asthma/COPD, mild CHF, syncope and decreased responsiveness, atrial arrhythmias, and renal colic all frequently are associated with the expectation of a brief (less than 24-hour) stay unless serious pathology is uncovered.2 Situations that do not meet the criteria for observation care are considered “not medically necessary” and separate payment is not permitted. Examples of circumstances that lack medical necessity include:

• Outpatient blood administration;
• Lack of/delay in patient transportation;
• Provision of a medical exam for patients who do not require skilled support;
• Routine preparation prior to and recovery after diagnostic testing;
• Routine recovery and post-operative care after ambulatory surgery;
• When used for the convenience of the physician, patient or patient’s family;
• While awaiting transfer to another facility;
• Duration of care exceeding 48 hours;
• When an overnight stay is planned prior to diagnostic testing;
• Standing orders following outpatient surgery;
• Services that would normally require inpatient stay;
• No physicians order to admit to observation;
• Observation following an uncomplicated treatment or procedure;
• Services that are not reasonable and necessary for care of the patient;
• Services provided concurrently with chemotherapy; and
• Inpatients discharged to outpatient observation status.3

The attending physician of record assumes responsibility for the patient’s admission to observation and is permitted to report observation care codes. In addition to the reason for admission, a medical record involving the observation stay must include dated and timed physician admitting orders outlining the care plan, physician progress notes, and discharge orders. This documentation must be added to any other record prepared as a result of an emergency department or outpatient clinic encounter. If physicians other than the admitting physician/group (i.e., physicians in different specialties) provide services to the patient during observation, they must use the appropriate outpatient visit (e.g., 99214) or consultation code (e.g., 99244).

Length of Stay⁴

In general, the duration of observation care services typically does not exceed 24 hours, although in some circumstances patients may require a second day. Observation care for greater than 48 hours without inpatient admission is not considered medically necessary but may be payable after medical review. When the stay spans two calendar days, physician billing is straightforward: Select an initial observation care code (99218-99220) for calendar day one and the observation discharge code (99217) for day two. Only the admitting physician/group may report the discharge service, when applicable. Documentation must demonstrate a face-to-face encounter by the physician for each date of service.

Should the stay only constitute one calendar day, the duration of care becomes a crucial factor in determining the code category. Standard OBS codes (99218-99220) are applicable if the patient stay is less than eight hours on any given date. The OBS discharge code (99217) is not reported in this instance, although the documentation should reflect the attending physician’s written order and appropriate discharge plan. Alternately, same day admit/discharge codes (99234-99236) apply to single-day stays lasting more than eight hours. The OBS discharge code (99217) also is not reported in this instance. Documentation must identify, at a minimum:

• Duration of the stay;
• Presence by the billing physician; and
• Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

Sometimes the patient requires inpatient admission after initially being placed in observation. If the inpatient admission occurs on the same day as the OBS admission, only one service is reported (e.g., 99222). The physician need not redocument a complete history and physical (H&P) but merely write the new order for admission and update the OBS assessment with any relevant, new information.

Should the inpatient admission occur on the second calendar day of the OBS stay, the physician is able to report the initial observation care code (e.g., 99219) on day one, and the initial inpatient care code (e.g., 99223) on day two. However, the physician must meet the documentation guidelines for initial hospital care and redocument the H&P associated with the reported visit level. In the case of 99223, the physician must document a comprehensive history (only referring to the previous review of systems and histories, while rewriting the history of present illness) and high complexity decision making. If the physician chooses not to document to this extent, a subsequent hospital care code (99231-99233) is reasonable because the episode of care is a continuation from the observation phase.

Beware that some insurers may change the patient’s status for the entire episode of care. In other words, the conversion to inpatient status occurs on day two of the patient stay, but the insurer may convert the entire stay, including day one, to an inpatient status. Should this happen, the physician is responsible for reporting the visit category that corresponds with the patient’s status. Inpatient services codes are required for claim submission when the patient stay qualifies as an inpatient admission. Because these conversions occur with some frequency, it is advisable to hold claims intended for observation patients until the correct patient status can be confirmed by the utilization review team, and communicated to the physician. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References

1. 1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
2. 2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.
3. 3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.
4. 4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.
5. 5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.
6. 6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

Observation care provides a mechanism to evaluate and treat patients without the resource utilization and financial responsibility associated with an inpatient admission. Hospitalists may not understand the billing compliance risk and corresponding revenue implications when observation services (OBS) are not captured correctly.

Are OBS best reported with observation care codes (99218-99220, 99234-99236), office visit codes (99201-99215), or initial hospital care codes (99221-99223)? Code selection depends upon the patient’s registered status, the nature of the provided service, and the length of stay. Review the following information before reporting OBS to ensure an accurate claim submission.

Attending Physician Responsibilities

The physician-documented reason for observation substantiates the medical necessity for the OBS admission. Contractors often evaluate medical records to determine the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient), and the medical necessity of those services, including the medical appropriateness of the inpatient or observation stay.

Certain diagnoses and procedures generally do not support an inpatient admission and fall within the definitions of outpatient observation. Uncomplicated presentations of chest pain (rule out MI), mild asthma/COPD, mild CHF, syncope and decreased responsiveness, atrial arrhythmias, and renal colic all frequently are associated with the expectation of a brief (less than 24-hour) stay unless serious pathology is uncovered.2 Situations that do not meet the criteria for observation care are considered “not medically necessary” and separate payment is not permitted. Examples of circumstances that lack medical necessity include:

• Outpatient blood administration;
• Lack of/delay in patient transportation;
• Provision of a medical exam for patients who do not require skilled support;
• Routine preparation prior to and recovery after diagnostic testing;
• Routine recovery and post-operative care after ambulatory surgery;
• When used for the convenience of the physician, patient or patient’s family;
• While awaiting transfer to another facility;
• Duration of care exceeding 48 hours;
• When an overnight stay is planned prior to diagnostic testing;
• Standing orders following outpatient surgery;
• Services that would normally require inpatient stay;
• No physicians order to admit to observation;
• Observation following an uncomplicated treatment or procedure;
• Services that are not reasonable and necessary for care of the patient;
• Services provided concurrently with chemotherapy; and
• Inpatients discharged to outpatient observation status.3

The attending physician of record assumes responsibility for the patient’s admission to observation and is permitted to report observation care codes. In addition to the reason for admission, a medical record involving the observation stay must include dated and timed physician admitting orders outlining the care plan, physician progress notes, and discharge orders. This documentation must be added to any other record prepared as a result of an emergency department or outpatient clinic encounter. If physicians other than the admitting physician/group (i.e., physicians in different specialties) provide services to the patient during observation, they must use the appropriate outpatient visit (e.g., 99214) or consultation code (e.g., 99244).

Length of Stay⁴

In general, the duration of observation care services typically does not exceed 24 hours, although in some circumstances patients may require a second day. Observation care for greater than 48 hours without inpatient admission is not considered medically necessary but may be payable after medical review. When the stay spans two calendar days, physician billing is straightforward: Select an initial observation care code (99218-99220) for calendar day one and the observation discharge code (99217) for day two. Only the admitting physician/group may report the discharge service, when applicable. Documentation must demonstrate a face-to-face encounter by the physician for each date of service.

Should the stay only constitute one calendar day, the duration of care becomes a crucial factor in determining the code category. Standard OBS codes (99218-99220) are applicable if the patient stay is less than eight hours on any given date. The OBS discharge code (99217) is not reported in this instance, although the documentation should reflect the attending physician’s written order and appropriate discharge plan. Alternately, same day admit/discharge codes (99234-99236) apply to single-day stays lasting more than eight hours. The OBS discharge code (99217) also is not reported in this instance. Documentation must identify, at a minimum:

• Duration of the stay;
• Presence by the billing physician; and
• Physician performance of each service (i.e., both an admission and discharge note).

Inpatient Admission^1,4-5

Sometimes the patient requires inpatient admission after initially being placed in observation. If the inpatient admission occurs on the same day as the OBS admission, only one service is reported (e.g., 99222). The physician need not redocument a complete history and physical (H&P) but merely write the new order for admission and update the OBS assessment with any relevant, new information.

Should the inpatient admission occur on the second calendar day of the OBS stay, the physician is able to report the initial observation care code (e.g., 99219) on day one, and the initial inpatient care code (e.g., 99223) on day two. However, the physician must meet the documentation guidelines for initial hospital care and redocument the H&P associated with the reported visit level. In the case of 99223, the physician must document a comprehensive history (only referring to the previous review of systems and histories, while rewriting the history of present illness) and high complexity decision making. If the physician chooses not to document to this extent, a subsequent hospital care code (99231-99233) is reasonable because the episode of care is a continuation from the observation phase.

Beware that some insurers may change the patient’s status for the entire episode of care. In other words, the conversion to inpatient status occurs on day two of the patient stay, but the insurer may convert the entire stay, including day one, to an inpatient status. Should this happen, the physician is responsible for reporting the visit category that corresponds with the patient’s status. Inpatient services codes are required for claim submission when the patient stay qualifies as an inpatient admission. Because these conversions occur with some frequency, it is advisable to hold claims intended for observation patients until the correct patient status can be confirmed by the utilization review team, and communicated to the physician. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References

1. 1. American Medical Association. cpt 2008, Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association, 2007; 9-16 CPT codes, descriptions and other data only are copyright 2007 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
2. 2. Highmark Medicare Services. Local Coverage Determination L27548 Acute Care: Inpatient, Observation and Treatment Room Services. Available at www.highmarkmedicareservices.com/policy/mac-ab/127548.html. Accessed July 14, 2008.
3. 3. Cigna. Healthcare Coverage Position: Observation Care. Available at www.cigna.com/customer_care/healthcare_ professional/coverage_positions/medical/mm_0411_coveragepositioncriteria_observation_care.pdf. Accessed July 12, 2008.
4. 4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at www.cms.hhs.gov/manuals/downloads/ clm104c12.pdf. Accessed July 13, 2008.
5. 5. Pohlig C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 57-69.
6. 6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 1, Section 50.3. Available at www.cms.hhs.gov/manuals/downloads/ clm104c01.pdf. Accessed July 13, 2008.

CMS has taken up the e-prescribing torch. In July, the agency announced a preliminary program to promote widespread adoption of electronic prescribing.

E-prescribing is a natural goal for CMS; it has been proven to improve quality of care, reduce medication errors, increase efficiency, and lower administrative costs. Kerry Weems, the acting CMS administrator, says an all-electronic prescribing system could save Medicare as much as $156 million over five years—largely through improved quality care.

Though details on the e-prescribing plan are not yet decided, CMS has revealed that beginning in 2009 (and for the next four years) it will provide incentive payments to physicians who are “successful electronic prescribers.”

Details to Be Determined

The e-prescribing plan will be included in the Physician Quality Reporting Initiative (PQRI), with guidelines included in the 2009 PQRI. (How the new plan will work with the current PQRI e-prescribing measure is one of the unknown details.)

Weems says CMS will use its standard rule-making process to shape the e-prescribing plan. Therefore, details of the incentives program will not be available until this fall, when Medicare releases its final rule on the 2009 physician fee schedule. According to Weems, the 2009 fee schedule and PQRI will clarify some murkiness. “They will be specific about what constitutes e-prescribing, including the extent and reporting of what needs to be done through PQRI,” he says.

Rewards, Then Possible Punishments

Physicians can start reporting on e-prescribing Jan. 1, and those who do will reap the benefits. Patrick Conway, MD, MSc, a hospitalist, an assistant professor at Cincinnati Children’s Hospital Medical Center, and a 2007-2008 White House Fellow working in the Department of Health and Human Services (HHS), says initial discussions about promoting e-prescribing included talk of an incentive-based plan.

“It’s my opinion that, for physicians, it’s beneficial to start with a reward or carrot rather than a punishment,” he says. “And generally, CMS has approached physician programs with this method—like the PQRI.”

The current plan’s outlines indicates that in 2009 and 2010, physicians who successfully report on e-prescribing will receive an incentive payment of up to 2% of their total Medicare allowed charges, matching the maximum bonus they can earn under the regular PQRI. Payment will be additive, so a physician can earn up to 4% (2% for PQRI and 2% for e-prescribing.)

The e-prescribing incentive will drop to 1% in 2011 and 2012, and to 0.5% incentive payment in 2013. After 2013, the carrot is replaced with a stick, and those who do not use e-prescribing will suffer a reduction in payment.

Cost Concerns

CMS estimates the cost of adopting e-prescribing will be approximately $3,000 per individual prescriber. This includes equipment, training, and program maintenance. That can add up to a sizeable expense—particularly for small groups. For that reason, the agency promises a built-in hardship exemption for small practices and others who prove they cannot afford to adopt e-prescribing.

Also, some funding is available: Dr. Conway says CMS has a financial-incentive program for electronic health records, many of which include e-prescribing. “The CMS Electronic Health Records Demonstration is a $150 million program that will provide funds to 1,200 physician practices to adopt this technology,” he says. “They’re currently recruiting practices.” Details on the demonstration are available at www.cms.hhs.gov/DemoProjectsEvalRpts/.

Will Hospitalists Participate?

Until details of the e-prescribing program are published, no one can say whether the plan will encompass hospitalists. However, Dr. Conway says, “I think this plan is conceptually relevant to hospitalists: It’s possible that hospitalists will be able to participate in the current plan. We don’t know yet. But CMS will continue to push forward on initiatives that increase quality and decrease costs, including e-prescribing. They’ll support electronic health records, whether this particular initiative applies to hospitals or not.”

Even if it turns out hospital medicine groups can’t reap incentive payments from the new plan, Dr. Conway hopes they still will adopt the technology. “Computerized physician order entry (CPOE) and e-prescribing have the potential to decrease errors and increase the quality of care,” he says. “Therefore, I would encourage hospitals and hospitalists to implement electronic health records with computerized order entry and e-prescribing when possible.”

He says the real benefit to hospitals seeking to improve quality and reduce error is not the electronic transmission of prescriptions to the pharmacy, but CPOE. “Most evidence of increased quality is around computerized physician order entry, which includes decision support at the time of the order,” he points out. “One could argue that you could have an incentive for hospitals that utilize CPOE, but I have no idea if CMS will pursue that.”

Next Steps

On Oct. 6-7 CMS will host a conference on the complete e-prescribing plan for pharmacists and physicians in Boston. For details, check the CMS site at www.cms.hhs.gov/eprescribing or www.cms.hhs.gov/pqri.

Dr. Conway thinks the meeting is a good next step for CMS. “I believe it’s very important to engage frontline providers and stakeholders, so the concept of holding a conference to ensure the design of the program is understood, and to get buy-in from the people participating, is a wise choice,” he says.

In the next few months, physicians likely will be inundated with information on e-prescribing processes under the CMS plan. Stay abreast of the latest information through the CMS Web site and, if it turns out, hospitalists can actively participate in the plan, through the SHM Web site at www.hospitalmedicine.org. TH

Jane Jerrard is a medical writer based in Chicago.

CMS has taken up the e-prescribing torch. In July, the agency announced a preliminary program to promote widespread adoption of electronic prescribing.

E-prescribing is a natural goal for CMS; it has been proven to improve quality of care, reduce medication errors, increase efficiency, and lower administrative costs. Kerry Weems, the acting CMS administrator, says an all-electronic prescribing system could save Medicare as much as $156 million over five years—largely through improved quality care.

Though details on the e-prescribing plan are not yet decided, CMS has revealed that beginning in 2009 (and for the next four years) it will provide incentive payments to physicians who are “successful electronic prescribers.”

Details to Be Determined

The e-prescribing plan will be included in the Physician Quality Reporting Initiative (PQRI), with guidelines included in the 2009 PQRI. (How the new plan will work with the current PQRI e-prescribing measure is one of the unknown details.)

Weems says CMS will use its standard rule-making process to shape the e-prescribing plan. Therefore, details of the incentives program will not be available until this fall, when Medicare releases its final rule on the 2009 physician fee schedule. According to Weems, the 2009 fee schedule and PQRI will clarify some murkiness. “They will be specific about what constitutes e-prescribing, including the extent and reporting of what needs to be done through PQRI,” he says.

Rewards, Then Possible Punishments

Physicians can start reporting on e-prescribing Jan. 1, and those who do will reap the benefits. Patrick Conway, MD, MSc, a hospitalist, an assistant professor at Cincinnati Children’s Hospital Medical Center, and a 2007-2008 White House Fellow working in the Department of Health and Human Services (HHS), says initial discussions about promoting e-prescribing included talk of an incentive-based plan.

“It’s my opinion that, for physicians, it’s beneficial to start with a reward or carrot rather than a punishment,” he says. “And generally, CMS has approached physician programs with this method—like the PQRI.”

The current plan’s outlines indicates that in 2009 and 2010, physicians who successfully report on e-prescribing will receive an incentive payment of up to 2% of their total Medicare allowed charges, matching the maximum bonus they can earn under the regular PQRI. Payment will be additive, so a physician can earn up to 4% (2% for PQRI and 2% for e-prescribing.)

The e-prescribing incentive will drop to 1% in 2011 and 2012, and to 0.5% incentive payment in 2013. After 2013, the carrot is replaced with a stick, and those who do not use e-prescribing will suffer a reduction in payment.

Cost Concerns

CMS estimates the cost of adopting e-prescribing will be approximately $3,000 per individual prescriber. This includes equipment, training, and program maintenance. That can add up to a sizeable expense—particularly for small groups. For that reason, the agency promises a built-in hardship exemption for small practices and others who prove they cannot afford to adopt e-prescribing.

Also, some funding is available: Dr. Conway says CMS has a financial-incentive program for electronic health records, many of which include e-prescribing. “The CMS Electronic Health Records Demonstration is a $150 million program that will provide funds to 1,200 physician practices to adopt this technology,” he says. “They’re currently recruiting practices.” Details on the demonstration are available at www.cms.hhs.gov/DemoProjectsEvalRpts/.

Will Hospitalists Participate?

Until details of the e-prescribing program are published, no one can say whether the plan will encompass hospitalists. However, Dr. Conway says, “I think this plan is conceptually relevant to hospitalists: It’s possible that hospitalists will be able to participate in the current plan. We don’t know yet. But CMS will continue to push forward on initiatives that increase quality and decrease costs, including e-prescribing. They’ll support electronic health records, whether this particular initiative applies to hospitals or not.”

Even if it turns out hospital medicine groups can’t reap incentive payments from the new plan, Dr. Conway hopes they still will adopt the technology. “Computerized physician order entry (CPOE) and e-prescribing have the potential to decrease errors and increase the quality of care,” he says. “Therefore, I would encourage hospitals and hospitalists to implement electronic health records with computerized order entry and e-prescribing when possible.”

He says the real benefit to hospitals seeking to improve quality and reduce error is not the electronic transmission of prescriptions to the pharmacy, but CPOE. “Most evidence of increased quality is around computerized physician order entry, which includes decision support at the time of the order,” he points out. “One could argue that you could have an incentive for hospitals that utilize CPOE, but I have no idea if CMS will pursue that.”

Next Steps

On Oct. 6-7 CMS will host a conference on the complete e-prescribing plan for pharmacists and physicians in Boston. For details, check the CMS site at www.cms.hhs.gov/eprescribing or www.cms.hhs.gov/pqri.

Dr. Conway thinks the meeting is a good next step for CMS. “I believe it’s very important to engage frontline providers and stakeholders, so the concept of holding a conference to ensure the design of the program is understood, and to get buy-in from the people participating, is a wise choice,” he says.

In the next few months, physicians likely will be inundated with information on e-prescribing processes under the CMS plan. Stay abreast of the latest information through the CMS Web site and, if it turns out, hospitalists can actively participate in the plan, through the SHM Web site at www.hospitalmedicine.org. TH

Jane Jerrard is a medical writer based in Chicago.

CMS has taken up the e-prescribing torch. In July, the agency announced a preliminary program to promote widespread adoption of electronic prescribing.

E-prescribing is a natural goal for CMS; it has been proven to improve quality of care, reduce medication errors, increase efficiency, and lower administrative costs. Kerry Weems, the acting CMS administrator, says an all-electronic prescribing system could save Medicare as much as $156 million over five years—largely through improved quality care.

Though details on the e-prescribing plan are not yet decided, CMS has revealed that beginning in 2009 (and for the next four years) it will provide incentive payments to physicians who are “successful electronic prescribers.”

Details to Be Determined

The e-prescribing plan will be included in the Physician Quality Reporting Initiative (PQRI), with guidelines included in the 2009 PQRI. (How the new plan will work with the current PQRI e-prescribing measure is one of the unknown details.)

Weems says CMS will use its standard rule-making process to shape the e-prescribing plan. Therefore, details of the incentives program will not be available until this fall, when Medicare releases its final rule on the 2009 physician fee schedule. According to Weems, the 2009 fee schedule and PQRI will clarify some murkiness. “They will be specific about what constitutes e-prescribing, including the extent and reporting of what needs to be done through PQRI,” he says.

Rewards, Then Possible Punishments

Physicians can start reporting on e-prescribing Jan. 1, and those who do will reap the benefits. Patrick Conway, MD, MSc, a hospitalist, an assistant professor at Cincinnati Children’s Hospital Medical Center, and a 2007-2008 White House Fellow working in the Department of Health and Human Services (HHS), says initial discussions about promoting e-prescribing included talk of an incentive-based plan.

“It’s my opinion that, for physicians, it’s beneficial to start with a reward or carrot rather than a punishment,” he says. “And generally, CMS has approached physician programs with this method—like the PQRI.”

The current plan’s outlines indicates that in 2009 and 2010, physicians who successfully report on e-prescribing will receive an incentive payment of up to 2% of their total Medicare allowed charges, matching the maximum bonus they can earn under the regular PQRI. Payment will be additive, so a physician can earn up to 4% (2% for PQRI and 2% for e-prescribing.)

The e-prescribing incentive will drop to 1% in 2011 and 2012, and to 0.5% incentive payment in 2013. After 2013, the carrot is replaced with a stick, and those who do not use e-prescribing will suffer a reduction in payment.

Cost Concerns

CMS estimates the cost of adopting e-prescribing will be approximately $3,000 per individual prescriber. This includes equipment, training, and program maintenance. That can add up to a sizeable expense—particularly for small groups. For that reason, the agency promises a built-in hardship exemption for small practices and others who prove they cannot afford to adopt e-prescribing.

Also, some funding is available: Dr. Conway says CMS has a financial-incentive program for electronic health records, many of which include e-prescribing. “The CMS Electronic Health Records Demonstration is a $150 million program that will provide funds to 1,200 physician practices to adopt this technology,” he says. “They’re currently recruiting practices.” Details on the demonstration are available at www.cms.hhs.gov/DemoProjectsEvalRpts/.

Will Hospitalists Participate?

Until details of the e-prescribing program are published, no one can say whether the plan will encompass hospitalists. However, Dr. Conway says, “I think this plan is conceptually relevant to hospitalists: It’s possible that hospitalists will be able to participate in the current plan. We don’t know yet. But CMS will continue to push forward on initiatives that increase quality and decrease costs, including e-prescribing. They’ll support electronic health records, whether this particular initiative applies to hospitals or not.”

Even if it turns out hospital medicine groups can’t reap incentive payments from the new plan, Dr. Conway hopes they still will adopt the technology. “Computerized physician order entry (CPOE) and e-prescribing have the potential to decrease errors and increase the quality of care,” he says. “Therefore, I would encourage hospitals and hospitalists to implement electronic health records with computerized order entry and e-prescribing when possible.”

He says the real benefit to hospitals seeking to improve quality and reduce error is not the electronic transmission of prescriptions to the pharmacy, but CPOE. “Most evidence of increased quality is around computerized physician order entry, which includes decision support at the time of the order,” he points out. “One could argue that you could have an incentive for hospitals that utilize CPOE, but I have no idea if CMS will pursue that.”

Next Steps

On Oct. 6-7 CMS will host a conference on the complete e-prescribing plan for pharmacists and physicians in Boston. For details, check the CMS site at www.cms.hhs.gov/eprescribing or www.cms.hhs.gov/pqri.

Dr. Conway thinks the meeting is a good next step for CMS. “I believe it’s very important to engage frontline providers and stakeholders, so the concept of holding a conference to ensure the design of the program is understood, and to get buy-in from the people participating, is a wise choice,” he says.

In the next few months, physicians likely will be inundated with information on e-prescribing processes under the CMS plan. Stay abreast of the latest information through the CMS Web site and, if it turns out, hospitalists can actively participate in the plan, through the SHM Web site at www.hospitalmedicine.org. TH

Jane Jerrard is a medical writer based in Chicago.

If you’re in an HM leadership position, don’t be surprised if you’re asked to be a mentor for a less-experienced hospitalist. Why should you voluntarily spend valuable time sharing your guidance and advice? Because to lead is to mentor, and when you dive into the process it rewards all parties involved.

To Lead Is to Mentor

Whether you were just promoted or you’re a leadership veteran approached for the first time by an eager new hospitalist, don’t hesitate to add mentoring to your schedule and responsibilities.

“When you start out as a leader, you get where you want to go by being a mentor,” says Eric E. Howell, MD, director of Collaborative Inpatient Medicine Service, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore and faculty for SHM’s Leadership Academy. “You gather disciples, as it were, who will then see you as a leader and support you as a good leadership choice.”

Not only that, but mentoring can add to your skill set as a leader, says Joan C. Faro, MD, FACP, MBA, chief medical officer at John T. Mather Memorial Hospital, Port Jefferson, N.Y. “If you’re interested in developing leadership skills, it’s one of those things you need to do, and do well. If you can’t mentor, then you really can’t lead.”

Plus, when you mentor, you get to feel the reward inherent in helping a young physician whose shoes you once filled. “It’s like raising a kid,” says Dr. Faro. “You want to do a good job because you want to see someone succeed.” This is especially true for mentoring relationships within your HM group.

That means fully flushing out the program and dedicating the time necessary to make it a success. “If you are the de facto leader of a group, you have some obligation to people interested in career development,” says Dr. Howell. “I think it’s part of the job to help advance those people.”

The Ground Rules

Any new mentoring arrangement should start with a discussion of expectations, responsibilities, time frames, and communication. What are the mentee’s expectations for the relationship? How much time can you, the mentor, offer?

Whether the arrangement is formal (a director mentoring a new hire) or casual (an established hospitalist asking a conference speaker for a long-distance mentoring relationship), ground rules are important, Dr. Howell insists. “The mentoring relationship can be established informally, but it’s worthwhile to set some rules on responsibilities: How is the feedback going to come, how frank and honest do you want to be, when should we meet? …Rules will depend on the relationship and on the individuals involved.”

If nothing else, agree to how frequently you will meet or speak. “It could be quarterly or it could be weekly,” says Dr. Howell. “Face time is important, but e-mail and phone calls will work, too, as long as you’ve established some ground rules about this. If the mentee expects a face-to-face meeting and you’re e-mailing your answers, that could be a problem. So you need to establish how you’re going to communicate.”

Those meetings can add up to a sizeable commitment. How much time, exactly, should a new mentor expect to devote to this aspect of leadership? “It varies widely,” Dr. Howell admits. “But I will say that many younger mentees require much more time than older mentors expect. If they’re struggling or haven’t found their stride yet, it can require several hours a week, which is a lot for a busy person’s schedule. But many relationships can be handled weekly or monthly.”

Dr. Faro, who has mentored many hospitalists within her organization, says, “You need to build the relationship; you need enough contact time so that you can understand each other.” For her, that amounts to 40 to 50 hours of getting-to-know-you time, she says. “After that, maybe an hour a week.”

Tailor Mentoring

Dr. Faro tailors her guidance to the personality, capabilities, and level of independence of each person she mentors—hence her lengthy initial time frame.

“You need to start with setting up a clear set of goals and outcomes,” she says. “They really need to know what they’re doing and why they’re doing it. So, set up a plan with specific time frames. It’s your job to determine how independent they are; you may end up giving them goals rather than them stating what they’re going to do.”

For example, she might tell one mentee to develop an order set for patients with syncope, and expect a document by an agreed-upon deadline. She might give another individual the same assignment, but walk that person through each step—within reason. “You can’t do it for them, or they’re not going to learn,” she maintains.

Each completed task is met with constructive criticism. How well was the task done? Did the physician leave out anything? If Dr. Faro senses that more guidance is necessary, she steps up her level of involvement.

What Makes a Successful Mentor?

Dr. Faro understands the mentor/mentee process because she’s been part of it for so long. How can you get to that point? Simply agreeing to be a mentor and having regular meetings with your mentee doesn’t necessarily mean you’re doing a good job.

“Good mentors probably listen more than they talk,” explains Dr. Howell. “For many people, if they can talk it out, they will reach their own conclusions and that’s much more powerful than being told something. That ‘Aha!’ moment is a big career moment.”

He also believes strong mentors can give even non-hospitalists helpful career advice. “Good mentors are able to step out of their own shoes and look at the unique situation of the other person, and give advice tailored to that situation,” he explains. “You have to be altruistic in your mentoring; you can’t do it for your own needs.”

Successful mentors also understand their mentees. For example, mentees in leadership positions should receive advice about how to invest in themselves and their careers. “I always recommend SHM’s Leadership Academy, as well as several books, including Getting to Yes and Good to Great to improve themselves as leaders,” says Dr. Howell.

Finally, a mentor who does the job well understands when the relationship isn’t working. If this is the case, “be up-front and honest, and if possible, point that person to another mentor,” Dr. Howell says. “If you can introduce them and get them started, that’s best. You can also share a mentee with someone else; you can each handle different areas. I have many different mentors in different areas. It’s more productive that way.” TH

Jane Jerrard also writes “Public Policy” for The Hospitalist.

If you’re in an HM leadership position, don’t be surprised if you’re asked to be a mentor for a less-experienced hospitalist. Why should you voluntarily spend valuable time sharing your guidance and advice? Because to lead is to mentor, and when you dive into the process it rewards all parties involved.

To Lead Is to Mentor

Whether you were just promoted or you’re a leadership veteran approached for the first time by an eager new hospitalist, don’t hesitate to add mentoring to your schedule and responsibilities.

“When you start out as a leader, you get where you want to go by being a mentor,” says Eric E. Howell, MD, director of Collaborative Inpatient Medicine Service, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore and faculty for SHM’s Leadership Academy. “You gather disciples, as it were, who will then see you as a leader and support you as a good leadership choice.”

Not only that, but mentoring can add to your skill set as a leader, says Joan C. Faro, MD, FACP, MBA, chief medical officer at John T. Mather Memorial Hospital, Port Jefferson, N.Y. “If you’re interested in developing leadership skills, it’s one of those things you need to do, and do well. If you can’t mentor, then you really can’t lead.”

Plus, when you mentor, you get to feel the reward inherent in helping a young physician whose shoes you once filled. “It’s like raising a kid,” says Dr. Faro. “You want to do a good job because you want to see someone succeed.” This is especially true for mentoring relationships within your HM group.

That means fully flushing out the program and dedicating the time necessary to make it a success. “If you are the de facto leader of a group, you have some obligation to people interested in career development,” says Dr. Howell. “I think it’s part of the job to help advance those people.”

The Ground Rules

Any new mentoring arrangement should start with a discussion of expectations, responsibilities, time frames, and communication. What are the mentee’s expectations for the relationship? How much time can you, the mentor, offer?

Whether the arrangement is formal (a director mentoring a new hire) or casual (an established hospitalist asking a conference speaker for a long-distance mentoring relationship), ground rules are important, Dr. Howell insists. “The mentoring relationship can be established informally, but it’s worthwhile to set some rules on responsibilities: How is the feedback going to come, how frank and honest do you want to be, when should we meet? …Rules will depend on the relationship and on the individuals involved.”

If nothing else, agree to how frequently you will meet or speak. “It could be quarterly or it could be weekly,” says Dr. Howell. “Face time is important, but e-mail and phone calls will work, too, as long as you’ve established some ground rules about this. If the mentee expects a face-to-face meeting and you’re e-mailing your answers, that could be a problem. So you need to establish how you’re going to communicate.”

Those meetings can add up to a sizeable commitment. How much time, exactly, should a new mentor expect to devote to this aspect of leadership? “It varies widely,” Dr. Howell admits. “But I will say that many younger mentees require much more time than older mentors expect. If they’re struggling or haven’t found their stride yet, it can require several hours a week, which is a lot for a busy person’s schedule. But many relationships can be handled weekly or monthly.”

Dr. Faro, who has mentored many hospitalists within her organization, says, “You need to build the relationship; you need enough contact time so that you can understand each other.” For her, that amounts to 40 to 50 hours of getting-to-know-you time, she says. “After that, maybe an hour a week.”

Tailor Mentoring

Dr. Faro tailors her guidance to the personality, capabilities, and level of independence of each person she mentors—hence her lengthy initial time frame.

“You need to start with setting up a clear set of goals and outcomes,” she says. “They really need to know what they’re doing and why they’re doing it. So, set up a plan with specific time frames. It’s your job to determine how independent they are; you may end up giving them goals rather than them stating what they’re going to do.”

For example, she might tell one mentee to develop an order set for patients with syncope, and expect a document by an agreed-upon deadline. She might give another individual the same assignment, but walk that person through each step—within reason. “You can’t do it for them, or they’re not going to learn,” she maintains.

Each completed task is met with constructive criticism. How well was the task done? Did the physician leave out anything? If Dr. Faro senses that more guidance is necessary, she steps up her level of involvement.

What Makes a Successful Mentor?

Dr. Faro understands the mentor/mentee process because she’s been part of it for so long. How can you get to that point? Simply agreeing to be a mentor and having regular meetings with your mentee doesn’t necessarily mean you’re doing a good job.

“Good mentors probably listen more than they talk,” explains Dr. Howell. “For many people, if they can talk it out, they will reach their own conclusions and that’s much more powerful than being told something. That ‘Aha!’ moment is a big career moment.”

He also believes strong mentors can give even non-hospitalists helpful career advice. “Good mentors are able to step out of their own shoes and look at the unique situation of the other person, and give advice tailored to that situation,” he explains. “You have to be altruistic in your mentoring; you can’t do it for your own needs.”

Successful mentors also understand their mentees. For example, mentees in leadership positions should receive advice about how to invest in themselves and their careers. “I always recommend SHM’s Leadership Academy, as well as several books, including Getting to Yes and Good to Great to improve themselves as leaders,” says Dr. Howell.

Finally, a mentor who does the job well understands when the relationship isn’t working. If this is the case, “be up-front and honest, and if possible, point that person to another mentor,” Dr. Howell says. “If you can introduce them and get them started, that’s best. You can also share a mentee with someone else; you can each handle different areas. I have many different mentors in different areas. It’s more productive that way.” TH

Jane Jerrard also writes “Public Policy” for The Hospitalist.

If you’re in an HM leadership position, don’t be surprised if you’re asked to be a mentor for a less-experienced hospitalist. Why should you voluntarily spend valuable time sharing your guidance and advice? Because to lead is to mentor, and when you dive into the process it rewards all parties involved.

To Lead Is to Mentor

Whether you were just promoted or you’re a leadership veteran approached for the first time by an eager new hospitalist, don’t hesitate to add mentoring to your schedule and responsibilities.

“When you start out as a leader, you get where you want to go by being a mentor,” says Eric E. Howell, MD, director of Collaborative Inpatient Medicine Service, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore and faculty for SHM’s Leadership Academy. “You gather disciples, as it were, who will then see you as a leader and support you as a good leadership choice.”

Not only that, but mentoring can add to your skill set as a leader, says Joan C. Faro, MD, FACP, MBA, chief medical officer at John T. Mather Memorial Hospital, Port Jefferson, N.Y. “If you’re interested in developing leadership skills, it’s one of those things you need to do, and do well. If you can’t mentor, then you really can’t lead.”

Plus, when you mentor, you get to feel the reward inherent in helping a young physician whose shoes you once filled. “It’s like raising a kid,” says Dr. Faro. “You want to do a good job because you want to see someone succeed.” This is especially true for mentoring relationships within your HM group.

That means fully flushing out the program and dedicating the time necessary to make it a success. “If you are the de facto leader of a group, you have some obligation to people interested in career development,” says Dr. Howell. “I think it’s part of the job to help advance those people.”

The Ground Rules

Any new mentoring arrangement should start with a discussion of expectations, responsibilities, time frames, and communication. What are the mentee’s expectations for the relationship? How much time can you, the mentor, offer?

Whether the arrangement is formal (a director mentoring a new hire) or casual (an established hospitalist asking a conference speaker for a long-distance mentoring relationship), ground rules are important, Dr. Howell insists. “The mentoring relationship can be established informally, but it’s worthwhile to set some rules on responsibilities: How is the feedback going to come, how frank and honest do you want to be, when should we meet? …Rules will depend on the relationship and on the individuals involved.”

If nothing else, agree to how frequently you will meet or speak. “It could be quarterly or it could be weekly,” says Dr. Howell. “Face time is important, but e-mail and phone calls will work, too, as long as you’ve established some ground rules about this. If the mentee expects a face-to-face meeting and you’re e-mailing your answers, that could be a problem. So you need to establish how you’re going to communicate.”

Those meetings can add up to a sizeable commitment. How much time, exactly, should a new mentor expect to devote to this aspect of leadership? “It varies widely,” Dr. Howell admits. “But I will say that many younger mentees require much more time than older mentors expect. If they’re struggling or haven’t found their stride yet, it can require several hours a week, which is a lot for a busy person’s schedule. But many relationships can be handled weekly or monthly.”

Dr. Faro, who has mentored many hospitalists within her organization, says, “You need to build the relationship; you need enough contact time so that you can understand each other.” For her, that amounts to 40 to 50 hours of getting-to-know-you time, she says. “After that, maybe an hour a week.”

Tailor Mentoring

Dr. Faro tailors her guidance to the personality, capabilities, and level of independence of each person she mentors—hence her lengthy initial time frame.

“You need to start with setting up a clear set of goals and outcomes,” she says. “They really need to know what they’re doing and why they’re doing it. So, set up a plan with specific time frames. It’s your job to determine how independent they are; you may end up giving them goals rather than them stating what they’re going to do.”

For example, she might tell one mentee to develop an order set for patients with syncope, and expect a document by an agreed-upon deadline. She might give another individual the same assignment, but walk that person through each step—within reason. “You can’t do it for them, or they’re not going to learn,” she maintains.

Each completed task is met with constructive criticism. How well was the task done? Did the physician leave out anything? If Dr. Faro senses that more guidance is necessary, she steps up her level of involvement.

What Makes a Successful Mentor?

Dr. Faro understands the mentor/mentee process because she’s been part of it for so long. How can you get to that point? Simply agreeing to be a mentor and having regular meetings with your mentee doesn’t necessarily mean you’re doing a good job.

“Good mentors probably listen more than they talk,” explains Dr. Howell. “For many people, if they can talk it out, they will reach their own conclusions and that’s much more powerful than being told something. That ‘Aha!’ moment is a big career moment.”

He also believes strong mentors can give even non-hospitalists helpful career advice. “Good mentors are able to step out of their own shoes and look at the unique situation of the other person, and give advice tailored to that situation,” he explains. “You have to be altruistic in your mentoring; you can’t do it for your own needs.”

Successful mentors also understand their mentees. For example, mentees in leadership positions should receive advice about how to invest in themselves and their careers. “I always recommend SHM’s Leadership Academy, as well as several books, including Getting to Yes and Good to Great to improve themselves as leaders,” says Dr. Howell.

Finally, a mentor who does the job well understands when the relationship isn’t working. If this is the case, “be up-front and honest, and if possible, point that person to another mentor,” Dr. Howell says. “If you can introduce them and get them started, that’s best. You can also share a mentee with someone else; you can each handle different areas. I have many different mentors in different areas. It’s more productive that way.” TH

Jane Jerrard also writes “Public Policy” for The Hospitalist.

A healthy 30-year-old female presented to the urgent care center with confusion, tremor, and a blood pressure of 160/110 mm Hg. She had no history of hypertension, diabetes, dyslipidemia, renal dysfunction, or smoking. A basic metabolic panel revealed no abnormalities.

Her medication history revealed use of paroxetine (20 mg) subsequent to a depressive episode two years prior. A source of the hypertension was not identified, and she was sent home without further follow-up. The next day, she was admitted to the hospital via the emergency department for stroke symptoms, including numbness and weakness on her right side (extremities and face), with confusion and diplopia. She remained hospitalized for four days during which time she continued to experience transient ischemic attacks. The paroxetine eventually was discontinued. She subsequently has recovered without negative sequelae.

Serotonin syndrome is a consequence of a hyperserotonergic state, due to drug-induced serotonin intensification.1 It can be mild or life-threatening and is characterized by a triad of clinical manifestations: mental status changes, autonomic hyperactivity, and neuromuscular abnormalities.2 Clinicians may miss mild symptoms, such as diarrhea, tremor, tachycardia, diaphoresis, or mydriasis. This can result in an increase in the dose of the causative agent or addition of a serotonergic agent, thus yielding a worsening clinical decline.3

Patients with a more severe clinical presentation include those with severe hypertension (as in the case above), tachycardia, muscular rigidity, and shock. Laboratory abnormalities may be present if the patient develops subsequent rhabdomyolysis, seizures, metabolic acidosis, or renal failure. Serotonin syndrome is diagnosed based on the patient’s presentation, history, and physical examination. It should be differentiated from neuroleptic malignant syndrome, which has a similar presentation.4

Serotonergic agents used alone, or in combination, may lead to serotonin syndrome.5 A recent report discussed the appearance of serotonin syndrome in patients receiving only sumatriptan. Other offenders include such antidepressants as monoamine oxidase inhibitors, buspirone, citalopram, clomipramine, escitalopram, fluoxetine, fluvoxamine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine. Other causative agents include dextromethorphan, fentanyl, granisetron, levodopa, linezolid, lithium, meperidine, metoclopramide, ondansetron, pentazocine, sibutramine, sumatriptan, tramadol, valproate, and drugs of abuse (e.g., amphetamines, cocaine, LSD, ecstasy). Additionally, ginseng, St. John’s Wort, and tryptophan have been implicated.

Many of these agents require an adequate washout period prior to beginning other serotonergic agents. Mild to moderately severe cases usually resolve within 24 to 72 hours, although most resolve within a week depending on the half-life of the medication. Serotonin syndrome carries an 11% mortality rate and is best managed by stopping the offending agent and providing supportive care. TH

Michele B. Kaufman is a freelance medical writer based in New York City.

References

1. Sorenson S. Serotonin syndrome. UTox Update 2002;4(4):1-2. A Publication of the Utah Poison Control Center for Health Professionals. Available at http://uuhsc.utah.edu/poison/healthpros/utox/vol4_no4.pdf. Last accessed June 20, 2008.
2. Soldin OP, Tonning JM. Serotonin syndrome associated with triptan monotherapy. N Engl J Med. 2008;358(20):2185-2186.
3. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112-1120.
4. Nolan S, Scoggin JA. Serotonin syndrome: recognition and management. US Pharm. 2002;23(2). www.uspharmacist.com/oldformat.asp?url=newlook/files/feat/acf2fa6.htm. Last accessed June 20, 2008.
5. Mayo Clinic.com. Diseases and conditions. www.mayoclinic.com/health/serotonin-syndrome/DS00860. Last accessed June 20, 2008.

    

A healthy 30-year-old female presented to the urgent care center with confusion, tremor, and a blood pressure of 160/110 mm Hg. She had no history of hypertension, diabetes, dyslipidemia, renal dysfunction, or smoking. A basic metabolic panel revealed no abnormalities.

Her medication history revealed use of paroxetine (20 mg) subsequent to a depressive episode two years prior. A source of the hypertension was not identified, and she was sent home without further follow-up. The next day, she was admitted to the hospital via the emergency department for stroke symptoms, including numbness and weakness on her right side (extremities and face), with confusion and diplopia. She remained hospitalized for four days during which time she continued to experience transient ischemic attacks. The paroxetine eventually was discontinued. She subsequently has recovered without negative sequelae.

Serotonin syndrome is a consequence of a hyperserotonergic state, due to drug-induced serotonin intensification.1 It can be mild or life-threatening and is characterized by a triad of clinical manifestations: mental status changes, autonomic hyperactivity, and neuromuscular abnormalities.2 Clinicians may miss mild symptoms, such as diarrhea, tremor, tachycardia, diaphoresis, or mydriasis. This can result in an increase in the dose of the causative agent or addition of a serotonergic agent, thus yielding a worsening clinical decline.3

Patients with a more severe clinical presentation include those with severe hypertension (as in the case above), tachycardia, muscular rigidity, and shock. Laboratory abnormalities may be present if the patient develops subsequent rhabdomyolysis, seizures, metabolic acidosis, or renal failure. Serotonin syndrome is diagnosed based on the patient’s presentation, history, and physical examination. It should be differentiated from neuroleptic malignant syndrome, which has a similar presentation.4

Serotonergic agents used alone, or in combination, may lead to serotonin syndrome.5 A recent report discussed the appearance of serotonin syndrome in patients receiving only sumatriptan. Other offenders include such antidepressants as monoamine oxidase inhibitors, buspirone, citalopram, clomipramine, escitalopram, fluoxetine, fluvoxamine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine. Other causative agents include dextromethorphan, fentanyl, granisetron, levodopa, linezolid, lithium, meperidine, metoclopramide, ondansetron, pentazocine, sibutramine, sumatriptan, tramadol, valproate, and drugs of abuse (e.g., amphetamines, cocaine, LSD, ecstasy). Additionally, ginseng, St. John’s Wort, and tryptophan have been implicated.

Many of these agents require an adequate washout period prior to beginning other serotonergic agents. Mild to moderately severe cases usually resolve within 24 to 72 hours, although most resolve within a week depending on the half-life of the medication. Serotonin syndrome carries an 11% mortality rate and is best managed by stopping the offending agent and providing supportive care. TH

Michele B. Kaufman is a freelance medical writer based in New York City.

References

1. Sorenson S. Serotonin syndrome. UTox Update 2002;4(4):1-2. A Publication of the Utah Poison Control Center for Health Professionals. Available at http://uuhsc.utah.edu/poison/healthpros/utox/vol4_no4.pdf. Last accessed June 20, 2008.
2. Soldin OP, Tonning JM. Serotonin syndrome associated with triptan monotherapy. N Engl J Med. 2008;358(20):2185-2186.
3. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112-1120.
4. Nolan S, Scoggin JA. Serotonin syndrome: recognition and management. US Pharm. 2002;23(2). www.uspharmacist.com/oldformat.asp?url=newlook/files/feat/acf2fa6.htm. Last accessed June 20, 2008.
5. Mayo Clinic.com. Diseases and conditions. www.mayoclinic.com/health/serotonin-syndrome/DS00860. Last accessed June 20, 2008.

    

A healthy 30-year-old female presented to the urgent care center with confusion, tremor, and a blood pressure of 160/110 mm Hg. She had no history of hypertension, diabetes, dyslipidemia, renal dysfunction, or smoking. A basic metabolic panel revealed no abnormalities.

Her medication history revealed use of paroxetine (20 mg) subsequent to a depressive episode two years prior. A source of the hypertension was not identified, and she was sent home without further follow-up. The next day, she was admitted to the hospital via the emergency department for stroke symptoms, including numbness and weakness on her right side (extremities and face), with confusion and diplopia. She remained hospitalized for four days during which time she continued to experience transient ischemic attacks. The paroxetine eventually was discontinued. She subsequently has recovered without negative sequelae.

Serotonin syndrome is a consequence of a hyperserotonergic state, due to drug-induced serotonin intensification.1 It can be mild or life-threatening and is characterized by a triad of clinical manifestations: mental status changes, autonomic hyperactivity, and neuromuscular abnormalities.2 Clinicians may miss mild symptoms, such as diarrhea, tremor, tachycardia, diaphoresis, or mydriasis. This can result in an increase in the dose of the causative agent or addition of a serotonergic agent, thus yielding a worsening clinical decline.3

Patients with a more severe clinical presentation include those with severe hypertension (as in the case above), tachycardia, muscular rigidity, and shock. Laboratory abnormalities may be present if the patient develops subsequent rhabdomyolysis, seizures, metabolic acidosis, or renal failure. Serotonin syndrome is diagnosed based on the patient’s presentation, history, and physical examination. It should be differentiated from neuroleptic malignant syndrome, which has a similar presentation.4

Serotonergic agents used alone, or in combination, may lead to serotonin syndrome.5 A recent report discussed the appearance of serotonin syndrome in patients receiving only sumatriptan. Other offenders include such antidepressants as monoamine oxidase inhibitors, buspirone, citalopram, clomipramine, escitalopram, fluoxetine, fluvoxamine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine. Other causative agents include dextromethorphan, fentanyl, granisetron, levodopa, linezolid, lithium, meperidine, metoclopramide, ondansetron, pentazocine, sibutramine, sumatriptan, tramadol, valproate, and drugs of abuse (e.g., amphetamines, cocaine, LSD, ecstasy). Additionally, ginseng, St. John’s Wort, and tryptophan have been implicated.

Many of these agents require an adequate washout period prior to beginning other serotonergic agents. Mild to moderately severe cases usually resolve within 24 to 72 hours, although most resolve within a week depending on the half-life of the medication. Serotonin syndrome carries an 11% mortality rate and is best managed by stopping the offending agent and providing supportive care. TH

Michele B. Kaufman is a freelance medical writer based in New York City.

References

1. Sorenson S. Serotonin syndrome. UTox Update 2002;4(4):1-2. A Publication of the Utah Poison Control Center for Health Professionals. Available at http://uuhsc.utah.edu/poison/healthpros/utox/vol4_no4.pdf. Last accessed June 20, 2008.
2. Soldin OP, Tonning JM. Serotonin syndrome associated with triptan monotherapy. N Engl J Med. 2008;358(20):2185-2186.
3. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112-1120.
4. Nolan S, Scoggin JA. Serotonin syndrome: recognition and management. US Pharm. 2002;23(2). www.uspharmacist.com/oldformat.asp?url=newlook/files/feat/acf2fa6.htm. Last accessed June 20, 2008.
5. Mayo Clinic.com. Diseases and conditions. www.mayoclinic.com/health/serotonin-syndrome/DS00860. Last accessed June 20, 2008.

    

Literature at a Glance

• ICU management by critical care physicians may increase the odds of hospital mortality
• Iatrogenic drug overdose common among patients with renal insufficiency
• An educational effort lowers hospital mortality for severe sepsis and septic shock
• SSRI and problem-solving therapy prevents post-stroke depression
• Stop orders for Foley catheters reduce the duration of inappropriate urinary catheterization
• No thromboembolism risk with interrupting anticoagulation in atrial fibrillation patients undergoing surgery
• Obese patients may be initially under-dosed with vancomycin
• Antipsychotic therapy is associated with short-term serious events in older adults with dementia
• Cardiac troponin is associated with worse outcome in acute heart failure

Does management of ICU patients by critical care physicians reduce mortality?

Background: There is variation in the extent of involvement by critical care physicians in managing patients in ICUs. Several small studies have demonstrated improved outcomes when patients are managed by critical care physicians. This study expanded these findings by examining a national database of multiple ICUs.

Study design: Retrospective database analysis.

Setting: 123 ICUs in 100 U.S. hospitals

Synopsis: Using a national database of ICU patients, 101,832 admissions were analyzed. Controlling for ICU characteristics, patient demographics, and severity of illness (SOI), the impact of critical care management (CCM) on the primary outcome of hospital mortality was analyzed. Patients who received CCM had higher SOI, received more procedures, and had higher mortality rates than those who did not receive CCM. After adjustment for these variables, hospital mortality rates were higher for those patients who received CCM.

Because this was a retrospective analysis, it is not possible to state there was a causal relationship between care by a critical care physician and worse outcome. Other unmeasured clinical differences between the patients receiving CCM and those that did not may have existed that resulted in the higher mortality. Additionally, although the database identified management by a critical care physician, it did not differentiate whether the management was by a full-time intensivist. Therefore, conclusions cannot be made regarding the value of full-time, on-site intensivist management.

Bottom line: Additional analysis is required to determine the value of intensivists in the management of critically ill patients.

Citation: Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Int Med 2008; 148: 801-809.

What is the frequency of iatrogenic drug overdose in patients with renal insufficiency?

Background: The Institute of Medicine Report, “To Err is Human” suggested 7,000 deaths occur annually because of medication errors. Renal insufficiency is relatively common in hospitalized patients. Previous studies have suggested overdose of medications is frequent in patients with renal insufficiency. There is a lack of large-scale studies identifying the most commonly overdosed medications and the predictive physician factors for these errors.

Study design: Retrospective observational study.

Setting: A single 1,080-bed tertiary teaching hospital

Synopsis: A clinical data mart was constructed that contained 48 months of prescription data, serum creatinine levels, along with physician characteristics. 28,954 patients with renal insufficiency had 431,119 prescription orders to analyze. 3.5% of drug doses were found excessive. The overdose rate in patients with moderate to severe renal insufficiency was 28.2%. 10 drugs accounted for 85.4% of the overdoses. There was a negative correlation between physician clinical experience and overdose rate.

Study results are limited by the study’s retrospective nature. Further, the prescribed dose was presumed to be the dose actually administered, and there were no data on the actual doses given to patients. The study was limited to a single institution and may not be generalizable.

Bottom line: Iatrogenic drug overdose is quite common among inpatients with renal insufficiency. Only a few drugs are commonly responsible. The physicians’ clinical experience, workload of prescriptions, and patients’ renal function correlated with overdose.

Citation: Sheen SS, Choi JE, Park RW, Kim EY, Lee YH, Kang UG. Overdoser rate of drugs requiring renal dose adjustment: data analysis of 4 years prescriptions at a tertiary teaching hospital. J Gen Intern Med 2007;23(4):423-8

Will a national education program based on the “Surviving Sepsis Campaign” guidelines improve survival and processes of care?

Background: Sepsis is one of the most prevalent diseases and one of the main causes of death among hospitalized patients. Several single-center studies have suggested quality improvement efforts based on the Surviving Sepsis Guidelines were associated with better outcomes.

Study design: Prospective multicenter before-and-after study design.

Setting: 59 medical and surgical ICUs throughout Spain.

Synopsis: 854 patients with severe sepsis were enrolled in the pre–intervention group. The intervention consisted of education on the use of bundles of care. The treatment was organized into two bundles: a resuscitation bundle (six tasks to be performed within six hours) and a management bundle (four tasks to be completed within 24 hours). 1,465 patients were enrolled in the post-training period. Hospital mortality, adherence to the bundles, ICU mortality, 28-day mortality, hospital and ICU length of stay were measured.

Patients in the post-intervention group had lower mortality (44.0% vs. 39.5% P=0.04) and better compliance with the bundles improved. No other outcomes improved. One year later, mortality gains persisted but compliance with the resuscitation bundle had lapsed.

This study did not employ a control group, making it difficult to ascribe the improvement in compliance solely to the training given (some improvement in processes may have occurred independent of the training).

Bottom line: A national education effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality.

Citation: Ferrer R, Artigas A, Levy MM, et al. Improvement in process of care and outcomes after a multicenter severe sepsis educational program in Spain. JAMA 2008;299(19):2294-2303.

Can SSRI and problem-solving therapy reduce the incidence of depression in non-depressed patients with a recent stroke?

Background: Depression occurs in more than half of previously non-depressed patients after a stroke. Post-stroke depression is associated with impaired recovery and increased mortality.

Study design: A multicenter randomized controlled trial.

Setting: Two urban university-affiliated hospitals and a suburban rehabilitation hospital in the U.S.

Synopsis: 178 patients age 50 to 90 were enrolled within three months of an index stroke in a 12-month trial. The patients were randomized into three groups of a double-blind placebo control comparison of escitalopram with placebo, and non-blinded problem-solving therapy group.

During the period of the trial, patients on escitalopram experienced significant reductions in the incidence of depression versus placebo (23.1% vs. 34.5%). Problem-solving therapy did not result in significant benefit over the placebo.

The study results were limited by several factors. The study did not include all patients with acute stroke, employed a relatively small sample size, used a non-blinded psychological problem-solving therapy group, and had a high drop out rate.

Bottom line: Consider SSRI use to prevent depression in post-stroke patients.

Citation: Robinson RG, Jorge RE, Moser DJ, et. al. Escitalopram and problem-solving therapy for prevention of post stroke depression: a randomized controlled trial. JAMA 2008;299 (20):2391-2400

Do stop orders for indwelling urinary catheters reduce the duration of inappropriate urinary catheterization and incidence of urinary tract infection?

Background: About 25% of hospitalized patients have an indwelling urinary catheter inserted, and in 30% to 50% of these patients, urinary catheters are not indicated. Approximately 50% of patients with a catheter inserted for five days or more will develop bacteriuria with about 80% of hospital-acquired urinary tract infections occurring in patients with a urinary catheter.

Study design: A randomized controlled study.

Setting: Three tertiary care hospitals in Ontario, Canada.

Synopsis: 692 patients with indwelling urinary catheters admitted to seven general medical units in three tertiary care hospitals from January 2004 to June 2006 were randomized into two groups: 269 in the stop-order group, and 252 in the usual care group. Patients in the stop-order group had fewer days of inappropriate and total urinary catheter used (2.20 days) compared with the usual care group (3.89 days). There was no difference in the incidence of urinary tract infection between both groups.

Study results were limited by several factors, including a lack of control for exposure of participants to antimicrobials, missing urine cultures, and lack of evaluation of the effect of reducing urinary catheter use on mobility and quality of life. The 1.34-day reduction in the duration of catheterization may not be sufficient to significantly reduce bacteriuria.

Bottom line: Consider using stop orders in all patients with indwelling urinary catheters.

Citation: Loeb M, Hunt D, O’Halloran K, et. al. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized control trial. J Gen Intern Med 2008;23(6):816-820.

Does interrupting anticoagulation in patients with atrial fibrillation undergoing surgery cause an increased rate of thromboembolism?

Background: There is a known risk of thromboembolism (between 0.5% and 20% annually) in patients with atrial fibrillation. Studies are limited regarding the risk of thromboembolism with holding anticoagulation in the perioperative period for nonvalvular atrial fibrillation. This study attempted to answer this question.

Study design: Prospective cohort.

Setting: Thromboembolism clinic of the Mayo Clinic.

Synopsis: 345 patients with nonvalvular atrial fibrillation whose anticoagulation was perioperatively held were monitored for three months after surgery for thromboembolic events. Warfarin therapy was held for 5.3 days +/- three days before surgery and restarted 1.3 days +/- 3.4 days after surgery. Bridging heparin therapy was used for 204/386 procedures.

Four patients suffered six thromboembolic events; two patients while receiving bridging heparin therapy and two without heparin. The total incidence of thromboembolic events was 1.1%. This is compared with an expected incidence of 0.09% to 2.07% for patients with atrial fibrillation on warfarin. Bleeding complications rates were also low.

The authors recognized a possible selection bias and the fact patients who received bridging heparin therapy were not randomized. Despite these potential flaws, there seems to be minimal risk of holding anticoagulation in the perioperative period. Bridging heparin therapy added no additional benefit.

Bottom line: There is no increased risk of thromboembolism if anticoagulation is interrupted without bridging therapy in nonvalvular atrial fibrillation patients undergoing surgery.

Citation: Wysokinski WE, McBane RD, Daniels PR, et al. Periprocedural anticoagulation management of patients with nonvalvular atrial fibrillation. Mayo Clinic Proceedings 2008;83(6):639-645.

Are obese patients under-dosed when prescribed intravenous vancomycin?

Background: Weight-based vancomycin dosing has been recommended by the Infectious Diseases Society of America, yet flat dosing is still commonly employed. Flat dosing has the potential of increasing resistance and having adverse clinical effects.

Study design: Retrospective cohort.

Setting: Two tertiary care medical centers without pharmacy-guided vancomycin dosing programs.

Synopsis: A retrospective review was done of pharmacy prescription files at two tertiary care medical centers that did not have pharmacy-guided vancomycin programs. Patients were divided into cohorts based on their body mass index: underweight (<18.5 kg/sqm) normal weight (18.5-24.9 kg/sqm) overweight (25.0-29.9 kg/sqm) and obese (>29.9 kg/sqm). Each class was studied for rates of adequate vancomycin dosing which was defined as >10 mg/kg/dose. A total of 421 patients were included. There were no other dissimilar baseline characteristics. Total daily dose was similar for all groups with adequate initial dosing achieved in 100%, 99.0%, 93.9% and 27.7% for underweight, normal weight, overweight and obese patients, respectively.

Bottom line: Use weight-based dosing of vancomycin to limit the possibility of under-dosing in obese patients.

Citation: Hall RG, Payne KD, Bain AB, et al. Multicenter evaluation of vancomycin dosing: emphasis on obesity. Am J of Med. 2008;121:515-518.

What is the rate of adverse events with short-term antipsychotic therapy in elderly demented patients?

Study design: Population-based retrospective cohort study.

Setting: Community-dwelling cohort and nursing home cohort.

Synopsis: A cohort of patients from Ontario age 66 and older with the diagnosis of dementia and a prescription for an anti-psychotic drug between April 1, 1997, and March 31, 2004, were divided into two groups by where they lived (community or nursing home). Each cohort was further divided into three groups based on antipsychotic exposure of none, atypical, or conventional.

All serious adverse events (defined as extra-pyramidal symptoms (EPS), cerebrovascular events, and acute care hospital admission or death) were evaluated within 30 days of initiating therapy. In the community group, individuals who received conventional antipsychotic therapy were 3.8 times more likely to have an adverse event compared with the group taking no antipsychotics. The patients prescribed an atypical antipsychotic medicine were 3.2 times more likely to experience an adverse event. In the nursing home group, patients who received conventional and atypical antipsychotic therapy were 2.4 and 1.9 times more likely to have a serious adverse event, respectively.

Bottom line: Serious events are frequent following the short-term use of antipsychotic therapy in older adults with dementia. Serious adverse events were more common among those who received a prescription for conventional rather than atypical antipsychotic drugs.

Citation: Rochon PA, Normand SL, Gomes T, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008;168(10):1090-1096

What is the association between troponin levels and adverse events in hospitalized patients with acute decompensated heart failure?

Background: There were more than 1 million hospitalizations for heart failure in 2007, making it the most costly medical condition based on diagnosis and treatment. Evidence suggests an initial risk stratification process allows for earlier implementation of aggressive therapy, which can affect hospital utilization.

Study design: Retrospective analysis of Acute Decompensated Heart Failure National Registry (ADHERE).

Setting: Hospitalization records from 274 hospitals from October 2001 to January 2004.

Synopsis: Evaluation of the data from ADHERE for outcomes associated with elevated troponin levels in patients with acute decompensated heart failure (ADHF). Patients who had a creatinine level above 2.0 mg per deciliter were excluded.

Cardiac troponin I was measured in 61,379 patients and cardiac troponin T in 7880 patients. Overall, 4,240 patients (6.2%) had an elevated troponin level. Troponin positive patients had a higher rate of in-hospital mortality than troponin negative patients (8.0% vs. 2.7%, P<0.001). The adjusted odds ratio for death among patients with a positive troponin test was 2.55. Ischemic heart failure was present in 53% of the troponin positive patients and was not a useful predictor of troponin status or mortality.

Bottom line: Measurement of troponin is an important prognostic indicator in the initial evaluation of patients with ADHF. This early assessment of risk should be factored into medical decisions with respect to triage and medical management.

Citation: Peacock FW, De Marco T, Fonarow GC, et al. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008;358:2117-26

Literature at a Glance

• ICU management by critical care physicians may increase the odds of hospital mortality
• Iatrogenic drug overdose common among patients with renal insufficiency
• An educational effort lowers hospital mortality for severe sepsis and septic shock
• SSRI and problem-solving therapy prevents post-stroke depression
• Stop orders for Foley catheters reduce the duration of inappropriate urinary catheterization
• No thromboembolism risk with interrupting anticoagulation in atrial fibrillation patients undergoing surgery
• Obese patients may be initially under-dosed with vancomycin
• Antipsychotic therapy is associated with short-term serious events in older adults with dementia
• Cardiac troponin is associated with worse outcome in acute heart failure

Does management of ICU patients by critical care physicians reduce mortality?

Background: There is variation in the extent of involvement by critical care physicians in managing patients in ICUs. Several small studies have demonstrated improved outcomes when patients are managed by critical care physicians. This study expanded these findings by examining a national database of multiple ICUs.

Study design: Retrospective database analysis.

Setting: 123 ICUs in 100 U.S. hospitals

Synopsis: Using a national database of ICU patients, 101,832 admissions were analyzed. Controlling for ICU characteristics, patient demographics, and severity of illness (SOI), the impact of critical care management (CCM) on the primary outcome of hospital mortality was analyzed. Patients who received CCM had higher SOI, received more procedures, and had higher mortality rates than those who did not receive CCM. After adjustment for these variables, hospital mortality rates were higher for those patients who received CCM.

Because this was a retrospective analysis, it is not possible to state there was a causal relationship between care by a critical care physician and worse outcome. Other unmeasured clinical differences between the patients receiving CCM and those that did not may have existed that resulted in the higher mortality. Additionally, although the database identified management by a critical care physician, it did not differentiate whether the management was by a full-time intensivist. Therefore, conclusions cannot be made regarding the value of full-time, on-site intensivist management.

Bottom line: Additional analysis is required to determine the value of intensivists in the management of critically ill patients.

Citation: Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Int Med 2008; 148: 801-809.

What is the frequency of iatrogenic drug overdose in patients with renal insufficiency?

Background: The Institute of Medicine Report, “To Err is Human” suggested 7,000 deaths occur annually because of medication errors. Renal insufficiency is relatively common in hospitalized patients. Previous studies have suggested overdose of medications is frequent in patients with renal insufficiency. There is a lack of large-scale studies identifying the most commonly overdosed medications and the predictive physician factors for these errors.

Study design: Retrospective observational study.

Setting: A single 1,080-bed tertiary teaching hospital

Synopsis: A clinical data mart was constructed that contained 48 months of prescription data, serum creatinine levels, along with physician characteristics. 28,954 patients with renal insufficiency had 431,119 prescription orders to analyze. 3.5% of drug doses were found excessive. The overdose rate in patients with moderate to severe renal insufficiency was 28.2%. 10 drugs accounted for 85.4% of the overdoses. There was a negative correlation between physician clinical experience and overdose rate.

Study results are limited by the study’s retrospective nature. Further, the prescribed dose was presumed to be the dose actually administered, and there were no data on the actual doses given to patients. The study was limited to a single institution and may not be generalizable.

Bottom line: Iatrogenic drug overdose is quite common among inpatients with renal insufficiency. Only a few drugs are commonly responsible. The physicians’ clinical experience, workload of prescriptions, and patients’ renal function correlated with overdose.

Citation: Sheen SS, Choi JE, Park RW, Kim EY, Lee YH, Kang UG. Overdoser rate of drugs requiring renal dose adjustment: data analysis of 4 years prescriptions at a tertiary teaching hospital. J Gen Intern Med 2007;23(4):423-8

Will a national education program based on the “Surviving Sepsis Campaign” guidelines improve survival and processes of care?

Background: Sepsis is one of the most prevalent diseases and one of the main causes of death among hospitalized patients. Several single-center studies have suggested quality improvement efforts based on the Surviving Sepsis Guidelines were associated with better outcomes.

Study design: Prospective multicenter before-and-after study design.

Setting: 59 medical and surgical ICUs throughout Spain.

Synopsis: 854 patients with severe sepsis were enrolled in the pre–intervention group. The intervention consisted of education on the use of bundles of care. The treatment was organized into two bundles: a resuscitation bundle (six tasks to be performed within six hours) and a management bundle (four tasks to be completed within 24 hours). 1,465 patients were enrolled in the post-training period. Hospital mortality, adherence to the bundles, ICU mortality, 28-day mortality, hospital and ICU length of stay were measured.

Patients in the post-intervention group had lower mortality (44.0% vs. 39.5% P=0.04) and better compliance with the bundles improved. No other outcomes improved. One year later, mortality gains persisted but compliance with the resuscitation bundle had lapsed.

This study did not employ a control group, making it difficult to ascribe the improvement in compliance solely to the training given (some improvement in processes may have occurred independent of the training).

Bottom line: A national education effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality.

Citation: Ferrer R, Artigas A, Levy MM, et al. Improvement in process of care and outcomes after a multicenter severe sepsis educational program in Spain. JAMA 2008;299(19):2294-2303.

Can SSRI and problem-solving therapy reduce the incidence of depression in non-depressed patients with a recent stroke?

Background: Depression occurs in more than half of previously non-depressed patients after a stroke. Post-stroke depression is associated with impaired recovery and increased mortality.

Study design: A multicenter randomized controlled trial.

Setting: Two urban university-affiliated hospitals and a suburban rehabilitation hospital in the U.S.

Synopsis: 178 patients age 50 to 90 were enrolled within three months of an index stroke in a 12-month trial. The patients were randomized into three groups of a double-blind placebo control comparison of escitalopram with placebo, and non-blinded problem-solving therapy group.

During the period of the trial, patients on escitalopram experienced significant reductions in the incidence of depression versus placebo (23.1% vs. 34.5%). Problem-solving therapy did not result in significant benefit over the placebo.

The study results were limited by several factors. The study did not include all patients with acute stroke, employed a relatively small sample size, used a non-blinded psychological problem-solving therapy group, and had a high drop out rate.

Bottom line: Consider SSRI use to prevent depression in post-stroke patients.

Citation: Robinson RG, Jorge RE, Moser DJ, et. al. Escitalopram and problem-solving therapy for prevention of post stroke depression: a randomized controlled trial. JAMA 2008;299 (20):2391-2400

Do stop orders for indwelling urinary catheters reduce the duration of inappropriate urinary catheterization and incidence of urinary tract infection?

Background: About 25% of hospitalized patients have an indwelling urinary catheter inserted, and in 30% to 50% of these patients, urinary catheters are not indicated. Approximately 50% of patients with a catheter inserted for five days or more will develop bacteriuria with about 80% of hospital-acquired urinary tract infections occurring in patients with a urinary catheter.

Study design: A randomized controlled study.

Setting: Three tertiary care hospitals in Ontario, Canada.

Synopsis: 692 patients with indwelling urinary catheters admitted to seven general medical units in three tertiary care hospitals from January 2004 to June 2006 were randomized into two groups: 269 in the stop-order group, and 252 in the usual care group. Patients in the stop-order group had fewer days of inappropriate and total urinary catheter used (2.20 days) compared with the usual care group (3.89 days). There was no difference in the incidence of urinary tract infection between both groups.

Study results were limited by several factors, including a lack of control for exposure of participants to antimicrobials, missing urine cultures, and lack of evaluation of the effect of reducing urinary catheter use on mobility and quality of life. The 1.34-day reduction in the duration of catheterization may not be sufficient to significantly reduce bacteriuria.

Bottom line: Consider using stop orders in all patients with indwelling urinary catheters.

Citation: Loeb M, Hunt D, O’Halloran K, et. al. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized control trial. J Gen Intern Med 2008;23(6):816-820.

Does interrupting anticoagulation in patients with atrial fibrillation undergoing surgery cause an increased rate of thromboembolism?

Background: There is a known risk of thromboembolism (between 0.5% and 20% annually) in patients with atrial fibrillation. Studies are limited regarding the risk of thromboembolism with holding anticoagulation in the perioperative period for nonvalvular atrial fibrillation. This study attempted to answer this question.

Study design: Prospective cohort.

Setting: Thromboembolism clinic of the Mayo Clinic.

Synopsis: 345 patients with nonvalvular atrial fibrillation whose anticoagulation was perioperatively held were monitored for three months after surgery for thromboembolic events. Warfarin therapy was held for 5.3 days +/- three days before surgery and restarted 1.3 days +/- 3.4 days after surgery. Bridging heparin therapy was used for 204/386 procedures.

Four patients suffered six thromboembolic events; two patients while receiving bridging heparin therapy and two without heparin. The total incidence of thromboembolic events was 1.1%. This is compared with an expected incidence of 0.09% to 2.07% for patients with atrial fibrillation on warfarin. Bleeding complications rates were also low.

The authors recognized a possible selection bias and the fact patients who received bridging heparin therapy were not randomized. Despite these potential flaws, there seems to be minimal risk of holding anticoagulation in the perioperative period. Bridging heparin therapy added no additional benefit.

Bottom line: There is no increased risk of thromboembolism if anticoagulation is interrupted without bridging therapy in nonvalvular atrial fibrillation patients undergoing surgery.

Citation: Wysokinski WE, McBane RD, Daniels PR, et al. Periprocedural anticoagulation management of patients with nonvalvular atrial fibrillation. Mayo Clinic Proceedings 2008;83(6):639-645.

Are obese patients under-dosed when prescribed intravenous vancomycin?

Background: Weight-based vancomycin dosing has been recommended by the Infectious Diseases Society of America, yet flat dosing is still commonly employed. Flat dosing has the potential of increasing resistance and having adverse clinical effects.

Study design: Retrospective cohort.

Setting: Two tertiary care medical centers without pharmacy-guided vancomycin dosing programs.

Synopsis: A retrospective review was done of pharmacy prescription files at two tertiary care medical centers that did not have pharmacy-guided vancomycin programs. Patients were divided into cohorts based on their body mass index: underweight (<18.5 kg/sqm) normal weight (18.5-24.9 kg/sqm) overweight (25.0-29.9 kg/sqm) and obese (>29.9 kg/sqm). Each class was studied for rates of adequate vancomycin dosing which was defined as >10 mg/kg/dose. A total of 421 patients were included. There were no other dissimilar baseline characteristics. Total daily dose was similar for all groups with adequate initial dosing achieved in 100%, 99.0%, 93.9% and 27.7% for underweight, normal weight, overweight and obese patients, respectively.

Bottom line: Use weight-based dosing of vancomycin to limit the possibility of under-dosing in obese patients.

Citation: Hall RG, Payne KD, Bain AB, et al. Multicenter evaluation of vancomycin dosing: emphasis on obesity. Am J of Med. 2008;121:515-518.

What is the rate of adverse events with short-term antipsychotic therapy in elderly demented patients?

Study design: Population-based retrospective cohort study.

Setting: Community-dwelling cohort and nursing home cohort.

Synopsis: A cohort of patients from Ontario age 66 and older with the diagnosis of dementia and a prescription for an anti-psychotic drug between April 1, 1997, and March 31, 2004, were divided into two groups by where they lived (community or nursing home). Each cohort was further divided into three groups based on antipsychotic exposure of none, atypical, or conventional.

All serious adverse events (defined as extra-pyramidal symptoms (EPS), cerebrovascular events, and acute care hospital admission or death) were evaluated within 30 days of initiating therapy. In the community group, individuals who received conventional antipsychotic therapy were 3.8 times more likely to have an adverse event compared with the group taking no antipsychotics. The patients prescribed an atypical antipsychotic medicine were 3.2 times more likely to experience an adverse event. In the nursing home group, patients who received conventional and atypical antipsychotic therapy were 2.4 and 1.9 times more likely to have a serious adverse event, respectively.

Bottom line: Serious events are frequent following the short-term use of antipsychotic therapy in older adults with dementia. Serious adverse events were more common among those who received a prescription for conventional rather than atypical antipsychotic drugs.

Citation: Rochon PA, Normand SL, Gomes T, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008;168(10):1090-1096

What is the association between troponin levels and adverse events in hospitalized patients with acute decompensated heart failure?

Background: There were more than 1 million hospitalizations for heart failure in 2007, making it the most costly medical condition based on diagnosis and treatment. Evidence suggests an initial risk stratification process allows for earlier implementation of aggressive therapy, which can affect hospital utilization.

Study design: Retrospective analysis of Acute Decompensated Heart Failure National Registry (ADHERE).

Setting: Hospitalization records from 274 hospitals from October 2001 to January 2004.

Synopsis: Evaluation of the data from ADHERE for outcomes associated with elevated troponin levels in patients with acute decompensated heart failure (ADHF). Patients who had a creatinine level above 2.0 mg per deciliter were excluded.

Cardiac troponin I was measured in 61,379 patients and cardiac troponin T in 7880 patients. Overall, 4,240 patients (6.2%) had an elevated troponin level. Troponin positive patients had a higher rate of in-hospital mortality than troponin negative patients (8.0% vs. 2.7%, P<0.001). The adjusted odds ratio for death among patients with a positive troponin test was 2.55. Ischemic heart failure was present in 53% of the troponin positive patients and was not a useful predictor of troponin status or mortality.

Bottom line: Measurement of troponin is an important prognostic indicator in the initial evaluation of patients with ADHF. This early assessment of risk should be factored into medical decisions with respect to triage and medical management.

Citation: Peacock FW, De Marco T, Fonarow GC, et al. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008;358:2117-26

Literature at a Glance

• ICU management by critical care physicians may increase the odds of hospital mortality
• Iatrogenic drug overdose common among patients with renal insufficiency
• An educational effort lowers hospital mortality for severe sepsis and septic shock
• SSRI and problem-solving therapy prevents post-stroke depression
• Stop orders for Foley catheters reduce the duration of inappropriate urinary catheterization
• No thromboembolism risk with interrupting anticoagulation in atrial fibrillation patients undergoing surgery
• Obese patients may be initially under-dosed with vancomycin
• Antipsychotic therapy is associated with short-term serious events in older adults with dementia
• Cardiac troponin is associated with worse outcome in acute heart failure

Does management of ICU patients by critical care physicians reduce mortality?

Background: There is variation in the extent of involvement by critical care physicians in managing patients in ICUs. Several small studies have demonstrated improved outcomes when patients are managed by critical care physicians. This study expanded these findings by examining a national database of multiple ICUs.

Study design: Retrospective database analysis.

Setting: 123 ICUs in 100 U.S. hospitals

Synopsis: Using a national database of ICU patients, 101,832 admissions were analyzed. Controlling for ICU characteristics, patient demographics, and severity of illness (SOI), the impact of critical care management (CCM) on the primary outcome of hospital mortality was analyzed. Patients who received CCM had higher SOI, received more procedures, and had higher mortality rates than those who did not receive CCM. After adjustment for these variables, hospital mortality rates were higher for those patients who received CCM.

Because this was a retrospective analysis, it is not possible to state there was a causal relationship between care by a critical care physician and worse outcome. Other unmeasured clinical differences between the patients receiving CCM and those that did not may have existed that resulted in the higher mortality. Additionally, although the database identified management by a critical care physician, it did not differentiate whether the management was by a full-time intensivist. Therefore, conclusions cannot be made regarding the value of full-time, on-site intensivist management.

Bottom line: Additional analysis is required to determine the value of intensivists in the management of critically ill patients.

Citation: Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Int Med 2008; 148: 801-809.

What is the frequency of iatrogenic drug overdose in patients with renal insufficiency?

Background: The Institute of Medicine Report, “To Err is Human” suggested 7,000 deaths occur annually because of medication errors. Renal insufficiency is relatively common in hospitalized patients. Previous studies have suggested overdose of medications is frequent in patients with renal insufficiency. There is a lack of large-scale studies identifying the most commonly overdosed medications and the predictive physician factors for these errors.

Study design: Retrospective observational study.

Setting: A single 1,080-bed tertiary teaching hospital

Synopsis: A clinical data mart was constructed that contained 48 months of prescription data, serum creatinine levels, along with physician characteristics. 28,954 patients with renal insufficiency had 431,119 prescription orders to analyze. 3.5% of drug doses were found excessive. The overdose rate in patients with moderate to severe renal insufficiency was 28.2%. 10 drugs accounted for 85.4% of the overdoses. There was a negative correlation between physician clinical experience and overdose rate.

Study results are limited by the study’s retrospective nature. Further, the prescribed dose was presumed to be the dose actually administered, and there were no data on the actual doses given to patients. The study was limited to a single institution and may not be generalizable.

Bottom line: Iatrogenic drug overdose is quite common among inpatients with renal insufficiency. Only a few drugs are commonly responsible. The physicians’ clinical experience, workload of prescriptions, and patients’ renal function correlated with overdose.

Citation: Sheen SS, Choi JE, Park RW, Kim EY, Lee YH, Kang UG. Overdoser rate of drugs requiring renal dose adjustment: data analysis of 4 years prescriptions at a tertiary teaching hospital. J Gen Intern Med 2007;23(4):423-8

Will a national education program based on the “Surviving Sepsis Campaign” guidelines improve survival and processes of care?

Background: Sepsis is one of the most prevalent diseases and one of the main causes of death among hospitalized patients. Several single-center studies have suggested quality improvement efforts based on the Surviving Sepsis Guidelines were associated with better outcomes.

Study design: Prospective multicenter before-and-after study design.

Setting: 59 medical and surgical ICUs throughout Spain.

Synopsis: 854 patients with severe sepsis were enrolled in the pre–intervention group. The intervention consisted of education on the use of bundles of care. The treatment was organized into two bundles: a resuscitation bundle (six tasks to be performed within six hours) and a management bundle (four tasks to be completed within 24 hours). 1,465 patients were enrolled in the post-training period. Hospital mortality, adherence to the bundles, ICU mortality, 28-day mortality, hospital and ICU length of stay were measured.

Patients in the post-intervention group had lower mortality (44.0% vs. 39.5% P=0.04) and better compliance with the bundles improved. No other outcomes improved. One year later, mortality gains persisted but compliance with the resuscitation bundle had lapsed.

This study did not employ a control group, making it difficult to ascribe the improvement in compliance solely to the training given (some improvement in processes may have occurred independent of the training).

Bottom line: A national education effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality.

Citation: Ferrer R, Artigas A, Levy MM, et al. Improvement in process of care and outcomes after a multicenter severe sepsis educational program in Spain. JAMA 2008;299(19):2294-2303.

Can SSRI and problem-solving therapy reduce the incidence of depression in non-depressed patients with a recent stroke?

Background: Depression occurs in more than half of previously non-depressed patients after a stroke. Post-stroke depression is associated with impaired recovery and increased mortality.

Study design: A multicenter randomized controlled trial.

Setting: Two urban university-affiliated hospitals and a suburban rehabilitation hospital in the U.S.

Synopsis: 178 patients age 50 to 90 were enrolled within three months of an index stroke in a 12-month trial. The patients were randomized into three groups of a double-blind placebo control comparison of escitalopram with placebo, and non-blinded problem-solving therapy group.

During the period of the trial, patients on escitalopram experienced significant reductions in the incidence of depression versus placebo (23.1% vs. 34.5%). Problem-solving therapy did not result in significant benefit over the placebo.

The study results were limited by several factors. The study did not include all patients with acute stroke, employed a relatively small sample size, used a non-blinded psychological problem-solving therapy group, and had a high drop out rate.

Bottom line: Consider SSRI use to prevent depression in post-stroke patients.

Citation: Robinson RG, Jorge RE, Moser DJ, et. al. Escitalopram and problem-solving therapy for prevention of post stroke depression: a randomized controlled trial. JAMA 2008;299 (20):2391-2400

Do stop orders for indwelling urinary catheters reduce the duration of inappropriate urinary catheterization and incidence of urinary tract infection?

Background: About 25% of hospitalized patients have an indwelling urinary catheter inserted, and in 30% to 50% of these patients, urinary catheters are not indicated. Approximately 50% of patients with a catheter inserted for five days or more will develop bacteriuria with about 80% of hospital-acquired urinary tract infections occurring in patients with a urinary catheter.

Study design: A randomized controlled study.

Setting: Three tertiary care hospitals in Ontario, Canada.

Synopsis: 692 patients with indwelling urinary catheters admitted to seven general medical units in three tertiary care hospitals from January 2004 to June 2006 were randomized into two groups: 269 in the stop-order group, and 252 in the usual care group. Patients in the stop-order group had fewer days of inappropriate and total urinary catheter used (2.20 days) compared with the usual care group (3.89 days). There was no difference in the incidence of urinary tract infection between both groups.

Study results were limited by several factors, including a lack of control for exposure of participants to antimicrobials, missing urine cultures, and lack of evaluation of the effect of reducing urinary catheter use on mobility and quality of life. The 1.34-day reduction in the duration of catheterization may not be sufficient to significantly reduce bacteriuria.

Bottom line: Consider using stop orders in all patients with indwelling urinary catheters.

Citation: Loeb M, Hunt D, O’Halloran K, et. al. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized control trial. J Gen Intern Med 2008;23(6):816-820.

Does interrupting anticoagulation in patients with atrial fibrillation undergoing surgery cause an increased rate of thromboembolism?

Background: There is a known risk of thromboembolism (between 0.5% and 20% annually) in patients with atrial fibrillation. Studies are limited regarding the risk of thromboembolism with holding anticoagulation in the perioperative period for nonvalvular atrial fibrillation. This study attempted to answer this question.

Study design: Prospective cohort.

Setting: Thromboembolism clinic of the Mayo Clinic.

Synopsis: 345 patients with nonvalvular atrial fibrillation whose anticoagulation was perioperatively held were monitored for three months after surgery for thromboembolic events. Warfarin therapy was held for 5.3 days +/- three days before surgery and restarted 1.3 days +/- 3.4 days after surgery. Bridging heparin therapy was used for 204/386 procedures.

Four patients suffered six thromboembolic events; two patients while receiving bridging heparin therapy and two without heparin. The total incidence of thromboembolic events was 1.1%. This is compared with an expected incidence of 0.09% to 2.07% for patients with atrial fibrillation on warfarin. Bleeding complications rates were also low.

The authors recognized a possible selection bias and the fact patients who received bridging heparin therapy were not randomized. Despite these potential flaws, there seems to be minimal risk of holding anticoagulation in the perioperative period. Bridging heparin therapy added no additional benefit.

Bottom line: There is no increased risk of thromboembolism if anticoagulation is interrupted without bridging therapy in nonvalvular atrial fibrillation patients undergoing surgery.

Citation: Wysokinski WE, McBane RD, Daniels PR, et al. Periprocedural anticoagulation management of patients with nonvalvular atrial fibrillation. Mayo Clinic Proceedings 2008;83(6):639-645.

Are obese patients under-dosed when prescribed intravenous vancomycin?

Background: Weight-based vancomycin dosing has been recommended by the Infectious Diseases Society of America, yet flat dosing is still commonly employed. Flat dosing has the potential of increasing resistance and having adverse clinical effects.

Study design: Retrospective cohort.

Setting: Two tertiary care medical centers without pharmacy-guided vancomycin dosing programs.

Synopsis: A retrospective review was done of pharmacy prescription files at two tertiary care medical centers that did not have pharmacy-guided vancomycin programs. Patients were divided into cohorts based on their body mass index: underweight (<18.5 kg/sqm) normal weight (18.5-24.9 kg/sqm) overweight (25.0-29.9 kg/sqm) and obese (>29.9 kg/sqm). Each class was studied for rates of adequate vancomycin dosing which was defined as >10 mg/kg/dose. A total of 421 patients were included. There were no other dissimilar baseline characteristics. Total daily dose was similar for all groups with adequate initial dosing achieved in 100%, 99.0%, 93.9% and 27.7% for underweight, normal weight, overweight and obese patients, respectively.

Bottom line: Use weight-based dosing of vancomycin to limit the possibility of under-dosing in obese patients.

Citation: Hall RG, Payne KD, Bain AB, et al. Multicenter evaluation of vancomycin dosing: emphasis on obesity. Am J of Med. 2008;121:515-518.

What is the rate of adverse events with short-term antipsychotic therapy in elderly demented patients?

Study design: Population-based retrospective cohort study.

Setting: Community-dwelling cohort and nursing home cohort.

Synopsis: A cohort of patients from Ontario age 66 and older with the diagnosis of dementia and a prescription for an anti-psychotic drug between April 1, 1997, and March 31, 2004, were divided into two groups by where they lived (community or nursing home). Each cohort was further divided into three groups based on antipsychotic exposure of none, atypical, or conventional.

All serious adverse events (defined as extra-pyramidal symptoms (EPS), cerebrovascular events, and acute care hospital admission or death) were evaluated within 30 days of initiating therapy. In the community group, individuals who received conventional antipsychotic therapy were 3.8 times more likely to have an adverse event compared with the group taking no antipsychotics. The patients prescribed an atypical antipsychotic medicine were 3.2 times more likely to experience an adverse event. In the nursing home group, patients who received conventional and atypical antipsychotic therapy were 2.4 and 1.9 times more likely to have a serious adverse event, respectively.

Bottom line: Serious events are frequent following the short-term use of antipsychotic therapy in older adults with dementia. Serious adverse events were more common among those who received a prescription for conventional rather than atypical antipsychotic drugs.

Citation: Rochon PA, Normand SL, Gomes T, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008;168(10):1090-1096

What is the association between troponin levels and adverse events in hospitalized patients with acute decompensated heart failure?

Background: There were more than 1 million hospitalizations for heart failure in 2007, making it the most costly medical condition based on diagnosis and treatment. Evidence suggests an initial risk stratification process allows for earlier implementation of aggressive therapy, which can affect hospital utilization.

Study design: Retrospective analysis of Acute Decompensated Heart Failure National Registry (ADHERE).

Setting: Hospitalization records from 274 hospitals from October 2001 to January 2004.

Synopsis: Evaluation of the data from ADHERE for outcomes associated with elevated troponin levels in patients with acute decompensated heart failure (ADHF). Patients who had a creatinine level above 2.0 mg per deciliter were excluded.

Cardiac troponin I was measured in 61,379 patients and cardiac troponin T in 7880 patients. Overall, 4,240 patients (6.2%) had an elevated troponin level. Troponin positive patients had a higher rate of in-hospital mortality than troponin negative patients (8.0% vs. 2.7%, P<0.001). The adjusted odds ratio for death among patients with a positive troponin test was 2.55. Ischemic heart failure was present in 53% of the troponin positive patients and was not a useful predictor of troponin status or mortality.

Bottom line: Measurement of troponin is an important prognostic indicator in the initial evaluation of patients with ADHF. This early assessment of risk should be factored into medical decisions with respect to triage and medical management.

Citation: Peacock FW, De Marco T, Fonarow GC, et al. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008;358:2117-26

In the last year, SHM has made great strides in improving the user experience at www. hospitalmedicine.org. Now it’s easier than ever to keep up with the latest news from the fastest-growing specialty in the history of modern healthcare. In an effort to bring as much energy as possible to this cutting-edge specialty, SHM strives to expand our online tools by offering our members the latest resources in education, events and publications over the newest mediums available. Like hospital medicine, Web 2.0 is a trend on the rise. From blogs to podcasts to our new RSS feeds, you will notice many new applications throughout SHM’s site.

hospitalmedicine.org: New and Improved

The first step in setting this new approach into motion was a complete overhaul of SHM’s Web site. This major renovation set the stage for a variety of new features, including seven resource rooms focused on Quality Improvement and supplemental clinical tools, as well as the introduction of online discussion forums and the SHM Career Center.

New Event Sites

Following our Web site expansion, we introduced several specialty sites for our most popular products, including SHM’s “2007-2008 State of the Hospital Medicine Movement” survey, as well as SHM’s Leadership Academy, Annual Meeting, and (coming soon) SHM’s One Day University.

These sites offer inside information about product news, meeting topics, curricula, and exclusive member offers. This year’s Hospital Medicine 2009 (HM09) site features more than 40 presentations from Hospital Medicine 2008 (HM08) for users to view such topics as quality improvement, operations, and clinical. With year-round access to resources, information from past meetings isn’t lost. It can be retrieved daily for practicing hospitalists.

Blogs

SHM first introduced blogs to our members in 2007 with the launch of “Wachter’s World” (www.wachtersworld.org), as well as the HM07 blog, which featured an inside look at the goings-on at the annual meeting. Blogs create an interactive forum to discuss relevant issues on a daily basis and introduce readers to the perspectives of some of the most reputable hospitalists in the specialty today.

This year, we expanded our blogs to reflect on past events, offering participants a chance to share highlights and feedback from our annual meetings. Not only does this help our members keep current on hospital medicine news, but it also provides an outlet to voice opinions and help influence the direction of the society.

click for large version

Podcasts

For those of you who enjoy auditory learning, you will find podcasts attached to event pages and CME listings. Our podcast library features guests, such as featured keynote speakers, industry specialists, SHM board members, and event attendees. Be on the lookout for SHM team members at upcoming events, as you may have the opportunity for a podcast interview of your own!

RSS Feeds

In June 2008 SHM created its own RSS feed, offering biweekly updates. Subscribers to SHM’s RSS feed receive up-to-the minute news streaming to their e-mail/PDAs, with updates ranging from SHM’s organizational growth and development to relative changes in legislation/public policy and anything relating to hospital medicine. Subscribe today so that you don’t miss the most current updates to hospitalmedicine.org.

Social Networking

Networking always has been one of the most important benefits of SHM membership. From communicating with local hospitalists at chapter meetings, to national and international colleagues at our annual meeting, there is a sense of community among those in the hospital medicine field. SHM recognizes the importance of building this community and has taken networking to a new level through participation in social networking sites such as Facebook and LinkedIn. If you currently are a user of these sites, join the SHM group and get connected!

All of these resources are at your fingertips. Visit us online at www.hospitalmedicine.org to try out one or all of these new features and upgrade your SHM experience. TH

In the last year, SHM has made great strides in improving the user experience at www. hospitalmedicine.org. Now it’s easier than ever to keep up with the latest news from the fastest-growing specialty in the history of modern healthcare. In an effort to bring as much energy as possible to this cutting-edge specialty, SHM strives to expand our online tools by offering our members the latest resources in education, events and publications over the newest mediums available. Like hospital medicine, Web 2.0 is a trend on the rise. From blogs to podcasts to our new RSS feeds, you will notice many new applications throughout SHM’s site.

hospitalmedicine.org: New and Improved

The first step in setting this new approach into motion was a complete overhaul of SHM’s Web site. This major renovation set the stage for a variety of new features, including seven resource rooms focused on Quality Improvement and supplemental clinical tools, as well as the introduction of online discussion forums and the SHM Career Center.

New Event Sites

Following our Web site expansion, we introduced several specialty sites for our most popular products, including SHM’s “2007-2008 State of the Hospital Medicine Movement” survey, as well as SHM’s Leadership Academy, Annual Meeting, and (coming soon) SHM’s One Day University.

These sites offer inside information about product news, meeting topics, curricula, and exclusive member offers. This year’s Hospital Medicine 2009 (HM09) site features more than 40 presentations from Hospital Medicine 2008 (HM08) for users to view such topics as quality improvement, operations, and clinical. With year-round access to resources, information from past meetings isn’t lost. It can be retrieved daily for practicing hospitalists.

Blogs

SHM first introduced blogs to our members in 2007 with the launch of “Wachter’s World” (www.wachtersworld.org), as well as the HM07 blog, which featured an inside look at the goings-on at the annual meeting. Blogs create an interactive forum to discuss relevant issues on a daily basis and introduce readers to the perspectives of some of the most reputable hospitalists in the specialty today.

This year, we expanded our blogs to reflect on past events, offering participants a chance to share highlights and feedback from our annual meetings. Not only does this help our members keep current on hospital medicine news, but it also provides an outlet to voice opinions and help influence the direction of the society.

click for large version

Podcasts

For those of you who enjoy auditory learning, you will find podcasts attached to event pages and CME listings. Our podcast library features guests, such as featured keynote speakers, industry specialists, SHM board members, and event attendees. Be on the lookout for SHM team members at upcoming events, as you may have the opportunity for a podcast interview of your own!

RSS Feeds

In June 2008 SHM created its own RSS feed, offering biweekly updates. Subscribers to SHM’s RSS feed receive up-to-the minute news streaming to their e-mail/PDAs, with updates ranging from SHM’s organizational growth and development to relative changes in legislation/public policy and anything relating to hospital medicine. Subscribe today so that you don’t miss the most current updates to hospitalmedicine.org.

Social Networking

Networking always has been one of the most important benefits of SHM membership. From communicating with local hospitalists at chapter meetings, to national and international colleagues at our annual meeting, there is a sense of community among those in the hospital medicine field. SHM recognizes the importance of building this community and has taken networking to a new level through participation in social networking sites such as Facebook and LinkedIn. If you currently are a user of these sites, join the SHM group and get connected!

All of these resources are at your fingertips. Visit us online at www.hospitalmedicine.org to try out one or all of these new features and upgrade your SHM experience. TH

In the last year, SHM has made great strides in improving the user experience at www. hospitalmedicine.org. Now it’s easier than ever to keep up with the latest news from the fastest-growing specialty in the history of modern healthcare. In an effort to bring as much energy as possible to this cutting-edge specialty, SHM strives to expand our online tools by offering our members the latest resources in education, events and publications over the newest mediums available. Like hospital medicine, Web 2.0 is a trend on the rise. From blogs to podcasts to our new RSS feeds, you will notice many new applications throughout SHM’s site.

hospitalmedicine.org: New and Improved

The first step in setting this new approach into motion was a complete overhaul of SHM’s Web site. This major renovation set the stage for a variety of new features, including seven resource rooms focused on Quality Improvement and supplemental clinical tools, as well as the introduction of online discussion forums and the SHM Career Center.

New Event Sites

Following our Web site expansion, we introduced several specialty sites for our most popular products, including SHM’s “2007-2008 State of the Hospital Medicine Movement” survey, as well as SHM’s Leadership Academy, Annual Meeting, and (coming soon) SHM’s One Day University.

These sites offer inside information about product news, meeting topics, curricula, and exclusive member offers. This year’s Hospital Medicine 2009 (HM09) site features more than 40 presentations from Hospital Medicine 2008 (HM08) for users to view such topics as quality improvement, operations, and clinical. With year-round access to resources, information from past meetings isn’t lost. It can be retrieved daily for practicing hospitalists.

Blogs

SHM first introduced blogs to our members in 2007 with the launch of “Wachter’s World” (www.wachtersworld.org), as well as the HM07 blog, which featured an inside look at the goings-on at the annual meeting. Blogs create an interactive forum to discuss relevant issues on a daily basis and introduce readers to the perspectives of some of the most reputable hospitalists in the specialty today.

This year, we expanded our blogs to reflect on past events, offering participants a chance to share highlights and feedback from our annual meetings. Not only does this help our members keep current on hospital medicine news, but it also provides an outlet to voice opinions and help influence the direction of the society.

click for large version

Podcasts

For those of you who enjoy auditory learning, you will find podcasts attached to event pages and CME listings. Our podcast library features guests, such as featured keynote speakers, industry specialists, SHM board members, and event attendees. Be on the lookout for SHM team members at upcoming events, as you may have the opportunity for a podcast interview of your own!

RSS Feeds

In June 2008 SHM created its own RSS feed, offering biweekly updates. Subscribers to SHM’s RSS feed receive up-to-the minute news streaming to their e-mail/PDAs, with updates ranging from SHM’s organizational growth and development to relative changes in legislation/public policy and anything relating to hospital medicine. Subscribe today so that you don’t miss the most current updates to hospitalmedicine.org.

Social Networking

Networking always has been one of the most important benefits of SHM membership. From communicating with local hospitalists at chapter meetings, to national and international colleagues at our annual meeting, there is a sense of community among those in the hospital medicine field. SHM recognizes the importance of building this community and has taken networking to a new level through participation in social networking sites such as Facebook and LinkedIn. If you currently are a user of these sites, join the SHM group and get connected!

All of these resources are at your fingertips. Visit us online at www.hospitalmedicine.org to try out one or all of these new features and upgrade your SHM experience. TH

I am a hospitalist outsider. A traditional internist, I cared for my patients in and out of the hospital, provided ICU and unassigned ED call, and later transitioned to hospital-only work. Our group developed a hospitalist program and has, hopefully, run an above-average system growing with our community. Even performing full-time hospital work, it took me a year to get over being referred to as a “hospitalist.” It seemed a confining label.

I also feel like an outsider while reading hospitalist literature’s divergent messages to hospitalists. On one hand, I hear great things about how hospitalists will revolutionize healthcare, spearheading improvements in safety, efficiency, and satisfaction, and filling administrative roles. I then see articles about negotiating out of working nights and weekends, about how the productivity of hospitalists remains stagnant but subsidy demands increase, and about how to limit caseloads. I see articles about hospitalist groups becoming privately held corporations, sending revenue that physicians generate (and hospitals subsidize) into the pockets of private investors.

There are two growing hospitalist camps. The first is filled with strategic thinkers driven to fix inefficient hospital care and save each of those 100,000 Institute of Medicine lives. These are the chief residents of yesterday, academically oriented problem solvers with IT savvy and a propensity for coffee-fueled all-nighters. You know them within your hospitalist groups and medical staffs.

The second camp consists of the lifestyle hospitalists; those for whom salary and 16 shifts a month are the goals that supersede professional loyalty to any particular group. These are the physicians who can help meet various metrics but want nothing to do with designing them.

These two groups read the literature with different eyes and career aspirations. As this division spreads, I strain to hear a drowning voice regarding another physician role: our responsibility to our patients. Drowning because both camps are swimming away from the patient, one toward a desk job, the other to a defined shift schedule.

Caring for patients is why we are in medicine in the first place. Most hospitalists came from primary care residencies, so the rewards of lifestyle and money must have been less important than direct patient contact. Primary care graduates entered traditional practices, promptly encountering the headaches of running a practice. Then suddenly a plum job with higher compensation and limited work hours was born, and, unsurprisingly, the primary care fields lost physicians to the hospitalist movement.

For new hospitalists exiting residency, there is no institutional knowledge of the old ways, and while they are not perfect, there are some noble qualities. Dedication to the profession is one, as is an enduring responsibility to one’s patient. Medicine required an occasional need to interrupt personal interests to help a sick human being—a patient—through a difficult time. For those physicians with traditional experience, can you recall articles suggesting negotiating for no nights and weekends? I’m not sure who we expect to provide this care to our patients if we can negotiate out of working.

There are certainly drawbacks to the traditional system: strained family relationships, substance abuse, and poor work-life balance—but don’t throw the baby out with the bathwater. These values elevated medicine to the position it holds today: a respected and well-compensated profession. I fear this young hospitalist specialty may not live up to its hype or responsibilities if hospitalists are motivated to focus on their “job” rather that their duties as the “doctor.” So what to do?

I think this can be a specialty that identifies members as physicians first and hospitalists second through the expectations of our peers in our own groups, medical staffs, and physician societies. We need to grow our groups with physicians dedicated not just to their partners, but the physician community at large; with those who want to improve care not just by meeting myocardial infarction guidelines, but with those who work with other physicians to help the patient manage their heart disease for 30 years; with physicians who ask about quality, teamwork, and the local community during the job interview and don’t begin with salary, patient caps, and weekend limitations.

Hospitalist group leaders need to expect these traits from their physicians. Otherwise practicing hospitalists will forever remain glorified residents and not leaders.

SHM needs to promote and recognize the values of being a physician in this field, instead of patting itself on the back for how trailblazing hospitalists could be while simultaneously ignoring what we are. TH

Edward Norman, MD, Internist/Hospitalist, Loveland, Colo.

I am a hospitalist outsider. A traditional internist, I cared for my patients in and out of the hospital, provided ICU and unassigned ED call, and later transitioned to hospital-only work. Our group developed a hospitalist program and has, hopefully, run an above-average system growing with our community. Even performing full-time hospital work, it took me a year to get over being referred to as a “hospitalist.” It seemed a confining label.

I also feel like an outsider while reading hospitalist literature’s divergent messages to hospitalists. On one hand, I hear great things about how hospitalists will revolutionize healthcare, spearheading improvements in safety, efficiency, and satisfaction, and filling administrative roles. I then see articles about negotiating out of working nights and weekends, about how the productivity of hospitalists remains stagnant but subsidy demands increase, and about how to limit caseloads. I see articles about hospitalist groups becoming privately held corporations, sending revenue that physicians generate (and hospitals subsidize) into the pockets of private investors.

There are two growing hospitalist camps. The first is filled with strategic thinkers driven to fix inefficient hospital care and save each of those 100,000 Institute of Medicine lives. These are the chief residents of yesterday, academically oriented problem solvers with IT savvy and a propensity for coffee-fueled all-nighters. You know them within your hospitalist groups and medical staffs.

The second camp consists of the lifestyle hospitalists; those for whom salary and 16 shifts a month are the goals that supersede professional loyalty to any particular group. These are the physicians who can help meet various metrics but want nothing to do with designing them.

These two groups read the literature with different eyes and career aspirations. As this division spreads, I strain to hear a drowning voice regarding another physician role: our responsibility to our patients. Drowning because both camps are swimming away from the patient, one toward a desk job, the other to a defined shift schedule.

Caring for patients is why we are in medicine in the first place. Most hospitalists came from primary care residencies, so the rewards of lifestyle and money must have been less important than direct patient contact. Primary care graduates entered traditional practices, promptly encountering the headaches of running a practice. Then suddenly a plum job with higher compensation and limited work hours was born, and, unsurprisingly, the primary care fields lost physicians to the hospitalist movement.

For new hospitalists exiting residency, there is no institutional knowledge of the old ways, and while they are not perfect, there are some noble qualities. Dedication to the profession is one, as is an enduring responsibility to one’s patient. Medicine required an occasional need to interrupt personal interests to help a sick human being—a patient—through a difficult time. For those physicians with traditional experience, can you recall articles suggesting negotiating for no nights and weekends? I’m not sure who we expect to provide this care to our patients if we can negotiate out of working.

There are certainly drawbacks to the traditional system: strained family relationships, substance abuse, and poor work-life balance—but don’t throw the baby out with the bathwater. These values elevated medicine to the position it holds today: a respected and well-compensated profession. I fear this young hospitalist specialty may not live up to its hype or responsibilities if hospitalists are motivated to focus on their “job” rather that their duties as the “doctor.” So what to do?

I think this can be a specialty that identifies members as physicians first and hospitalists second through the expectations of our peers in our own groups, medical staffs, and physician societies. We need to grow our groups with physicians dedicated not just to their partners, but the physician community at large; with those who want to improve care not just by meeting myocardial infarction guidelines, but with those who work with other physicians to help the patient manage their heart disease for 30 years; with physicians who ask about quality, teamwork, and the local community during the job interview and don’t begin with salary, patient caps, and weekend limitations.

Hospitalist group leaders need to expect these traits from their physicians. Otherwise practicing hospitalists will forever remain glorified residents and not leaders.

SHM needs to promote and recognize the values of being a physician in this field, instead of patting itself on the back for how trailblazing hospitalists could be while simultaneously ignoring what we are. TH

Edward Norman, MD, Internist/Hospitalist, Loveland, Colo.

I am a hospitalist outsider. A traditional internist, I cared for my patients in and out of the hospital, provided ICU and unassigned ED call, and later transitioned to hospital-only work. Our group developed a hospitalist program and has, hopefully, run an above-average system growing with our community. Even performing full-time hospital work, it took me a year to get over being referred to as a “hospitalist.” It seemed a confining label.

I also feel like an outsider while reading hospitalist literature’s divergent messages to hospitalists. On one hand, I hear great things about how hospitalists will revolutionize healthcare, spearheading improvements in safety, efficiency, and satisfaction, and filling administrative roles. I then see articles about negotiating out of working nights and weekends, about how the productivity of hospitalists remains stagnant but subsidy demands increase, and about how to limit caseloads. I see articles about hospitalist groups becoming privately held corporations, sending revenue that physicians generate (and hospitals subsidize) into the pockets of private investors.

There are two growing hospitalist camps. The first is filled with strategic thinkers driven to fix inefficient hospital care and save each of those 100,000 Institute of Medicine lives. These are the chief residents of yesterday, academically oriented problem solvers with IT savvy and a propensity for coffee-fueled all-nighters. You know them within your hospitalist groups and medical staffs.

The second camp consists of the lifestyle hospitalists; those for whom salary and 16 shifts a month are the goals that supersede professional loyalty to any particular group. These are the physicians who can help meet various metrics but want nothing to do with designing them.

These two groups read the literature with different eyes and career aspirations. As this division spreads, I strain to hear a drowning voice regarding another physician role: our responsibility to our patients. Drowning because both camps are swimming away from the patient, one toward a desk job, the other to a defined shift schedule.

Caring for patients is why we are in medicine in the first place. Most hospitalists came from primary care residencies, so the rewards of lifestyle and money must have been less important than direct patient contact. Primary care graduates entered traditional practices, promptly encountering the headaches of running a practice. Then suddenly a plum job with higher compensation and limited work hours was born, and, unsurprisingly, the primary care fields lost physicians to the hospitalist movement.

For new hospitalists exiting residency, there is no institutional knowledge of the old ways, and while they are not perfect, there are some noble qualities. Dedication to the profession is one, as is an enduring responsibility to one’s patient. Medicine required an occasional need to interrupt personal interests to help a sick human being—a patient—through a difficult time. For those physicians with traditional experience, can you recall articles suggesting negotiating for no nights and weekends? I’m not sure who we expect to provide this care to our patients if we can negotiate out of working.

There are certainly drawbacks to the traditional system: strained family relationships, substance abuse, and poor work-life balance—but don’t throw the baby out with the bathwater. These values elevated medicine to the position it holds today: a respected and well-compensated profession. I fear this young hospitalist specialty may not live up to its hype or responsibilities if hospitalists are motivated to focus on their “job” rather that their duties as the “doctor.” So what to do?

I think this can be a specialty that identifies members as physicians first and hospitalists second through the expectations of our peers in our own groups, medical staffs, and physician societies. We need to grow our groups with physicians dedicated not just to their partners, but the physician community at large; with those who want to improve care not just by meeting myocardial infarction guidelines, but with those who work with other physicians to help the patient manage their heart disease for 30 years; with physicians who ask about quality, teamwork, and the local community during the job interview and don’t begin with salary, patient caps, and weekend limitations.

Hospitalist group leaders need to expect these traits from their physicians. Otherwise practicing hospitalists will forever remain glorified residents and not leaders.

SHM needs to promote and recognize the values of being a physician in this field, instead of patting itself on the back for how trailblazing hospitalists could be while simultaneously ignoring what we are. TH

Edward Norman, MD, Internist/Hospitalist, Loveland, Colo.

In late June 2006, hospitalists in British Columbia (B.C.) were on the verge of walking out of their regions’ hospitals in protest over payment and workload. The strike was narrowly averted (see “Tough Negotiations Avert B.C. Hospitalist Walkout,” August 2006, p. 1), and chief negotiators for the B.C. hospitalists signed an interim agreement that left the door open for future pay hikes and an examination of workload among other issues.

Two years later, some progress in providing pay increases and adjusting workloads has happened, according to some B.C. hospitalists. David Wilton, MD, is one of the directors of the Vancouver Hospitalist Society, a nonprofit organization that contracts with Vancouver General Hospital and the University of British Columbia Hospital (both overseen by the Vancouver Coastal Health Authority). Although Dr. Wilton reports “things have been working at a snail’s pace,” he and his colleagues have made important inroads in developing more collegial relations with the British Columbia Medical Association (BCMA) and the Canadian College of Family Physicians (CCFP). By taking guidance from SHM, Canadian hospitalists are strengthening their own association by increasing awareness of the value of hospital medicine in Canada.

Where the Trouble Began

BC is divided into six regional health authorities—five of which have active hospitalist programs. Hospitals are administered by the health authorities, whose administrators have come to appreciate hospitalists’ value in increasing patient flow and thus reducing emergency room crowding. However, the health authority administrators do not determine hospitalists’ salaries. All B.C. physicians’ compensation is established through periodic negotiations between the BCMA and the province’s Ministry of Health (MOH).

A Letter of Agreement signed by the two sides in April 2006 revealed serious problems for the hospitalists. The association, dominated by establishment physicians, had (for purposes of the Letter of Agreement) placed hospitalists lower on the pay scale grid than community-based family physicians. Even though hospitalists in Canada predominantly are from a family practice background (the opposite of the United States, where the majority of hospitalists come from internal medicine backgrounds) the BCMA’s under-appreciation of hospitalists’ workloads led to a low base rate for calculating salary increases.

Subsequently, the B.C. hospitalists realized they needed to be proactive about their own interests and hired an attorney to attend meetings with the ministry. Although the ministry never agreed this second, public round of talks were negotiations, an agreement to re-examine contracts was reached.

The contract (signed in June 2006) stipulated timelines for a wind-down provision if there were no satisfactory outcomes with the alternate payments committee or the newly established tripartite Hospitalist Workload Model Working Group, comprised of MOH, local health authority, and hospitalist representatives. An interim contract was signed in September 2007 (retroactive to March 2007) and is again up for renewal since it is now past the April 1, 2008 deadline. The strategy for the near-term is to renew the compensation contract for shorter time periods and wait until the BCMA re-opens negotiations with the MOH in 2010 for an updated Letter of Agreement.

Repairing the Divide

In the meantime, B.C. hospitalists have delved into multiple initiatives they believe eventually will bear fruit. Chief among these is establishment of a hospitalist section within the BCMA. In 2006, the situation was “somewhat antagonistic” between hospitalists and the BCMA, says Geoff Appleton, MD, the current BCMA president.

“There has been friction between GPs and hospitalists because GPs have felt themselves pushed out of the hospital sector,” he says, “and they felt that hospitalists were getting paid more for hospital work than they were.”

Hospitalists, on the other hand, contend GPs were abandoning hospital-based practice, which created a new opportunity for those specializing in inpatient service delivery.

“Hospitalists did not feel they were represented as well as they should have been with the last round of [MOH] negotiations,” Dr. Appleton says. “They feel that they have been undervalued from a BCMA point of view, we don’t like to see that kind of conflict. I think once hospitalists help their colleagues understand the services that they are providing, then some of that resistance can go away. I’m hoping that they’re happier with what we’ve been doing and that their sectional status has improved things for them.”

Others in British Columbia agree with Dr. Appleton’s prognosis. “I think we’ve got optimism,” says Wayne DeMott, MD, a hospitalist at Royal Jubilee Hospital in Victoria, B.C. and chief negotiator for the BCMA’s Section of Hospitalist Medicine. “I think we’re trying to seek a much better representation of our issues from our parent organization that has struggled with figuring out what the heck to do with hospitalists. I do sense that they are trying to accommodate us a bit better and that they’re going to look at how they will represent us in the future.”

Understandably, though, Dr. DeMott also expresses wariness: “We had to go on a pretty tough journey in 2006 and we still haven’t forgotten how we were treated two years ago. We’re definitely going to continue to advocate strongly for ourselves.”

U.S.-Canadian Similarities, Differences

As U.S. hospitalists observe the growing pains of hospitalists in the Canadian healthcare system, it might look like deja vu all over again.

“In many ways, Canadian hospitalists are following a similar arc [as our U.S. HM colleagues] in carving out their niche,” says Dr. Wilton. The void created when family practice physicians abandoned hospital care in the late 1980s and early ’90s has turned into an opportunity for hospitalists. In turn, family practice physicians who at first were resistant have become accepting as they begin to appreciate the service hospitalists provide.

Even though U.S. and Canadian healthcare delivery and reimbursement systems differ, hospitalists “have a similar scope of practice” in the two countries, says Echo- Marie Enns, MD, CCFP, a hospitalist in Calgary, Alberta, and the first president of the Canadian chapter of SHM. John Nelson, MD, medical director of the Hospitalist Practice at Overlake Hospital in Bellevue, WA, a consultant for hospitalist practices with Nelson/Flores Associates, and co-founder and past president of SHM, agrees. “Eighty to ninety percent of the issues with hospitalists would apply to both settings,” he says. “There are ways in which they differ, but in broad strokes, they’re almost identical.”

Hospitalists’ situations and reimbursement agreements do vary from province to province, Dr. Enns notes. She was the lead hospitalist when the Calgary program started in 1998. She also worked in B.C. for a time and noticed that the MOH can be adversarial toward physicians at times. On the other hand, hospitalists in Alberta say they are “very well treated,” and have reported high satisfaction levels overall.

“The hospitalists here admit greater than fifty percent of the patients to medical beds in the region. So, we are the admitting force for the hospital,” she says. “We have a very cooperative relationship with the administration and have been able to initiate a lot of excellent initiatives to improve patient flow in moving patients to the most appropriate bed at the right time. As a result, we’re also getting to be more well known amongst the public.”

More Developments

Currently, the Hospitalist Workload Model Working Group awaits money to hire an external consultant to study hospitalists’ workloads across the province. B.C. hospitalists also are forging a new partnership with the Canadian College of Family Physicians (CCFP). Family practice physicians formerly were wedded to the “mantra of the full-service family physician who did everything—patients, obstetrics, pediatrics—and now they are recognizing that practice patterns are changing,” explains Dr. Wilton. “In order to remain relevant, they need to acknowledge hospital medicine, embrace it and regulate it, to make sure that it is done well.”

The CCFP is now partnering with hospitalists to establish a hospital medicine certification process. Another positive step: the University of Toronto is beginning a new one-year hospital medicine fellowship program. (www.sunnybrook.ca/education/Hospitalist).

Hospitalists across Canada are “in the middle stages” of forming their HM society, reports Dr. Wilton, who has led efforts to build a national database and to launch a survey of Canadian hospitalists. Dr. Enns, who initiated the first Canadian SHM chapter in 2000, thinks opportunities abound for increased collaborations across the border. For instance, she says, having Canadian hospitals involved in multicenter trials of DVT prophylaxis or diabetes initiatives could prove fruitful.

Dr. Nelson also agrees SHM and Canadian hospitalists should continue to consult and work with each other. “There are a number of Canadians who are active in SHM and I think that should continue,” he says. “We have a lot to learn from one another because for most of the issues we face the solutions are going to be the same.”

Drs. Wilton and DeMott invite their U.S. colleagues to attend the 6th annual Canadian Hospitalist Conference from Sept. 27-28, at the Morris J. Wosk Centre for Dialogue in Vancouver, BC. SHM CEO Larry Wellikson, MD, will be the keynote speaker. To register visit www.cpdkt.ubc.ca.

Stay Optimistic

Dr. Wilton notes that despite the slow rate of change for hospitalists, there are positive aspects to their work. “We all know—fundamentally—that we are essential to the functioning of the hospitals,” he says. “We know we’re needed and valued on the frontlines. The [government] bureaucracy and the medical establishment are slow to change, but they eventually will.”

Dr. DeMott considers the future of BCMA hopeful. “We’re going to have a bigger role at the BCMA. They’re going to come to completely appreciate us, and things will hopefully be less acrimonious in the future.”

Both physicians agree the crisis of June 2006 served to heighten awareness of hospitalists’ value.

“It was the hospitalists’ time to make people recognize what we do and that we need to be adequately compensated for it,” Dr. Wilton says. TH

Gretchen Henkel is a medical writer based in California.

In late June 2006, hospitalists in British Columbia (B.C.) were on the verge of walking out of their regions’ hospitals in protest over payment and workload. The strike was narrowly averted (see “Tough Negotiations Avert B.C. Hospitalist Walkout,” August 2006, p. 1), and chief negotiators for the B.C. hospitalists signed an interim agreement that left the door open for future pay hikes and an examination of workload among other issues.

Two years later, some progress in providing pay increases and adjusting workloads has happened, according to some B.C. hospitalists. David Wilton, MD, is one of the directors of the Vancouver Hospitalist Society, a nonprofit organization that contracts with Vancouver General Hospital and the University of British Columbia Hospital (both overseen by the Vancouver Coastal Health Authority). Although Dr. Wilton reports “things have been working at a snail’s pace,” he and his colleagues have made important inroads in developing more collegial relations with the British Columbia Medical Association (BCMA) and the Canadian College of Family Physicians (CCFP). By taking guidance from SHM, Canadian hospitalists are strengthening their own association by increasing awareness of the value of hospital medicine in Canada.

Where the Trouble Began

BC is divided into six regional health authorities—five of which have active hospitalist programs. Hospitals are administered by the health authorities, whose administrators have come to appreciate hospitalists’ value in increasing patient flow and thus reducing emergency room crowding. However, the health authority administrators do not determine hospitalists’ salaries. All B.C. physicians’ compensation is established through periodic negotiations between the BCMA and the province’s Ministry of Health (MOH).

A Letter of Agreement signed by the two sides in April 2006 revealed serious problems for the hospitalists. The association, dominated by establishment physicians, had (for purposes of the Letter of Agreement) placed hospitalists lower on the pay scale grid than community-based family physicians. Even though hospitalists in Canada predominantly are from a family practice background (the opposite of the United States, where the majority of hospitalists come from internal medicine backgrounds) the BCMA’s under-appreciation of hospitalists’ workloads led to a low base rate for calculating salary increases.

Subsequently, the B.C. hospitalists realized they needed to be proactive about their own interests and hired an attorney to attend meetings with the ministry. Although the ministry never agreed this second, public round of talks were negotiations, an agreement to re-examine contracts was reached.

The contract (signed in June 2006) stipulated timelines for a wind-down provision if there were no satisfactory outcomes with the alternate payments committee or the newly established tripartite Hospitalist Workload Model Working Group, comprised of MOH, local health authority, and hospitalist representatives. An interim contract was signed in September 2007 (retroactive to March 2007) and is again up for renewal since it is now past the April 1, 2008 deadline. The strategy for the near-term is to renew the compensation contract for shorter time periods and wait until the BCMA re-opens negotiations with the MOH in 2010 for an updated Letter of Agreement.

Repairing the Divide

In the meantime, B.C. hospitalists have delved into multiple initiatives they believe eventually will bear fruit. Chief among these is establishment of a hospitalist section within the BCMA. In 2006, the situation was “somewhat antagonistic” between hospitalists and the BCMA, says Geoff Appleton, MD, the current BCMA president.

“There has been friction between GPs and hospitalists because GPs have felt themselves pushed out of the hospital sector,” he says, “and they felt that hospitalists were getting paid more for hospital work than they were.”

Hospitalists, on the other hand, contend GPs were abandoning hospital-based practice, which created a new opportunity for those specializing in inpatient service delivery.

“Hospitalists did not feel they were represented as well as they should have been with the last round of [MOH] negotiations,” Dr. Appleton says. “They feel that they have been undervalued from a BCMA point of view, we don’t like to see that kind of conflict. I think once hospitalists help their colleagues understand the services that they are providing, then some of that resistance can go away. I’m hoping that they’re happier with what we’ve been doing and that their sectional status has improved things for them.”

Others in British Columbia agree with Dr. Appleton’s prognosis. “I think we’ve got optimism,” says Wayne DeMott, MD, a hospitalist at Royal Jubilee Hospital in Victoria, B.C. and chief negotiator for the BCMA’s Section of Hospitalist Medicine. “I think we’re trying to seek a much better representation of our issues from our parent organization that has struggled with figuring out what the heck to do with hospitalists. I do sense that they are trying to accommodate us a bit better and that they’re going to look at how they will represent us in the future.”

Understandably, though, Dr. DeMott also expresses wariness: “We had to go on a pretty tough journey in 2006 and we still haven’t forgotten how we were treated two years ago. We’re definitely going to continue to advocate strongly for ourselves.”

U.S.-Canadian Similarities, Differences

As U.S. hospitalists observe the growing pains of hospitalists in the Canadian healthcare system, it might look like deja vu all over again.

“In many ways, Canadian hospitalists are following a similar arc [as our U.S. HM colleagues] in carving out their niche,” says Dr. Wilton. The void created when family practice physicians abandoned hospital care in the late 1980s and early ’90s has turned into an opportunity for hospitalists. In turn, family practice physicians who at first were resistant have become accepting as they begin to appreciate the service hospitalists provide.

Even though U.S. and Canadian healthcare delivery and reimbursement systems differ, hospitalists “have a similar scope of practice” in the two countries, says Echo- Marie Enns, MD, CCFP, a hospitalist in Calgary, Alberta, and the first president of the Canadian chapter of SHM. John Nelson, MD, medical director of the Hospitalist Practice at Overlake Hospital in Bellevue, WA, a consultant for hospitalist practices with Nelson/Flores Associates, and co-founder and past president of SHM, agrees. “Eighty to ninety percent of the issues with hospitalists would apply to both settings,” he says. “There are ways in which they differ, but in broad strokes, they’re almost identical.”

Hospitalists’ situations and reimbursement agreements do vary from province to province, Dr. Enns notes. She was the lead hospitalist when the Calgary program started in 1998. She also worked in B.C. for a time and noticed that the MOH can be adversarial toward physicians at times. On the other hand, hospitalists in Alberta say they are “very well treated,” and have reported high satisfaction levels overall.

“The hospitalists here admit greater than fifty percent of the patients to medical beds in the region. So, we are the admitting force for the hospital,” she says. “We have a very cooperative relationship with the administration and have been able to initiate a lot of excellent initiatives to improve patient flow in moving patients to the most appropriate bed at the right time. As a result, we’re also getting to be more well known amongst the public.”

More Developments

Currently, the Hospitalist Workload Model Working Group awaits money to hire an external consultant to study hospitalists’ workloads across the province. B.C. hospitalists also are forging a new partnership with the Canadian College of Family Physicians (CCFP). Family practice physicians formerly were wedded to the “mantra of the full-service family physician who did everything—patients, obstetrics, pediatrics—and now they are recognizing that practice patterns are changing,” explains Dr. Wilton. “In order to remain relevant, they need to acknowledge hospital medicine, embrace it and regulate it, to make sure that it is done well.”

The CCFP is now partnering with hospitalists to establish a hospital medicine certification process. Another positive step: the University of Toronto is beginning a new one-year hospital medicine fellowship program. (www.sunnybrook.ca/education/Hospitalist).

Hospitalists across Canada are “in the middle stages” of forming their HM society, reports Dr. Wilton, who has led efforts to build a national database and to launch a survey of Canadian hospitalists. Dr. Enns, who initiated the first Canadian SHM chapter in 2000, thinks opportunities abound for increased collaborations across the border. For instance, she says, having Canadian hospitals involved in multicenter trials of DVT prophylaxis or diabetes initiatives could prove fruitful.

Dr. Nelson also agrees SHM and Canadian hospitalists should continue to consult and work with each other. “There are a number of Canadians who are active in SHM and I think that should continue,” he says. “We have a lot to learn from one another because for most of the issues we face the solutions are going to be the same.”

Drs. Wilton and DeMott invite their U.S. colleagues to attend the 6th annual Canadian Hospitalist Conference from Sept. 27-28, at the Morris J. Wosk Centre for Dialogue in Vancouver, BC. SHM CEO Larry Wellikson, MD, will be the keynote speaker. To register visit www.cpdkt.ubc.ca.

Stay Optimistic

Dr. Wilton notes that despite the slow rate of change for hospitalists, there are positive aspects to their work. “We all know—fundamentally—that we are essential to the functioning of the hospitals,” he says. “We know we’re needed and valued on the frontlines. The [government] bureaucracy and the medical establishment are slow to change, but they eventually will.”

Dr. DeMott considers the future of BCMA hopeful. “We’re going to have a bigger role at the BCMA. They’re going to come to completely appreciate us, and things will hopefully be less acrimonious in the future.”

Both physicians agree the crisis of June 2006 served to heighten awareness of hospitalists’ value.

“It was the hospitalists’ time to make people recognize what we do and that we need to be adequately compensated for it,” Dr. Wilton says. TH

Gretchen Henkel is a medical writer based in California.

In late June 2006, hospitalists in British Columbia (B.C.) were on the verge of walking out of their regions’ hospitals in protest over payment and workload. The strike was narrowly averted (see “Tough Negotiations Avert B.C. Hospitalist Walkout,” August 2006, p. 1), and chief negotiators for the B.C. hospitalists signed an interim agreement that left the door open for future pay hikes and an examination of workload among other issues.

Two years later, some progress in providing pay increases and adjusting workloads has happened, according to some B.C. hospitalists. David Wilton, MD, is one of the directors of the Vancouver Hospitalist Society, a nonprofit organization that contracts with Vancouver General Hospital and the University of British Columbia Hospital (both overseen by the Vancouver Coastal Health Authority). Although Dr. Wilton reports “things have been working at a snail’s pace,” he and his colleagues have made important inroads in developing more collegial relations with the British Columbia Medical Association (BCMA) and the Canadian College of Family Physicians (CCFP). By taking guidance from SHM, Canadian hospitalists are strengthening their own association by increasing awareness of the value of hospital medicine in Canada.

Where the Trouble Began

BC is divided into six regional health authorities—five of which have active hospitalist programs. Hospitals are administered by the health authorities, whose administrators have come to appreciate hospitalists’ value in increasing patient flow and thus reducing emergency room crowding. However, the health authority administrators do not determine hospitalists’ salaries. All B.C. physicians’ compensation is established through periodic negotiations between the BCMA and the province’s Ministry of Health (MOH).

A Letter of Agreement signed by the two sides in April 2006 revealed serious problems for the hospitalists. The association, dominated by establishment physicians, had (for purposes of the Letter of Agreement) placed hospitalists lower on the pay scale grid than community-based family physicians. Even though hospitalists in Canada predominantly are from a family practice background (the opposite of the United States, where the majority of hospitalists come from internal medicine backgrounds) the BCMA’s under-appreciation of hospitalists’ workloads led to a low base rate for calculating salary increases.

Subsequently, the B.C. hospitalists realized they needed to be proactive about their own interests and hired an attorney to attend meetings with the ministry. Although the ministry never agreed this second, public round of talks were negotiations, an agreement to re-examine contracts was reached.

The contract (signed in June 2006) stipulated timelines for a wind-down provision if there were no satisfactory outcomes with the alternate payments committee or the newly established tripartite Hospitalist Workload Model Working Group, comprised of MOH, local health authority, and hospitalist representatives. An interim contract was signed in September 2007 (retroactive to March 2007) and is again up for renewal since it is now past the April 1, 2008 deadline. The strategy for the near-term is to renew the compensation contract for shorter time periods and wait until the BCMA re-opens negotiations with the MOH in 2010 for an updated Letter of Agreement.

Repairing the Divide

In the meantime, B.C. hospitalists have delved into multiple initiatives they believe eventually will bear fruit. Chief among these is establishment of a hospitalist section within the BCMA. In 2006, the situation was “somewhat antagonistic” between hospitalists and the BCMA, says Geoff Appleton, MD, the current BCMA president.

“There has been friction between GPs and hospitalists because GPs have felt themselves pushed out of the hospital sector,” he says, “and they felt that hospitalists were getting paid more for hospital work than they were.”

Hospitalists, on the other hand, contend GPs were abandoning hospital-based practice, which created a new opportunity for those specializing in inpatient service delivery.

“Hospitalists did not feel they were represented as well as they should have been with the last round of [MOH] negotiations,” Dr. Appleton says. “They feel that they have been undervalued from a BCMA point of view, we don’t like to see that kind of conflict. I think once hospitalists help their colleagues understand the services that they are providing, then some of that resistance can go away. I’m hoping that they’re happier with what we’ve been doing and that their sectional status has improved things for them.”

Others in British Columbia agree with Dr. Appleton’s prognosis. “I think we’ve got optimism,” says Wayne DeMott, MD, a hospitalist at Royal Jubilee Hospital in Victoria, B.C. and chief negotiator for the BCMA’s Section of Hospitalist Medicine. “I think we’re trying to seek a much better representation of our issues from our parent organization that has struggled with figuring out what the heck to do with hospitalists. I do sense that they are trying to accommodate us a bit better and that they’re going to look at how they will represent us in the future.”

Understandably, though, Dr. DeMott also expresses wariness: “We had to go on a pretty tough journey in 2006 and we still haven’t forgotten how we were treated two years ago. We’re definitely going to continue to advocate strongly for ourselves.”

U.S.-Canadian Similarities, Differences

As U.S. hospitalists observe the growing pains of hospitalists in the Canadian healthcare system, it might look like deja vu all over again.

“In many ways, Canadian hospitalists are following a similar arc [as our U.S. HM colleagues] in carving out their niche,” says Dr. Wilton. The void created when family practice physicians abandoned hospital care in the late 1980s and early ’90s has turned into an opportunity for hospitalists. In turn, family practice physicians who at first were resistant have become accepting as they begin to appreciate the service hospitalists provide.

Even though U.S. and Canadian healthcare delivery and reimbursement systems differ, hospitalists “have a similar scope of practice” in the two countries, says Echo- Marie Enns, MD, CCFP, a hospitalist in Calgary, Alberta, and the first president of the Canadian chapter of SHM. John Nelson, MD, medical director of the Hospitalist Practice at Overlake Hospital in Bellevue, WA, a consultant for hospitalist practices with Nelson/Flores Associates, and co-founder and past president of SHM, agrees. “Eighty to ninety percent of the issues with hospitalists would apply to both settings,” he says. “There are ways in which they differ, but in broad strokes, they’re almost identical.”

Hospitalists’ situations and reimbursement agreements do vary from province to province, Dr. Enns notes. She was the lead hospitalist when the Calgary program started in 1998. She also worked in B.C. for a time and noticed that the MOH can be adversarial toward physicians at times. On the other hand, hospitalists in Alberta say they are “very well treated,” and have reported high satisfaction levels overall.

“The hospitalists here admit greater than fifty percent of the patients to medical beds in the region. So, we are the admitting force for the hospital,” she says. “We have a very cooperative relationship with the administration and have been able to initiate a lot of excellent initiatives to improve patient flow in moving patients to the most appropriate bed at the right time. As a result, we’re also getting to be more well known amongst the public.”

More Developments

Currently, the Hospitalist Workload Model Working Group awaits money to hire an external consultant to study hospitalists’ workloads across the province. B.C. hospitalists also are forging a new partnership with the Canadian College of Family Physicians (CCFP). Family practice physicians formerly were wedded to the “mantra of the full-service family physician who did everything—patients, obstetrics, pediatrics—and now they are recognizing that practice patterns are changing,” explains Dr. Wilton. “In order to remain relevant, they need to acknowledge hospital medicine, embrace it and regulate it, to make sure that it is done well.”

The CCFP is now partnering with hospitalists to establish a hospital medicine certification process. Another positive step: the University of Toronto is beginning a new one-year hospital medicine fellowship program. (www.sunnybrook.ca/education/Hospitalist).

Hospitalists across Canada are “in the middle stages” of forming their HM society, reports Dr. Wilton, who has led efforts to build a national database and to launch a survey of Canadian hospitalists. Dr. Enns, who initiated the first Canadian SHM chapter in 2000, thinks opportunities abound for increased collaborations across the border. For instance, she says, having Canadian hospitals involved in multicenter trials of DVT prophylaxis or diabetes initiatives could prove fruitful.

Dr. Nelson also agrees SHM and Canadian hospitalists should continue to consult and work with each other. “There are a number of Canadians who are active in SHM and I think that should continue,” he says. “We have a lot to learn from one another because for most of the issues we face the solutions are going to be the same.”

Drs. Wilton and DeMott invite their U.S. colleagues to attend the 6th annual Canadian Hospitalist Conference from Sept. 27-28, at the Morris J. Wosk Centre for Dialogue in Vancouver, BC. SHM CEO Larry Wellikson, MD, will be the keynote speaker. To register visit www.cpdkt.ubc.ca.

Stay Optimistic

Dr. Wilton notes that despite the slow rate of change for hospitalists, there are positive aspects to their work. “We all know—fundamentally—that we are essential to the functioning of the hospitals,” he says. “We know we’re needed and valued on the frontlines. The [government] bureaucracy and the medical establishment are slow to change, but they eventually will.”

Dr. DeMott considers the future of BCMA hopeful. “We’re going to have a bigger role at the BCMA. They’re going to come to completely appreciate us, and things will hopefully be less acrimonious in the future.”

Both physicians agree the crisis of June 2006 served to heighten awareness of hospitalists’ value.

“It was the hospitalists’ time to make people recognize what we do and that we need to be adequately compensated for it,” Dr. Wilton says. TH

Gretchen Henkel is a medical writer based in California.

No matter how big a hospital medicine group is, the leader is likely to say “but we need a couple more.” As the fastest-growing medical specialty in the history of American medicine, there never seem to be enough hospitalists (see Figure 1, p. 28).

“The programs are getting larger and larger, ranging anywhere from 20 to 100 physicians in a hospitalist group,” says Jeffrey Hay, MD, senior vice president of medical operations for Lakeside Systems Inc. in Los Angeles.

Because of this rapid growth, two questions become apparent:

1. How is a big hospitalist group defined?

2. What does it take to manage a big group well?

How Big is Big?

Although what constitutes a big hospitalist group is relative, Leslie Flores and her partner, John Nelson, MD, of Nelson/Flores Associates, LLC, La Quinta, Calif., estimate with about 20-30 hospitalists, the role of the medical director becomes a different job than for the typical-sized practice of 10-15 hospitalists.

According to SHM Executive Advisor to the CEO Joseph Miller, this year’s “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” revealed only eight groups with more than 40 hospitalists (excluding the multistate hospitalist management companies). In the approximate 2,200 hospitalist groups in the U.S., Miller estimates there are perhaps 40 groups with 40 or more physicians compared with two in the previous 2005-06 survey.

Medical directors of hospital medicine groups (HMGs) ranging from 22-100 people offer varied insights about how the role of medical director changes as groups grow from big to bigger to biggest.

click for large version

Big

Jeffery Kin, MD, medical director of the private-practice group Fredericks Hospitalist Group PC, manages 22 hospitalists, and about 130-140 inpatients and 45 admissions a day at Mary Washington Hospital in Fredericksburg, Va. They began as a team of three in 2000 as the outgrowth of a hospital house-doctor program.

“The medical director’s role changes and evolves with the growth of the group,” says Dr. Kin. He and other medical directors of larger groups find it more difficult to retain the informal shift arrival or departure and lunches together that were possible when the HMG was smaller. “Now that we are bigger it is more ‘protocolized,’” Dr. Kin says, “but we try to maintain a family-like atmosphere because I think it makes physicians want to stay with the group long term and not move on with every little problem or challenge that inevitably arises in the changing filed of hospital medicine.”

William Ford, MD, program medical director for Cogent Healthcare and the chief of hospital medicine at Temple University in Philadelphia, considers his group of 28 hospitalists to be a “small” big group. Dr. Ford’s group, which covers three of the four hospitals in the university health systems, grew from five hospitalists in September 2006. He devotes about half his time on personnel issues, including recruitment, retention, and staff development.

As groups grow, so does diversity, requiring more flexibility to manage leaves of absence, scheduling, and day-to-day practice. “In a large group we tend to bring on new measures,” Dr. Ford says. “We change like the wind, so if you aren’t ready for that, you will have a lot of turnover.”

Bigger

Jasen W. Gundersen, MD, MBA, division chief, hospital medicine, University of Massachusetts Memorial Medical Center, Worcester, grew his HMG from 3.6 FTEs three years ago to the 47.5 FTEs (40 physician FTEs and 7.5 FTEs nurse practitioners) they now employ. The group, which covers four hospitals ranging from a 30-bed community hospital to a 770-bed academic hospital, is the biggest HMG in New England. “Our budget numbers for charges and volume are 2.19 times what we projected in the budget,” he says.

With an average of 185 billable patient encounters per day, Dr. Gundersen attributes his successes to a management style based on a financial business model and a revision of the compensation plan. By increasing effectiveness, they reward their doctors with more free time and subsequently improved physician retention.

As the group, the budget, and the financial impact all expand, formal training becomes more important for leaders. While few HMG leaders have a background in the strategic processes of running a company, Dr. Gundersen earned his MBA and believes his training made it easier to talk to administrators, meet clients, track data, effect change, and better handle the politics inherent to the job. “The role is a lot more political than people are aware of because you are such a big presence to the hospital,” he says. “Everybody wants something from you.”

Part of that phenomenon, coined “medical creep” by one hospitalist, can best be defined as the gradual increase in workload shifted to HMGs without a proportional shift in resources to do the work. Work previously done by either surgical specialists or medical subspecialists must be shifted as they more narrowly define their workload; what is left over (more general medical care, phone calls, after-hours work, and paperwork) goes to “co-managing” hospitalists.

Asked about this phenomenon, Tom Lorence, MD, chief of hospitalist medicine for the Northwest Kaiser Permanente region, Portland, Ore., says: “The larger the hospitalist groups become, the bigger a target we are for this shifting. Most try to justify it by saying, ‘It is only a little more work.’ ”

Dr. Lorence and two colleagues began his HMG in 1990; he now manages 55 hospitalists at three facilities. “Administrators have to be convinced that it is worth the money to reshift their priorities and give more resources to the hospital medicine groups,” he says.

Mark V. Williams, MD, FACP, professor and chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago, moved to his current post last September. Northwestern Memorial Hospital almost doubled its hospitalists to 42 in one year. The initial challenges at Northwestern primarily include assimilating new faculty and establishing a culture of thriving on change, says Dr. Williams, who is also editor in chief of the Journal of Hospital Medicine.

click for large version

Biggest

The distinction between academic and non-academic programs is an important one says Michael B. Heisler, MD, MPH, who became the interim medical director of Emory Healthcare, Atlanta, in March 2007 when Dr. Williams moved to Northwestern. Generally, the Emory group has increased in size by 20% each of the past five years. Beginning with nine hospitalists in 1999, it now exceeds 80 (see Figure 2, p. 28).

Academic hospitals have additional stakeholders and deliverables expected by those to whom the medical director reports. Whereas community hospital medicine programs are driven by patient encounters/RVUs, quality improvement, and the bottom line, academic groups also must engage in scholarly activities.

Dr. Heisler and his group have just completed a three-year strategic plan that emphasizes medical education and research and a plateau to the group’s growth.

“We can’t be the premier academic program with growth going through the roof,” Dr. Heisler says. “With some limits we are not going to increase services within our institutions and will not entertain requests to grow into any other facilities through 2010. You can’t develop faculty, define protected time, and invest in scholarly work when you are constantly in growth mode.”

Strategic planning has a different tone for Tyler Jung, MD, director of inpatient services of the multi-specialty group HealthCare Partners, who took over that position three years ago when Dr. Hay left. About 100 hospitalists are employed under the HealthCare Partners umbrella; approximately 85 are on the payroll, and 15 work in a strategic alliance. The HMG covers 14 community hospitals in Southern California, about 14 hospitals in Las Vegas, Nevada, and about five hospitals in the Tampa/Orlando area of Florida.

The full-risk California medical model drives a lot of the metrics. “We look at [relative value unit] goals for our hospitalists, but mostly to ensure proper staffing,” Dr. Jung says. “We are satisfied when our docs have 12 to 14 encounters a day. In the service market you’d go broke with that, but I’d rather have our hospitalists see our patients twice a day because it drives quality and it turns out to be more cost effective.”

Some of the outcomes Dr. Jung regularly reviews include patient utilization per membership (admit rates, readmit data, and length of stay), and these metrics are largely unchanged as they have grown. “Additionally, maintaining high patient satisfaction can be overlooked, but is critical with the growth of any program,” he says (see Figure 3, p. 28).

click for large version

Dr. Williams, who began the hospitalist group at Emory Healthcare, says the primary challenges he faced as that program grew were finding capable physicians willing to join a new or expanding program; managing the different cultures at different hospitals and working to ensure they all felt a part of the whole; having sufficient administrative support time to manage recruitment and credentialing; and keeping up constant communications with individuals and leadership at all sites. He found it helpful to occasionally rotate hospitalists, especially the more senior physicians, so they could appreciate the workload and issues at different sites.

Dr. Williams, who trained in internal medicine but later became board certified in emergency medicine, is not surprised Dr. Jung has some background in critical care, as does Dr. Heisler. He surmises they also all have well-honed administrative skills. “The experience I had in running a 65,000-visit-a-year emergency room and a 45,000-visit-a-year urgent-care center gave me the skills to run a large hospital medicine program,” Dr. Williams says. TH

Andrea M. Sattinger is a medical writer based in North Carolina.

No matter how big a hospital medicine group is, the leader is likely to say “but we need a couple more.” As the fastest-growing medical specialty in the history of American medicine, there never seem to be enough hospitalists (see Figure 1, p. 28).

“The programs are getting larger and larger, ranging anywhere from 20 to 100 physicians in a hospitalist group,” says Jeffrey Hay, MD, senior vice president of medical operations for Lakeside Systems Inc. in Los Angeles.

Because of this rapid growth, two questions become apparent:

1. How is a big hospitalist group defined?

2. What does it take to manage a big group well?

How Big is Big?

Although what constitutes a big hospitalist group is relative, Leslie Flores and her partner, John Nelson, MD, of Nelson/Flores Associates, LLC, La Quinta, Calif., estimate with about 20-30 hospitalists, the role of the medical director becomes a different job than for the typical-sized practice of 10-15 hospitalists.

According to SHM Executive Advisor to the CEO Joseph Miller, this year’s “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” revealed only eight groups with more than 40 hospitalists (excluding the multistate hospitalist management companies). In the approximate 2,200 hospitalist groups in the U.S., Miller estimates there are perhaps 40 groups with 40 or more physicians compared with two in the previous 2005-06 survey.

Medical directors of hospital medicine groups (HMGs) ranging from 22-100 people offer varied insights about how the role of medical director changes as groups grow from big to bigger to biggest.

click for large version

Big

Jeffery Kin, MD, medical director of the private-practice group Fredericks Hospitalist Group PC, manages 22 hospitalists, and about 130-140 inpatients and 45 admissions a day at Mary Washington Hospital in Fredericksburg, Va. They began as a team of three in 2000 as the outgrowth of a hospital house-doctor program.

“The medical director’s role changes and evolves with the growth of the group,” says Dr. Kin. He and other medical directors of larger groups find it more difficult to retain the informal shift arrival or departure and lunches together that were possible when the HMG was smaller. “Now that we are bigger it is more ‘protocolized,’” Dr. Kin says, “but we try to maintain a family-like atmosphere because I think it makes physicians want to stay with the group long term and not move on with every little problem or challenge that inevitably arises in the changing filed of hospital medicine.”

William Ford, MD, program medical director for Cogent Healthcare and the chief of hospital medicine at Temple University in Philadelphia, considers his group of 28 hospitalists to be a “small” big group. Dr. Ford’s group, which covers three of the four hospitals in the university health systems, grew from five hospitalists in September 2006. He devotes about half his time on personnel issues, including recruitment, retention, and staff development.

As groups grow, so does diversity, requiring more flexibility to manage leaves of absence, scheduling, and day-to-day practice. “In a large group we tend to bring on new measures,” Dr. Ford says. “We change like the wind, so if you aren’t ready for that, you will have a lot of turnover.”

Bigger

Jasen W. Gundersen, MD, MBA, division chief, hospital medicine, University of Massachusetts Memorial Medical Center, Worcester, grew his HMG from 3.6 FTEs three years ago to the 47.5 FTEs (40 physician FTEs and 7.5 FTEs nurse practitioners) they now employ. The group, which covers four hospitals ranging from a 30-bed community hospital to a 770-bed academic hospital, is the biggest HMG in New England. “Our budget numbers for charges and volume are 2.19 times what we projected in the budget,” he says.

With an average of 185 billable patient encounters per day, Dr. Gundersen attributes his successes to a management style based on a financial business model and a revision of the compensation plan. By increasing effectiveness, they reward their doctors with more free time and subsequently improved physician retention.

As the group, the budget, and the financial impact all expand, formal training becomes more important for leaders. While few HMG leaders have a background in the strategic processes of running a company, Dr. Gundersen earned his MBA and believes his training made it easier to talk to administrators, meet clients, track data, effect change, and better handle the politics inherent to the job. “The role is a lot more political than people are aware of because you are such a big presence to the hospital,” he says. “Everybody wants something from you.”

Part of that phenomenon, coined “medical creep” by one hospitalist, can best be defined as the gradual increase in workload shifted to HMGs without a proportional shift in resources to do the work. Work previously done by either surgical specialists or medical subspecialists must be shifted as they more narrowly define their workload; what is left over (more general medical care, phone calls, after-hours work, and paperwork) goes to “co-managing” hospitalists.

Asked about this phenomenon, Tom Lorence, MD, chief of hospitalist medicine for the Northwest Kaiser Permanente region, Portland, Ore., says: “The larger the hospitalist groups become, the bigger a target we are for this shifting. Most try to justify it by saying, ‘It is only a little more work.’ ”

Dr. Lorence and two colleagues began his HMG in 1990; he now manages 55 hospitalists at three facilities. “Administrators have to be convinced that it is worth the money to reshift their priorities and give more resources to the hospital medicine groups,” he says.

Mark V. Williams, MD, FACP, professor and chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago, moved to his current post last September. Northwestern Memorial Hospital almost doubled its hospitalists to 42 in one year. The initial challenges at Northwestern primarily include assimilating new faculty and establishing a culture of thriving on change, says Dr. Williams, who is also editor in chief of the Journal of Hospital Medicine.

click for large version

Biggest

The distinction between academic and non-academic programs is an important one says Michael B. Heisler, MD, MPH, who became the interim medical director of Emory Healthcare, Atlanta, in March 2007 when Dr. Williams moved to Northwestern. Generally, the Emory group has increased in size by 20% each of the past five years. Beginning with nine hospitalists in 1999, it now exceeds 80 (see Figure 2, p. 28).

Academic hospitals have additional stakeholders and deliverables expected by those to whom the medical director reports. Whereas community hospital medicine programs are driven by patient encounters/RVUs, quality improvement, and the bottom line, academic groups also must engage in scholarly activities.

Dr. Heisler and his group have just completed a three-year strategic plan that emphasizes medical education and research and a plateau to the group’s growth.

“We can’t be the premier academic program with growth going through the roof,” Dr. Heisler says. “With some limits we are not going to increase services within our institutions and will not entertain requests to grow into any other facilities through 2010. You can’t develop faculty, define protected time, and invest in scholarly work when you are constantly in growth mode.”

Strategic planning has a different tone for Tyler Jung, MD, director of inpatient services of the multi-specialty group HealthCare Partners, who took over that position three years ago when Dr. Hay left. About 100 hospitalists are employed under the HealthCare Partners umbrella; approximately 85 are on the payroll, and 15 work in a strategic alliance. The HMG covers 14 community hospitals in Southern California, about 14 hospitals in Las Vegas, Nevada, and about five hospitals in the Tampa/Orlando area of Florida.

The full-risk California medical model drives a lot of the metrics. “We look at [relative value unit] goals for our hospitalists, but mostly to ensure proper staffing,” Dr. Jung says. “We are satisfied when our docs have 12 to 14 encounters a day. In the service market you’d go broke with that, but I’d rather have our hospitalists see our patients twice a day because it drives quality and it turns out to be more cost effective.”

Some of the outcomes Dr. Jung regularly reviews include patient utilization per membership (admit rates, readmit data, and length of stay), and these metrics are largely unchanged as they have grown. “Additionally, maintaining high patient satisfaction can be overlooked, but is critical with the growth of any program,” he says (see Figure 3, p. 28).

click for large version

Dr. Williams, who began the hospitalist group at Emory Healthcare, says the primary challenges he faced as that program grew were finding capable physicians willing to join a new or expanding program; managing the different cultures at different hospitals and working to ensure they all felt a part of the whole; having sufficient administrative support time to manage recruitment and credentialing; and keeping up constant communications with individuals and leadership at all sites. He found it helpful to occasionally rotate hospitalists, especially the more senior physicians, so they could appreciate the workload and issues at different sites.

Dr. Williams, who trained in internal medicine but later became board certified in emergency medicine, is not surprised Dr. Jung has some background in critical care, as does Dr. Heisler. He surmises they also all have well-honed administrative skills. “The experience I had in running a 65,000-visit-a-year emergency room and a 45,000-visit-a-year urgent-care center gave me the skills to run a large hospital medicine program,” Dr. Williams says. TH

Andrea M. Sattinger is a medical writer based in North Carolina.

No matter how big a hospital medicine group is, the leader is likely to say “but we need a couple more.” As the fastest-growing medical specialty in the history of American medicine, there never seem to be enough hospitalists (see Figure 1, p. 28).

“The programs are getting larger and larger, ranging anywhere from 20 to 100 physicians in a hospitalist group,” says Jeffrey Hay, MD, senior vice president of medical operations for Lakeside Systems Inc. in Los Angeles.

Because of this rapid growth, two questions become apparent:

1. How is a big hospitalist group defined?

2. What does it take to manage a big group well?

How Big is Big?

Although what constitutes a big hospitalist group is relative, Leslie Flores and her partner, John Nelson, MD, of Nelson/Flores Associates, LLC, La Quinta, Calif., estimate with about 20-30 hospitalists, the role of the medical director becomes a different job than for the typical-sized practice of 10-15 hospitalists.

According to SHM Executive Advisor to the CEO Joseph Miller, this year’s “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” revealed only eight groups with more than 40 hospitalists (excluding the multistate hospitalist management companies). In the approximate 2,200 hospitalist groups in the U.S., Miller estimates there are perhaps 40 groups with 40 or more physicians compared with two in the previous 2005-06 survey.

Medical directors of hospital medicine groups (HMGs) ranging from 22-100 people offer varied insights about how the role of medical director changes as groups grow from big to bigger to biggest.

click for large version

Big

Jeffery Kin, MD, medical director of the private-practice group Fredericks Hospitalist Group PC, manages 22 hospitalists, and about 130-140 inpatients and 45 admissions a day at Mary Washington Hospital in Fredericksburg, Va. They began as a team of three in 2000 as the outgrowth of a hospital house-doctor program.

“The medical director’s role changes and evolves with the growth of the group,” says Dr. Kin. He and other medical directors of larger groups find it more difficult to retain the informal shift arrival or departure and lunches together that were possible when the HMG was smaller. “Now that we are bigger it is more ‘protocolized,’” Dr. Kin says, “but we try to maintain a family-like atmosphere because I think it makes physicians want to stay with the group long term and not move on with every little problem or challenge that inevitably arises in the changing filed of hospital medicine.”

William Ford, MD, program medical director for Cogent Healthcare and the chief of hospital medicine at Temple University in Philadelphia, considers his group of 28 hospitalists to be a “small” big group. Dr. Ford’s group, which covers three of the four hospitals in the university health systems, grew from five hospitalists in September 2006. He devotes about half his time on personnel issues, including recruitment, retention, and staff development.

As groups grow, so does diversity, requiring more flexibility to manage leaves of absence, scheduling, and day-to-day practice. “In a large group we tend to bring on new measures,” Dr. Ford says. “We change like the wind, so if you aren’t ready for that, you will have a lot of turnover.”

Bigger

Jasen W. Gundersen, MD, MBA, division chief, hospital medicine, University of Massachusetts Memorial Medical Center, Worcester, grew his HMG from 3.6 FTEs three years ago to the 47.5 FTEs (40 physician FTEs and 7.5 FTEs nurse practitioners) they now employ. The group, which covers four hospitals ranging from a 30-bed community hospital to a 770-bed academic hospital, is the biggest HMG in New England. “Our budget numbers for charges and volume are 2.19 times what we projected in the budget,” he says.

With an average of 185 billable patient encounters per day, Dr. Gundersen attributes his successes to a management style based on a financial business model and a revision of the compensation plan. By increasing effectiveness, they reward their doctors with more free time and subsequently improved physician retention.

As the group, the budget, and the financial impact all expand, formal training becomes more important for leaders. While few HMG leaders have a background in the strategic processes of running a company, Dr. Gundersen earned his MBA and believes his training made it easier to talk to administrators, meet clients, track data, effect change, and better handle the politics inherent to the job. “The role is a lot more political than people are aware of because you are such a big presence to the hospital,” he says. “Everybody wants something from you.”

Part of that phenomenon, coined “medical creep” by one hospitalist, can best be defined as the gradual increase in workload shifted to HMGs without a proportional shift in resources to do the work. Work previously done by either surgical specialists or medical subspecialists must be shifted as they more narrowly define their workload; what is left over (more general medical care, phone calls, after-hours work, and paperwork) goes to “co-managing” hospitalists.

Asked about this phenomenon, Tom Lorence, MD, chief of hospitalist medicine for the Northwest Kaiser Permanente region, Portland, Ore., says: “The larger the hospitalist groups become, the bigger a target we are for this shifting. Most try to justify it by saying, ‘It is only a little more work.’ ”

Dr. Lorence and two colleagues began his HMG in 1990; he now manages 55 hospitalists at three facilities. “Administrators have to be convinced that it is worth the money to reshift their priorities and give more resources to the hospital medicine groups,” he says.

Mark V. Williams, MD, FACP, professor and chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago, moved to his current post last September. Northwestern Memorial Hospital almost doubled its hospitalists to 42 in one year. The initial challenges at Northwestern primarily include assimilating new faculty and establishing a culture of thriving on change, says Dr. Williams, who is also editor in chief of the Journal of Hospital Medicine.

click for large version

Biggest

The distinction between academic and non-academic programs is an important one says Michael B. Heisler, MD, MPH, who became the interim medical director of Emory Healthcare, Atlanta, in March 2007 when Dr. Williams moved to Northwestern. Generally, the Emory group has increased in size by 20% each of the past five years. Beginning with nine hospitalists in 1999, it now exceeds 80 (see Figure 2, p. 28).

Academic hospitals have additional stakeholders and deliverables expected by those to whom the medical director reports. Whereas community hospital medicine programs are driven by patient encounters/RVUs, quality improvement, and the bottom line, academic groups also must engage in scholarly activities.

Dr. Heisler and his group have just completed a three-year strategic plan that emphasizes medical education and research and a plateau to the group’s growth.

“We can’t be the premier academic program with growth going through the roof,” Dr. Heisler says. “With some limits we are not going to increase services within our institutions and will not entertain requests to grow into any other facilities through 2010. You can’t develop faculty, define protected time, and invest in scholarly work when you are constantly in growth mode.”

Strategic planning has a different tone for Tyler Jung, MD, director of inpatient services of the multi-specialty group HealthCare Partners, who took over that position three years ago when Dr. Hay left. About 100 hospitalists are employed under the HealthCare Partners umbrella; approximately 85 are on the payroll, and 15 work in a strategic alliance. The HMG covers 14 community hospitals in Southern California, about 14 hospitals in Las Vegas, Nevada, and about five hospitals in the Tampa/Orlando area of Florida.

The full-risk California medical model drives a lot of the metrics. “We look at [relative value unit] goals for our hospitalists, but mostly to ensure proper staffing,” Dr. Jung says. “We are satisfied when our docs have 12 to 14 encounters a day. In the service market you’d go broke with that, but I’d rather have our hospitalists see our patients twice a day because it drives quality and it turns out to be more cost effective.”

Some of the outcomes Dr. Jung regularly reviews include patient utilization per membership (admit rates, readmit data, and length of stay), and these metrics are largely unchanged as they have grown. “Additionally, maintaining high patient satisfaction can be overlooked, but is critical with the growth of any program,” he says (see Figure 3, p. 28).

click for large version

Dr. Williams, who began the hospitalist group at Emory Healthcare, says the primary challenges he faced as that program grew were finding capable physicians willing to join a new or expanding program; managing the different cultures at different hospitals and working to ensure they all felt a part of the whole; having sufficient administrative support time to manage recruitment and credentialing; and keeping up constant communications with individuals and leadership at all sites. He found it helpful to occasionally rotate hospitalists, especially the more senior physicians, so they could appreciate the workload and issues at different sites.

Dr. Williams, who trained in internal medicine but later became board certified in emergency medicine, is not surprised Dr. Jung has some background in critical care, as does Dr. Heisler. He surmises they also all have well-honed administrative skills. “The experience I had in running a 65,000-visit-a-year emergency room and a 45,000-visit-a-year urgent-care center gave me the skills to run a large hospital medicine program,” Dr. Williams says. TH

Andrea M. Sattinger is a medical writer based in North Carolina.