As I embark on my tenure as physician editor of The Hospitalist, I am struck by the similarities between the editor transition and the transitions of care that happen as part of the daily backdrop of our hospitalist lives.

Both scenarios depend on open communication, a multidisciplinary team approach, a well-considered plan, and constituent feedback.

Similar to the communication between providers in patient handoffs, the previous editor, Jamie Newman, MD, and I talked about the history, course, and plan for the publication. Unlike most of my hospital handoffs, this patient is in great condition.

Jamie took over 24 months ago during a major transition for the publication and masterfully shepherded it to the place of prominence it holds today. For this he deserves a ton of credit. The content is top-notch, the reporting timely and noteworthy, and the design compelling.

As a consequence the readership is strong; so strong, it has played an influential role in our transitional communication. Several months ago we asked you to submit feedback about the publication in the form of a reader survey. From that data it was clear The Hospitalist was headed in the right direction but could use a slight “rehab” consult to make it even stronger. You provided several inputs instrumental to enhancing the publication. In short, you clearly desired more clinical content, an easier-to-use “In the Literature” section, and more concise material. These ideas formed the cornerstone of the upcoming changes in the publication.

More Clinical Content

In the near future we will begin to run more articles about the topics that induce the most angina in hospitalists. In general, we will de-emphasize comprehensive topic reviews (e.g., “Congestive heart failure from A to Z: genomics, pathogenesis, presentation, diagnostics, therapeutics and beyond”).

In its place we will introduce shorter articles centered on controversial questions in hospital medicine, the type and scope of questions that by their very nature are common, contentious, and stress-inducing (e.g.,

When should nesiritide therapy be initiated in acute decompensated CHF?).

New “In the Lit”

While this is one of the most well-read sections, many noted it can be difficult to navigate and sometimes seems bloated. To remedy this, we will increase the number of articles reviewed while decreasing the amount of detail per article. What we lose in depth we hope to gain in breadth.

We feel this will provide a general overview of all the pertinent literature so you can be confident you are up to date on take-home points of the most current studies. The department will also be reformatted so it is much easier to find the most crucial information. Look for these changes in the next month or two.

New Departments

The “Legal Eagle” and “Billing and Coding” departments will provide important information on medical malpractice and reimbursement documentation, while the “Hospital Pharmacy” department will offer up-to-the minute highlights of advances in therapeutics.

Finally, an advice column will give you the opportunity to ask experts your questions about the practice of hospital medicine.

Of course, much of The Hospitalist will remain unchanged. We will preserve your favorite features such John Nelson’s “Practice Management” column, Larry Wellikson’s “SHM Point of View” column, and the “Society Pages” and “Public Policy” departments. All this will happen against the backdrop of timely, in-depth reporting that keeps you abreast of the world of hospital medicine.

In all this transitioning it is important to recognize the team effort this publication requires. Indeed, the success of this publication is multidisciplinary and includes the expertise of the many folks at Wiley, notably Lisa Dionne (editorial director), Geoff Giordano (editor), and our colleagues at SHM—Larry Wellikson (CEO of SHM) and Todd Von Deak (director of membership and marketing) as well as the entire editorial and publishing staff at Wiley.

Most importantly, the success of this transition—and indeed the publication itself—depends on feedback from you, the reader. My e-mail box is always open to suggestions on how to improve the publication, including feedback on what we’re doing right and what we need to change. I’m also interested in hearing your ideas about clinical content areas that need to be covered. Just shoot me an e-mail saying, “I’d like to learn more about … .” And, we always welcome offers to contribute content to the publication.

To all of you: Thanks for helping make this transition such a successful one. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver and Health Sciences Center, where he serves as director of the Hospital Medicine Program, Inpatient Clinical Services in the Department of Medicine, and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

As I embark on my tenure as physician editor of The Hospitalist, I am struck by the similarities between the editor transition and the transitions of care that happen as part of the daily backdrop of our hospitalist lives.

Both scenarios depend on open communication, a multidisciplinary team approach, a well-considered plan, and constituent feedback.

Similar to the communication between providers in patient handoffs, the previous editor, Jamie Newman, MD, and I talked about the history, course, and plan for the publication. Unlike most of my hospital handoffs, this patient is in great condition.

Jamie took over 24 months ago during a major transition for the publication and masterfully shepherded it to the place of prominence it holds today. For this he deserves a ton of credit. The content is top-notch, the reporting timely and noteworthy, and the design compelling.

As a consequence the readership is strong; so strong, it has played an influential role in our transitional communication. Several months ago we asked you to submit feedback about the publication in the form of a reader survey. From that data it was clear The Hospitalist was headed in the right direction but could use a slight “rehab” consult to make it even stronger. You provided several inputs instrumental to enhancing the publication. In short, you clearly desired more clinical content, an easier-to-use “In the Literature” section, and more concise material. These ideas formed the cornerstone of the upcoming changes in the publication.

More Clinical Content

In the near future we will begin to run more articles about the topics that induce the most angina in hospitalists. In general, we will de-emphasize comprehensive topic reviews (e.g., “Congestive heart failure from A to Z: genomics, pathogenesis, presentation, diagnostics, therapeutics and beyond”).

In its place we will introduce shorter articles centered on controversial questions in hospital medicine, the type and scope of questions that by their very nature are common, contentious, and stress-inducing (e.g.,

When should nesiritide therapy be initiated in acute decompensated CHF?).

New “In the Lit”

While this is one of the most well-read sections, many noted it can be difficult to navigate and sometimes seems bloated. To remedy this, we will increase the number of articles reviewed while decreasing the amount of detail per article. What we lose in depth we hope to gain in breadth.

We feel this will provide a general overview of all the pertinent literature so you can be confident you are up to date on take-home points of the most current studies. The department will also be reformatted so it is much easier to find the most crucial information. Look for these changes in the next month or two.

New Departments

The “Legal Eagle” and “Billing and Coding” departments will provide important information on medical malpractice and reimbursement documentation, while the “Hospital Pharmacy” department will offer up-to-the minute highlights of advances in therapeutics.

Finally, an advice column will give you the opportunity to ask experts your questions about the practice of hospital medicine.

Of course, much of The Hospitalist will remain unchanged. We will preserve your favorite features such John Nelson’s “Practice Management” column, Larry Wellikson’s “SHM Point of View” column, and the “Society Pages” and “Public Policy” departments. All this will happen against the backdrop of timely, in-depth reporting that keeps you abreast of the world of hospital medicine.

In all this transitioning it is important to recognize the team effort this publication requires. Indeed, the success of this publication is multidisciplinary and includes the expertise of the many folks at Wiley, notably Lisa Dionne (editorial director), Geoff Giordano (editor), and our colleagues at SHM—Larry Wellikson (CEO of SHM) and Todd Von Deak (director of membership and marketing) as well as the entire editorial and publishing staff at Wiley.

Most importantly, the success of this transition—and indeed the publication itself—depends on feedback from you, the reader. My e-mail box is always open to suggestions on how to improve the publication, including feedback on what we’re doing right and what we need to change. I’m also interested in hearing your ideas about clinical content areas that need to be covered. Just shoot me an e-mail saying, “I’d like to learn more about … .” And, we always welcome offers to contribute content to the publication.

To all of you: Thanks for helping make this transition such a successful one. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver and Health Sciences Center, where he serves as director of the Hospital Medicine Program, Inpatient Clinical Services in the Department of Medicine, and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

As I embark on my tenure as physician editor of The Hospitalist, I am struck by the similarities between the editor transition and the transitions of care that happen as part of the daily backdrop of our hospitalist lives.

Both scenarios depend on open communication, a multidisciplinary team approach, a well-considered plan, and constituent feedback.

Similar to the communication between providers in patient handoffs, the previous editor, Jamie Newman, MD, and I talked about the history, course, and plan for the publication. Unlike most of my hospital handoffs, this patient is in great condition.

Jamie took over 24 months ago during a major transition for the publication and masterfully shepherded it to the place of prominence it holds today. For this he deserves a ton of credit. The content is top-notch, the reporting timely and noteworthy, and the design compelling.

As a consequence the readership is strong; so strong, it has played an influential role in our transitional communication. Several months ago we asked you to submit feedback about the publication in the form of a reader survey. From that data it was clear The Hospitalist was headed in the right direction but could use a slight “rehab” consult to make it even stronger. You provided several inputs instrumental to enhancing the publication. In short, you clearly desired more clinical content, an easier-to-use “In the Literature” section, and more concise material. These ideas formed the cornerstone of the upcoming changes in the publication.

More Clinical Content

In the near future we will begin to run more articles about the topics that induce the most angina in hospitalists. In general, we will de-emphasize comprehensive topic reviews (e.g., “Congestive heart failure from A to Z: genomics, pathogenesis, presentation, diagnostics, therapeutics and beyond”).

In its place we will introduce shorter articles centered on controversial questions in hospital medicine, the type and scope of questions that by their very nature are common, contentious, and stress-inducing (e.g.,

When should nesiritide therapy be initiated in acute decompensated CHF?).

New “In the Lit”

While this is one of the most well-read sections, many noted it can be difficult to navigate and sometimes seems bloated. To remedy this, we will increase the number of articles reviewed while decreasing the amount of detail per article. What we lose in depth we hope to gain in breadth.

We feel this will provide a general overview of all the pertinent literature so you can be confident you are up to date on take-home points of the most current studies. The department will also be reformatted so it is much easier to find the most crucial information. Look for these changes in the next month or two.

New Departments

The “Legal Eagle” and “Billing and Coding” departments will provide important information on medical malpractice and reimbursement documentation, while the “Hospital Pharmacy” department will offer up-to-the minute highlights of advances in therapeutics.

Finally, an advice column will give you the opportunity to ask experts your questions about the practice of hospital medicine.

Of course, much of The Hospitalist will remain unchanged. We will preserve your favorite features such John Nelson’s “Practice Management” column, Larry Wellikson’s “SHM Point of View” column, and the “Society Pages” and “Public Policy” departments. All this will happen against the backdrop of timely, in-depth reporting that keeps you abreast of the world of hospital medicine.

In all this transitioning it is important to recognize the team effort this publication requires. Indeed, the success of this publication is multidisciplinary and includes the expertise of the many folks at Wiley, notably Lisa Dionne (editorial director), Geoff Giordano (editor), and our colleagues at SHM—Larry Wellikson (CEO of SHM) and Todd Von Deak (director of membership and marketing) as well as the entire editorial and publishing staff at Wiley.

Most importantly, the success of this transition—and indeed the publication itself—depends on feedback from you, the reader. My e-mail box is always open to suggestions on how to improve the publication, including feedback on what we’re doing right and what we need to change. I’m also interested in hearing your ideas about clinical content areas that need to be covered. Just shoot me an e-mail saying, “I’d like to learn more about … .” And, we always welcome offers to contribute content to the publication.

To all of you: Thanks for helping make this transition such a successful one. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver and Health Sciences Center, where he serves as director of the Hospital Medicine Program, Inpatient Clinical Services in the Department of Medicine, and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

If you heat water sufficiently, you get steam. When you cool the steam, you get water again. Using the same process for chocolate—more “busy” than water and composed of multiple ingredients—will take you from solid to liquid and back again. So why won’t this technique also apply to the egg?

Eggs, or egg whites to be specific, are made up almost exclusively of the protein albumin. The chains of amino acids in proteins are normally configured in elaborate and precise folds, spirals, and sheets. Upon heating, the albumin becomes denatured and alters its molecular structure in such a way that it unfolds and adheres to itself in a dysfunctional manner known as aggregates. In the end, albumin permanently changes from clear to white and retains a rigid form.

No intervention has been successful in returning albumin to its original viscosity and color—not cooling, not anything. The caveat is that there is exciting research being done with naturally existing heat shock proteins called chaperones that have the potential to return proteins to their native state. This research has enormous implications for treating diseases such as cystic fibrosis and Alzheimer’s.

It may seem idiosyncratic that while we can manipulate water and chocolate, we can’t unfry an egg. The answer is, simply, that proteins are too complex for simple logic or techniques.

In its June report, the Medicare Payment Advisory Commission (MedPAC), the group that advises Congress on issues affecting the Medicare program, formulated recommendations for amending the construct for payments to hospitals based on their readmission rates. The rationale for targeting readmission rates, according to MedPAC, is to create favorable financial incentives for hospitals that achieve lower readmissions. Sounds simple enough. The MedPAC report identified potential savings of $12 billion given a 13.3% rate of “potentially preventable readmissions” within 30 days. Not only does it sound simple, it sounds compelling for quality and financial imperatives.

SHM has long identified transitions of care as one of the most vulnerable events for patients. Some of the earliest presentations at SHM meetings vividly described the “voltage drop” of information that can occur when a patient enters or leaves the hospital—not to mention during intra-hospital transitions. SHM has embraced transitions of care as a core competency in hospital medicine, has built a quality improvement resource room online for care transitions of older adults, and in July year co-sponsored a summit on transitions of care.

Readmission rates are commonly considered a proxy outcome measure to reflect the broader issue of quality of care transitions at the time of hospital discharge; however, we must be clear that these two entities are not nearly synonymous. A hospital readmission does not necessarily reflect a poorly executed hospital discharge, and high-quality discharges do not absolutely prevent hospital readmissions. The challenge with improving transitions of care and reducing preventable readmissions lies in the systems, processes, facilities, and people involved.

To drive lower readmission rates, MedPAC is suggesting a bifurcated strategy: public reporting and altering payment schedules to hospitals. I believe the former, combined with appropriate public education on the multifactorial nature of readmissions and how to interpret the data, can be a positive step toward improving care transitions. The more transparent the healthcare system becomes, the more frank conversations we can have in the pursuit of higher quality care. Those conversations open the door to understanding the complexity of care processes and the dependency of various resources and stakeholders on one another. They also help to confront the brutal truth of care transitions: that there must be shared accountability for ensuring our patients receive the support they need, where and when they need it.

By recommending changes in payment methodology to hospitals, however, MedPAC is isolating the facility from the intricate composite of systems and processes involved in transitions of care. While I realize the analogy is a bit of a stretch, this approach strikes me as similar to applying the logic of cooling to unfry an egg. A generally simple tactic to address a highly complex issue. Just as albumin has precise folds, spirals, and sheets to allow it to perform its proper function as a protein, so too must the healthcare system provide proper coordination, communication and support services to ensure proper health and well-being of patients.

Restructuring hospital payments in no way addresses the role of physicians in the hospital, physicians in the ambulatory or sub-acute setting, home-care agencies, other vendors, caregiver compliance, patient self-care, or chronic disease management. MedPAC’s proposal holds one party accountable in a scenario where only joint accountability will render the results we desire. In a recent article in the Harvard Business Review, Roger Martin eloquently describes a common coping mechanism people use to address complexity and ambiguity—simplification whenever possible. Within organizations, “When a colleague admonishes us to ‘quit complicating the issue,’ it’s not just an impatient reminder to get on with the damn job—it’s also a plea to keep the complexity at a comfortable level.”

I do not mean to imply incentives are not important; they are vital to stimulate change and manage behavior. That being said, I also believe incentive programs often beget unintended consequences and may drive undesirable behavior.

Would MedPAC’s proposal cause hospitals to become apprehensive about accepting more complex cases? Even the best severity-adjustment methods account for only a fraction of the variations among patients, so hospitals may feel compelled to screen or select out certain complex populations as opposed to relying on severity-adjustment measures to account for true differences in patient outcomes.

Don Berwick, MD, the CEO of the Institute of Healthcare Improvement (IHI), is often quoted as saying, “Every system is perfectly designed to achieve the results it gets.” If this is so, a singular focus on incentives and penalties directed toward hospitals will bring either unilateral facility actions and/or a lack of leverage to effect needed improvements in the rest of the care system.

Alternatively, the Centers for Medicare and Medicaid Systems (CMS) could focus on several areas that constructively address the interdependent systems and multiple stakeholders involved in transitions of care. CMS could:

• Adopt a public reporting system for readmission rates for hospitals according to select discharge diagnoses. Transparency likely will drive some improvements via the “Hawthorne effect,” and it will serve as a common basis for key parties discussing the issues to drive improvement;
• Advocate that public reporting should be accompanied by rigorous public education on transitions of care. Such education should include a clear outline of the complexities, interdependencies, and pitfalls common to care transitions, and should also include clear steps patients and caregivers can take to play an effective role in the process;
• Participate in the development of improvement tools to address readmission rates. IHI is a terrific example of an organization that has created such a device to improve hospital mortality rates. Their Mortality Diagnostic Tool identifies potentially avoidable hospital deaths;
• Sponsor collaborative meetings with key industry organizations to discuss the issues, gain consensus on standards and expectations, and promote necessary change; and
• Take the framework of reporting, education, improvement tools and practice standards to create aligned incentives across facilities, providers, vendors, and beneficiaries.

While it’s tempting to seek simple answers to complex issues, they often fall short of the best solution. As leaders in healthcare, we must embrace complexity and find answers that reflect an integrated and aligned approach. We must acknowledge that accountability for high-quality transitions of care and reductions in readmissions has to be shared. With the support of CMS, SHM, and other agencies and professional organizations, we have every resource available to improve this vulnerable time in the lives of our patients. Only then will we have an environment suitable to unfry the egg. Or perhaps we’ll engineer an environment where the egg is never fried in the first place. TH

Dr. Holman is the president of SHM.

If you heat water sufficiently, you get steam. When you cool the steam, you get water again. Using the same process for chocolate—more “busy” than water and composed of multiple ingredients—will take you from solid to liquid and back again. So why won’t this technique also apply to the egg?

Eggs, or egg whites to be specific, are made up almost exclusively of the protein albumin. The chains of amino acids in proteins are normally configured in elaborate and precise folds, spirals, and sheets. Upon heating, the albumin becomes denatured and alters its molecular structure in such a way that it unfolds and adheres to itself in a dysfunctional manner known as aggregates. In the end, albumin permanently changes from clear to white and retains a rigid form.

No intervention has been successful in returning albumin to its original viscosity and color—not cooling, not anything. The caveat is that there is exciting research being done with naturally existing heat shock proteins called chaperones that have the potential to return proteins to their native state. This research has enormous implications for treating diseases such as cystic fibrosis and Alzheimer’s.

It may seem idiosyncratic that while we can manipulate water and chocolate, we can’t unfry an egg. The answer is, simply, that proteins are too complex for simple logic or techniques.

In its June report, the Medicare Payment Advisory Commission (MedPAC), the group that advises Congress on issues affecting the Medicare program, formulated recommendations for amending the construct for payments to hospitals based on their readmission rates. The rationale for targeting readmission rates, according to MedPAC, is to create favorable financial incentives for hospitals that achieve lower readmissions. Sounds simple enough. The MedPAC report identified potential savings of $12 billion given a 13.3% rate of “potentially preventable readmissions” within 30 days. Not only does it sound simple, it sounds compelling for quality and financial imperatives.

SHM has long identified transitions of care as one of the most vulnerable events for patients. Some of the earliest presentations at SHM meetings vividly described the “voltage drop” of information that can occur when a patient enters or leaves the hospital—not to mention during intra-hospital transitions. SHM has embraced transitions of care as a core competency in hospital medicine, has built a quality improvement resource room online for care transitions of older adults, and in July year co-sponsored a summit on transitions of care.

Readmission rates are commonly considered a proxy outcome measure to reflect the broader issue of quality of care transitions at the time of hospital discharge; however, we must be clear that these two entities are not nearly synonymous. A hospital readmission does not necessarily reflect a poorly executed hospital discharge, and high-quality discharges do not absolutely prevent hospital readmissions. The challenge with improving transitions of care and reducing preventable readmissions lies in the systems, processes, facilities, and people involved.

To drive lower readmission rates, MedPAC is suggesting a bifurcated strategy: public reporting and altering payment schedules to hospitals. I believe the former, combined with appropriate public education on the multifactorial nature of readmissions and how to interpret the data, can be a positive step toward improving care transitions. The more transparent the healthcare system becomes, the more frank conversations we can have in the pursuit of higher quality care. Those conversations open the door to understanding the complexity of care processes and the dependency of various resources and stakeholders on one another. They also help to confront the brutal truth of care transitions: that there must be shared accountability for ensuring our patients receive the support they need, where and when they need it.

By recommending changes in payment methodology to hospitals, however, MedPAC is isolating the facility from the intricate composite of systems and processes involved in transitions of care. While I realize the analogy is a bit of a stretch, this approach strikes me as similar to applying the logic of cooling to unfry an egg. A generally simple tactic to address a highly complex issue. Just as albumin has precise folds, spirals, and sheets to allow it to perform its proper function as a protein, so too must the healthcare system provide proper coordination, communication and support services to ensure proper health and well-being of patients.

Restructuring hospital payments in no way addresses the role of physicians in the hospital, physicians in the ambulatory or sub-acute setting, home-care agencies, other vendors, caregiver compliance, patient self-care, or chronic disease management. MedPAC’s proposal holds one party accountable in a scenario where only joint accountability will render the results we desire. In a recent article in the Harvard Business Review, Roger Martin eloquently describes a common coping mechanism people use to address complexity and ambiguity—simplification whenever possible. Within organizations, “When a colleague admonishes us to ‘quit complicating the issue,’ it’s not just an impatient reminder to get on with the damn job—it’s also a plea to keep the complexity at a comfortable level.”

I do not mean to imply incentives are not important; they are vital to stimulate change and manage behavior. That being said, I also believe incentive programs often beget unintended consequences and may drive undesirable behavior.

Would MedPAC’s proposal cause hospitals to become apprehensive about accepting more complex cases? Even the best severity-adjustment methods account for only a fraction of the variations among patients, so hospitals may feel compelled to screen or select out certain complex populations as opposed to relying on severity-adjustment measures to account for true differences in patient outcomes.

Don Berwick, MD, the CEO of the Institute of Healthcare Improvement (IHI), is often quoted as saying, “Every system is perfectly designed to achieve the results it gets.” If this is so, a singular focus on incentives and penalties directed toward hospitals will bring either unilateral facility actions and/or a lack of leverage to effect needed improvements in the rest of the care system.

Alternatively, the Centers for Medicare and Medicaid Systems (CMS) could focus on several areas that constructively address the interdependent systems and multiple stakeholders involved in transitions of care. CMS could:

• Adopt a public reporting system for readmission rates for hospitals according to select discharge diagnoses. Transparency likely will drive some improvements via the “Hawthorne effect,” and it will serve as a common basis for key parties discussing the issues to drive improvement;
• Advocate that public reporting should be accompanied by rigorous public education on transitions of care. Such education should include a clear outline of the complexities, interdependencies, and pitfalls common to care transitions, and should also include clear steps patients and caregivers can take to play an effective role in the process;
• Participate in the development of improvement tools to address readmission rates. IHI is a terrific example of an organization that has created such a device to improve hospital mortality rates. Their Mortality Diagnostic Tool identifies potentially avoidable hospital deaths;
• Sponsor collaborative meetings with key industry organizations to discuss the issues, gain consensus on standards and expectations, and promote necessary change; and
• Take the framework of reporting, education, improvement tools and practice standards to create aligned incentives across facilities, providers, vendors, and beneficiaries.

While it’s tempting to seek simple answers to complex issues, they often fall short of the best solution. As leaders in healthcare, we must embrace complexity and find answers that reflect an integrated and aligned approach. We must acknowledge that accountability for high-quality transitions of care and reductions in readmissions has to be shared. With the support of CMS, SHM, and other agencies and professional organizations, we have every resource available to improve this vulnerable time in the lives of our patients. Only then will we have an environment suitable to unfry the egg. Or perhaps we’ll engineer an environment where the egg is never fried in the first place. TH

Dr. Holman is the president of SHM.

If you heat water sufficiently, you get steam. When you cool the steam, you get water again. Using the same process for chocolate—more “busy” than water and composed of multiple ingredients—will take you from solid to liquid and back again. So why won’t this technique also apply to the egg?

Eggs, or egg whites to be specific, are made up almost exclusively of the protein albumin. The chains of amino acids in proteins are normally configured in elaborate and precise folds, spirals, and sheets. Upon heating, the albumin becomes denatured and alters its molecular structure in such a way that it unfolds and adheres to itself in a dysfunctional manner known as aggregates. In the end, albumin permanently changes from clear to white and retains a rigid form.

No intervention has been successful in returning albumin to its original viscosity and color—not cooling, not anything. The caveat is that there is exciting research being done with naturally existing heat shock proteins called chaperones that have the potential to return proteins to their native state. This research has enormous implications for treating diseases such as cystic fibrosis and Alzheimer’s.

It may seem idiosyncratic that while we can manipulate water and chocolate, we can’t unfry an egg. The answer is, simply, that proteins are too complex for simple logic or techniques.

In its June report, the Medicare Payment Advisory Commission (MedPAC), the group that advises Congress on issues affecting the Medicare program, formulated recommendations for amending the construct for payments to hospitals based on their readmission rates. The rationale for targeting readmission rates, according to MedPAC, is to create favorable financial incentives for hospitals that achieve lower readmissions. Sounds simple enough. The MedPAC report identified potential savings of $12 billion given a 13.3% rate of “potentially preventable readmissions” within 30 days. Not only does it sound simple, it sounds compelling for quality and financial imperatives.

SHM has long identified transitions of care as one of the most vulnerable events for patients. Some of the earliest presentations at SHM meetings vividly described the “voltage drop” of information that can occur when a patient enters or leaves the hospital—not to mention during intra-hospital transitions. SHM has embraced transitions of care as a core competency in hospital medicine, has built a quality improvement resource room online for care transitions of older adults, and in July year co-sponsored a summit on transitions of care.

Readmission rates are commonly considered a proxy outcome measure to reflect the broader issue of quality of care transitions at the time of hospital discharge; however, we must be clear that these two entities are not nearly synonymous. A hospital readmission does not necessarily reflect a poorly executed hospital discharge, and high-quality discharges do not absolutely prevent hospital readmissions. The challenge with improving transitions of care and reducing preventable readmissions lies in the systems, processes, facilities, and people involved.

To drive lower readmission rates, MedPAC is suggesting a bifurcated strategy: public reporting and altering payment schedules to hospitals. I believe the former, combined with appropriate public education on the multifactorial nature of readmissions and how to interpret the data, can be a positive step toward improving care transitions. The more transparent the healthcare system becomes, the more frank conversations we can have in the pursuit of higher quality care. Those conversations open the door to understanding the complexity of care processes and the dependency of various resources and stakeholders on one another. They also help to confront the brutal truth of care transitions: that there must be shared accountability for ensuring our patients receive the support they need, where and when they need it.

By recommending changes in payment methodology to hospitals, however, MedPAC is isolating the facility from the intricate composite of systems and processes involved in transitions of care. While I realize the analogy is a bit of a stretch, this approach strikes me as similar to applying the logic of cooling to unfry an egg. A generally simple tactic to address a highly complex issue. Just as albumin has precise folds, spirals, and sheets to allow it to perform its proper function as a protein, so too must the healthcare system provide proper coordination, communication and support services to ensure proper health and well-being of patients.

Restructuring hospital payments in no way addresses the role of physicians in the hospital, physicians in the ambulatory or sub-acute setting, home-care agencies, other vendors, caregiver compliance, patient self-care, or chronic disease management. MedPAC’s proposal holds one party accountable in a scenario where only joint accountability will render the results we desire. In a recent article in the Harvard Business Review, Roger Martin eloquently describes a common coping mechanism people use to address complexity and ambiguity—simplification whenever possible. Within organizations, “When a colleague admonishes us to ‘quit complicating the issue,’ it’s not just an impatient reminder to get on with the damn job—it’s also a plea to keep the complexity at a comfortable level.”

I do not mean to imply incentives are not important; they are vital to stimulate change and manage behavior. That being said, I also believe incentive programs often beget unintended consequences and may drive undesirable behavior.

Would MedPAC’s proposal cause hospitals to become apprehensive about accepting more complex cases? Even the best severity-adjustment methods account for only a fraction of the variations among patients, so hospitals may feel compelled to screen or select out certain complex populations as opposed to relying on severity-adjustment measures to account for true differences in patient outcomes.

Don Berwick, MD, the CEO of the Institute of Healthcare Improvement (IHI), is often quoted as saying, “Every system is perfectly designed to achieve the results it gets.” If this is so, a singular focus on incentives and penalties directed toward hospitals will bring either unilateral facility actions and/or a lack of leverage to effect needed improvements in the rest of the care system.

Alternatively, the Centers for Medicare and Medicaid Systems (CMS) could focus on several areas that constructively address the interdependent systems and multiple stakeholders involved in transitions of care. CMS could:

• Adopt a public reporting system for readmission rates for hospitals according to select discharge diagnoses. Transparency likely will drive some improvements via the “Hawthorne effect,” and it will serve as a common basis for key parties discussing the issues to drive improvement;
• Advocate that public reporting should be accompanied by rigorous public education on transitions of care. Such education should include a clear outline of the complexities, interdependencies, and pitfalls common to care transitions, and should also include clear steps patients and caregivers can take to play an effective role in the process;
• Participate in the development of improvement tools to address readmission rates. IHI is a terrific example of an organization that has created such a device to improve hospital mortality rates. Their Mortality Diagnostic Tool identifies potentially avoidable hospital deaths;
• Sponsor collaborative meetings with key industry organizations to discuss the issues, gain consensus on standards and expectations, and promote necessary change; and
• Take the framework of reporting, education, improvement tools and practice standards to create aligned incentives across facilities, providers, vendors, and beneficiaries.

While it’s tempting to seek simple answers to complex issues, they often fall short of the best solution. As leaders in healthcare, we must embrace complexity and find answers that reflect an integrated and aligned approach. We must acknowledge that accountability for high-quality transitions of care and reductions in readmissions has to be shared. With the support of CMS, SHM, and other agencies and professional organizations, we have every resource available to improve this vulnerable time in the lives of our patients. Only then will we have an environment suitable to unfry the egg. Or perhaps we’ll engineer an environment where the egg is never fried in the first place. TH

Dr. Holman is the president of SHM.

In 2004, 370 of 1,394 reporting hospitals offered some complementary alternative medicine (CAM) services in the U.S. Of the 370 hospitals reporting CAM services, 11.5% (42 hospitals) reported inpatient acupuncture services.1

This threefold increase since 1998 demonstrates the growing use of and demand for acupuncture services in hospitals. This trend is driven by patient demand and clinical effectiveness. Acupuncture is a safe treatment modality hospital physicians should be familiar because it can benefit patients in the inpatient setting.

click for large version

Origins of Acupuncture

The first use of acupuncture is not known. The earliest medical textbook on acupuncture was The Medical Classic of the Yellow Emperor, written about 100 B.C. The first translation of this text into English was in 1949.2

The book outlined the theory of a system of six sets of symmetrical channels on the body’s surface, which it called meridians; along these, it posited an intricate network of points.3 Needling the points was supposed to manipulate or release the flow of energy or life force—Qi—to the internal organs, thereby alleviating symptoms. Heating acupuncture points with burning herbs—moxibustion—was also purported to relieve pain.

Acupuncture in the U.S.

The first documented use of acupuncture in the United States occurred in the 19th century. In 1826, Bache used it to treat lumbago.4 During that same era, William Mosley used acupuncture to treat patients with lumbago and sciatica.5

In 1971, a first-person account of the use of acupuncture by New York Times reporter James Reston excited great interest in the technique. Reston was introduced to the procedure to relieve pain after an emergency appendectomy during a trip to China with Henry A. Kissinger.6

Since then, there has been a steady increase in the use of acupuncture by physicians. The American Academy of Medical Acupuncture, the only physician-based acupuncture society in North America, was formed in 1987; in 1992, the Office of Alternative Medicine was created within the NIH. In November 1997, the Food and Drug Administration (FDA) removed the experimental designation for acupuncture needles and approved their use by licensed practitioners. By 1993, the FDA had a record of more than 9,000 licensed acupuncturists, estimated to be providing more than 10 million treatments annually at a cost in excess of $500 million.7

Acupuncture is part of the quasi-medical area of complementary and alternative medicine, whose practitioners field more visits annually than all primary-care physicians in this country combined.8 Most acupuncturists practice the Chinese technique.9

Licensing requirements vary by state.10 As acupuncture has gained popularity and respect, and as its benefit for various medical conditions has been proved in high-quality studies, many well-established medical institutions and universities have begun to integrate it with more traditional Western medical treatments.

Acupuncture Theories

The early Chinese theories about how best to perform acupuncture were varied and sometimes conflicting.11 Early treatments using heat, bloodletting, and crude stone implementation evolved over centuries into the intricate practice known today.

Western scientists first became seriously interested in researching the effects of acupuncture in the 1970s. Many of the early studies were poorly designed, and the results were often not reproducible. They were not sufficiently randomized or blinded, and placebo controls were unreliable or nonexistent. To date, no single theory has been put forth that can explain all the phenomena associated with acupuncture treatment.

In 1991, the World Health Organization proposed a standard nomenclature for the 400 acupuncture points and the 20 meridians connecting those points.12 The precise anatomical locations of these areas have not yet been identified definitively. They have a low electrical resistance compared with surrounding tissue. Theories attempting to correlate the acupuncture points with neurovascular bundles have been postulated but remain unproved. The existence of acupuncture points has been verified with galvanometer scanning. These devices measure electrical conductance and emit an audio signal when an area of low resistance is encountered. New points have been added and the location of some of the original ones redefined by this technique.

In some of the earliest research conducted, French acupuncturists Niboyet and Grall mapped many of the points.13,14 Darras attempted to prove the existence of the meridians by tracing the flow of the radionuclide technetium TC 99m sulfur colloid after it was injected into them.15 No published reports in the English-language medical literature have reliably confirmed scientific studies documenting either the existence or location of the meridians.16

The neurohumoral theory postulates that the analgesic effects of acupuncture are related to the release of neurotransmitters such as endogenous opioids. In addition, acupuncture appears to inhibit the transmission of C-fiber pain at the level of the spinal cord.17,18 Other physiological phenomena have also been observed with acupuncture by needling. They include vasodilation, increased serum cortisol, variations in serum glucose and cholesterol levels, increased white blood cell counts, and acid suppression.5 Their significance continues to be questioned.

Evidence-Based Approach

Many studies of acupuncture have methodological flaws. The biggest problem as yet unresolved is an appropriate placebo control.19 Sham acupuncture, which involves needling non-acupuncture points, is frequently the control of choice but has serious limitations.

In 1997, the landmark NIH consensus statement was probably the most important presentation of evidence supporting the efficacy of acupuncture.20 Conclusions made about the effectiveness of acupuncture were based on evidence from reliable studies. Many promising results emerged. Specific indications for use of acupuncture were identified on the basis of published reports of its effectiveness. Efficacy in treating dental pain and post-operative and chemotherapy-induced nausea were demonstrated. Research suggested its usefulness as an adjunct or alternative treatment for lower-back pain, osteoarthritis, addiction, and stroke rehabilitation. The panel also concluded that further research would likely uncover additional uses for acupuncture.

From the standpoint of acupuncture’s effectiveness, it can clearly benefit specific patient groups. It is most commonly used as a treatment for back pain.21 Since the NIH conference, further research has confirmed its effectiveness in treating a variety of medical conditions. (See Table 1, above)

Much of the ongoing research on acupuncture has focused on the use of functional magnetic resonance imaging of the brain, specifically on the areas that light up, or show brain activity, during activities or a state of pain.22-24 Acupuncture has been found to reduce the intensity of signals in such areas. The mechanism for the analgesic effects of acupuncture may be the result of reduced blood flow to the brain.24 Several studies have identified specific areas of the brain affected by pressure on various acupuncture points.25

Practical Aspects

Acupuncture treatments are extremely time efficient and require minimal equipment. They can be administered with the patient in the recumbent position or sitting upright. For initial sessions, I prefer the former, especially for younger males, who are more prone to vasovagal reactions. Any of several different methods of acupuncture can be used to stimulate points. In addition to needling, acupuncture can be conducted by electro-acupuncture, moxibustion, cupping, scraping, tapping, acupressure, or laser.

Most inpatient referrals are for pain management. Other common indications include post-operative or chemotherapy-induced nausea (emesis), anxiety, and prevention of withdrawal symptoms from narcotics.

Acupuncture Safety

Overall, acupuncture is a safe treatment method. Many large studies have confirmed that most types of acupuncture have a low rate of complications and that most of these complications are transient and minor in nature.28,29 They are incident-reporting studies, however, and have the limitations inherent in these studies. Nausea, dizziness, bruising, and needle pain are some of the most commonly reported. The rare but serious adverse events, such as pneumothorax, usually occur as a result of the practitioner’s poor training or technique.30

Future of Acupuncture

Public acceptance of, and demand for, acupuncture for pain relief is increasing. Additional clinical studies are needed, however, to expand the types of conditions for which acupuncture may be useful. It is essential to maintain a constant focus on safe practice, which would be aided by the establishment of a standardized accreditation and training system. Hospitals need to establish uniform credentialing guidelines similar to those for other procedures that require evidence of medical competence and safety.31

In February 2005, the Federal Acupuncture Coverage Act was introduced to Congress. If enacted, the measure would allow acupuncture to be covered under Part B for Medicare recipients.

The trend toward an integrated approach to patient therapy in large academic medical institutions is encouraging. The incorporation of the teaching of acupuncture within the current medical school curricula would no doubt complement this approach. TH

ACUPUNCTURE METHODS

Needles

Stainless steel, disposable needles are most commonly used. They vary in length from a few millimeters to needle ear points to as long as 6 inches and are used to treat deeper tissue points on the back. The depth of insertion is variable, and they are typically inserted for five to 25 minutes.

Electro-acupuncture involves connecting the needles to a battery-powered device that passes a low current into them. This provides a more powerful analgesic effect.26 Insertion is effected by a swift downward stroke followed by gradual advancement until the patient experiences “de Qi.” This term describes a variety of sensations experienced at the needle tip, such as tingling or mild aching. Absolute contraindications to electro-acupuncture include fever and hypotension. Relative contraindications include the use of a pacemaker, the presence of epilepsy or pregnancy, and uncontrolled anticoagulation therapy.

Tapping

This procedure utilizes a flexible hammer that has tiny dermal needles at one end. The acupuncture points are tapped repetitively for several minutes. There are no reliable studies comparing the efficacy of this method with needling.

Cupping

This method involves applying a vacuum suction to cups that have been placed over acupuncture points. There are no randomized trials to support the efficacy of this treatment.

Acupressure

This is a popular and simple treatment employing the application of pressure to acupuncture points with the thumbs. Studies on its efficacy have been less than convincing.32

Gua Sha

A traditional practice employed less commonly in the U.S., but popular in the Far East. Ceramic or metal spoons are used to abrade the skin overlying the acupuncture points; this results in a hyperemia that warms them. Bleeding over a wide area can occur and may cause infection.

Moxibustion

This practice uses an herb, Artemia vulgaris, that burns at a low temperature and delivers heat to the points. Traditionally, it was wrapped around the needle head after insertion to enhance the analgesic effects of acupuncture. More modern methods employ a “cigar” held above them. Its use is limited by its unpleasant odor and the risk of skin burns, in addition to the lack of reliable data supporting its efficacy.

Lasers

This practice is gaining in popularity because it is easy and painless to apply. Optical stimulation of acupuncture points using handheld devices has a theoretical basis, but is not, at this time, backed by any large, reliable clinical trials. A large meta-analysis of the use of low-intensity laser for musculoskeletal pain did not show this method to be efficacious.27 More research is needed about laser acupuncture.

Joseph C. Charles, MD, FACP, is an assistant professor of medicine and division education coordinator for the Department of Hospital Internal Medicine at the Mayo Clinic Hospital Arizona.

References

• Ananth, S. Health Forum 2005 Complementary and Alternative Medicine Survey of Hospitals, July 19, 2006. News release, American Hospital Association.
• Veith I (trans). The Yellow Emperor’s Classic of Internal Medicine. Baltimore; Lippincott, Williams & Wilkins: 1949.
• Ming Z (trans). The Medical Classic of the Yellow Emperor. Beijing; Foreign Languages Press: 2001.
• Cassedy JH. Early uses of acupuncture in the United States, with an addendum (1826) by Franklin Bache, M.D. Bull N Y Acad Med. 1974 Sep;50(8):892-906.
• Osler W. The Principles and Practice of Medicine. New York: D. Appleton and Company; 1892.
• Reston J. Now, let me tell you about my appendectomy in Peking. New York Times. July 26, 1971.
• Mitchell BB. Educational and licensing requirements for acupuncturists. J Altern Complement Med. 1996 spring;2(1):33-35.
• Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993 Jan 28;328(4):246-252.
• Sherman KJ, Cherkin DC, Eisenberg DM, et al. The practice of acupuncture: who are the providers and what do they do? Ann Fam Med. 2005 Mar-Apr;3(2):151-158.
• Leake R, Broderick JE. Current licensure for acupuncture in the United States. Altern Ther Health Med. 1999 Jul;5(4):94-96.
• Shang C. The past, present, and future of meridian system research. In: Stux G, Hammerschlag R, eds. Clinical Acupuncture: Scientific Basis. Berlin: Springer; 2001:69-82.
• WHO Scientific Group on International Acupuncture Nomenclature. A proposed standard international acupuncture nomenclature: report of a WHO Scientific Group. Geneva: World Health Organization; 1991.
• Niboyet JEH. Nouvelles constatations sur les proprietes electriques des points chinois. Bull Soc Acupunct. 1938;4:30-79.
• Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif.: Medical Acupuncture Publishers; 1995:23-24.
• De Vernejoul P, Albarede P, Darras JC. Study of acupuncture meridians using radioactive tracers [in French]. Bull Acad Natl Med. 1985 Oct;169(7):1071-1075.
• Simon J, Guiraud G, Esquerre JP, et al. Acupuncture meridians demythified. Contribution of radiotracer methodology [in French]. Presse Med. 1988 Jul 2;17(26):1341-1344.
• Pomeranz B, Chiu D. Naloxone blockade of acupuncture analgesia: endorphin implicated. Life Sci. 1976 Dec 1;19(11):1757-1762.
• Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med. 2002;136:374-383.
• Vincent C, Lewith G. Placebo controls for acupuncture studies. J R Soc Med. 1995 Apr;88(4):199-202.
• Acupuncture. NIH Consensus Statement 1997; 15:1-34
• Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142:651-663.
• Tank DW, Oqawa S, Uqurbil K. Mapping the brain with MRI. Curr Biol. 1992;525-528.
• Salvatore S. Brain imaging suggests acupuncture works, study says. [monograph on the Internet]. CNN.com with WebMD.com. Dec. 1, 1999. Available at http://archives.cnn.com/1999/HEALTH/alternative/12/01/brain.acupuncture/index.html. Last accessed April 14, 2007.
• Fang JL, Krings T, Weidemann J, et al. Functional MRI in healthy subjects during acupuncture: different effects of needle rotation in real and false acupoints. Neuroradiology. 2004;46:359-362.
• Cho ZH, Chung SC, Jones JP, et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Natl Acad Sci USA. 1998 Mar;95(5):2670-2673. Retraction in Cho ZH, Chung SC, Lee HJ, Wong EK, Min BI. Proc Natl Acad Sci USA. 2006 Jul 5;103(27):10527.
• Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry. 1998;44:129-138.
• Gam AN, Thorsen H, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain: a meta-analysis. Pain. 1993;52:63-66.
• White A, Hayhoe S, Hart A, et al. Adverse events following acupuncture: prospective survey of 32, 000 consultations with doctors and physiotherapists. BMJ. 2001 Sep 1;323(7311):485-486.
• MacPherson H, Thomas K, Walters S, et al. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ. 2001;323:486-487. Comment in BMJ. 2001 Sep 1;323(7311):467-8. BMJ. 2002 Jan 19;324(7330):170-1.
• Chauffe RJ, Duskin AL. Pneumothorax secondary to acupuncture therapy. South Med J. 2006;99:1297-1299.
• Cohen MH, Hrbek A, Davis RB, et al. Emerging credentialing practices, malpractice liability policies, and guidelines governing complementary and alternative medical practices and dietary supplement recommendations: a descriptive study of 19 integrative health care centers in the United States. Arch Intern Med. 2005;165:289-295.
• Linde K, Jobst K, Panton J. Acupuncture for chronic asthma. Cochrane Database Syst Rev. 2000;(2):CD000008.
• Kleijnen J, Ter Riet G, Knipschild P. Acupuncture and asthma: a review of controlled trials. Thorax. 1991;46:799-802.
• Ter Reit G, Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract. 1990;40:379-382.
• Vincent CA. A controlled trial of the treatment of migraine by acupuncture. Clin J Pain. 1989;5:305-312.
• White AR, Rampes H, Ernst E. Acupuncture for smoking cessation. Cochrane Database Syst Rev. 2002;(2):CD000009.
• Mann E. Using acupuncture and acupressure to treat postoperative emesis. Prof Nurse. 1999; 14:691-694.
• Macklin EA, Wayne PM, Kalish LA, et al. Stop hypertension with the acupuncture research program (SHARP): results of a randomized, controlled clinical trial. Hypertension. 2006;48:838-845.
• Lee JD, Chon JS, Jeong HK, et al. The cerebrovascular response to traditional acupuncture after stroke. Neuroradiology. 2003;45:780-784.
• Scharf HP, Mansmann U, Streitberger K, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med. 2006;145:12-20.
• Martin DP, Sletten CD, Williams BA, et al. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc. 2006;81:749-757.
• Lu DP, Lu GP. Anatomical relevance of some acupuncture points in the head and neck region that dictate medical or dental application depending on depth of needle insertion. Acupunct Electrother Res. 2003;28(3-4):145-156.
• Ernst E, Pittler MH. The effectiveness of acupuncture in treating acute dental pain: a systemic review. Br Dent J. 1998;184:443-447.
• Chen HM, Chen CH. Effects of acupressure at the Sanyinjiao point on primary dysmenorrhoea. J Adv Nurs. 2004;48(4):380-387.
• Pouresmail Z, Ibrahimzadeh R. Effects of acupressure and ibuprofen on the severity of primary dysmenorrhea. J Tradit Chin Med. 2002 Sep; 22(3):205-210.
• Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005 May 4;293(17):2118-2125.
• Allais G, De Lorenzo C, Quirico PE, et al. Acupuncture in the prophylactic treatment of migraine without aura: a comparison with flunarizine. Headache. 2002 Oct;42(9):855-861.
• Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev. 2002;(1):CD003527. Review.
• Trinh KV, Phillips SD. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford). 2004:43:1085-1090.
• David J, Townsend S, Sathanathan R, et al. The effect of acupuncture on patients with rheumatoid arthritis: a randomized, placebo-controlled cross-over study. Rheumatology (Oxford). 1999 Sep;38(9):864-869. Comment in Rheumatology (Oxford). 2000 Oct;39(10):1153-1154.
• Irnich D, Behrens N, Molzen H, et al. Randomised trial of acupuncture compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck pain. BMJ. 2001 Jun 30;322(7302):1574-1578. Comment in BMJ. 2001 Dec 1;323(7324):1306-7.
• White P, Lewith G, Prescott P, et al. Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Ann Intern Med. 2004 Dec 21;141(12):911-919. Comment in Ann Intern Med. 2004 Dec 21;141(12):957-958. Ann Intern Med. 2005 May 17;142(10):873; author reply 873-874.
• Cheuk DK, Wong V. Acupuncture for epilepsy. Cochrane Database Syst Rev. 2006;(2):CD005062.
• Griggs C, Jensen J. Effectiveness of acupuncture for migraine: critical literature review. J Adv Nurs. 2006 May;54(4):491-501.
• Kim YH, Schiff E, Waalen J, et al. Efficacy of acupuncture for treating cocaine addiction: a review paper. J Addict Dis. 2005;24(4):115-132.
• Forbes A, Jackson S, Walter C, et al. Acupuncture for irritable bowel syndrome: a blinded placebo-controlled trial. World J Gastroenterol. 2005 Jul 14;11(26):4040-4044.
• Schneider A, Enck P, Streitberger K, et al. Acupuncture treatment in irritable bowel syndrome. Gut. 2006;55:649-654.

In 2004, 370 of 1,394 reporting hospitals offered some complementary alternative medicine (CAM) services in the U.S. Of the 370 hospitals reporting CAM services, 11.5% (42 hospitals) reported inpatient acupuncture services.1

This threefold increase since 1998 demonstrates the growing use of and demand for acupuncture services in hospitals. This trend is driven by patient demand and clinical effectiveness. Acupuncture is a safe treatment modality hospital physicians should be familiar because it can benefit patients in the inpatient setting.

click for large version

Origins of Acupuncture

The first use of acupuncture is not known. The earliest medical textbook on acupuncture was The Medical Classic of the Yellow Emperor, written about 100 B.C. The first translation of this text into English was in 1949.2

The book outlined the theory of a system of six sets of symmetrical channels on the body’s surface, which it called meridians; along these, it posited an intricate network of points.3 Needling the points was supposed to manipulate or release the flow of energy or life force—Qi—to the internal organs, thereby alleviating symptoms. Heating acupuncture points with burning herbs—moxibustion—was also purported to relieve pain.

Acupuncture in the U.S.

The first documented use of acupuncture in the United States occurred in the 19th century. In 1826, Bache used it to treat lumbago.4 During that same era, William Mosley used acupuncture to treat patients with lumbago and sciatica.5

In 1971, a first-person account of the use of acupuncture by New York Times reporter James Reston excited great interest in the technique. Reston was introduced to the procedure to relieve pain after an emergency appendectomy during a trip to China with Henry A. Kissinger.6

Since then, there has been a steady increase in the use of acupuncture by physicians. The American Academy of Medical Acupuncture, the only physician-based acupuncture society in North America, was formed in 1987; in 1992, the Office of Alternative Medicine was created within the NIH. In November 1997, the Food and Drug Administration (FDA) removed the experimental designation for acupuncture needles and approved their use by licensed practitioners. By 1993, the FDA had a record of more than 9,000 licensed acupuncturists, estimated to be providing more than 10 million treatments annually at a cost in excess of $500 million.7

Acupuncture is part of the quasi-medical area of complementary and alternative medicine, whose practitioners field more visits annually than all primary-care physicians in this country combined.8 Most acupuncturists practice the Chinese technique.9

Licensing requirements vary by state.10 As acupuncture has gained popularity and respect, and as its benefit for various medical conditions has been proved in high-quality studies, many well-established medical institutions and universities have begun to integrate it with more traditional Western medical treatments.

Acupuncture Theories

The early Chinese theories about how best to perform acupuncture were varied and sometimes conflicting.11 Early treatments using heat, bloodletting, and crude stone implementation evolved over centuries into the intricate practice known today.

Western scientists first became seriously interested in researching the effects of acupuncture in the 1970s. Many of the early studies were poorly designed, and the results were often not reproducible. They were not sufficiently randomized or blinded, and placebo controls were unreliable or nonexistent. To date, no single theory has been put forth that can explain all the phenomena associated with acupuncture treatment.

In 1991, the World Health Organization proposed a standard nomenclature for the 400 acupuncture points and the 20 meridians connecting those points.12 The precise anatomical locations of these areas have not yet been identified definitively. They have a low electrical resistance compared with surrounding tissue. Theories attempting to correlate the acupuncture points with neurovascular bundles have been postulated but remain unproved. The existence of acupuncture points has been verified with galvanometer scanning. These devices measure electrical conductance and emit an audio signal when an area of low resistance is encountered. New points have been added and the location of some of the original ones redefined by this technique.

In some of the earliest research conducted, French acupuncturists Niboyet and Grall mapped many of the points.13,14 Darras attempted to prove the existence of the meridians by tracing the flow of the radionuclide technetium TC 99m sulfur colloid after it was injected into them.15 No published reports in the English-language medical literature have reliably confirmed scientific studies documenting either the existence or location of the meridians.16

The neurohumoral theory postulates that the analgesic effects of acupuncture are related to the release of neurotransmitters such as endogenous opioids. In addition, acupuncture appears to inhibit the transmission of C-fiber pain at the level of the spinal cord.17,18 Other physiological phenomena have also been observed with acupuncture by needling. They include vasodilation, increased serum cortisol, variations in serum glucose and cholesterol levels, increased white blood cell counts, and acid suppression.5 Their significance continues to be questioned.

Evidence-Based Approach

Many studies of acupuncture have methodological flaws. The biggest problem as yet unresolved is an appropriate placebo control.19 Sham acupuncture, which involves needling non-acupuncture points, is frequently the control of choice but has serious limitations.

In 1997, the landmark NIH consensus statement was probably the most important presentation of evidence supporting the efficacy of acupuncture.20 Conclusions made about the effectiveness of acupuncture were based on evidence from reliable studies. Many promising results emerged. Specific indications for use of acupuncture were identified on the basis of published reports of its effectiveness. Efficacy in treating dental pain and post-operative and chemotherapy-induced nausea were demonstrated. Research suggested its usefulness as an adjunct or alternative treatment for lower-back pain, osteoarthritis, addiction, and stroke rehabilitation. The panel also concluded that further research would likely uncover additional uses for acupuncture.

From the standpoint of acupuncture’s effectiveness, it can clearly benefit specific patient groups. It is most commonly used as a treatment for back pain.21 Since the NIH conference, further research has confirmed its effectiveness in treating a variety of medical conditions. (See Table 1, above)

Much of the ongoing research on acupuncture has focused on the use of functional magnetic resonance imaging of the brain, specifically on the areas that light up, or show brain activity, during activities or a state of pain.22-24 Acupuncture has been found to reduce the intensity of signals in such areas. The mechanism for the analgesic effects of acupuncture may be the result of reduced blood flow to the brain.24 Several studies have identified specific areas of the brain affected by pressure on various acupuncture points.25

Practical Aspects

Acupuncture treatments are extremely time efficient and require minimal equipment. They can be administered with the patient in the recumbent position or sitting upright. For initial sessions, I prefer the former, especially for younger males, who are more prone to vasovagal reactions. Any of several different methods of acupuncture can be used to stimulate points. In addition to needling, acupuncture can be conducted by electro-acupuncture, moxibustion, cupping, scraping, tapping, acupressure, or laser.

Most inpatient referrals are for pain management. Other common indications include post-operative or chemotherapy-induced nausea (emesis), anxiety, and prevention of withdrawal symptoms from narcotics.

Acupuncture Safety

Overall, acupuncture is a safe treatment method. Many large studies have confirmed that most types of acupuncture have a low rate of complications and that most of these complications are transient and minor in nature.28,29 They are incident-reporting studies, however, and have the limitations inherent in these studies. Nausea, dizziness, bruising, and needle pain are some of the most commonly reported. The rare but serious adverse events, such as pneumothorax, usually occur as a result of the practitioner’s poor training or technique.30

Future of Acupuncture

Public acceptance of, and demand for, acupuncture for pain relief is increasing. Additional clinical studies are needed, however, to expand the types of conditions for which acupuncture may be useful. It is essential to maintain a constant focus on safe practice, which would be aided by the establishment of a standardized accreditation and training system. Hospitals need to establish uniform credentialing guidelines similar to those for other procedures that require evidence of medical competence and safety.31

In February 2005, the Federal Acupuncture Coverage Act was introduced to Congress. If enacted, the measure would allow acupuncture to be covered under Part B for Medicare recipients.

The trend toward an integrated approach to patient therapy in large academic medical institutions is encouraging. The incorporation of the teaching of acupuncture within the current medical school curricula would no doubt complement this approach. TH

ACUPUNCTURE METHODS

Needles

Stainless steel, disposable needles are most commonly used. They vary in length from a few millimeters to needle ear points to as long as 6 inches and are used to treat deeper tissue points on the back. The depth of insertion is variable, and they are typically inserted for five to 25 minutes.

Electro-acupuncture involves connecting the needles to a battery-powered device that passes a low current into them. This provides a more powerful analgesic effect.26 Insertion is effected by a swift downward stroke followed by gradual advancement until the patient experiences “de Qi.” This term describes a variety of sensations experienced at the needle tip, such as tingling or mild aching. Absolute contraindications to electro-acupuncture include fever and hypotension. Relative contraindications include the use of a pacemaker, the presence of epilepsy or pregnancy, and uncontrolled anticoagulation therapy.

Tapping

This procedure utilizes a flexible hammer that has tiny dermal needles at one end. The acupuncture points are tapped repetitively for several minutes. There are no reliable studies comparing the efficacy of this method with needling.

Cupping

This method involves applying a vacuum suction to cups that have been placed over acupuncture points. There are no randomized trials to support the efficacy of this treatment.

Acupressure

This is a popular and simple treatment employing the application of pressure to acupuncture points with the thumbs. Studies on its efficacy have been less than convincing.32

Gua Sha

A traditional practice employed less commonly in the U.S., but popular in the Far East. Ceramic or metal spoons are used to abrade the skin overlying the acupuncture points; this results in a hyperemia that warms them. Bleeding over a wide area can occur and may cause infection.

Moxibustion

This practice uses an herb, Artemia vulgaris, that burns at a low temperature and delivers heat to the points. Traditionally, it was wrapped around the needle head after insertion to enhance the analgesic effects of acupuncture. More modern methods employ a “cigar” held above them. Its use is limited by its unpleasant odor and the risk of skin burns, in addition to the lack of reliable data supporting its efficacy.

Lasers

This practice is gaining in popularity because it is easy and painless to apply. Optical stimulation of acupuncture points using handheld devices has a theoretical basis, but is not, at this time, backed by any large, reliable clinical trials. A large meta-analysis of the use of low-intensity laser for musculoskeletal pain did not show this method to be efficacious.27 More research is needed about laser acupuncture.

Joseph C. Charles, MD, FACP, is an assistant professor of medicine and division education coordinator for the Department of Hospital Internal Medicine at the Mayo Clinic Hospital Arizona.

References

• Ananth, S. Health Forum 2005 Complementary and Alternative Medicine Survey of Hospitals, July 19, 2006. News release, American Hospital Association.
• Veith I (trans). The Yellow Emperor’s Classic of Internal Medicine. Baltimore; Lippincott, Williams & Wilkins: 1949.
• Ming Z (trans). The Medical Classic of the Yellow Emperor. Beijing; Foreign Languages Press: 2001.
• Cassedy JH. Early uses of acupuncture in the United States, with an addendum (1826) by Franklin Bache, M.D. Bull N Y Acad Med. 1974 Sep;50(8):892-906.
• Osler W. The Principles and Practice of Medicine. New York: D. Appleton and Company; 1892.
• Reston J. Now, let me tell you about my appendectomy in Peking. New York Times. July 26, 1971.
• Mitchell BB. Educational and licensing requirements for acupuncturists. J Altern Complement Med. 1996 spring;2(1):33-35.
• Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993 Jan 28;328(4):246-252.
• Sherman KJ, Cherkin DC, Eisenberg DM, et al. The practice of acupuncture: who are the providers and what do they do? Ann Fam Med. 2005 Mar-Apr;3(2):151-158.
• Leake R, Broderick JE. Current licensure for acupuncture in the United States. Altern Ther Health Med. 1999 Jul;5(4):94-96.
• Shang C. The past, present, and future of meridian system research. In: Stux G, Hammerschlag R, eds. Clinical Acupuncture: Scientific Basis. Berlin: Springer; 2001:69-82.
• WHO Scientific Group on International Acupuncture Nomenclature. A proposed standard international acupuncture nomenclature: report of a WHO Scientific Group. Geneva: World Health Organization; 1991.
• Niboyet JEH. Nouvelles constatations sur les proprietes electriques des points chinois. Bull Soc Acupunct. 1938;4:30-79.
• Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif.: Medical Acupuncture Publishers; 1995:23-24.
• De Vernejoul P, Albarede P, Darras JC. Study of acupuncture meridians using radioactive tracers [in French]. Bull Acad Natl Med. 1985 Oct;169(7):1071-1075.
• Simon J, Guiraud G, Esquerre JP, et al. Acupuncture meridians demythified. Contribution of radiotracer methodology [in French]. Presse Med. 1988 Jul 2;17(26):1341-1344.
• Pomeranz B, Chiu D. Naloxone blockade of acupuncture analgesia: endorphin implicated. Life Sci. 1976 Dec 1;19(11):1757-1762.
• Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med. 2002;136:374-383.
• Vincent C, Lewith G. Placebo controls for acupuncture studies. J R Soc Med. 1995 Apr;88(4):199-202.
• Acupuncture. NIH Consensus Statement 1997; 15:1-34
• Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142:651-663.
• Tank DW, Oqawa S, Uqurbil K. Mapping the brain with MRI. Curr Biol. 1992;525-528.
• Salvatore S. Brain imaging suggests acupuncture works, study says. [monograph on the Internet]. CNN.com with WebMD.com. Dec. 1, 1999. Available at http://archives.cnn.com/1999/HEALTH/alternative/12/01/brain.acupuncture/index.html. Last accessed April 14, 2007.
• Fang JL, Krings T, Weidemann J, et al. Functional MRI in healthy subjects during acupuncture: different effects of needle rotation in real and false acupoints. Neuroradiology. 2004;46:359-362.
• Cho ZH, Chung SC, Jones JP, et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Natl Acad Sci USA. 1998 Mar;95(5):2670-2673. Retraction in Cho ZH, Chung SC, Lee HJ, Wong EK, Min BI. Proc Natl Acad Sci USA. 2006 Jul 5;103(27):10527.
• Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry. 1998;44:129-138.
• Gam AN, Thorsen H, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain: a meta-analysis. Pain. 1993;52:63-66.
• White A, Hayhoe S, Hart A, et al. Adverse events following acupuncture: prospective survey of 32, 000 consultations with doctors and physiotherapists. BMJ. 2001 Sep 1;323(7311):485-486.
• MacPherson H, Thomas K, Walters S, et al. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ. 2001;323:486-487. Comment in BMJ. 2001 Sep 1;323(7311):467-8. BMJ. 2002 Jan 19;324(7330):170-1.
• Chauffe RJ, Duskin AL. Pneumothorax secondary to acupuncture therapy. South Med J. 2006;99:1297-1299.
• Cohen MH, Hrbek A, Davis RB, et al. Emerging credentialing practices, malpractice liability policies, and guidelines governing complementary and alternative medical practices and dietary supplement recommendations: a descriptive study of 19 integrative health care centers in the United States. Arch Intern Med. 2005;165:289-295.
• Linde K, Jobst K, Panton J. Acupuncture for chronic asthma. Cochrane Database Syst Rev. 2000;(2):CD000008.
• Kleijnen J, Ter Riet G, Knipschild P. Acupuncture and asthma: a review of controlled trials. Thorax. 1991;46:799-802.
• Ter Reit G, Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract. 1990;40:379-382.
• Vincent CA. A controlled trial of the treatment of migraine by acupuncture. Clin J Pain. 1989;5:305-312.
• White AR, Rampes H, Ernst E. Acupuncture for smoking cessation. Cochrane Database Syst Rev. 2002;(2):CD000009.
• Mann E. Using acupuncture and acupressure to treat postoperative emesis. Prof Nurse. 1999; 14:691-694.
• Macklin EA, Wayne PM, Kalish LA, et al. Stop hypertension with the acupuncture research program (SHARP): results of a randomized, controlled clinical trial. Hypertension. 2006;48:838-845.
• Lee JD, Chon JS, Jeong HK, et al. The cerebrovascular response to traditional acupuncture after stroke. Neuroradiology. 2003;45:780-784.
• Scharf HP, Mansmann U, Streitberger K, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med. 2006;145:12-20.
• Martin DP, Sletten CD, Williams BA, et al. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc. 2006;81:749-757.
• Lu DP, Lu GP. Anatomical relevance of some acupuncture points in the head and neck region that dictate medical or dental application depending on depth of needle insertion. Acupunct Electrother Res. 2003;28(3-4):145-156.
• Ernst E, Pittler MH. The effectiveness of acupuncture in treating acute dental pain: a systemic review. Br Dent J. 1998;184:443-447.
• Chen HM, Chen CH. Effects of acupressure at the Sanyinjiao point on primary dysmenorrhoea. J Adv Nurs. 2004;48(4):380-387.
• Pouresmail Z, Ibrahimzadeh R. Effects of acupressure and ibuprofen on the severity of primary dysmenorrhea. J Tradit Chin Med. 2002 Sep; 22(3):205-210.
• Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005 May 4;293(17):2118-2125.
• Allais G, De Lorenzo C, Quirico PE, et al. Acupuncture in the prophylactic treatment of migraine without aura: a comparison with flunarizine. Headache. 2002 Oct;42(9):855-861.
• Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev. 2002;(1):CD003527. Review.
• Trinh KV, Phillips SD. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford). 2004:43:1085-1090.
• David J, Townsend S, Sathanathan R, et al. The effect of acupuncture on patients with rheumatoid arthritis: a randomized, placebo-controlled cross-over study. Rheumatology (Oxford). 1999 Sep;38(9):864-869. Comment in Rheumatology (Oxford). 2000 Oct;39(10):1153-1154.
• Irnich D, Behrens N, Molzen H, et al. Randomised trial of acupuncture compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck pain. BMJ. 2001 Jun 30;322(7302):1574-1578. Comment in BMJ. 2001 Dec 1;323(7324):1306-7.
• White P, Lewith G, Prescott P, et al. Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Ann Intern Med. 2004 Dec 21;141(12):911-919. Comment in Ann Intern Med. 2004 Dec 21;141(12):957-958. Ann Intern Med. 2005 May 17;142(10):873; author reply 873-874.
• Cheuk DK, Wong V. Acupuncture for epilepsy. Cochrane Database Syst Rev. 2006;(2):CD005062.
• Griggs C, Jensen J. Effectiveness of acupuncture for migraine: critical literature review. J Adv Nurs. 2006 May;54(4):491-501.
• Kim YH, Schiff E, Waalen J, et al. Efficacy of acupuncture for treating cocaine addiction: a review paper. J Addict Dis. 2005;24(4):115-132.
• Forbes A, Jackson S, Walter C, et al. Acupuncture for irritable bowel syndrome: a blinded placebo-controlled trial. World J Gastroenterol. 2005 Jul 14;11(26):4040-4044.
• Schneider A, Enck P, Streitberger K, et al. Acupuncture treatment in irritable bowel syndrome. Gut. 2006;55:649-654.

In 2004, 370 of 1,394 reporting hospitals offered some complementary alternative medicine (CAM) services in the U.S. Of the 370 hospitals reporting CAM services, 11.5% (42 hospitals) reported inpatient acupuncture services.1

This threefold increase since 1998 demonstrates the growing use of and demand for acupuncture services in hospitals. This trend is driven by patient demand and clinical effectiveness. Acupuncture is a safe treatment modality hospital physicians should be familiar because it can benefit patients in the inpatient setting.

click for large version

Origins of Acupuncture

The first use of acupuncture is not known. The earliest medical textbook on acupuncture was The Medical Classic of the Yellow Emperor, written about 100 B.C. The first translation of this text into English was in 1949.2

The book outlined the theory of a system of six sets of symmetrical channels on the body’s surface, which it called meridians; along these, it posited an intricate network of points.3 Needling the points was supposed to manipulate or release the flow of energy or life force—Qi—to the internal organs, thereby alleviating symptoms. Heating acupuncture points with burning herbs—moxibustion—was also purported to relieve pain.

Acupuncture in the U.S.

The first documented use of acupuncture in the United States occurred in the 19th century. In 1826, Bache used it to treat lumbago.4 During that same era, William Mosley used acupuncture to treat patients with lumbago and sciatica.5

In 1971, a first-person account of the use of acupuncture by New York Times reporter James Reston excited great interest in the technique. Reston was introduced to the procedure to relieve pain after an emergency appendectomy during a trip to China with Henry A. Kissinger.6

Since then, there has been a steady increase in the use of acupuncture by physicians. The American Academy of Medical Acupuncture, the only physician-based acupuncture society in North America, was formed in 1987; in 1992, the Office of Alternative Medicine was created within the NIH. In November 1997, the Food and Drug Administration (FDA) removed the experimental designation for acupuncture needles and approved their use by licensed practitioners. By 1993, the FDA had a record of more than 9,000 licensed acupuncturists, estimated to be providing more than 10 million treatments annually at a cost in excess of $500 million.7

Acupuncture is part of the quasi-medical area of complementary and alternative medicine, whose practitioners field more visits annually than all primary-care physicians in this country combined.8 Most acupuncturists practice the Chinese technique.9

Licensing requirements vary by state.10 As acupuncture has gained popularity and respect, and as its benefit for various medical conditions has been proved in high-quality studies, many well-established medical institutions and universities have begun to integrate it with more traditional Western medical treatments.

Acupuncture Theories

The early Chinese theories about how best to perform acupuncture were varied and sometimes conflicting.11 Early treatments using heat, bloodletting, and crude stone implementation evolved over centuries into the intricate practice known today.

Western scientists first became seriously interested in researching the effects of acupuncture in the 1970s. Many of the early studies were poorly designed, and the results were often not reproducible. They were not sufficiently randomized or blinded, and placebo controls were unreliable or nonexistent. To date, no single theory has been put forth that can explain all the phenomena associated with acupuncture treatment.

In 1991, the World Health Organization proposed a standard nomenclature for the 400 acupuncture points and the 20 meridians connecting those points.12 The precise anatomical locations of these areas have not yet been identified definitively. They have a low electrical resistance compared with surrounding tissue. Theories attempting to correlate the acupuncture points with neurovascular bundles have been postulated but remain unproved. The existence of acupuncture points has been verified with galvanometer scanning. These devices measure electrical conductance and emit an audio signal when an area of low resistance is encountered. New points have been added and the location of some of the original ones redefined by this technique.

In some of the earliest research conducted, French acupuncturists Niboyet and Grall mapped many of the points.13,14 Darras attempted to prove the existence of the meridians by tracing the flow of the radionuclide technetium TC 99m sulfur colloid after it was injected into them.15 No published reports in the English-language medical literature have reliably confirmed scientific studies documenting either the existence or location of the meridians.16

The neurohumoral theory postulates that the analgesic effects of acupuncture are related to the release of neurotransmitters such as endogenous opioids. In addition, acupuncture appears to inhibit the transmission of C-fiber pain at the level of the spinal cord.17,18 Other physiological phenomena have also been observed with acupuncture by needling. They include vasodilation, increased serum cortisol, variations in serum glucose and cholesterol levels, increased white blood cell counts, and acid suppression.5 Their significance continues to be questioned.

Evidence-Based Approach

Many studies of acupuncture have methodological flaws. The biggest problem as yet unresolved is an appropriate placebo control.19 Sham acupuncture, which involves needling non-acupuncture points, is frequently the control of choice but has serious limitations.

In 1997, the landmark NIH consensus statement was probably the most important presentation of evidence supporting the efficacy of acupuncture.20 Conclusions made about the effectiveness of acupuncture were based on evidence from reliable studies. Many promising results emerged. Specific indications for use of acupuncture were identified on the basis of published reports of its effectiveness. Efficacy in treating dental pain and post-operative and chemotherapy-induced nausea were demonstrated. Research suggested its usefulness as an adjunct or alternative treatment for lower-back pain, osteoarthritis, addiction, and stroke rehabilitation. The panel also concluded that further research would likely uncover additional uses for acupuncture.

From the standpoint of acupuncture’s effectiveness, it can clearly benefit specific patient groups. It is most commonly used as a treatment for back pain.21 Since the NIH conference, further research has confirmed its effectiveness in treating a variety of medical conditions. (See Table 1, above)

Much of the ongoing research on acupuncture has focused on the use of functional magnetic resonance imaging of the brain, specifically on the areas that light up, or show brain activity, during activities or a state of pain.22-24 Acupuncture has been found to reduce the intensity of signals in such areas. The mechanism for the analgesic effects of acupuncture may be the result of reduced blood flow to the brain.24 Several studies have identified specific areas of the brain affected by pressure on various acupuncture points.25

Practical Aspects

Acupuncture treatments are extremely time efficient and require minimal equipment. They can be administered with the patient in the recumbent position or sitting upright. For initial sessions, I prefer the former, especially for younger males, who are more prone to vasovagal reactions. Any of several different methods of acupuncture can be used to stimulate points. In addition to needling, acupuncture can be conducted by electro-acupuncture, moxibustion, cupping, scraping, tapping, acupressure, or laser.

Most inpatient referrals are for pain management. Other common indications include post-operative or chemotherapy-induced nausea (emesis), anxiety, and prevention of withdrawal symptoms from narcotics.

Acupuncture Safety

Overall, acupuncture is a safe treatment method. Many large studies have confirmed that most types of acupuncture have a low rate of complications and that most of these complications are transient and minor in nature.28,29 They are incident-reporting studies, however, and have the limitations inherent in these studies. Nausea, dizziness, bruising, and needle pain are some of the most commonly reported. The rare but serious adverse events, such as pneumothorax, usually occur as a result of the practitioner’s poor training or technique.30

Future of Acupuncture

Public acceptance of, and demand for, acupuncture for pain relief is increasing. Additional clinical studies are needed, however, to expand the types of conditions for which acupuncture may be useful. It is essential to maintain a constant focus on safe practice, which would be aided by the establishment of a standardized accreditation and training system. Hospitals need to establish uniform credentialing guidelines similar to those for other procedures that require evidence of medical competence and safety.31

In February 2005, the Federal Acupuncture Coverage Act was introduced to Congress. If enacted, the measure would allow acupuncture to be covered under Part B for Medicare recipients.

The trend toward an integrated approach to patient therapy in large academic medical institutions is encouraging. The incorporation of the teaching of acupuncture within the current medical school curricula would no doubt complement this approach. TH

ACUPUNCTURE METHODS

Needles

Stainless steel, disposable needles are most commonly used. They vary in length from a few millimeters to needle ear points to as long as 6 inches and are used to treat deeper tissue points on the back. The depth of insertion is variable, and they are typically inserted for five to 25 minutes.

Electro-acupuncture involves connecting the needles to a battery-powered device that passes a low current into them. This provides a more powerful analgesic effect.26 Insertion is effected by a swift downward stroke followed by gradual advancement until the patient experiences “de Qi.” This term describes a variety of sensations experienced at the needle tip, such as tingling or mild aching. Absolute contraindications to electro-acupuncture include fever and hypotension. Relative contraindications include the use of a pacemaker, the presence of epilepsy or pregnancy, and uncontrolled anticoagulation therapy.

Tapping

This procedure utilizes a flexible hammer that has tiny dermal needles at one end. The acupuncture points are tapped repetitively for several minutes. There are no reliable studies comparing the efficacy of this method with needling.

Cupping

This method involves applying a vacuum suction to cups that have been placed over acupuncture points. There are no randomized trials to support the efficacy of this treatment.

Acupressure

This is a popular and simple treatment employing the application of pressure to acupuncture points with the thumbs. Studies on its efficacy have been less than convincing.32

Gua Sha

A traditional practice employed less commonly in the U.S., but popular in the Far East. Ceramic or metal spoons are used to abrade the skin overlying the acupuncture points; this results in a hyperemia that warms them. Bleeding over a wide area can occur and may cause infection.

Moxibustion

This practice uses an herb, Artemia vulgaris, that burns at a low temperature and delivers heat to the points. Traditionally, it was wrapped around the needle head after insertion to enhance the analgesic effects of acupuncture. More modern methods employ a “cigar” held above them. Its use is limited by its unpleasant odor and the risk of skin burns, in addition to the lack of reliable data supporting its efficacy.

Lasers

This practice is gaining in popularity because it is easy and painless to apply. Optical stimulation of acupuncture points using handheld devices has a theoretical basis, but is not, at this time, backed by any large, reliable clinical trials. A large meta-analysis of the use of low-intensity laser for musculoskeletal pain did not show this method to be efficacious.27 More research is needed about laser acupuncture.

Joseph C. Charles, MD, FACP, is an assistant professor of medicine and division education coordinator for the Department of Hospital Internal Medicine at the Mayo Clinic Hospital Arizona.

References

• Ananth, S. Health Forum 2005 Complementary and Alternative Medicine Survey of Hospitals, July 19, 2006. News release, American Hospital Association.
• Veith I (trans). The Yellow Emperor’s Classic of Internal Medicine. Baltimore; Lippincott, Williams & Wilkins: 1949.
• Ming Z (trans). The Medical Classic of the Yellow Emperor. Beijing; Foreign Languages Press: 2001.
• Cassedy JH. Early uses of acupuncture in the United States, with an addendum (1826) by Franklin Bache, M.D. Bull N Y Acad Med. 1974 Sep;50(8):892-906.
• Osler W. The Principles and Practice of Medicine. New York: D. Appleton and Company; 1892.
• Reston J. Now, let me tell you about my appendectomy in Peking. New York Times. July 26, 1971.
• Mitchell BB. Educational and licensing requirements for acupuncturists. J Altern Complement Med. 1996 spring;2(1):33-35.
• Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993 Jan 28;328(4):246-252.
• Sherman KJ, Cherkin DC, Eisenberg DM, et al. The practice of acupuncture: who are the providers and what do they do? Ann Fam Med. 2005 Mar-Apr;3(2):151-158.
• Leake R, Broderick JE. Current licensure for acupuncture in the United States. Altern Ther Health Med. 1999 Jul;5(4):94-96.
• Shang C. The past, present, and future of meridian system research. In: Stux G, Hammerschlag R, eds. Clinical Acupuncture: Scientific Basis. Berlin: Springer; 2001:69-82.
• WHO Scientific Group on International Acupuncture Nomenclature. A proposed standard international acupuncture nomenclature: report of a WHO Scientific Group. Geneva: World Health Organization; 1991.
• Niboyet JEH. Nouvelles constatations sur les proprietes electriques des points chinois. Bull Soc Acupunct. 1938;4:30-79.
• Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif.: Medical Acupuncture Publishers; 1995:23-24.
• De Vernejoul P, Albarede P, Darras JC. Study of acupuncture meridians using radioactive tracers [in French]. Bull Acad Natl Med. 1985 Oct;169(7):1071-1075.
• Simon J, Guiraud G, Esquerre JP, et al. Acupuncture meridians demythified. Contribution of radiotracer methodology [in French]. Presse Med. 1988 Jul 2;17(26):1341-1344.
• Pomeranz B, Chiu D. Naloxone blockade of acupuncture analgesia: endorphin implicated. Life Sci. 1976 Dec 1;19(11):1757-1762.
• Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med. 2002;136:374-383.
• Vincent C, Lewith G. Placebo controls for acupuncture studies. J R Soc Med. 1995 Apr;88(4):199-202.
• Acupuncture. NIH Consensus Statement 1997; 15:1-34
• Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142:651-663.
• Tank DW, Oqawa S, Uqurbil K. Mapping the brain with MRI. Curr Biol. 1992;525-528.
• Salvatore S. Brain imaging suggests acupuncture works, study says. [monograph on the Internet]. CNN.com with WebMD.com. Dec. 1, 1999. Available at http://archives.cnn.com/1999/HEALTH/alternative/12/01/brain.acupuncture/index.html. Last accessed April 14, 2007.
• Fang JL, Krings T, Weidemann J, et al. Functional MRI in healthy subjects during acupuncture: different effects of needle rotation in real and false acupoints. Neuroradiology. 2004;46:359-362.
• Cho ZH, Chung SC, Jones JP, et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Natl Acad Sci USA. 1998 Mar;95(5):2670-2673. Retraction in Cho ZH, Chung SC, Lee HJ, Wong EK, Min BI. Proc Natl Acad Sci USA. 2006 Jul 5;103(27):10527.
• Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry. 1998;44:129-138.
• Gam AN, Thorsen H, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain: a meta-analysis. Pain. 1993;52:63-66.
• White A, Hayhoe S, Hart A, et al. Adverse events following acupuncture: prospective survey of 32, 000 consultations with doctors and physiotherapists. BMJ. 2001 Sep 1;323(7311):485-486.
• MacPherson H, Thomas K, Walters S, et al. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ. 2001;323:486-487. Comment in BMJ. 2001 Sep 1;323(7311):467-8. BMJ. 2002 Jan 19;324(7330):170-1.
• Chauffe RJ, Duskin AL. Pneumothorax secondary to acupuncture therapy. South Med J. 2006;99:1297-1299.
• Cohen MH, Hrbek A, Davis RB, et al. Emerging credentialing practices, malpractice liability policies, and guidelines governing complementary and alternative medical practices and dietary supplement recommendations: a descriptive study of 19 integrative health care centers in the United States. Arch Intern Med. 2005;165:289-295.
• Linde K, Jobst K, Panton J. Acupuncture for chronic asthma. Cochrane Database Syst Rev. 2000;(2):CD000008.
• Kleijnen J, Ter Riet G, Knipschild P. Acupuncture and asthma: a review of controlled trials. Thorax. 1991;46:799-802.
• Ter Reit G, Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract. 1990;40:379-382.
• Vincent CA. A controlled trial of the treatment of migraine by acupuncture. Clin J Pain. 1989;5:305-312.
• White AR, Rampes H, Ernst E. Acupuncture for smoking cessation. Cochrane Database Syst Rev. 2002;(2):CD000009.
• Mann E. Using acupuncture and acupressure to treat postoperative emesis. Prof Nurse. 1999; 14:691-694.
• Macklin EA, Wayne PM, Kalish LA, et al. Stop hypertension with the acupuncture research program (SHARP): results of a randomized, controlled clinical trial. Hypertension. 2006;48:838-845.
• Lee JD, Chon JS, Jeong HK, et al. The cerebrovascular response to traditional acupuncture after stroke. Neuroradiology. 2003;45:780-784.
• Scharf HP, Mansmann U, Streitberger K, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med. 2006;145:12-20.
• Martin DP, Sletten CD, Williams BA, et al. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc. 2006;81:749-757.
• Lu DP, Lu GP. Anatomical relevance of some acupuncture points in the head and neck region that dictate medical or dental application depending on depth of needle insertion. Acupunct Electrother Res. 2003;28(3-4):145-156.
• Ernst E, Pittler MH. The effectiveness of acupuncture in treating acute dental pain: a systemic review. Br Dent J. 1998;184:443-447.
• Chen HM, Chen CH. Effects of acupressure at the Sanyinjiao point on primary dysmenorrhoea. J Adv Nurs. 2004;48(4):380-387.
• Pouresmail Z, Ibrahimzadeh R. Effects of acupressure and ibuprofen on the severity of primary dysmenorrhea. J Tradit Chin Med. 2002 Sep; 22(3):205-210.
• Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005 May 4;293(17):2118-2125.
• Allais G, De Lorenzo C, Quirico PE, et al. Acupuncture in the prophylactic treatment of migraine without aura: a comparison with flunarizine. Headache. 2002 Oct;42(9):855-861.
• Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev. 2002;(1):CD003527. Review.
• Trinh KV, Phillips SD. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford). 2004:43:1085-1090.
• David J, Townsend S, Sathanathan R, et al. The effect of acupuncture on patients with rheumatoid arthritis: a randomized, placebo-controlled cross-over study. Rheumatology (Oxford). 1999 Sep;38(9):864-869. Comment in Rheumatology (Oxford). 2000 Oct;39(10):1153-1154.
• Irnich D, Behrens N, Molzen H, et al. Randomised trial of acupuncture compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck pain. BMJ. 2001 Jun 30;322(7302):1574-1578. Comment in BMJ. 2001 Dec 1;323(7324):1306-7.
• White P, Lewith G, Prescott P, et al. Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Ann Intern Med. 2004 Dec 21;141(12):911-919. Comment in Ann Intern Med. 2004 Dec 21;141(12):957-958. Ann Intern Med. 2005 May 17;142(10):873; author reply 873-874.
• Cheuk DK, Wong V. Acupuncture for epilepsy. Cochrane Database Syst Rev. 2006;(2):CD005062.
• Griggs C, Jensen J. Effectiveness of acupuncture for migraine: critical literature review. J Adv Nurs. 2006 May;54(4):491-501.
• Kim YH, Schiff E, Waalen J, et al. Efficacy of acupuncture for treating cocaine addiction: a review paper. J Addict Dis. 2005;24(4):115-132.
• Forbes A, Jackson S, Walter C, et al. Acupuncture for irritable bowel syndrome: a blinded placebo-controlled trial. World J Gastroenterol. 2005 Jul 14;11(26):4040-4044.
• Schneider A, Enck P, Streitberger K, et al. Acupuncture treatment in irritable bowel syndrome. Gut. 2006;55:649-654.

Never before have doctors had such an abundance of therapeutic options. And—not surprisingly—elderly patients are taking more medications than ever.

A national survey from 1998 revealed that more than 40% of elderly American adults take five or more medications a day—and that’s at home. Meantime, drug-related complications have risen steadily.

In 2005, the United States spent $177 billion in the management of drug-related problems—$34 billion more than was spent on the drugs themselves.1 Because up to a third of adverse medication effects warrant a hospital admission, hospitalists are the front line in the diagnosis and treatment of these syndromes.

Additionally, medication-related consequences can complicate hospitalizations required for other reasons. They can be observed as frequently as weekly according to hospitalist Balazs Zsenits, MD, FACP, of Rochester (N.Y.) General Hospital—and they’re often serious. In fact, medication reactions are so frequently fatal they represent the fifth-leading cause of death in the United States.

As one might expect, the elderly are disproportionately affected by the potentially toxic consequences of medication. In fact, a 2005 study published in Pharmacotherapy revealed that more than two-thirds of hospitalized elderly adults had an adverse drug effect over a four-year period.2 Among the more common outcomes were constipation, falls, immobility, confusion, hip fractures, and a decline in functional status requiring nursing home placement. Moreover, the authors noted that drug side effects frequently mimicked other geriatric syndromes, prompting physicians to prescribe additional medication.

While multiple medications may be necessary to prevent the progression of disease in older people, the overuse and misuse of drugs has been linked to serious health problems, including hospitalizations and death.

click for large version

Polypharmacy

Patients at greatest risk for a polypharmacy-associated medical complication are those taking five or more concurrent drugs, those with multiple physicians, patients with significant medical comorbidities or impairments in vision or dexterity, and individuals who have recently been hospitalized.4-5 At least 25% of elderly Americans fall into at least one of these categories

But polypharmacy is not the only reason elderly patients experience a disproportionately high rate of adverse medication effects. Age-related altered drug metabolism is also responsible for unexpected drug consequences in this age group.

Aging influences every aspect of physiologic drug processing. While the absorption of oral medications from the GI tract remains relatively constant in the absence of disease states and gastric pH altering medications, bioavailability and clearance dramatically change with aging. These changes become the most pronounced after age 75, when kidney and liver function become limited.

As people age, their total body water decreases, their lean body mass is reduced, and their percentage of body fat increases. This increase in body fat expands the volume of distribution for lipophilic drugs and also decreases the volume of distribution for hydrophilic drugs.6 The result is that water-soluble medications have an elevated active serum concentration, and lipid-soluble agents, while they may have a decreased serum concentration, have a prolonged half-life.

These effects are best exemplified by examining what happens after a geriatric patient takes diazepam. A lipid-soluble drug, diazepam and its metabolites will be stored in an increasingly large body compartment. This will temporarily decrease the serum level of the drug, but will prolong the half-life from an average of 20 hours to greater than 50 hours. Repeated dosing will quickly result in toxic serum levels, at which point the patient is at risk for CNS side effects as well as falls and fractures.

The aging process also affects the role of drug-binding serum proteins. The total serum protein level is usually maintained (while albumin levels may diminish slightly, increasing levels of alpha 1 antitrypsin keeps the total protein level normal). More significantly, the affinity of the serum proteins for protein-bound drugs lessens as patients age. The degree of plasma protein binding has a significant impact on the pharmacologic activity of the drug, because it is the free drug that is physiologically active and exerts the pharmacologic effect.

In treating patients with highly protein-bound drugs, like phenytoin, one should expect toxic reactions at a normal serum level because more of the drug is unbound, and, hence, active. Elderly patients with low albumin levels secondary to malnutrition or liver disease will have an even more pronounced effect.

Effects of Metabolism

Many drugs undergo hepatic metabolism to produce more soluble forms for subsequent elimination through renal excretion. Though hepatic metabolism is affected by multiple variables including genotype, lifestyle, hepatic blood flow, hepatic diseases, and interactions with other medications, aging also plays a significant role.7

Of the two biotransformation systems through which hepatic metabolism occurs, it is the cytochrome P450 system (Phase I) most affected by increasing years. For most drugs, this leads to increased serum levels of the unmetabolized entity, leading to a greater potential for toxicity. Disease states that reduce blood flow to the liver, like congestive heart failure and cirrhosis, further inhibit this process. For drugs whose pharmacological activity requires biotransformation from a pro-drug form, inhibition can lead to decreased efficacy.

In contrast, Phase II metabolism, including acetylation, sulfonation, conjugation, and glucuronidation, is little influenced by advanced age.

Drug Elimination

The renal elimination of drugs is altered by aging, although there is significant variation between individuals for any given decade.8 Drug excretion does correlate with creatinine clearance, which declines by 50% by age 75. However, because lean body mass decreases with aging, the serum creatinine level tends to overestimate the creatinine clearance of older adults.

Utilization of the Cockroft-Gault formula (Figure 1, above) allows for an accurate estimation of the creatinine clearance in these patients.9 For example, a 25-year-old man and an 85-year-old man, each weighing 158 pounds and having a serum creatinine value of 1 mg per dL, would have different estimated creatinine clearance even though their serum creatinine value is the same. The younger man would have an estimated creatinine clearance of 115 mL per minute, while the older man’s would be 55 mL per minute.

Approximating creatinine clearance is particularly important when prescribing medications that have a narrow therapeutic index (aminoglycosides, lithium, digoxin, procainamide, vancomycin). Even minimally excessive doses of these drugs will result in a prolonged the half-life, and an increased potential for toxic effects.

Expect and account for these alterations in drug metabolism in elderly patients. Typical changes result in increased active serum concentrations of the drug and extended half-life. Elevated drug concentrations result in more adverse drug events, and these include not only known complications, but also uncommon problems such as blood dyscrasias. If a rare adverse drug reaction does occur, it is most likely to happen in an elderly person.

click for large version

The Acute Care Setting

In light of the physiologic changes associated with aging, as well as the problems posed by taking multiple medications, it is clear that active intervention is required to prevent adverse drug reactions in geriatric patients.

A large cohort study of Medicare enrollees with more than 30,000 patient-years of observation found that 28% of adverse drug reactions were potentially avoidable. Most errors occurred during prescribing and monitoring. A number of strategies have been proposed for reducing these unwanted medication consequences in the hospital setting, including:

• Avoid inappropriate drug prescribing;
• Avoid overprescribing;
• Implement age-appropriate dosing; and
• Encourage a multidisciplinary ap-proach.

Drugs to Avoid

Though precise clinical data regarding which medications are harmful to elderly patients in the acute care setting is lacking, multiple expert panels have attempted to delineate which drugs should be generally avoided in this population (Table 1, above).

The most notable of these evaluations is the Beers criteria, a frequently updated set of medications deemed inappropriate for use in geriatric patients. Most recently amended in 2003, this list is formulated by experts in pharmacology and geriatrics, and has been validated in large studies as a useful tool for decreasing medication-related problems in the nursing home setting.10

Though a 2006 study of hospital morbidity found that adverse drug reactions in the acute care setting often occur from drugs not listed in the Beers criteria, avoiding medications like those listed above is still a useful tool in preventing side effects.11-12

Avoid Overprescribing

To prevent a polypharmacy-induced iatrogenic illness, it is important to consider any new signs and symptoms to be a possible consequence of current drug therapy. Steps for reducing polypharmacy include:

• Get into the habit of identifying all drugs by generic name and drug class;
• Make certain the drug being prescribed has a clinical indication;
• Know the side-effect profile of the drugs being prescribed;
• Understand how changes in drug distribution, metabolism, and elimination associated with aging increase the risk of adverse drug events;
• Stop any drug without known benefit;
• Stop any drug without a clinical indication;
• Attempt to substitute a less-toxic drug; and
• Be aware of the prescribing-cascade treating an adverse drug reaction as an illness with another drug.

Age-Appropriate Dosing

When starting a new drug, start with a low dose and titrate slowly to the desired clinical effect. While the manufacturers of many commonly used medications do not delineate the lower-dosage recommendations necessary for elderly patients, you can bypass this problem by starting with one-third to half the recommended dosage.

After observing that the patient tolerates the new drug, slowly increase the dose until the desired result is obtained. This approach is particularly important in minimizing potential harmful drug effects in patients with severely reduced renal function.14

Multidisciplinary Approach

In its 2001 report “Crossing the Quality Chasm: A New Health System of the 21st Century,” the U.S. Institute of Medicine declared: “The current care systems cannot do the job. Trying harder will not work. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”

While hospitalists are on the front line for preventing adverse drug reactions, they can’t do it by themselves. Here are a few tips for making your job easier:

• Request that medications inappropriate for geriatric patients (based on the Beers criteria) be notated as such by the pharmacist;
• Ask for a geriatric dosing option in the computer-based medication ordering system;
• Flag charts of patients with previous adverse drug effects with the name of the offending drug;
• Warn nurses and other caregivers to monitor for specific side effects; and
• Advocate that midlevel providers receive hospital-based training in the prevention of medication-related adverse events.

The elderly portion of the population is expanding more rapidly than the population as a whole, and the recognition and prevention of medication side effects in this group is one of the most critical safety and economic issues facing the healthcare system today. While the magnitude of this problem demands multidisciplinary involvement, hospitalists can be key players in making a difference. TH

Dr. Landis is a rheumatologist and a freelance writer

References

1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997 Jan 22-29;277(4):307-311. Comment in: JAMA. 1997 Jan 22-29;277(4):341-3422: JAMA. 1997 May 7;277(17):1351-1352; author reply 1353-1354.
2. Zarowitz BJ, Stebelsky LA, Muma BK, et al. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25(11):1636-1645. Comment in: Pharmacotherapy. 2006 Jun;26(6):886-887; discussion 887.
3. Byron C, Hochberg MC. Changing the patterns of Coxibs/NSAIDs prescribing: balancing CV and GI risks. Medscape. Available at www.medscape.com/viewprogram/5060. Last accessed May 2, 2007.
4. Shapiro K. The Complexities of Geriatric Pain Management. 20th Annual Meeting of the American Pain Society. Medscape CME. Available at www.medscape.com/viewarticle/416593. Last accessed May 2, 2007.
5. Lau DT, Kasper JD, Potter DE, et al. Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics. Health Serv Res. 2004 Oct; 39(5):1257-1276.
6. Longa GJ, Cross RE. Laboratory Monitoring of Drug Therapy. Part II: Variable Protein Binding and Free (Unbound) Drug Concentration. Bull Lab Me. 1984;80:1-6. 7. Chutka DS, Evans JM, Fleming KC, et al. Symposium on geriatrics—Part I: Drug prescribing for elderly patients. Mayo Clin Proc. 1995 Jul;70(7):685-693.
7. Feely J, Coakley D. Altered pharmacodynamics in the elderly. Clin Geriatr Med. 1990 May; 6(2): 269-283.
8. Williams CM. Using medications appropriately in older adults. Am Fam Phys. 2002 Nov 15;66(10):1917-1924.
9. Fick DN, Cooper JW, Wade WE. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003 Dec 8-22;163(22):2716-2724. Erratum in: Arch Intern Med. 2004 Feb 9;164(3):298. Comment in: Arch Intern Med. 2004 Aug 9-23;164(15):1701.
10. Johnston PE, France DJ, Byrne DW, et al. Assessment of adverse drug events among patients in a tertiary care medical center. Am J Health Syst Pharm., 2006;63(22):2218-2227.
11. Page RL, Ruscin JM. The risk of adverse drug events and hospital related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother. 2006 Dec;4(4):297-305.
12. Avidan AY. Sleep changes and disorders in the elderly patient. Curr Neurol Neurosci Rep. 2002 Mar;2(2):178-185.
13. Pugh MJV, Fincke G, Bierman AS, et al. Potentially inappropriate prescribing in elderly veterans: Are we using the wrong drug, wrong dose, or wrong duration? J Am Geriatr Soc. 2005 Aug;53(8):1282-1289.

Never before have doctors had such an abundance of therapeutic options. And—not surprisingly—elderly patients are taking more medications than ever.

A national survey from 1998 revealed that more than 40% of elderly American adults take five or more medications a day—and that’s at home. Meantime, drug-related complications have risen steadily.

In 2005, the United States spent $177 billion in the management of drug-related problems—$34 billion more than was spent on the drugs themselves.1 Because up to a third of adverse medication effects warrant a hospital admission, hospitalists are the front line in the diagnosis and treatment of these syndromes.

Additionally, medication-related consequences can complicate hospitalizations required for other reasons. They can be observed as frequently as weekly according to hospitalist Balazs Zsenits, MD, FACP, of Rochester (N.Y.) General Hospital—and they’re often serious. In fact, medication reactions are so frequently fatal they represent the fifth-leading cause of death in the United States.

As one might expect, the elderly are disproportionately affected by the potentially toxic consequences of medication. In fact, a 2005 study published in Pharmacotherapy revealed that more than two-thirds of hospitalized elderly adults had an adverse drug effect over a four-year period.2 Among the more common outcomes were constipation, falls, immobility, confusion, hip fractures, and a decline in functional status requiring nursing home placement. Moreover, the authors noted that drug side effects frequently mimicked other geriatric syndromes, prompting physicians to prescribe additional medication.

While multiple medications may be necessary to prevent the progression of disease in older people, the overuse and misuse of drugs has been linked to serious health problems, including hospitalizations and death.

click for large version

Polypharmacy

Patients at greatest risk for a polypharmacy-associated medical complication are those taking five or more concurrent drugs, those with multiple physicians, patients with significant medical comorbidities or impairments in vision or dexterity, and individuals who have recently been hospitalized.4-5 At least 25% of elderly Americans fall into at least one of these categories

But polypharmacy is not the only reason elderly patients experience a disproportionately high rate of adverse medication effects. Age-related altered drug metabolism is also responsible for unexpected drug consequences in this age group.

Aging influences every aspect of physiologic drug processing. While the absorption of oral medications from the GI tract remains relatively constant in the absence of disease states and gastric pH altering medications, bioavailability and clearance dramatically change with aging. These changes become the most pronounced after age 75, when kidney and liver function become limited.

As people age, their total body water decreases, their lean body mass is reduced, and their percentage of body fat increases. This increase in body fat expands the volume of distribution for lipophilic drugs and also decreases the volume of distribution for hydrophilic drugs.6 The result is that water-soluble medications have an elevated active serum concentration, and lipid-soluble agents, while they may have a decreased serum concentration, have a prolonged half-life.

These effects are best exemplified by examining what happens after a geriatric patient takes diazepam. A lipid-soluble drug, diazepam and its metabolites will be stored in an increasingly large body compartment. This will temporarily decrease the serum level of the drug, but will prolong the half-life from an average of 20 hours to greater than 50 hours. Repeated dosing will quickly result in toxic serum levels, at which point the patient is at risk for CNS side effects as well as falls and fractures.

The aging process also affects the role of drug-binding serum proteins. The total serum protein level is usually maintained (while albumin levels may diminish slightly, increasing levels of alpha 1 antitrypsin keeps the total protein level normal). More significantly, the affinity of the serum proteins for protein-bound drugs lessens as patients age. The degree of plasma protein binding has a significant impact on the pharmacologic activity of the drug, because it is the free drug that is physiologically active and exerts the pharmacologic effect.

In treating patients with highly protein-bound drugs, like phenytoin, one should expect toxic reactions at a normal serum level because more of the drug is unbound, and, hence, active. Elderly patients with low albumin levels secondary to malnutrition or liver disease will have an even more pronounced effect.

Effects of Metabolism

Many drugs undergo hepatic metabolism to produce more soluble forms for subsequent elimination through renal excretion. Though hepatic metabolism is affected by multiple variables including genotype, lifestyle, hepatic blood flow, hepatic diseases, and interactions with other medications, aging also plays a significant role.7

Of the two biotransformation systems through which hepatic metabolism occurs, it is the cytochrome P450 system (Phase I) most affected by increasing years. For most drugs, this leads to increased serum levels of the unmetabolized entity, leading to a greater potential for toxicity. Disease states that reduce blood flow to the liver, like congestive heart failure and cirrhosis, further inhibit this process. For drugs whose pharmacological activity requires biotransformation from a pro-drug form, inhibition can lead to decreased efficacy.

In contrast, Phase II metabolism, including acetylation, sulfonation, conjugation, and glucuronidation, is little influenced by advanced age.

Drug Elimination

The renal elimination of drugs is altered by aging, although there is significant variation between individuals for any given decade.8 Drug excretion does correlate with creatinine clearance, which declines by 50% by age 75. However, because lean body mass decreases with aging, the serum creatinine level tends to overestimate the creatinine clearance of older adults.

Utilization of the Cockroft-Gault formula (Figure 1, above) allows for an accurate estimation of the creatinine clearance in these patients.9 For example, a 25-year-old man and an 85-year-old man, each weighing 158 pounds and having a serum creatinine value of 1 mg per dL, would have different estimated creatinine clearance even though their serum creatinine value is the same. The younger man would have an estimated creatinine clearance of 115 mL per minute, while the older man’s would be 55 mL per minute.

Approximating creatinine clearance is particularly important when prescribing medications that have a narrow therapeutic index (aminoglycosides, lithium, digoxin, procainamide, vancomycin). Even minimally excessive doses of these drugs will result in a prolonged the half-life, and an increased potential for toxic effects.

Expect and account for these alterations in drug metabolism in elderly patients. Typical changes result in increased active serum concentrations of the drug and extended half-life. Elevated drug concentrations result in more adverse drug events, and these include not only known complications, but also uncommon problems such as blood dyscrasias. If a rare adverse drug reaction does occur, it is most likely to happen in an elderly person.

click for large version

The Acute Care Setting

In light of the physiologic changes associated with aging, as well as the problems posed by taking multiple medications, it is clear that active intervention is required to prevent adverse drug reactions in geriatric patients.

A large cohort study of Medicare enrollees with more than 30,000 patient-years of observation found that 28% of adverse drug reactions were potentially avoidable. Most errors occurred during prescribing and monitoring. A number of strategies have been proposed for reducing these unwanted medication consequences in the hospital setting, including:

• Avoid inappropriate drug prescribing;
• Avoid overprescribing;
• Implement age-appropriate dosing; and
• Encourage a multidisciplinary ap-proach.

Drugs to Avoid

Though precise clinical data regarding which medications are harmful to elderly patients in the acute care setting is lacking, multiple expert panels have attempted to delineate which drugs should be generally avoided in this population (Table 1, above).

The most notable of these evaluations is the Beers criteria, a frequently updated set of medications deemed inappropriate for use in geriatric patients. Most recently amended in 2003, this list is formulated by experts in pharmacology and geriatrics, and has been validated in large studies as a useful tool for decreasing medication-related problems in the nursing home setting.10

Though a 2006 study of hospital morbidity found that adverse drug reactions in the acute care setting often occur from drugs not listed in the Beers criteria, avoiding medications like those listed above is still a useful tool in preventing side effects.11-12

Avoid Overprescribing

To prevent a polypharmacy-induced iatrogenic illness, it is important to consider any new signs and symptoms to be a possible consequence of current drug therapy. Steps for reducing polypharmacy include:

• Get into the habit of identifying all drugs by generic name and drug class;
• Make certain the drug being prescribed has a clinical indication;
• Know the side-effect profile of the drugs being prescribed;
• Understand how changes in drug distribution, metabolism, and elimination associated with aging increase the risk of adverse drug events;
• Stop any drug without known benefit;
• Stop any drug without a clinical indication;
• Attempt to substitute a less-toxic drug; and
• Be aware of the prescribing-cascade treating an adverse drug reaction as an illness with another drug.

Age-Appropriate Dosing

When starting a new drug, start with a low dose and titrate slowly to the desired clinical effect. While the manufacturers of many commonly used medications do not delineate the lower-dosage recommendations necessary for elderly patients, you can bypass this problem by starting with one-third to half the recommended dosage.

After observing that the patient tolerates the new drug, slowly increase the dose until the desired result is obtained. This approach is particularly important in minimizing potential harmful drug effects in patients with severely reduced renal function.14

Multidisciplinary Approach

In its 2001 report “Crossing the Quality Chasm: A New Health System of the 21st Century,” the U.S. Institute of Medicine declared: “The current care systems cannot do the job. Trying harder will not work. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”

While hospitalists are on the front line for preventing adverse drug reactions, they can’t do it by themselves. Here are a few tips for making your job easier:

• Request that medications inappropriate for geriatric patients (based on the Beers criteria) be notated as such by the pharmacist;
• Ask for a geriatric dosing option in the computer-based medication ordering system;
• Flag charts of patients with previous adverse drug effects with the name of the offending drug;
• Warn nurses and other caregivers to monitor for specific side effects; and
• Advocate that midlevel providers receive hospital-based training in the prevention of medication-related adverse events.

The elderly portion of the population is expanding more rapidly than the population as a whole, and the recognition and prevention of medication side effects in this group is one of the most critical safety and economic issues facing the healthcare system today. While the magnitude of this problem demands multidisciplinary involvement, hospitalists can be key players in making a difference. TH

Dr. Landis is a rheumatologist and a freelance writer

References

1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997 Jan 22-29;277(4):307-311. Comment in: JAMA. 1997 Jan 22-29;277(4):341-3422: JAMA. 1997 May 7;277(17):1351-1352; author reply 1353-1354.
2. Zarowitz BJ, Stebelsky LA, Muma BK, et al. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25(11):1636-1645. Comment in: Pharmacotherapy. 2006 Jun;26(6):886-887; discussion 887.
3. Byron C, Hochberg MC. Changing the patterns of Coxibs/NSAIDs prescribing: balancing CV and GI risks. Medscape. Available at www.medscape.com/viewprogram/5060. Last accessed May 2, 2007.
4. Shapiro K. The Complexities of Geriatric Pain Management. 20th Annual Meeting of the American Pain Society. Medscape CME. Available at www.medscape.com/viewarticle/416593. Last accessed May 2, 2007.
5. Lau DT, Kasper JD, Potter DE, et al. Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics. Health Serv Res. 2004 Oct; 39(5):1257-1276.
6. Longa GJ, Cross RE. Laboratory Monitoring of Drug Therapy. Part II: Variable Protein Binding and Free (Unbound) Drug Concentration. Bull Lab Me. 1984;80:1-6. 7. Chutka DS, Evans JM, Fleming KC, et al. Symposium on geriatrics—Part I: Drug prescribing for elderly patients. Mayo Clin Proc. 1995 Jul;70(7):685-693.
7. Feely J, Coakley D. Altered pharmacodynamics in the elderly. Clin Geriatr Med. 1990 May; 6(2): 269-283.
8. Williams CM. Using medications appropriately in older adults. Am Fam Phys. 2002 Nov 15;66(10):1917-1924.
9. Fick DN, Cooper JW, Wade WE. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003 Dec 8-22;163(22):2716-2724. Erratum in: Arch Intern Med. 2004 Feb 9;164(3):298. Comment in: Arch Intern Med. 2004 Aug 9-23;164(15):1701.
10. Johnston PE, France DJ, Byrne DW, et al. Assessment of adverse drug events among patients in a tertiary care medical center. Am J Health Syst Pharm., 2006;63(22):2218-2227.
11. Page RL, Ruscin JM. The risk of adverse drug events and hospital related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother. 2006 Dec;4(4):297-305.
12. Avidan AY. Sleep changes and disorders in the elderly patient. Curr Neurol Neurosci Rep. 2002 Mar;2(2):178-185.
13. Pugh MJV, Fincke G, Bierman AS, et al. Potentially inappropriate prescribing in elderly veterans: Are we using the wrong drug, wrong dose, or wrong duration? J Am Geriatr Soc. 2005 Aug;53(8):1282-1289.

Never before have doctors had such an abundance of therapeutic options. And—not surprisingly—elderly patients are taking more medications than ever.

A national survey from 1998 revealed that more than 40% of elderly American adults take five or more medications a day—and that’s at home. Meantime, drug-related complications have risen steadily.

In 2005, the United States spent $177 billion in the management of drug-related problems—$34 billion more than was spent on the drugs themselves.1 Because up to a third of adverse medication effects warrant a hospital admission, hospitalists are the front line in the diagnosis and treatment of these syndromes.

Additionally, medication-related consequences can complicate hospitalizations required for other reasons. They can be observed as frequently as weekly according to hospitalist Balazs Zsenits, MD, FACP, of Rochester (N.Y.) General Hospital—and they’re often serious. In fact, medication reactions are so frequently fatal they represent the fifth-leading cause of death in the United States.

As one might expect, the elderly are disproportionately affected by the potentially toxic consequences of medication. In fact, a 2005 study published in Pharmacotherapy revealed that more than two-thirds of hospitalized elderly adults had an adverse drug effect over a four-year period.2 Among the more common outcomes were constipation, falls, immobility, confusion, hip fractures, and a decline in functional status requiring nursing home placement. Moreover, the authors noted that drug side effects frequently mimicked other geriatric syndromes, prompting physicians to prescribe additional medication.

While multiple medications may be necessary to prevent the progression of disease in older people, the overuse and misuse of drugs has been linked to serious health problems, including hospitalizations and death.

click for large version

Polypharmacy

Patients at greatest risk for a polypharmacy-associated medical complication are those taking five or more concurrent drugs, those with multiple physicians, patients with significant medical comorbidities or impairments in vision or dexterity, and individuals who have recently been hospitalized.4-5 At least 25% of elderly Americans fall into at least one of these categories

But polypharmacy is not the only reason elderly patients experience a disproportionately high rate of adverse medication effects. Age-related altered drug metabolism is also responsible for unexpected drug consequences in this age group.

Aging influences every aspect of physiologic drug processing. While the absorption of oral medications from the GI tract remains relatively constant in the absence of disease states and gastric pH altering medications, bioavailability and clearance dramatically change with aging. These changes become the most pronounced after age 75, when kidney and liver function become limited.

As people age, their total body water decreases, their lean body mass is reduced, and their percentage of body fat increases. This increase in body fat expands the volume of distribution for lipophilic drugs and also decreases the volume of distribution for hydrophilic drugs.6 The result is that water-soluble medications have an elevated active serum concentration, and lipid-soluble agents, while they may have a decreased serum concentration, have a prolonged half-life.

These effects are best exemplified by examining what happens after a geriatric patient takes diazepam. A lipid-soluble drug, diazepam and its metabolites will be stored in an increasingly large body compartment. This will temporarily decrease the serum level of the drug, but will prolong the half-life from an average of 20 hours to greater than 50 hours. Repeated dosing will quickly result in toxic serum levels, at which point the patient is at risk for CNS side effects as well as falls and fractures.

The aging process also affects the role of drug-binding serum proteins. The total serum protein level is usually maintained (while albumin levels may diminish slightly, increasing levels of alpha 1 antitrypsin keeps the total protein level normal). More significantly, the affinity of the serum proteins for protein-bound drugs lessens as patients age. The degree of plasma protein binding has a significant impact on the pharmacologic activity of the drug, because it is the free drug that is physiologically active and exerts the pharmacologic effect.

In treating patients with highly protein-bound drugs, like phenytoin, one should expect toxic reactions at a normal serum level because more of the drug is unbound, and, hence, active. Elderly patients with low albumin levels secondary to malnutrition or liver disease will have an even more pronounced effect.

Effects of Metabolism

Many drugs undergo hepatic metabolism to produce more soluble forms for subsequent elimination through renal excretion. Though hepatic metabolism is affected by multiple variables including genotype, lifestyle, hepatic blood flow, hepatic diseases, and interactions with other medications, aging also plays a significant role.7

Of the two biotransformation systems through which hepatic metabolism occurs, it is the cytochrome P450 system (Phase I) most affected by increasing years. For most drugs, this leads to increased serum levels of the unmetabolized entity, leading to a greater potential for toxicity. Disease states that reduce blood flow to the liver, like congestive heart failure and cirrhosis, further inhibit this process. For drugs whose pharmacological activity requires biotransformation from a pro-drug form, inhibition can lead to decreased efficacy.

In contrast, Phase II metabolism, including acetylation, sulfonation, conjugation, and glucuronidation, is little influenced by advanced age.

Drug Elimination

The renal elimination of drugs is altered by aging, although there is significant variation between individuals for any given decade.8 Drug excretion does correlate with creatinine clearance, which declines by 50% by age 75. However, because lean body mass decreases with aging, the serum creatinine level tends to overestimate the creatinine clearance of older adults.

Utilization of the Cockroft-Gault formula (Figure 1, above) allows for an accurate estimation of the creatinine clearance in these patients.9 For example, a 25-year-old man and an 85-year-old man, each weighing 158 pounds and having a serum creatinine value of 1 mg per dL, would have different estimated creatinine clearance even though their serum creatinine value is the same. The younger man would have an estimated creatinine clearance of 115 mL per minute, while the older man’s would be 55 mL per minute.

Approximating creatinine clearance is particularly important when prescribing medications that have a narrow therapeutic index (aminoglycosides, lithium, digoxin, procainamide, vancomycin). Even minimally excessive doses of these drugs will result in a prolonged the half-life, and an increased potential for toxic effects.

Expect and account for these alterations in drug metabolism in elderly patients. Typical changes result in increased active serum concentrations of the drug and extended half-life. Elevated drug concentrations result in more adverse drug events, and these include not only known complications, but also uncommon problems such as blood dyscrasias. If a rare adverse drug reaction does occur, it is most likely to happen in an elderly person.

click for large version

The Acute Care Setting

In light of the physiologic changes associated with aging, as well as the problems posed by taking multiple medications, it is clear that active intervention is required to prevent adverse drug reactions in geriatric patients.

A large cohort study of Medicare enrollees with more than 30,000 patient-years of observation found that 28% of adverse drug reactions were potentially avoidable. Most errors occurred during prescribing and monitoring. A number of strategies have been proposed for reducing these unwanted medication consequences in the hospital setting, including:

• Avoid inappropriate drug prescribing;
• Avoid overprescribing;
• Implement age-appropriate dosing; and
• Encourage a multidisciplinary ap-proach.

Drugs to Avoid

Though precise clinical data regarding which medications are harmful to elderly patients in the acute care setting is lacking, multiple expert panels have attempted to delineate which drugs should be generally avoided in this population (Table 1, above).

The most notable of these evaluations is the Beers criteria, a frequently updated set of medications deemed inappropriate for use in geriatric patients. Most recently amended in 2003, this list is formulated by experts in pharmacology and geriatrics, and has been validated in large studies as a useful tool for decreasing medication-related problems in the nursing home setting.10

Though a 2006 study of hospital morbidity found that adverse drug reactions in the acute care setting often occur from drugs not listed in the Beers criteria, avoiding medications like those listed above is still a useful tool in preventing side effects.11-12

Avoid Overprescribing

To prevent a polypharmacy-induced iatrogenic illness, it is important to consider any new signs and symptoms to be a possible consequence of current drug therapy. Steps for reducing polypharmacy include:

• Get into the habit of identifying all drugs by generic name and drug class;
• Make certain the drug being prescribed has a clinical indication;
• Know the side-effect profile of the drugs being prescribed;
• Understand how changes in drug distribution, metabolism, and elimination associated with aging increase the risk of adverse drug events;
• Stop any drug without known benefit;
• Stop any drug without a clinical indication;
• Attempt to substitute a less-toxic drug; and
• Be aware of the prescribing-cascade treating an adverse drug reaction as an illness with another drug.

Age-Appropriate Dosing

When starting a new drug, start with a low dose and titrate slowly to the desired clinical effect. While the manufacturers of many commonly used medications do not delineate the lower-dosage recommendations necessary for elderly patients, you can bypass this problem by starting with one-third to half the recommended dosage.

After observing that the patient tolerates the new drug, slowly increase the dose until the desired result is obtained. This approach is particularly important in minimizing potential harmful drug effects in patients with severely reduced renal function.14

Multidisciplinary Approach

In its 2001 report “Crossing the Quality Chasm: A New Health System of the 21st Century,” the U.S. Institute of Medicine declared: “The current care systems cannot do the job. Trying harder will not work. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”

While hospitalists are on the front line for preventing adverse drug reactions, they can’t do it by themselves. Here are a few tips for making your job easier:

• Request that medications inappropriate for geriatric patients (based on the Beers criteria) be notated as such by the pharmacist;
• Ask for a geriatric dosing option in the computer-based medication ordering system;
• Flag charts of patients with previous adverse drug effects with the name of the offending drug;
• Warn nurses and other caregivers to monitor for specific side effects; and
• Advocate that midlevel providers receive hospital-based training in the prevention of medication-related adverse events.

The elderly portion of the population is expanding more rapidly than the population as a whole, and the recognition and prevention of medication side effects in this group is one of the most critical safety and economic issues facing the healthcare system today. While the magnitude of this problem demands multidisciplinary involvement, hospitalists can be key players in making a difference. TH

Dr. Landis is a rheumatologist and a freelance writer

References

1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997 Jan 22-29;277(4):307-311. Comment in: JAMA. 1997 Jan 22-29;277(4):341-3422: JAMA. 1997 May 7;277(17):1351-1352; author reply 1353-1354.
2. Zarowitz BJ, Stebelsky LA, Muma BK, et al. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25(11):1636-1645. Comment in: Pharmacotherapy. 2006 Jun;26(6):886-887; discussion 887.
3. Byron C, Hochberg MC. Changing the patterns of Coxibs/NSAIDs prescribing: balancing CV and GI risks. Medscape. Available at www.medscape.com/viewprogram/5060. Last accessed May 2, 2007.
4. Shapiro K. The Complexities of Geriatric Pain Management. 20th Annual Meeting of the American Pain Society. Medscape CME. Available at www.medscape.com/viewarticle/416593. Last accessed May 2, 2007.
5. Lau DT, Kasper JD, Potter DE, et al. Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics. Health Serv Res. 2004 Oct; 39(5):1257-1276.
6. Longa GJ, Cross RE. Laboratory Monitoring of Drug Therapy. Part II: Variable Protein Binding and Free (Unbound) Drug Concentration. Bull Lab Me. 1984;80:1-6. 7. Chutka DS, Evans JM, Fleming KC, et al. Symposium on geriatrics—Part I: Drug prescribing for elderly patients. Mayo Clin Proc. 1995 Jul;70(7):685-693.
7. Feely J, Coakley D. Altered pharmacodynamics in the elderly. Clin Geriatr Med. 1990 May; 6(2): 269-283.
8. Williams CM. Using medications appropriately in older adults. Am Fam Phys. 2002 Nov 15;66(10):1917-1924.
9. Fick DN, Cooper JW, Wade WE. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003 Dec 8-22;163(22):2716-2724. Erratum in: Arch Intern Med. 2004 Feb 9;164(3):298. Comment in: Arch Intern Med. 2004 Aug 9-23;164(15):1701.
10. Johnston PE, France DJ, Byrne DW, et al. Assessment of adverse drug events among patients in a tertiary care medical center. Am J Health Syst Pharm., 2006;63(22):2218-2227.
11. Page RL, Ruscin JM. The risk of adverse drug events and hospital related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother. 2006 Dec;4(4):297-305.
12. Avidan AY. Sleep changes and disorders in the elderly patient. Curr Neurol Neurosci Rep. 2002 Mar;2(2):178-185.
13. Pugh MJV, Fincke G, Bierman AS, et al. Potentially inappropriate prescribing in elderly veterans: Are we using the wrong drug, wrong dose, or wrong duration? J Am Geriatr Soc. 2005 Aug;53(8):1282-1289.

The expansion of information technology (IT) in U.S. hospitals is an evolutionary process. Billing, collections, and admission and discharge records have long been computerized, but now electronic medical administration records, patient electronic health records, and computerized physician order entry (CPOE) systems are joining the ranks.

Hospitalists are more likely to encounter sophisticated IT systems in larger, urban, or teaching hospitals, according to a 2005 survey by the American Hospital Association.1

The Hospitalist’s first installment about hospital informatics (“Charts to Screens,” January 2007, p. 25) focused on the challenges of health IT and the barriers to effective adoption of computer-based documentation systems. This installment explores the potentially rich vein of data available to hospitalists from those information systems and the opportunities for research and QI applications.

The mechanics of conducting clinical research and QI projects will depend to a large extent on the progress each hospital medical group’s institution has made in the IT adoption process. Some say hospitalists have powerful contributions to make in influencing how the IT process evolves so their research opportunities will also improve.

QI Topics

Data in information systems differ from hospital to hospital, says Tejal K. Gandhi, MD, MPH, director of patient safety at Boston’s Brigham and Women’s Hospital (BWH) and assistant professor of medicine in the Department of Medicine at Harvard Medical School in Boston.

Dr. Gandhi’s research focuses on redesigning hospital and outpatient processes to improve patient safety. She notes that hospitalists can take advantage of data the hospital is collecting to satisfy its reporting requirements to spearhead more quality-improvement efforts.

“For example,” says Dr. Gandhi, “the hospital has to document how it’s doing on pneumonia measures, acute myocardial infarction measures (was the patient having a heart attack given aspirin and a beta-blocker?), and others. These are fruitful topics for quality-improvement projects.”

Hospitalist Andrew Karson, MD, MPH, associate director of the Decision Support and Quality Management Unit and associate program director for the Internal Medicine Residency Program at Massachusetts General Hospital, Boston, also focuses on patient safety issues in his research. Given hospitalists’ knowledge of decision-making systems in the hospital, they are in a unique situation to initiate such projects, he believes.

For example, Dr. Karson participated in a study initiated by colleague Christopher L. Roy, MD, associate director of the hospitalist program at BWH.2 Dr. Roy posited that pending test results could be an important patient safety issue and, at the very least, might affect continuity of care. The researchers identified 2,644 consecutive patients discharged from BWH and Massachusetts General between February and June 2004. During that time, a mixture of hospitalists and non-hospitalists were responsible for discharging patients on house staff and non-house-staff services. Using a Results Manager application integrated into each patient’s electronic medical record (EMR) at the hospitals, the team identified and tracked pending laboratory and/or radiologic test results that had been returned after the patients were discharged.

The team used physician reviewers to determine whether the pending test results were potentially actionable. They found that 41% (1,095) of the discharged patients had a total of 2,033 test results return after their discharge. Of those tests, the physician reviewer determined that 9.4% (191) were potentially actionable. Examples of actionable results of which discharging physicians had been unaware included a levofloxacin-resistant Klebsiella infection in a patient being treated with levofloxacin, and a thyroid-stimulating hormone level that was dangerously low in a patient with rapid atrial fibrillation. A coauthor of the study, Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care at BWH, is working on a results-management system that will automatically alert hospitalists and other physicians in the process of discharging patients when those patients are awaiting test results.

Research Potential

CPOE systems afford opportunities to delve further into clinical research and QI projects.

The flow of care in hospitals is inextricably linked with writing orders—for medications, tests, consultations, or interventional care processes. “Interfacing with CPOEs, therefore, can help influence the way care is practiced more broadly for our patients,” says Dr. Karson. “By embedding rules and decision support elements within our CPOE systems, we can improve the quality and safety of the care that we provide.”

The effect of CPOE on ICU patient care was highlighted in a 2005 study conducted by intensivist Stephen P. Hoffmann, MD, medical director, ICU, and associate professor of medicine at Ohio State University Medical Center, Columbus, and his colleagues. The team compared orders for ICU care before and after modification of a CPOE system and found that use of higher-efficiency CPOE order paths led to significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management.3

Paul D. Hain, MD, interim chief of staff and director of the Pediatric Hospitalist Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., and his colleagues at Vanderbilt University’s School of Medicine have been able to use their institution’s advanced CPOE to increase adherence to evidence-based treatments.

With the help of IT support staff, Dr. Hain inserted a pop-up window into the CPOE to remind providers that bronchodilators (albuterol) and steroids are ineffective for the treatment of bronchiolitis. Working with a third-year medical student, Ryan Bailey, Dr. Hain compared orders for these treatments in the years preceding installation of his pop-up reminder with those afterward. There was a significant drop in the non-evidence-based treatments, he notes, based on the installation of the pop-up window. “The reminder actually worked!” he exclaims. “It got people to stop using inappropriate therapies.”

This type of quality improvement, says Dr. Hain, is good for the hospital, for the hospitalists, and for their non-hospitalist colleagues. “This type of reminder allows us to share evidence-based guidelines with other admitting physicians in real time, and it appears to be a much more effective way to communicate information, as evidenced by our success in decreasing non-evidence-based treatments for bronchiolitis,” he asserts. The pop-up window includes a link to the treatment guidelines, so it also offers users an educational opportunity.

Close the Loop

Dr. Hoffmann and others caution about the limitations of using CPOE data. Most CPOE systems, notes Dr. Hoffmann, do not have a way of capturing whether an order or intervention was actually carried out.

“With CPOE, you can get a very good handle on how many order sets for processes of care have been ordered, but it doesn’t complete the loop—it doesn’t tell you whether that process of care happened once it has been ordered,” Dr. Hoffman says. “If you use the CPOE data set alone and stop there, the process is going to be fraught with unreliable information.”

CPOE can be a good tool for organizing clinical improvement projects but may not be the perfect tool for verifying outcomes of the order set. This was underscored by a project Dr. Hoffmann and his team conducted in collaboration with the University HealthSystem Consortium (UHC) on ventilator-associated pneumonia (VAP). The team wrote policy and processes based on current evidence for preventing VAP—such as raising the heads of patients’ beds to 30 degrees when they are mechanically ventilated—and created a flowchart of those processes. The aim of the project was to tie these care processes to the order for a ventilator, so that each time one was ordered, the other care items were bundled with it to trigger changes at the bedside. Now, it won’t be possible for a provider to order a ventilator without at least reviewing and ordering the additional care processes.

For the UHC project, Dr. Hoffmann and his team had to manually review charts and documentation to verify that the VAP bundle had been ordered and then utilized. “We looked at what documentation needed to be done, and we have modified nursing and respiratory therapy documentation to ensure that all these bundled-care process steps are adequately documented,” he says. The next step will be to tie CPOE with bedside charting and decision support, so that verification of order sets will also be stored in the hospital system’s information warehouse and will be accessible to physician researchers. The project is ongoing, states Dr. Hoffmann, and another evaluation will be conducted manually after a six-month interval to validate the data collection points that will be most useful in the automation process.

There are other ways to verify CPOE implementation. At BWH, says Dr. Gandhi, the electronic medication administration record (eMAR) provides a powerful adjunct to the CPOE.

“The fact that we have eMAR data is really advantageous,” notes Dr. Gandhi, “because now we can actually tell what patients have received.” For example, she says, Narcan (naloxone hydrochloride) is usually ordered and kept at the bedside for a patient receiving opioids in case the patient develops respiratory depression. Before institution of the hospital’s eMAR, “we could never tell how much Narcan was actually being given without doing laborious chart reviews. Now, with our eMAR, we can easily track how many times it was given, and this supplies a much better indicator of potential problems with the use of narcotics.”

At Vanderbilt, says Dr. Hain, a dosage checker application installed behind the CPOE has allowed his colleague Neal Patel, MD, MPH, to verify that medication errors in the Pediatric ICU dropped dramatically after its implementation. But, on other projects, researchers must know in advance that they intend to follow up on order entries so that they can convert order entries into binary procedures. The CPOE and EMR systems have the capability of inserting text boxes, drop-down menus, and click buttons for verifying medications, procedures, or even safety check-offs. If the CPOE is not set up in advance for this feature, however, it’s back to manual extraction to confirm the data—“a painful process, just as it is from paper charts,” Dr. Hain notes.

Privacy and Other Issues

Are there privacy issues of which hospitalists should be aware when using their hospital information system databases for their research?

“In general, if you’re doing quality improvement projects solely for the sake of improving the quality of patient care at your institution,” says Dr. Karson, “you do not need IRB [institutional review board] approval.” Whenever hospitalists plan to publish or present the data to external audiences, however, prior IRB approval must be obtained to show that patients’ identities will be protected and that use of the data will cause no harm.

There could be wrinkles in following these guidelines if the results of a QI project reveal surprisingly good results or important lessons about quality patient care that researchers think are worth sharing. Although it is possible to apply post-hoc for IRB approval, Dr. Gandhi and others suggest obtaining approval prior to the start of the project if researchers think there is any chance they may want to share results externally. Researchers must also adhere to the quality rules during QI projects, asserts Dr. Hain, to make sure patients’ identities are protected.

The IT/MD Interface

Whether hospitals use off-the-shelf or custom-built, institution-specific CPOEs, hospitalists are well positioned to play important roles in enhancing their designs, believes Dr. Karson. “If you’re going to support [clinicians’] decisions with computerized decision support, then CPOE systems are a great way to broadly affect the care of patients,” he says.

As those CPOE systems are designed, they require decisions along the way so they will achieve the quality, safety, and efficiency goals for the hospital and for the patients that the hospital cares for. Who better to interface with information systems designers than process-oriented hospitalists? As a hospitalist, Dr. Karson is taking a lead role in updating the pneumonia order set in his hospital’s provider order entry system.

It is sometimes possible for hospitalists to extract data manually to effect a proof of concept as justification for an IT system upgrade, says Dr. Hain. For example, in Vanderbilt’s outpatient clinic, one physician wanted to know whether all diabetic patients received foot exams at their regular visits. They inserted a paper form with check boxes into patients’ charts and then aggregated these forms to show it was possible to track quality measures for diabetics. This has led to a diabetics dashboard on the outpatient clinic computers that tracks foot exams by the day, week, or month.

Hospitalists report varying degrees of expertise with IT. Dr. Hoffmann’s introduction to IT came when he assumed the medical directorship of Ohio State University’s ICU. Since that time, he has been charged with collaborating with the medical center’s information systems (IS) personnel to improve the CPOE. “We have a group here that embraces the system—so much so that the IS people sometimes are inundated with our enthusiasm to make changes,” Dr. Hoffman says.

Dr. Hain, who has a background in engineering, relies on IT support when designing changes to the CPOE. “Our IT department here has done a really good job of reaching out to its users,” he says. Several physicians in the medical informatics department specialize in the CPOE, as is the case in many academic institutions. “It’s important that the gap be bridged between computer programmers and MDs,” he says. “The best way to do that is to have MDs with master’s degrees in informatics working with the programmers, making it all the more seamless.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. American Hospital Association. Forward momentum: hospital use of information technology. October 2005. Available at www.aha.org/aha/content/2005/pdf/FINALNonEmbITSurvey105.pdf. Last accessed April 10, 2007.
2. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19; 143(2):121-128.
3. Ali NA, Mekhjian HS, Kuehn PL, et al. Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Crit Care Med. 2005 Jan;33(1):110-114.

The expansion of information technology (IT) in U.S. hospitals is an evolutionary process. Billing, collections, and admission and discharge records have long been computerized, but now electronic medical administration records, patient electronic health records, and computerized physician order entry (CPOE) systems are joining the ranks.

Hospitalists are more likely to encounter sophisticated IT systems in larger, urban, or teaching hospitals, according to a 2005 survey by the American Hospital Association.1

The Hospitalist’s first installment about hospital informatics (“Charts to Screens,” January 2007, p. 25) focused on the challenges of health IT and the barriers to effective adoption of computer-based documentation systems. This installment explores the potentially rich vein of data available to hospitalists from those information systems and the opportunities for research and QI applications.

The mechanics of conducting clinical research and QI projects will depend to a large extent on the progress each hospital medical group’s institution has made in the IT adoption process. Some say hospitalists have powerful contributions to make in influencing how the IT process evolves so their research opportunities will also improve.

QI Topics

Data in information systems differ from hospital to hospital, says Tejal K. Gandhi, MD, MPH, director of patient safety at Boston’s Brigham and Women’s Hospital (BWH) and assistant professor of medicine in the Department of Medicine at Harvard Medical School in Boston.

Dr. Gandhi’s research focuses on redesigning hospital and outpatient processes to improve patient safety. She notes that hospitalists can take advantage of data the hospital is collecting to satisfy its reporting requirements to spearhead more quality-improvement efforts.

“For example,” says Dr. Gandhi, “the hospital has to document how it’s doing on pneumonia measures, acute myocardial infarction measures (was the patient having a heart attack given aspirin and a beta-blocker?), and others. These are fruitful topics for quality-improvement projects.”

Hospitalist Andrew Karson, MD, MPH, associate director of the Decision Support and Quality Management Unit and associate program director for the Internal Medicine Residency Program at Massachusetts General Hospital, Boston, also focuses on patient safety issues in his research. Given hospitalists’ knowledge of decision-making systems in the hospital, they are in a unique situation to initiate such projects, he believes.

For example, Dr. Karson participated in a study initiated by colleague Christopher L. Roy, MD, associate director of the hospitalist program at BWH.2 Dr. Roy posited that pending test results could be an important patient safety issue and, at the very least, might affect continuity of care. The researchers identified 2,644 consecutive patients discharged from BWH and Massachusetts General between February and June 2004. During that time, a mixture of hospitalists and non-hospitalists were responsible for discharging patients on house staff and non-house-staff services. Using a Results Manager application integrated into each patient’s electronic medical record (EMR) at the hospitals, the team identified and tracked pending laboratory and/or radiologic test results that had been returned after the patients were discharged.

The team used physician reviewers to determine whether the pending test results were potentially actionable. They found that 41% (1,095) of the discharged patients had a total of 2,033 test results return after their discharge. Of those tests, the physician reviewer determined that 9.4% (191) were potentially actionable. Examples of actionable results of which discharging physicians had been unaware included a levofloxacin-resistant Klebsiella infection in a patient being treated with levofloxacin, and a thyroid-stimulating hormone level that was dangerously low in a patient with rapid atrial fibrillation. A coauthor of the study, Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care at BWH, is working on a results-management system that will automatically alert hospitalists and other physicians in the process of discharging patients when those patients are awaiting test results.

Research Potential

CPOE systems afford opportunities to delve further into clinical research and QI projects.

The flow of care in hospitals is inextricably linked with writing orders—for medications, tests, consultations, or interventional care processes. “Interfacing with CPOEs, therefore, can help influence the way care is practiced more broadly for our patients,” says Dr. Karson. “By embedding rules and decision support elements within our CPOE systems, we can improve the quality and safety of the care that we provide.”

The effect of CPOE on ICU patient care was highlighted in a 2005 study conducted by intensivist Stephen P. Hoffmann, MD, medical director, ICU, and associate professor of medicine at Ohio State University Medical Center, Columbus, and his colleagues. The team compared orders for ICU care before and after modification of a CPOE system and found that use of higher-efficiency CPOE order paths led to significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management.3

Paul D. Hain, MD, interim chief of staff and director of the Pediatric Hospitalist Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., and his colleagues at Vanderbilt University’s School of Medicine have been able to use their institution’s advanced CPOE to increase adherence to evidence-based treatments.

With the help of IT support staff, Dr. Hain inserted a pop-up window into the CPOE to remind providers that bronchodilators (albuterol) and steroids are ineffective for the treatment of bronchiolitis. Working with a third-year medical student, Ryan Bailey, Dr. Hain compared orders for these treatments in the years preceding installation of his pop-up reminder with those afterward. There was a significant drop in the non-evidence-based treatments, he notes, based on the installation of the pop-up window. “The reminder actually worked!” he exclaims. “It got people to stop using inappropriate therapies.”

This type of quality improvement, says Dr. Hain, is good for the hospital, for the hospitalists, and for their non-hospitalist colleagues. “This type of reminder allows us to share evidence-based guidelines with other admitting physicians in real time, and it appears to be a much more effective way to communicate information, as evidenced by our success in decreasing non-evidence-based treatments for bronchiolitis,” he asserts. The pop-up window includes a link to the treatment guidelines, so it also offers users an educational opportunity.

Close the Loop

Dr. Hoffmann and others caution about the limitations of using CPOE data. Most CPOE systems, notes Dr. Hoffmann, do not have a way of capturing whether an order or intervention was actually carried out.

“With CPOE, you can get a very good handle on how many order sets for processes of care have been ordered, but it doesn’t complete the loop—it doesn’t tell you whether that process of care happened once it has been ordered,” Dr. Hoffman says. “If you use the CPOE data set alone and stop there, the process is going to be fraught with unreliable information.”

CPOE can be a good tool for organizing clinical improvement projects but may not be the perfect tool for verifying outcomes of the order set. This was underscored by a project Dr. Hoffmann and his team conducted in collaboration with the University HealthSystem Consortium (UHC) on ventilator-associated pneumonia (VAP). The team wrote policy and processes based on current evidence for preventing VAP—such as raising the heads of patients’ beds to 30 degrees when they are mechanically ventilated—and created a flowchart of those processes. The aim of the project was to tie these care processes to the order for a ventilator, so that each time one was ordered, the other care items were bundled with it to trigger changes at the bedside. Now, it won’t be possible for a provider to order a ventilator without at least reviewing and ordering the additional care processes.

For the UHC project, Dr. Hoffmann and his team had to manually review charts and documentation to verify that the VAP bundle had been ordered and then utilized. “We looked at what documentation needed to be done, and we have modified nursing and respiratory therapy documentation to ensure that all these bundled-care process steps are adequately documented,” he says. The next step will be to tie CPOE with bedside charting and decision support, so that verification of order sets will also be stored in the hospital system’s information warehouse and will be accessible to physician researchers. The project is ongoing, states Dr. Hoffmann, and another evaluation will be conducted manually after a six-month interval to validate the data collection points that will be most useful in the automation process.

There are other ways to verify CPOE implementation. At BWH, says Dr. Gandhi, the electronic medication administration record (eMAR) provides a powerful adjunct to the CPOE.

“The fact that we have eMAR data is really advantageous,” notes Dr. Gandhi, “because now we can actually tell what patients have received.” For example, she says, Narcan (naloxone hydrochloride) is usually ordered and kept at the bedside for a patient receiving opioids in case the patient develops respiratory depression. Before institution of the hospital’s eMAR, “we could never tell how much Narcan was actually being given without doing laborious chart reviews. Now, with our eMAR, we can easily track how many times it was given, and this supplies a much better indicator of potential problems with the use of narcotics.”

At Vanderbilt, says Dr. Hain, a dosage checker application installed behind the CPOE has allowed his colleague Neal Patel, MD, MPH, to verify that medication errors in the Pediatric ICU dropped dramatically after its implementation. But, on other projects, researchers must know in advance that they intend to follow up on order entries so that they can convert order entries into binary procedures. The CPOE and EMR systems have the capability of inserting text boxes, drop-down menus, and click buttons for verifying medications, procedures, or even safety check-offs. If the CPOE is not set up in advance for this feature, however, it’s back to manual extraction to confirm the data—“a painful process, just as it is from paper charts,” Dr. Hain notes.

Privacy and Other Issues

Are there privacy issues of which hospitalists should be aware when using their hospital information system databases for their research?

“In general, if you’re doing quality improvement projects solely for the sake of improving the quality of patient care at your institution,” says Dr. Karson, “you do not need IRB [institutional review board] approval.” Whenever hospitalists plan to publish or present the data to external audiences, however, prior IRB approval must be obtained to show that patients’ identities will be protected and that use of the data will cause no harm.

There could be wrinkles in following these guidelines if the results of a QI project reveal surprisingly good results or important lessons about quality patient care that researchers think are worth sharing. Although it is possible to apply post-hoc for IRB approval, Dr. Gandhi and others suggest obtaining approval prior to the start of the project if researchers think there is any chance they may want to share results externally. Researchers must also adhere to the quality rules during QI projects, asserts Dr. Hain, to make sure patients’ identities are protected.

The IT/MD Interface

Whether hospitals use off-the-shelf or custom-built, institution-specific CPOEs, hospitalists are well positioned to play important roles in enhancing their designs, believes Dr. Karson. “If you’re going to support [clinicians’] decisions with computerized decision support, then CPOE systems are a great way to broadly affect the care of patients,” he says.

As those CPOE systems are designed, they require decisions along the way so they will achieve the quality, safety, and efficiency goals for the hospital and for the patients that the hospital cares for. Who better to interface with information systems designers than process-oriented hospitalists? As a hospitalist, Dr. Karson is taking a lead role in updating the pneumonia order set in his hospital’s provider order entry system.

It is sometimes possible for hospitalists to extract data manually to effect a proof of concept as justification for an IT system upgrade, says Dr. Hain. For example, in Vanderbilt’s outpatient clinic, one physician wanted to know whether all diabetic patients received foot exams at their regular visits. They inserted a paper form with check boxes into patients’ charts and then aggregated these forms to show it was possible to track quality measures for diabetics. This has led to a diabetics dashboard on the outpatient clinic computers that tracks foot exams by the day, week, or month.

Hospitalists report varying degrees of expertise with IT. Dr. Hoffmann’s introduction to IT came when he assumed the medical directorship of Ohio State University’s ICU. Since that time, he has been charged with collaborating with the medical center’s information systems (IS) personnel to improve the CPOE. “We have a group here that embraces the system—so much so that the IS people sometimes are inundated with our enthusiasm to make changes,” Dr. Hoffman says.

Dr. Hain, who has a background in engineering, relies on IT support when designing changes to the CPOE. “Our IT department here has done a really good job of reaching out to its users,” he says. Several physicians in the medical informatics department specialize in the CPOE, as is the case in many academic institutions. “It’s important that the gap be bridged between computer programmers and MDs,” he says. “The best way to do that is to have MDs with master’s degrees in informatics working with the programmers, making it all the more seamless.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. American Hospital Association. Forward momentum: hospital use of information technology. October 2005. Available at www.aha.org/aha/content/2005/pdf/FINALNonEmbITSurvey105.pdf. Last accessed April 10, 2007.
2. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19; 143(2):121-128.
3. Ali NA, Mekhjian HS, Kuehn PL, et al. Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Crit Care Med. 2005 Jan;33(1):110-114.

The expansion of information technology (IT) in U.S. hospitals is an evolutionary process. Billing, collections, and admission and discharge records have long been computerized, but now electronic medical administration records, patient electronic health records, and computerized physician order entry (CPOE) systems are joining the ranks.

Hospitalists are more likely to encounter sophisticated IT systems in larger, urban, or teaching hospitals, according to a 2005 survey by the American Hospital Association.1

The Hospitalist’s first installment about hospital informatics (“Charts to Screens,” January 2007, p. 25) focused on the challenges of health IT and the barriers to effective adoption of computer-based documentation systems. This installment explores the potentially rich vein of data available to hospitalists from those information systems and the opportunities for research and QI applications.

The mechanics of conducting clinical research and QI projects will depend to a large extent on the progress each hospital medical group’s institution has made in the IT adoption process. Some say hospitalists have powerful contributions to make in influencing how the IT process evolves so their research opportunities will also improve.

QI Topics

Data in information systems differ from hospital to hospital, says Tejal K. Gandhi, MD, MPH, director of patient safety at Boston’s Brigham and Women’s Hospital (BWH) and assistant professor of medicine in the Department of Medicine at Harvard Medical School in Boston.

Dr. Gandhi’s research focuses on redesigning hospital and outpatient processes to improve patient safety. She notes that hospitalists can take advantage of data the hospital is collecting to satisfy its reporting requirements to spearhead more quality-improvement efforts.

“For example,” says Dr. Gandhi, “the hospital has to document how it’s doing on pneumonia measures, acute myocardial infarction measures (was the patient having a heart attack given aspirin and a beta-blocker?), and others. These are fruitful topics for quality-improvement projects.”

Hospitalist Andrew Karson, MD, MPH, associate director of the Decision Support and Quality Management Unit and associate program director for the Internal Medicine Residency Program at Massachusetts General Hospital, Boston, also focuses on patient safety issues in his research. Given hospitalists’ knowledge of decision-making systems in the hospital, they are in a unique situation to initiate such projects, he believes.

For example, Dr. Karson participated in a study initiated by colleague Christopher L. Roy, MD, associate director of the hospitalist program at BWH.2 Dr. Roy posited that pending test results could be an important patient safety issue and, at the very least, might affect continuity of care. The researchers identified 2,644 consecutive patients discharged from BWH and Massachusetts General between February and June 2004. During that time, a mixture of hospitalists and non-hospitalists were responsible for discharging patients on house staff and non-house-staff services. Using a Results Manager application integrated into each patient’s electronic medical record (EMR) at the hospitals, the team identified and tracked pending laboratory and/or radiologic test results that had been returned after the patients were discharged.

The team used physician reviewers to determine whether the pending test results were potentially actionable. They found that 41% (1,095) of the discharged patients had a total of 2,033 test results return after their discharge. Of those tests, the physician reviewer determined that 9.4% (191) were potentially actionable. Examples of actionable results of which discharging physicians had been unaware included a levofloxacin-resistant Klebsiella infection in a patient being treated with levofloxacin, and a thyroid-stimulating hormone level that was dangerously low in a patient with rapid atrial fibrillation. A coauthor of the study, Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care at BWH, is working on a results-management system that will automatically alert hospitalists and other physicians in the process of discharging patients when those patients are awaiting test results.

Research Potential

CPOE systems afford opportunities to delve further into clinical research and QI projects.

The flow of care in hospitals is inextricably linked with writing orders—for medications, tests, consultations, or interventional care processes. “Interfacing with CPOEs, therefore, can help influence the way care is practiced more broadly for our patients,” says Dr. Karson. “By embedding rules and decision support elements within our CPOE systems, we can improve the quality and safety of the care that we provide.”

The effect of CPOE on ICU patient care was highlighted in a 2005 study conducted by intensivist Stephen P. Hoffmann, MD, medical director, ICU, and associate professor of medicine at Ohio State University Medical Center, Columbus, and his colleagues. The team compared orders for ICU care before and after modification of a CPOE system and found that use of higher-efficiency CPOE order paths led to significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management.3

Paul D. Hain, MD, interim chief of staff and director of the Pediatric Hospitalist Program at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn., and his colleagues at Vanderbilt University’s School of Medicine have been able to use their institution’s advanced CPOE to increase adherence to evidence-based treatments.

With the help of IT support staff, Dr. Hain inserted a pop-up window into the CPOE to remind providers that bronchodilators (albuterol) and steroids are ineffective for the treatment of bronchiolitis. Working with a third-year medical student, Ryan Bailey, Dr. Hain compared orders for these treatments in the years preceding installation of his pop-up reminder with those afterward. There was a significant drop in the non-evidence-based treatments, he notes, based on the installation of the pop-up window. “The reminder actually worked!” he exclaims. “It got people to stop using inappropriate therapies.”

This type of quality improvement, says Dr. Hain, is good for the hospital, for the hospitalists, and for their non-hospitalist colleagues. “This type of reminder allows us to share evidence-based guidelines with other admitting physicians in real time, and it appears to be a much more effective way to communicate information, as evidenced by our success in decreasing non-evidence-based treatments for bronchiolitis,” he asserts. The pop-up window includes a link to the treatment guidelines, so it also offers users an educational opportunity.

Close the Loop

Dr. Hoffmann and others caution about the limitations of using CPOE data. Most CPOE systems, notes Dr. Hoffmann, do not have a way of capturing whether an order or intervention was actually carried out.

“With CPOE, you can get a very good handle on how many order sets for processes of care have been ordered, but it doesn’t complete the loop—it doesn’t tell you whether that process of care happened once it has been ordered,” Dr. Hoffman says. “If you use the CPOE data set alone and stop there, the process is going to be fraught with unreliable information.”

CPOE can be a good tool for organizing clinical improvement projects but may not be the perfect tool for verifying outcomes of the order set. This was underscored by a project Dr. Hoffmann and his team conducted in collaboration with the University HealthSystem Consortium (UHC) on ventilator-associated pneumonia (VAP). The team wrote policy and processes based on current evidence for preventing VAP—such as raising the heads of patients’ beds to 30 degrees when they are mechanically ventilated—and created a flowchart of those processes. The aim of the project was to tie these care processes to the order for a ventilator, so that each time one was ordered, the other care items were bundled with it to trigger changes at the bedside. Now, it won’t be possible for a provider to order a ventilator without at least reviewing and ordering the additional care processes.

For the UHC project, Dr. Hoffmann and his team had to manually review charts and documentation to verify that the VAP bundle had been ordered and then utilized. “We looked at what documentation needed to be done, and we have modified nursing and respiratory therapy documentation to ensure that all these bundled-care process steps are adequately documented,” he says. The next step will be to tie CPOE with bedside charting and decision support, so that verification of order sets will also be stored in the hospital system’s information warehouse and will be accessible to physician researchers. The project is ongoing, states Dr. Hoffmann, and another evaluation will be conducted manually after a six-month interval to validate the data collection points that will be most useful in the automation process.

There are other ways to verify CPOE implementation. At BWH, says Dr. Gandhi, the electronic medication administration record (eMAR) provides a powerful adjunct to the CPOE.

“The fact that we have eMAR data is really advantageous,” notes Dr. Gandhi, “because now we can actually tell what patients have received.” For example, she says, Narcan (naloxone hydrochloride) is usually ordered and kept at the bedside for a patient receiving opioids in case the patient develops respiratory depression. Before institution of the hospital’s eMAR, “we could never tell how much Narcan was actually being given without doing laborious chart reviews. Now, with our eMAR, we can easily track how many times it was given, and this supplies a much better indicator of potential problems with the use of narcotics.”

At Vanderbilt, says Dr. Hain, a dosage checker application installed behind the CPOE has allowed his colleague Neal Patel, MD, MPH, to verify that medication errors in the Pediatric ICU dropped dramatically after its implementation. But, on other projects, researchers must know in advance that they intend to follow up on order entries so that they can convert order entries into binary procedures. The CPOE and EMR systems have the capability of inserting text boxes, drop-down menus, and click buttons for verifying medications, procedures, or even safety check-offs. If the CPOE is not set up in advance for this feature, however, it’s back to manual extraction to confirm the data—“a painful process, just as it is from paper charts,” Dr. Hain notes.

Privacy and Other Issues

Are there privacy issues of which hospitalists should be aware when using their hospital information system databases for their research?

“In general, if you’re doing quality improvement projects solely for the sake of improving the quality of patient care at your institution,” says Dr. Karson, “you do not need IRB [institutional review board] approval.” Whenever hospitalists plan to publish or present the data to external audiences, however, prior IRB approval must be obtained to show that patients’ identities will be protected and that use of the data will cause no harm.

There could be wrinkles in following these guidelines if the results of a QI project reveal surprisingly good results or important lessons about quality patient care that researchers think are worth sharing. Although it is possible to apply post-hoc for IRB approval, Dr. Gandhi and others suggest obtaining approval prior to the start of the project if researchers think there is any chance they may want to share results externally. Researchers must also adhere to the quality rules during QI projects, asserts Dr. Hain, to make sure patients’ identities are protected.

The IT/MD Interface

Whether hospitals use off-the-shelf or custom-built, institution-specific CPOEs, hospitalists are well positioned to play important roles in enhancing their designs, believes Dr. Karson. “If you’re going to support [clinicians’] decisions with computerized decision support, then CPOE systems are a great way to broadly affect the care of patients,” he says.

As those CPOE systems are designed, they require decisions along the way so they will achieve the quality, safety, and efficiency goals for the hospital and for the patients that the hospital cares for. Who better to interface with information systems designers than process-oriented hospitalists? As a hospitalist, Dr. Karson is taking a lead role in updating the pneumonia order set in his hospital’s provider order entry system.

It is sometimes possible for hospitalists to extract data manually to effect a proof of concept as justification for an IT system upgrade, says Dr. Hain. For example, in Vanderbilt’s outpatient clinic, one physician wanted to know whether all diabetic patients received foot exams at their regular visits. They inserted a paper form with check boxes into patients’ charts and then aggregated these forms to show it was possible to track quality measures for diabetics. This has led to a diabetics dashboard on the outpatient clinic computers that tracks foot exams by the day, week, or month.

Hospitalists report varying degrees of expertise with IT. Dr. Hoffmann’s introduction to IT came when he assumed the medical directorship of Ohio State University’s ICU. Since that time, he has been charged with collaborating with the medical center’s information systems (IS) personnel to improve the CPOE. “We have a group here that embraces the system—so much so that the IS people sometimes are inundated with our enthusiasm to make changes,” Dr. Hoffman says.

Dr. Hain, who has a background in engineering, relies on IT support when designing changes to the CPOE. “Our IT department here has done a really good job of reaching out to its users,” he says. Several physicians in the medical informatics department specialize in the CPOE, as is the case in many academic institutions. “It’s important that the gap be bridged between computer programmers and MDs,” he says. “The best way to do that is to have MDs with master’s degrees in informatics working with the programmers, making it all the more seamless.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.

References

1. American Hospital Association. Forward momentum: hospital use of information technology. October 2005. Available at www.aha.org/aha/content/2005/pdf/FINALNonEmbITSurvey105.pdf. Last accessed April 10, 2007.
2. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19; 143(2):121-128.
3. Ali NA, Mekhjian HS, Kuehn PL, et al. Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. Crit Care Med. 2005 Jan;33(1):110-114.

Few topics in hospital-based pain management generate such diverse viewpoints as the use of methadone as an analgesic. Increasingly ordered by hospice physicians and some hospitalists as a tool for managing difficult pain cases, it is also coming under scrutiny for risks related to cardiac complications, respiratory depression, and the challenges of determining appropriate doses.

For some, the risks are grave enough to contraindicate methadone prescription for use in routine hospital practice, unless the hospitalist is well-versed in its use and has access to a pharmacist or other pain expert to review medication orders. Hospitalists should also be aware of the Food and Drug Administration’s strongly worded November 2006 Public Health Advisory, “Methadone Use for Pain Control May Result in Death and Life-Threatening Changes in Breathing and Heart Beat.”1

The FDA stopped short of recommending against the use of methadone as an analgesic, but it admonished physicians to use caution when prescribing it for patients unused to the drug—particularly during drug initiation, conversion from another opioid, or titration upward. Patients should be cautioned to take the drug exactly as prescribed. The advisory also recommended a new maximum initial dose of 30 mg per day (typically prescribed 10 mg tid), when initiating methadone for pain management.

Jean Youngwerth, MD, associate program director of the University of Colorado at Denver and Health Sciences Center, is well aware of the benefits and risks of prescribing methadone in her dual roles as hospitalist and palliative care consultant. “It is a great analgesic, becoming a lot more popular in recent years,” Dr. Youngwerth says. “It’s also ridiculously cheap [often under a dollar a day], which is an important consideration for some of our patients returning home with chronic pain. For other patients, it’s an extra analgesic tool, giving good pain relief, especially for refractory somatic or neuropathic pain.”

But methadone also has downsides. “Its pharmaco-kinetics are so complex and poorly understood that people unfamiliar with prescribing it can get in trouble in a hurry,” Dr. Youngwerth says. “You can kill people with oversedation. I do not prescribe it in my hospitalist practice and I discourage other hospitalists from prescribing it for their patients without consulting a pain or palliative care specialist. You don’t see its maximal effects until at least three to four days out, and that’s usually too long for the hospitalist. When I start palliative care patients on methadone, I normally keep them in the hospital for three or four days so that I can monitor the effects.”

Dr. Youngwerth believes her experience in pain management justifies prescribing methadone for palliative care patients. Even so, she always calls one of the local physician pain experts she works with or a hospital pharmacist to make sure she is ordering it safely and correctly. “I don’t think doctors should be scared off by all the bad publicity about methadone, but they need to realize these are valid concerns,” she says. “People run into problems when they assume that it is just another opioid.”

Hospitalists must recognize the stark realities of using the drug.

“Methadone is the easiest opioid to kill someone with,” says Gail Gazelle, MD, palliative care physician with MD Can Help and Harvard Medical School in Boston. “At the same time, its unique properties can give analgesic effects you can get from no other drug.”

For hospitalists, these issues are complicated by their short involvement with hospitalized patients, who are quickly prepped for discharge back to various community settings and living situations.

Dr. Gazelle wonders, “Is a short hospital stay the right place to initiate methadone treatment, given all of the complications?” If the answer is yes, communicating with the attending and agreeing on a plan for its continued use after discharge from the hospital are essential.

Although narcotic abuse is notoriously difficult to manage, with high relapse rates in every setting, methadone maintenance therapy (MMT) has been shown to reduce overall rates of abuse of other drugs, overdose and death, criminal activity, needle sharing, and commercial sex work. Methadone maintenance is a long-term strategy. The drug is provided as a substitute, not a cure, for narcotic abuse. Patients may continue to receive their daily maintenance dose for years. One-year retention rates in several large studies of MMT have ranged from 25% to 60%, while rates of relapse after leaving MMT are high. Stopping methadone use poses the same challenges as quitting any narcotic and should only be done under a doctor’s care.

Methadone is also used to treat heroin withdrawal, an issue for some hospitalized patients. Prescribing methadone for maintenance therapy is limited to federally licensed methadone treatment programs.

Complications

There are several critical facets of this drug hospitalists must be aware of:

Unpredictable half-life: Meth­a­­done, relative to other opioids, has high lipid solubility, slow metabolism, and a typical half-life ranging from 15 to 60 hours—although it can be longer. Methadone’s analgesic effect is shorter-lived, so analgesic doses should be given two, three, or four times daily. But the longer half-life means it can take three days or more after the initial dose before the drug’s full effect—on respiration for example—is known. That is why therapeutic doses can build to toxic levels. There is also wide variation in its effects among patients. Guidelines suggest titrating methadone upward for increased analgesic effect should not be attempted until at least three days after the first dose.

Respiratory depression: This is an issue when the drug is initiated in an opioid-naïve patient or is too rapidly titrated. Deaths from methadone have been seen at doses once considered safe. Physicians are cautioned to start patients on low doses while using other, short-acting opioids for breakthrough pain and frequently assessing for signs of overdose or respiratory depression, such as difficulty in breathing, shallow breathing, extreme sleepiness, or inability to think, talk, or walk normally.

Effect on heart arrhythmias: Methadone can prolong the QTc interval in heart function, leading to a potentially serious cardiac abnormality known as torsade de pointes. The potential for cardiac deaths is another complicating factor that may contraindicate methadone for patients at risk for developing a prolonged QTc interval, including patients with cardiac hypertrophy, hypokalemia, or hypomagnesemia, or a history of cardiac conduction abnormalities or taking medications affecting cardiac conduction. A current EKG may be an appropriate precaution when initiating methadone in elderly patients who have a cardiac history or are receiving methadone in high doses or by intravenous administration.

Drug interactions: The list of drugs that interact with methadone is long, with potential for unwanted side effects and increased or decreased potency. This list includes most anti-retroviral treatments for HIV; sedatives, tranquilizers, barbiturates, seizure medications, muscle relaxants, or any central nervous system depressants; certain steroids and anti-fungals; even over-the-counter cough and cold medications. Also watch for medications that treat irregular heartbeat or prolong the QTc interval. Pharmaceutical company labels for methadone, as well as the FDA advisory, contain a more complete list of drugs that interact with methadone. Always review with patients the other medications they take, including over-the-counter medications and alternative treatments.

Other complications: Metha­done should not be prescribed when opioids in general are contraindicated. It can be a management challenge to convert patients from methadone back to other opioids. Another complication of prescribing methadone is the negative publicity it has received in recent years, combined with the stigma of its associations with drug treatment. Some patients, families, or attending physicians may be leery of using it as a pain reliever. It may not be worth titrating methadone to the correct dose in the hospital if it is going to be discontinued post-discharge.

A series of articles in The Charleston (W.Va.) Gazette starting in June 2006 alerted many to the fact methadone is listed by medical examiners nationwide as a cause of death more often than any other prescription pain reliever.10 Methadone was implicated in nearly 4,000 deaths in 2006, four times as many as in 1999. Most of the deaths were considered accidental, and many involved combinations with other drugs—although some were in patients taking methadone as prescribed.

Hospitalists can expect that the diverse caseloads they see likely will include some patients taking methadone. Some may be getting it as an analgesic prescribed by a community physician, pain clinic, or hospice. Others in MMT and receiving a daily dose to manage their addiction disorder may present at the hospital with a different medical problem and perhaps new pain issues.

The hospitalist should not take it for granted that patients on MMT are not also intoxicated or abusing methadone or other drugs, says Michael Weaver, MD, pain and addiction specialist at Virginia Commonwealth University Medical Center in Richmond. Nor should they assume MMT doses are providing adequate analgesia.

“The bottom line in all of these situations is communication,” Dr. Weaver says. Talk to the medical director of the methadone clinic or the community physician who prescribed methadone as an analgesic. Verify the patient’s status, confirm dosage, and discuss the pain issues that need to be addressed—while recognizing pain relief is an appropriate expectation of any hospitalized patient, regardless of drug history or treatment.

Generally, Dr. Weaver says, the maintenance dose of methadone would continue during the hospital stay, and a different analgesic would be ordered for the pain—although the clinic physician may have other ideas. Changing methadone dose or schedule—or attempting to wean a patient off methadone—is not a decision a hospitalist should make unilaterally.11

Methadone’s Merits

Why would a hospitalist want to prescribe a drug that comes with so many caveats?

Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., uses methadone—often in combination with the anti-depressant desipramine or the anticonvulsant gabapentin—to treat complex regional pain syndromes and neuropathic pain.

Dr. Jessop carefully assesses patients for neuropathic pain, listening for descriptors such as burning, stinging, or numbing. These are the patients for whom she most often receives palliative care consultations, often following years of out-of-control pain or lack of response to high doses of other opioids. “My job is much easier now that I understand the difference between nocioceptive and neuropathic pain,” she notes.

“I think methadone is magic, perhaps due to its effect on the NMDA (n-methyl, d-asparte) receptors,” Dr. Jessop says. “I’m also convinced from my clinical experience that there can be nerve healing going on when these pain syndromes are effectively treated. I had a patient with horrible phantom pain following multiple hip surgeries and amputation of his leg. He was referred by a family practitioner, who said, ‘I cannot get this man’s pain under control.’ ” The patient’s pain is now controlled with methadone, 30 mg three times a day. He rarely needs to take his hydromorphone (Dilaudid) for breakthrough pain, and he is able to use his prosthetic leg—which would have been unthinkable before.

Dr. Jessop believes low doses of methadone—even lower than the conversion charts recommend—can have a big effect. “I don’t have problems with methadone because I’m so careful in prescribing it,” she says. “I also work closely with the attending physician and give patients my cell phone number when they return home. It is important to get the family involved and to be clear about the risks and benefits.”

Brad Stuart, MD, senior medical director of Sutter VNA and Hospice in Northern California, also believes methadone can be a wonderful pain management tool. “There is no substitute, in my estimation, to adding a little methadone to the opioid regimen—even just 5 mg of liquid three times a day—for difficult neuropathic pain cases,” Dr. Stuart says. “It’s true that you don’t want to raise the dose too quickly. But I find that it’s unusual not to see benefit in these kinds of patients. I disagree with those who would advise hospitalists to stay away from methadone for treating refractory neuropathic pain. If you start slow and go slow, the risks are small relative to the gain.”

Eduardo Bruera, MD, a palliative care physician at M.D. Anderson Cancer Center in Houston, is another believer in methadone for difficult pain cases, although he emphasizes that his experience is limited to the pain associated with cancer. Dr. Bruera does not use methadone as a first-line analgesic, but he finds it effective when other opioids have not been. “Patients who continue to have a lot of pain after multiple escalating opioid doses or signs of opioid toxicity may be signaling that the opioid you’re using is not working,” he says. “If we make three or four dose changes without response, it’s time to change the opioid.”

Dr. Bruera acknowledges that persuasive research studies to establish methadone’s purported efficacy in treating neuropathic pain have not been conducted. “Unfortunately, methadone is an orphan drug, so we don’t know who would pay for those studies. Should we consider it as a first-line opioid for cancer pain? Again, that is an unanswered question.”

Dr. Bruera has been involved in a number of the few published studies and reviews of methadone’s analgesic efficacy, and he is engaged in ongoing orphan drug status research.12, 13

Methadone as Analgesic

Stephen Bekanich, MD, hospitalist and palliative care consultant at the University of Utah Medical Center in Salt Lake City, falls in the middle range of opinions on methadone.

“From the hospitalist’s standpoint, there are downsides,” Dr. Bekanich says. “People who don’t understand how to titrate it may change doses on a daily basis or more often, which is dangerous. They may not understand the dosing equivalents or pay enough attention to drug interactions.

“Of all the opioids, careful assessment and follow-up may be the most important with methadone. Always make sure you have concrete post-discharge plans. If I didn’t have a pharmacist to collaborate with, as a hospitalist I’d probably stay away from it. But it’s different when I put on my palliative care hat.”

Rachelle Bernacki, MD, a hospitalist, palliative care physician and geriatrician at the University of California-San Francisco Medical Center, agrees methadone can be a useful analgesic­—particularly when other opioids have failed to relieve the pain. “But I don’t start with it; I may add a small dose of methadone to the existing regimen for complex pain,” she says.

“I caution my residents not to try methadone without consulting with someone familiar with the drug,” explains Dr. Bernacki, who adds that she is fortunate to work with a pharmacist at UCSF who is an expert in pain management and palliative medicine. “Having taught residents, I can confirm that there is a lot of confusion about its use. But I have also used methadone in my outpatient geriatric practice—with fantastic results.”

Paresh Patel, MD, a hospitalist at VCU Medical Center, says he and his colleagues use methadone as a second-line analgesic when pain is not well managed with morphine. He always keeps an eye out for the risks, including potential interactions with psychiatric medications and the need to look at EKGs.

Dr. Patel says conversion from other opioids is one of the biggest challenges in using methadone. He is not satisfied with the various published opioid conversion charts and relies on experience and trial and error. “I always wait 48 hours before titrating up,” he says.

More research is needed in this area, Dr. Patel says, and he is thinking of getting involved in a methadone research project. TH

Larry Beresford is a frequent contributor to The Hospitalist.

References

1. Food and Drug Administration. FDA Public Health Advisory: Methadone use for pain control may result in death and life-threatening changes in breathing and heart beat. Available at: www.fda.gov/cder/drug/advisory/methadone.htm. Last accessed June 4, 2007.
2. Moulin DE, Palma D, Watling C, et al. Methadone in the management of intractable neuropathic noncancer pain. Can J Neurol Sci. 2005 Aug: 32(3); 340-343.
3. Altier N, Dion D, Boulanger A, et al. Management of chronic neuropathic pain with methadone: A review of 13 cases. Clin J Pain. 2005 Jul-Aug;21(4):364-369.
4. Morley JS, Bridson J, Nash TP, et al. Low-dose methadone has an analgesic effect in neuropathic pain: A double-blind randomized controlled crossover trial. Palliat Med. 2003 Oct;17(7):576-587.
5. Lawlor PG, Turner KS, Hanson J, et al. Dose ratio between morphine and methadone in patients with cancer pain: A retrospective study. Cancer. 1998 Mar;82(6):1167-1173.
6. Ripamonti C, De Conno F, Groff L, et al. Equianal-gesic dose/ratio between methadone and other opioid agonists in cancer pain: Comparison of two clinical experiences. Ann Oncol. 1998 Jan;9(1):79-83.
7. Gazelle G, Fine PG. Fast Fact and Concept #75: Methadone for the treatment of pain. End-of-Life/Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee, www.eperc.mcw.edu/ff_index.htm; and Roxane Laboratories, Inc., label for dolophine hydrochloride CH (methadone hydrochloride tablets).
8. American Methadone Treatment Association. 1998 Methadone Maintenance Program and Patient Census in the U.S., New York, NY, April 1999.
9. Office of National Drug Control Policy. Fact sheet. Available at: www.whitehousedrugpolicy.gov. Last accessed June 4, 2007.
10. Finn S, Tuckwiller T. The Killer Cure. The Charlotte (W. Va.) Gazette. Available at: www.wvgazette.com. Last accessed June 29, 2007.
11. Weaver MF, Schnoll SH. Opioid treatment of chronic pain in patients with addiction. J Pain Palliat Care Pharmacother. 2002:16(3);5-26.
12. Bruera E, Sweeney C. Methadone use in cancer patients with pain: A review. J Palliat Med. 2002 Feb;5(1):127-137.
13. Bruera E, Palmer JL, Bosnjak S, et al. Methadone versus morphine as a first-line strong opioid for cancer pain: A randomized, double-blind study. J Clin Oncol. 2004 Jan 1;22(1):185-192.

Few topics in hospital-based pain management generate such diverse viewpoints as the use of methadone as an analgesic. Increasingly ordered by hospice physicians and some hospitalists as a tool for managing difficult pain cases, it is also coming under scrutiny for risks related to cardiac complications, respiratory depression, and the challenges of determining appropriate doses.

For some, the risks are grave enough to contraindicate methadone prescription for use in routine hospital practice, unless the hospitalist is well-versed in its use and has access to a pharmacist or other pain expert to review medication orders. Hospitalists should also be aware of the Food and Drug Administration’s strongly worded November 2006 Public Health Advisory, “Methadone Use for Pain Control May Result in Death and Life-Threatening Changes in Breathing and Heart Beat.”1

The FDA stopped short of recommending against the use of methadone as an analgesic, but it admonished physicians to use caution when prescribing it for patients unused to the drug—particularly during drug initiation, conversion from another opioid, or titration upward. Patients should be cautioned to take the drug exactly as prescribed. The advisory also recommended a new maximum initial dose of 30 mg per day (typically prescribed 10 mg tid), when initiating methadone for pain management.

Jean Youngwerth, MD, associate program director of the University of Colorado at Denver and Health Sciences Center, is well aware of the benefits and risks of prescribing methadone in her dual roles as hospitalist and palliative care consultant. “It is a great analgesic, becoming a lot more popular in recent years,” Dr. Youngwerth says. “It’s also ridiculously cheap [often under a dollar a day], which is an important consideration for some of our patients returning home with chronic pain. For other patients, it’s an extra analgesic tool, giving good pain relief, especially for refractory somatic or neuropathic pain.”

But methadone also has downsides. “Its pharmaco-kinetics are so complex and poorly understood that people unfamiliar with prescribing it can get in trouble in a hurry,” Dr. Youngwerth says. “You can kill people with oversedation. I do not prescribe it in my hospitalist practice and I discourage other hospitalists from prescribing it for their patients without consulting a pain or palliative care specialist. You don’t see its maximal effects until at least three to four days out, and that’s usually too long for the hospitalist. When I start palliative care patients on methadone, I normally keep them in the hospital for three or four days so that I can monitor the effects.”

Dr. Youngwerth believes her experience in pain management justifies prescribing methadone for palliative care patients. Even so, she always calls one of the local physician pain experts she works with or a hospital pharmacist to make sure she is ordering it safely and correctly. “I don’t think doctors should be scared off by all the bad publicity about methadone, but they need to realize these are valid concerns,” she says. “People run into problems when they assume that it is just another opioid.”

Hospitalists must recognize the stark realities of using the drug.

“Methadone is the easiest opioid to kill someone with,” says Gail Gazelle, MD, palliative care physician with MD Can Help and Harvard Medical School in Boston. “At the same time, its unique properties can give analgesic effects you can get from no other drug.”

For hospitalists, these issues are complicated by their short involvement with hospitalized patients, who are quickly prepped for discharge back to various community settings and living situations.

Dr. Gazelle wonders, “Is a short hospital stay the right place to initiate methadone treatment, given all of the complications?” If the answer is yes, communicating with the attending and agreeing on a plan for its continued use after discharge from the hospital are essential.

Although narcotic abuse is notoriously difficult to manage, with high relapse rates in every setting, methadone maintenance therapy (MMT) has been shown to reduce overall rates of abuse of other drugs, overdose and death, criminal activity, needle sharing, and commercial sex work. Methadone maintenance is a long-term strategy. The drug is provided as a substitute, not a cure, for narcotic abuse. Patients may continue to receive their daily maintenance dose for years. One-year retention rates in several large studies of MMT have ranged from 25% to 60%, while rates of relapse after leaving MMT are high. Stopping methadone use poses the same challenges as quitting any narcotic and should only be done under a doctor’s care.

Methadone is also used to treat heroin withdrawal, an issue for some hospitalized patients. Prescribing methadone for maintenance therapy is limited to federally licensed methadone treatment programs.

Complications

There are several critical facets of this drug hospitalists must be aware of:

Unpredictable half-life: Meth­a­­done, relative to other opioids, has high lipid solubility, slow metabolism, and a typical half-life ranging from 15 to 60 hours—although it can be longer. Methadone’s analgesic effect is shorter-lived, so analgesic doses should be given two, three, or four times daily. But the longer half-life means it can take three days or more after the initial dose before the drug’s full effect—on respiration for example—is known. That is why therapeutic doses can build to toxic levels. There is also wide variation in its effects among patients. Guidelines suggest titrating methadone upward for increased analgesic effect should not be attempted until at least three days after the first dose.

Respiratory depression: This is an issue when the drug is initiated in an opioid-naïve patient or is too rapidly titrated. Deaths from methadone have been seen at doses once considered safe. Physicians are cautioned to start patients on low doses while using other, short-acting opioids for breakthrough pain and frequently assessing for signs of overdose or respiratory depression, such as difficulty in breathing, shallow breathing, extreme sleepiness, or inability to think, talk, or walk normally.

Effect on heart arrhythmias: Methadone can prolong the QTc interval in heart function, leading to a potentially serious cardiac abnormality known as torsade de pointes. The potential for cardiac deaths is another complicating factor that may contraindicate methadone for patients at risk for developing a prolonged QTc interval, including patients with cardiac hypertrophy, hypokalemia, or hypomagnesemia, or a history of cardiac conduction abnormalities or taking medications affecting cardiac conduction. A current EKG may be an appropriate precaution when initiating methadone in elderly patients who have a cardiac history or are receiving methadone in high doses or by intravenous administration.

Drug interactions: The list of drugs that interact with methadone is long, with potential for unwanted side effects and increased or decreased potency. This list includes most anti-retroviral treatments for HIV; sedatives, tranquilizers, barbiturates, seizure medications, muscle relaxants, or any central nervous system depressants; certain steroids and anti-fungals; even over-the-counter cough and cold medications. Also watch for medications that treat irregular heartbeat or prolong the QTc interval. Pharmaceutical company labels for methadone, as well as the FDA advisory, contain a more complete list of drugs that interact with methadone. Always review with patients the other medications they take, including over-the-counter medications and alternative treatments.

Other complications: Metha­done should not be prescribed when opioids in general are contraindicated. It can be a management challenge to convert patients from methadone back to other opioids. Another complication of prescribing methadone is the negative publicity it has received in recent years, combined with the stigma of its associations with drug treatment. Some patients, families, or attending physicians may be leery of using it as a pain reliever. It may not be worth titrating methadone to the correct dose in the hospital if it is going to be discontinued post-discharge.

A series of articles in The Charleston (W.Va.) Gazette starting in June 2006 alerted many to the fact methadone is listed by medical examiners nationwide as a cause of death more often than any other prescription pain reliever.10 Methadone was implicated in nearly 4,000 deaths in 2006, four times as many as in 1999. Most of the deaths were considered accidental, and many involved combinations with other drugs—although some were in patients taking methadone as prescribed.

Hospitalists can expect that the diverse caseloads they see likely will include some patients taking methadone. Some may be getting it as an analgesic prescribed by a community physician, pain clinic, or hospice. Others in MMT and receiving a daily dose to manage their addiction disorder may present at the hospital with a different medical problem and perhaps new pain issues.

The hospitalist should not take it for granted that patients on MMT are not also intoxicated or abusing methadone or other drugs, says Michael Weaver, MD, pain and addiction specialist at Virginia Commonwealth University Medical Center in Richmond. Nor should they assume MMT doses are providing adequate analgesia.

“The bottom line in all of these situations is communication,” Dr. Weaver says. Talk to the medical director of the methadone clinic or the community physician who prescribed methadone as an analgesic. Verify the patient’s status, confirm dosage, and discuss the pain issues that need to be addressed—while recognizing pain relief is an appropriate expectation of any hospitalized patient, regardless of drug history or treatment.

Generally, Dr. Weaver says, the maintenance dose of methadone would continue during the hospital stay, and a different analgesic would be ordered for the pain—although the clinic physician may have other ideas. Changing methadone dose or schedule—or attempting to wean a patient off methadone—is not a decision a hospitalist should make unilaterally.11

Methadone’s Merits

Why would a hospitalist want to prescribe a drug that comes with so many caveats?

Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., uses methadone—often in combination with the anti-depressant desipramine or the anticonvulsant gabapentin—to treat complex regional pain syndromes and neuropathic pain.

Dr. Jessop carefully assesses patients for neuropathic pain, listening for descriptors such as burning, stinging, or numbing. These are the patients for whom she most often receives palliative care consultations, often following years of out-of-control pain or lack of response to high doses of other opioids. “My job is much easier now that I understand the difference between nocioceptive and neuropathic pain,” she notes.

“I think methadone is magic, perhaps due to its effect on the NMDA (n-methyl, d-asparte) receptors,” Dr. Jessop says. “I’m also convinced from my clinical experience that there can be nerve healing going on when these pain syndromes are effectively treated. I had a patient with horrible phantom pain following multiple hip surgeries and amputation of his leg. He was referred by a family practitioner, who said, ‘I cannot get this man’s pain under control.’ ” The patient’s pain is now controlled with methadone, 30 mg three times a day. He rarely needs to take his hydromorphone (Dilaudid) for breakthrough pain, and he is able to use his prosthetic leg—which would have been unthinkable before.

Dr. Jessop believes low doses of methadone—even lower than the conversion charts recommend—can have a big effect. “I don’t have problems with methadone because I’m so careful in prescribing it,” she says. “I also work closely with the attending physician and give patients my cell phone number when they return home. It is important to get the family involved and to be clear about the risks and benefits.”

Brad Stuart, MD, senior medical director of Sutter VNA and Hospice in Northern California, also believes methadone can be a wonderful pain management tool. “There is no substitute, in my estimation, to adding a little methadone to the opioid regimen—even just 5 mg of liquid three times a day—for difficult neuropathic pain cases,” Dr. Stuart says. “It’s true that you don’t want to raise the dose too quickly. But I find that it’s unusual not to see benefit in these kinds of patients. I disagree with those who would advise hospitalists to stay away from methadone for treating refractory neuropathic pain. If you start slow and go slow, the risks are small relative to the gain.”

Eduardo Bruera, MD, a palliative care physician at M.D. Anderson Cancer Center in Houston, is another believer in methadone for difficult pain cases, although he emphasizes that his experience is limited to the pain associated with cancer. Dr. Bruera does not use methadone as a first-line analgesic, but he finds it effective when other opioids have not been. “Patients who continue to have a lot of pain after multiple escalating opioid doses or signs of opioid toxicity may be signaling that the opioid you’re using is not working,” he says. “If we make three or four dose changes without response, it’s time to change the opioid.”

Dr. Bruera acknowledges that persuasive research studies to establish methadone’s purported efficacy in treating neuropathic pain have not been conducted. “Unfortunately, methadone is an orphan drug, so we don’t know who would pay for those studies. Should we consider it as a first-line opioid for cancer pain? Again, that is an unanswered question.”

Dr. Bruera has been involved in a number of the few published studies and reviews of methadone’s analgesic efficacy, and he is engaged in ongoing orphan drug status research.12, 13

Methadone as Analgesic

Stephen Bekanich, MD, hospitalist and palliative care consultant at the University of Utah Medical Center in Salt Lake City, falls in the middle range of opinions on methadone.

“From the hospitalist’s standpoint, there are downsides,” Dr. Bekanich says. “People who don’t understand how to titrate it may change doses on a daily basis or more often, which is dangerous. They may not understand the dosing equivalents or pay enough attention to drug interactions.

“Of all the opioids, careful assessment and follow-up may be the most important with methadone. Always make sure you have concrete post-discharge plans. If I didn’t have a pharmacist to collaborate with, as a hospitalist I’d probably stay away from it. But it’s different when I put on my palliative care hat.”

Rachelle Bernacki, MD, a hospitalist, palliative care physician and geriatrician at the University of California-San Francisco Medical Center, agrees methadone can be a useful analgesic­—particularly when other opioids have failed to relieve the pain. “But I don’t start with it; I may add a small dose of methadone to the existing regimen for complex pain,” she says.

“I caution my residents not to try methadone without consulting with someone familiar with the drug,” explains Dr. Bernacki, who adds that she is fortunate to work with a pharmacist at UCSF who is an expert in pain management and palliative medicine. “Having taught residents, I can confirm that there is a lot of confusion about its use. But I have also used methadone in my outpatient geriatric practice—with fantastic results.”

Paresh Patel, MD, a hospitalist at VCU Medical Center, says he and his colleagues use methadone as a second-line analgesic when pain is not well managed with morphine. He always keeps an eye out for the risks, including potential interactions with psychiatric medications and the need to look at EKGs.

Dr. Patel says conversion from other opioids is one of the biggest challenges in using methadone. He is not satisfied with the various published opioid conversion charts and relies on experience and trial and error. “I always wait 48 hours before titrating up,” he says.

More research is needed in this area, Dr. Patel says, and he is thinking of getting involved in a methadone research project. TH

Larry Beresford is a frequent contributor to The Hospitalist.

References

1. Food and Drug Administration. FDA Public Health Advisory: Methadone use for pain control may result in death and life-threatening changes in breathing and heart beat. Available at: www.fda.gov/cder/drug/advisory/methadone.htm. Last accessed June 4, 2007.
2. Moulin DE, Palma D, Watling C, et al. Methadone in the management of intractable neuropathic noncancer pain. Can J Neurol Sci. 2005 Aug: 32(3); 340-343.
3. Altier N, Dion D, Boulanger A, et al. Management of chronic neuropathic pain with methadone: A review of 13 cases. Clin J Pain. 2005 Jul-Aug;21(4):364-369.
4. Morley JS, Bridson J, Nash TP, et al. Low-dose methadone has an analgesic effect in neuropathic pain: A double-blind randomized controlled crossover trial. Palliat Med. 2003 Oct;17(7):576-587.
5. Lawlor PG, Turner KS, Hanson J, et al. Dose ratio between morphine and methadone in patients with cancer pain: A retrospective study. Cancer. 1998 Mar;82(6):1167-1173.
6. Ripamonti C, De Conno F, Groff L, et al. Equianal-gesic dose/ratio between methadone and other opioid agonists in cancer pain: Comparison of two clinical experiences. Ann Oncol. 1998 Jan;9(1):79-83.
7. Gazelle G, Fine PG. Fast Fact and Concept #75: Methadone for the treatment of pain. End-of-Life/Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee, www.eperc.mcw.edu/ff_index.htm; and Roxane Laboratories, Inc., label for dolophine hydrochloride CH (methadone hydrochloride tablets).
8. American Methadone Treatment Association. 1998 Methadone Maintenance Program and Patient Census in the U.S., New York, NY, April 1999.
9. Office of National Drug Control Policy. Fact sheet. Available at: www.whitehousedrugpolicy.gov. Last accessed June 4, 2007.
10. Finn S, Tuckwiller T. The Killer Cure. The Charlotte (W. Va.) Gazette. Available at: www.wvgazette.com. Last accessed June 29, 2007.
11. Weaver MF, Schnoll SH. Opioid treatment of chronic pain in patients with addiction. J Pain Palliat Care Pharmacother. 2002:16(3);5-26.
12. Bruera E, Sweeney C. Methadone use in cancer patients with pain: A review. J Palliat Med. 2002 Feb;5(1):127-137.
13. Bruera E, Palmer JL, Bosnjak S, et al. Methadone versus morphine as a first-line strong opioid for cancer pain: A randomized, double-blind study. J Clin Oncol. 2004 Jan 1;22(1):185-192.

Few topics in hospital-based pain management generate such diverse viewpoints as the use of methadone as an analgesic. Increasingly ordered by hospice physicians and some hospitalists as a tool for managing difficult pain cases, it is also coming under scrutiny for risks related to cardiac complications, respiratory depression, and the challenges of determining appropriate doses.

For some, the risks are grave enough to contraindicate methadone prescription for use in routine hospital practice, unless the hospitalist is well-versed in its use and has access to a pharmacist or other pain expert to review medication orders. Hospitalists should also be aware of the Food and Drug Administration’s strongly worded November 2006 Public Health Advisory, “Methadone Use for Pain Control May Result in Death and Life-Threatening Changes in Breathing and Heart Beat.”1

The FDA stopped short of recommending against the use of methadone as an analgesic, but it admonished physicians to use caution when prescribing it for patients unused to the drug—particularly during drug initiation, conversion from another opioid, or titration upward. Patients should be cautioned to take the drug exactly as prescribed. The advisory also recommended a new maximum initial dose of 30 mg per day (typically prescribed 10 mg tid), when initiating methadone for pain management.

Jean Youngwerth, MD, associate program director of the University of Colorado at Denver and Health Sciences Center, is well aware of the benefits and risks of prescribing methadone in her dual roles as hospitalist and palliative care consultant. “It is a great analgesic, becoming a lot more popular in recent years,” Dr. Youngwerth says. “It’s also ridiculously cheap [often under a dollar a day], which is an important consideration for some of our patients returning home with chronic pain. For other patients, it’s an extra analgesic tool, giving good pain relief, especially for refractory somatic or neuropathic pain.”

But methadone also has downsides. “Its pharmaco-kinetics are so complex and poorly understood that people unfamiliar with prescribing it can get in trouble in a hurry,” Dr. Youngwerth says. “You can kill people with oversedation. I do not prescribe it in my hospitalist practice and I discourage other hospitalists from prescribing it for their patients without consulting a pain or palliative care specialist. You don’t see its maximal effects until at least three to four days out, and that’s usually too long for the hospitalist. When I start palliative care patients on methadone, I normally keep them in the hospital for three or four days so that I can monitor the effects.”

Dr. Youngwerth believes her experience in pain management justifies prescribing methadone for palliative care patients. Even so, she always calls one of the local physician pain experts she works with or a hospital pharmacist to make sure she is ordering it safely and correctly. “I don’t think doctors should be scared off by all the bad publicity about methadone, but they need to realize these are valid concerns,” she says. “People run into problems when they assume that it is just another opioid.”

Hospitalists must recognize the stark realities of using the drug.

“Methadone is the easiest opioid to kill someone with,” says Gail Gazelle, MD, palliative care physician with MD Can Help and Harvard Medical School in Boston. “At the same time, its unique properties can give analgesic effects you can get from no other drug.”

For hospitalists, these issues are complicated by their short involvement with hospitalized patients, who are quickly prepped for discharge back to various community settings and living situations.

Dr. Gazelle wonders, “Is a short hospital stay the right place to initiate methadone treatment, given all of the complications?” If the answer is yes, communicating with the attending and agreeing on a plan for its continued use after discharge from the hospital are essential.

Although narcotic abuse is notoriously difficult to manage, with high relapse rates in every setting, methadone maintenance therapy (MMT) has been shown to reduce overall rates of abuse of other drugs, overdose and death, criminal activity, needle sharing, and commercial sex work. Methadone maintenance is a long-term strategy. The drug is provided as a substitute, not a cure, for narcotic abuse. Patients may continue to receive their daily maintenance dose for years. One-year retention rates in several large studies of MMT have ranged from 25% to 60%, while rates of relapse after leaving MMT are high. Stopping methadone use poses the same challenges as quitting any narcotic and should only be done under a doctor’s care.

Methadone is also used to treat heroin withdrawal, an issue for some hospitalized patients. Prescribing methadone for maintenance therapy is limited to federally licensed methadone treatment programs.

Complications

There are several critical facets of this drug hospitalists must be aware of:

Unpredictable half-life: Meth­a­­done, relative to other opioids, has high lipid solubility, slow metabolism, and a typical half-life ranging from 15 to 60 hours—although it can be longer. Methadone’s analgesic effect is shorter-lived, so analgesic doses should be given two, three, or four times daily. But the longer half-life means it can take three days or more after the initial dose before the drug’s full effect—on respiration for example—is known. That is why therapeutic doses can build to toxic levels. There is also wide variation in its effects among patients. Guidelines suggest titrating methadone upward for increased analgesic effect should not be attempted until at least three days after the first dose.

Respiratory depression: This is an issue when the drug is initiated in an opioid-naïve patient or is too rapidly titrated. Deaths from methadone have been seen at doses once considered safe. Physicians are cautioned to start patients on low doses while using other, short-acting opioids for breakthrough pain and frequently assessing for signs of overdose or respiratory depression, such as difficulty in breathing, shallow breathing, extreme sleepiness, or inability to think, talk, or walk normally.

Effect on heart arrhythmias: Methadone can prolong the QTc interval in heart function, leading to a potentially serious cardiac abnormality known as torsade de pointes. The potential for cardiac deaths is another complicating factor that may contraindicate methadone for patients at risk for developing a prolonged QTc interval, including patients with cardiac hypertrophy, hypokalemia, or hypomagnesemia, or a history of cardiac conduction abnormalities or taking medications affecting cardiac conduction. A current EKG may be an appropriate precaution when initiating methadone in elderly patients who have a cardiac history or are receiving methadone in high doses or by intravenous administration.

Drug interactions: The list of drugs that interact with methadone is long, with potential for unwanted side effects and increased or decreased potency. This list includes most anti-retroviral treatments for HIV; sedatives, tranquilizers, barbiturates, seizure medications, muscle relaxants, or any central nervous system depressants; certain steroids and anti-fungals; even over-the-counter cough and cold medications. Also watch for medications that treat irregular heartbeat or prolong the QTc interval. Pharmaceutical company labels for methadone, as well as the FDA advisory, contain a more complete list of drugs that interact with methadone. Always review with patients the other medications they take, including over-the-counter medications and alternative treatments.

Other complications: Metha­done should not be prescribed when opioids in general are contraindicated. It can be a management challenge to convert patients from methadone back to other opioids. Another complication of prescribing methadone is the negative publicity it has received in recent years, combined with the stigma of its associations with drug treatment. Some patients, families, or attending physicians may be leery of using it as a pain reliever. It may not be worth titrating methadone to the correct dose in the hospital if it is going to be discontinued post-discharge.

A series of articles in The Charleston (W.Va.) Gazette starting in June 2006 alerted many to the fact methadone is listed by medical examiners nationwide as a cause of death more often than any other prescription pain reliever.10 Methadone was implicated in nearly 4,000 deaths in 2006, four times as many as in 1999. Most of the deaths were considered accidental, and many involved combinations with other drugs—although some were in patients taking methadone as prescribed.

Hospitalists can expect that the diverse caseloads they see likely will include some patients taking methadone. Some may be getting it as an analgesic prescribed by a community physician, pain clinic, or hospice. Others in MMT and receiving a daily dose to manage their addiction disorder may present at the hospital with a different medical problem and perhaps new pain issues.

The hospitalist should not take it for granted that patients on MMT are not also intoxicated or abusing methadone or other drugs, says Michael Weaver, MD, pain and addiction specialist at Virginia Commonwealth University Medical Center in Richmond. Nor should they assume MMT doses are providing adequate analgesia.

“The bottom line in all of these situations is communication,” Dr. Weaver says. Talk to the medical director of the methadone clinic or the community physician who prescribed methadone as an analgesic. Verify the patient’s status, confirm dosage, and discuss the pain issues that need to be addressed—while recognizing pain relief is an appropriate expectation of any hospitalized patient, regardless of drug history or treatment.

Generally, Dr. Weaver says, the maintenance dose of methadone would continue during the hospital stay, and a different analgesic would be ordered for the pain—although the clinic physician may have other ideas. Changing methadone dose or schedule—or attempting to wean a patient off methadone—is not a decision a hospitalist should make unilaterally.11

Methadone’s Merits

Why would a hospitalist want to prescribe a drug that comes with so many caveats?

Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., uses methadone—often in combination with the anti-depressant desipramine or the anticonvulsant gabapentin—to treat complex regional pain syndromes and neuropathic pain.

Dr. Jessop carefully assesses patients for neuropathic pain, listening for descriptors such as burning, stinging, or numbing. These are the patients for whom she most often receives palliative care consultations, often following years of out-of-control pain or lack of response to high doses of other opioids. “My job is much easier now that I understand the difference between nocioceptive and neuropathic pain,” she notes.

“I think methadone is magic, perhaps due to its effect on the NMDA (n-methyl, d-asparte) receptors,” Dr. Jessop says. “I’m also convinced from my clinical experience that there can be nerve healing going on when these pain syndromes are effectively treated. I had a patient with horrible phantom pain following multiple hip surgeries and amputation of his leg. He was referred by a family practitioner, who said, ‘I cannot get this man’s pain under control.’ ” The patient’s pain is now controlled with methadone, 30 mg three times a day. He rarely needs to take his hydromorphone (Dilaudid) for breakthrough pain, and he is able to use his prosthetic leg—which would have been unthinkable before.

Dr. Jessop believes low doses of methadone—even lower than the conversion charts recommend—can have a big effect. “I don’t have problems with methadone because I’m so careful in prescribing it,” she says. “I also work closely with the attending physician and give patients my cell phone number when they return home. It is important to get the family involved and to be clear about the risks and benefits.”

Brad Stuart, MD, senior medical director of Sutter VNA and Hospice in Northern California, also believes methadone can be a wonderful pain management tool. “There is no substitute, in my estimation, to adding a little methadone to the opioid regimen—even just 5 mg of liquid three times a day—for difficult neuropathic pain cases,” Dr. Stuart says. “It’s true that you don’t want to raise the dose too quickly. But I find that it’s unusual not to see benefit in these kinds of patients. I disagree with those who would advise hospitalists to stay away from methadone for treating refractory neuropathic pain. If you start slow and go slow, the risks are small relative to the gain.”

Eduardo Bruera, MD, a palliative care physician at M.D. Anderson Cancer Center in Houston, is another believer in methadone for difficult pain cases, although he emphasizes that his experience is limited to the pain associated with cancer. Dr. Bruera does not use methadone as a first-line analgesic, but he finds it effective when other opioids have not been. “Patients who continue to have a lot of pain after multiple escalating opioid doses or signs of opioid toxicity may be signaling that the opioid you’re using is not working,” he says. “If we make three or four dose changes without response, it’s time to change the opioid.”

Dr. Bruera acknowledges that persuasive research studies to establish methadone’s purported efficacy in treating neuropathic pain have not been conducted. “Unfortunately, methadone is an orphan drug, so we don’t know who would pay for those studies. Should we consider it as a first-line opioid for cancer pain? Again, that is an unanswered question.”

Dr. Bruera has been involved in a number of the few published studies and reviews of methadone’s analgesic efficacy, and he is engaged in ongoing orphan drug status research.12, 13

Methadone as Analgesic

Stephen Bekanich, MD, hospitalist and palliative care consultant at the University of Utah Medical Center in Salt Lake City, falls in the middle range of opinions on methadone.

“From the hospitalist’s standpoint, there are downsides,” Dr. Bekanich says. “People who don’t understand how to titrate it may change doses on a daily basis or more often, which is dangerous. They may not understand the dosing equivalents or pay enough attention to drug interactions.

“Of all the opioids, careful assessment and follow-up may be the most important with methadone. Always make sure you have concrete post-discharge plans. If I didn’t have a pharmacist to collaborate with, as a hospitalist I’d probably stay away from it. But it’s different when I put on my palliative care hat.”

Rachelle Bernacki, MD, a hospitalist, palliative care physician and geriatrician at the University of California-San Francisco Medical Center, agrees methadone can be a useful analgesic­—particularly when other opioids have failed to relieve the pain. “But I don’t start with it; I may add a small dose of methadone to the existing regimen for complex pain,” she says.

“I caution my residents not to try methadone without consulting with someone familiar with the drug,” explains Dr. Bernacki, who adds that she is fortunate to work with a pharmacist at UCSF who is an expert in pain management and palliative medicine. “Having taught residents, I can confirm that there is a lot of confusion about its use. But I have also used methadone in my outpatient geriatric practice—with fantastic results.”

Paresh Patel, MD, a hospitalist at VCU Medical Center, says he and his colleagues use methadone as a second-line analgesic when pain is not well managed with morphine. He always keeps an eye out for the risks, including potential interactions with psychiatric medications and the need to look at EKGs.

Dr. Patel says conversion from other opioids is one of the biggest challenges in using methadone. He is not satisfied with the various published opioid conversion charts and relies on experience and trial and error. “I always wait 48 hours before titrating up,” he says.

More research is needed in this area, Dr. Patel says, and he is thinking of getting involved in a methadone research project. TH

Larry Beresford is a frequent contributor to The Hospitalist.

References

1. Food and Drug Administration. FDA Public Health Advisory: Methadone use for pain control may result in death and life-threatening changes in breathing and heart beat. Available at: www.fda.gov/cder/drug/advisory/methadone.htm. Last accessed June 4, 2007.
2. Moulin DE, Palma D, Watling C, et al. Methadone in the management of intractable neuropathic noncancer pain. Can J Neurol Sci. 2005 Aug: 32(3); 340-343.
3. Altier N, Dion D, Boulanger A, et al. Management of chronic neuropathic pain with methadone: A review of 13 cases. Clin J Pain. 2005 Jul-Aug;21(4):364-369.
4. Morley JS, Bridson J, Nash TP, et al. Low-dose methadone has an analgesic effect in neuropathic pain: A double-blind randomized controlled crossover trial. Palliat Med. 2003 Oct;17(7):576-587.
5. Lawlor PG, Turner KS, Hanson J, et al. Dose ratio between morphine and methadone in patients with cancer pain: A retrospective study. Cancer. 1998 Mar;82(6):1167-1173.
6. Ripamonti C, De Conno F, Groff L, et al. Equianal-gesic dose/ratio between methadone and other opioid agonists in cancer pain: Comparison of two clinical experiences. Ann Oncol. 1998 Jan;9(1):79-83.
7. Gazelle G, Fine PG. Fast Fact and Concept #75: Methadone for the treatment of pain. End-of-Life/Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee, www.eperc.mcw.edu/ff_index.htm; and Roxane Laboratories, Inc., label for dolophine hydrochloride CH (methadone hydrochloride tablets).
8. American Methadone Treatment Association. 1998 Methadone Maintenance Program and Patient Census in the U.S., New York, NY, April 1999.
9. Office of National Drug Control Policy. Fact sheet. Available at: www.whitehousedrugpolicy.gov. Last accessed June 4, 2007.
10. Finn S, Tuckwiller T. The Killer Cure. The Charlotte (W. Va.) Gazette. Available at: www.wvgazette.com. Last accessed June 29, 2007.
11. Weaver MF, Schnoll SH. Opioid treatment of chronic pain in patients with addiction. J Pain Palliat Care Pharmacother. 2002:16(3);5-26.
12. Bruera E, Sweeney C. Methadone use in cancer patients with pain: A review. J Palliat Med. 2002 Feb;5(1):127-137.
13. Bruera E, Palmer JL, Bosnjak S, et al. Methadone versus morphine as a first-line strong opioid for cancer pain: A randomized, double-blind study. J Clin Oncol. 2004 Jan 1;22(1):185-192.

Two pharmacist-hospitalist teams each won $50,000 grants June 12 from the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation (Bethesda, Md.) to support development of screening tools and order sets to prevent and treat hospital-acquired venous thromboembolism (VTE).

The grant winners and lead co-investigators from each team:

• Robert Weibert, PharmD, health sciences clinical professor and director of the Anticoagulation Clinic, School of Pharmacy, and Gregory Maynard, MD, MS, head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego (UCSD); and
• Rachel Hroncich, PharmD, pharmacy clinical coordinator of Presbyterian Healthcare Service, and Randle Adair, DO, PhD, a PMG hospitalist in adult medicine from Albuquerque, N.M.

The ASHP, a nonprofit organization, fosters safe medication use.

“We are thrilled that our grant application was selected by the ASHP and excited about the opportunity for our research to improve patient care,” says Dr. Hroncich.

The ASHP Research and Education Foundation grant program, sponsored by Sanofi-Aventis, supports research by hospitalists and hospital pharmacists to treat VTE, with a focus on hospitalized patients and post-discharge follow-up. The grants are geared to help hospitalists and pharmacists reduce hospital-acquired VTE, a significant cause of morbidity and mortality in hospitals.

VTE-related treatment costs $1.5 billion a year, according to researchers at the University of Washington School of Pharmacy in Seattle. ASHP statistics indicate VTE affects more than 450,000 hospitalized patients annually. The condition—an amalgam of deep vein thrombosis (DVT) and pulmonary embolism (PE)—affects a range of hospitalized patients. Gynecologic, orthopedic, urologic, vascular, trauma, and cancer patients all are at risk—as are those with other medical conditions such as congestive heart failure, severe respiratory disease, and obesity, or those who are bedridden.

The ASHP grants help pharmacist-hospitalist teams find tools to screen for VTE. Such tools let clinicians intervene early with at-risk patients. Better screening and intervention requires sound clinical, administrative, and IT processes.

The trick is to encourage busy hospitalists to use a consensus-based VTE screening tool for all hospitalized patients.

Rachel Hroncich, PharmD, pharmacy clinical coordinator of Presbyterian Healthcare Service, and Randle Adair, DO, PhD, a PMG hospitalist in adult medicine from Albuquerque, N.M.

While most VTE research involves retrospective chart review of diagnostic codes, Drs. Weibert and Maynard’s grant research goes beyond such studies by identifying patients at risk concurrent with their hospitalizations. Dr. Maynard says the need is urgent: “Hospitals grossly underestimate the risk of VTE. In a 300-bed hospital, at least 150 patients are at risk of hospital-acquired VTE at any time.”

Gregory Maynard, MD, MS, head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego.

The UCSD team hopes to improve VTE screening by integrating an order set into the hospital’s computer physician order entry (CPOE) system. “The literature points to a bundle of best practices for VTE,” says Dr. Maynard, “including baseline lab work, use of compression stockings, using heparin for an optimal time period, patient education for those on anticoagulants, timely follow-up post discharge, the Society of Hospital Medicine collaborative, etc.”

Based on that body of knowledge and the input of its 15 full-time equivalent hospitalists, UCSD stakeholders in VTE screening debate what is practical and workable, conduct small, paper-based pilot projects, and fine-tune the protocol to integrate it with patient flow through admissions. “As we transition fully to a CPOE in our health system, we will incorporate a VTE order set that is doable and user-friendly,” adds Dr. Maynard.

UCSD’s pharmacist-hospitalist collaboration also encourages residents from both disciplines to work together on integrating protocols into clinical care processes. The team hopes that the VTE protocol will go beyond the inpatient stay by wrapping the protocol into the discharge plan. Dr. Weibert’s anticoagulation and pulmonary embolism clinics also help “build on our strengths,” he says.

The second team is led by newcomers to the grant winner’s circle, Drs. Hroncich (pharmacist) and Adair (hospitalist) from Presbyterian Healthcare Services, Albuquerque, N.M. They base their research on this question: Is it more efficient for the system’s 34 hospitalists to screen out those at low risk of VTE than to screen everyone for high risk?

Robert Weibert, PharmD, health sciences clinical professor and director of the Anticoagulation Clinic, School of Pharmacy.

The investigators have been collecting baseline data on compliance with VTE screening since 2003. Hospitalist use of a VTE screening tool on admissions was 60%, improving to 88% with reminders. “The implication is that 12% of the hospitalists didn’t use the screening tool,” says Dr. Adair. “We found that they were resistant to another piece of paper.” PHS data also showed that seven out of 10 patients had some VTE risk, that co-morbidities and hospitalization increase VTE risk, and that the age at which patients fall prey to VTE is dropping to between 50 and 60.

For the ASHP grant, Drs. Hroncich and Adair will monitor VTE screening on admission to all PHS general medical units. All patients 18 or older admitted to those units during a three-month period will be routinely screened on admission for VTE risk. Drs. Hroncich and Adair will make two VTE-related admission order sets available to hospitalists to complete. The current screening tool is designed to identify patients at risk of developing a VTE based on the presence of risk factors. The second, shorter admission order set will contain a screening tool that assumes that all patients need VTE prophylaxis, except low-risk patients and those with VTE prophylaxis contraindications. “The shorter tool should take only one or two minutes to complete,” says Dr. Hroncich.

The PHS team hopes that the shorter screening tool will overcome resistance to VTE screening. Dr. Hroncich says there are many barriers to VTE screening. They include lack of consensus on the best screening tool on admission, the misperception that VTE isn’t a big problem, lack of reliable processes so at-risk patients don’t fall through the cracks, and a misperception that anti-coagulant therapy is dangerous.

“It’s one thing to treat COPD and heart failure,” adds Dr. Adair, “but if I can prevent VTE with less than a 60-second screening, I can prevent a disease state from happening.” TH

Marlene Piturro is a frequent contributor to The Hospitalist.

Two pharmacist-hospitalist teams each won $50,000 grants June 12 from the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation (Bethesda, Md.) to support development of screening tools and order sets to prevent and treat hospital-acquired venous thromboembolism (VTE).

The grant winners and lead co-investigators from each team:

• Robert Weibert, PharmD, health sciences clinical professor and director of the Anticoagulation Clinic, School of Pharmacy, and Gregory Maynard, MD, MS, head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego (UCSD); and
• Rachel Hroncich, PharmD, pharmacy clinical coordinator of Presbyterian Healthcare Service, and Randle Adair, DO, PhD, a PMG hospitalist in adult medicine from Albuquerque, N.M.

The ASHP, a nonprofit organization, fosters safe medication use.

“We are thrilled that our grant application was selected by the ASHP and excited about the opportunity for our research to improve patient care,” says Dr. Hroncich.

The ASHP Research and Education Foundation grant program, sponsored by Sanofi-Aventis, supports research by hospitalists and hospital pharmacists to treat VTE, with a focus on hospitalized patients and post-discharge follow-up. The grants are geared to help hospitalists and pharmacists reduce hospital-acquired VTE, a significant cause of morbidity and mortality in hospitals.

VTE-related treatment costs $1.5 billion a year, according to researchers at the University of Washington School of Pharmacy in Seattle. ASHP statistics indicate VTE affects more than 450,000 hospitalized patients annually. The condition—an amalgam of deep vein thrombosis (DVT) and pulmonary embolism (PE)—affects a range of hospitalized patients. Gynecologic, orthopedic, urologic, vascular, trauma, and cancer patients all are at risk—as are those with other medical conditions such as congestive heart failure, severe respiratory disease, and obesity, or those who are bedridden.

The ASHP grants help pharmacist-hospitalist teams find tools to screen for VTE. Such tools let clinicians intervene early with at-risk patients. Better screening and intervention requires sound clinical, administrative, and IT processes.

The trick is to encourage busy hospitalists to use a consensus-based VTE screening tool for all hospitalized patients.

Rachel Hroncich, PharmD, pharmacy clinical coordinator of Presbyterian Healthcare Service, and Randle Adair, DO, PhD, a PMG hospitalist in adult medicine from Albuquerque, N.M.

While most VTE research involves retrospective chart review of diagnostic codes, Drs. Weibert and Maynard’s grant research goes beyond such studies by identifying patients at risk concurrent with their hospitalizations. Dr. Maynard says the need is urgent: “Hospitals grossly underestimate the risk of VTE. In a 300-bed hospital, at least 150 patients are at risk of hospital-acquired VTE at any time.”

Gregory Maynard, MD, MS, head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego.

The UCSD team hopes to improve VTE screening by integrating an order set into the hospital’s computer physician order entry (CPOE) system. “The literature points to a bundle of best practices for VTE,” says Dr. Maynard, “including baseline lab work, use of compression stockings, using heparin for an optimal time period, patient education for those on anticoagulants, timely follow-up post discharge, the Society of Hospital Medicine collaborative, etc.”

Based on that body of knowledge and the input of its 15 full-time equivalent hospitalists, UCSD stakeholders in VTE screening debate what is practical and workable, conduct small, paper-based pilot projects, and fine-tune the protocol to integrate it with patient flow through admissions. “As we transition fully to a CPOE in our health system, we will incorporate a VTE order set that is doable and user-friendly,” adds Dr. Maynard.

UCSD’s pharmacist-hospitalist collaboration also encourages residents from both disciplines to work together on integrating protocols into clinical care processes. The team hopes that the VTE protocol will go beyond the inpatient stay by wrapping the protocol into the discharge plan. Dr. Weibert’s anticoagulation and pulmonary embolism clinics also help “build on our strengths,” he says.

The second team is led by newcomers to the grant winner’s circle, Drs. Hroncich (pharmacist) and Adair (hospitalist) from Presbyterian Healthcare Services, Albuquerque, N.M. They base their research on this question: Is it more efficient for the system’s 34 hospitalists to screen out those at low risk of VTE than to screen everyone for high risk?

Robert Weibert, PharmD, health sciences clinical professor and director of the Anticoagulation Clinic, School of Pharmacy.

The investigators have been collecting baseline data on compliance with VTE screening since 2003. Hospitalist use of a VTE screening tool on admissions was 60%, improving to 88% with reminders. “The implication is that 12% of the hospitalists didn’t use the screening tool,” says Dr. Adair. “We found that they were resistant to another piece of paper.” PHS data also showed that seven out of 10 patients had some VTE risk, that co-morbidities and hospitalization increase VTE risk, and that the age at which patients fall prey to VTE is dropping to between 50 and 60.

For the ASHP grant, Drs. Hroncich and Adair will monitor VTE screening on admission to all PHS general medical units. All patients 18 or older admitted to those units during a three-month period will be routinely screened on admission for VTE risk. Drs. Hroncich and Adair will make two VTE-related admission order sets available to hospitalists to complete. The current screening tool is designed to identify patients at risk of developing a VTE based on the presence of risk factors. The second, shorter admission order set will contain a screening tool that assumes that all patients need VTE prophylaxis, except low-risk patients and those with VTE prophylaxis contraindications. “The shorter tool should take only one or two minutes to complete,” says Dr. Hroncich.

The PHS team hopes that the shorter screening tool will overcome resistance to VTE screening. Dr. Hroncich says there are many barriers to VTE screening. They include lack of consensus on the best screening tool on admission, the misperception that VTE isn’t a big problem, lack of reliable processes so at-risk patients don’t fall through the cracks, and a misperception that anti-coagulant therapy is dangerous.

“It’s one thing to treat COPD and heart failure,” adds Dr. Adair, “but if I can prevent VTE with less than a 60-second screening, I can prevent a disease state from happening.” TH

Marlene Piturro is a frequent contributor to The Hospitalist.

Two pharmacist-hospitalist teams each won $50,000 grants June 12 from the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation (Bethesda, Md.) to support development of screening tools and order sets to prevent and treat hospital-acquired venous thromboembolism (VTE).

The grant winners and lead co-investigators from each team:

• Robert Weibert, PharmD, health sciences clinical professor and director of the Anticoagulation Clinic, School of Pharmacy, and Gregory Maynard, MD, MS, head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego (UCSD); and
• Rachel Hroncich, PharmD, pharmacy clinical coordinator of Presbyterian Healthcare Service, and Randle Adair, DO, PhD, a PMG hospitalist in adult medicine from Albuquerque, N.M.

The ASHP, a nonprofit organization, fosters safe medication use.

“We are thrilled that our grant application was selected by the ASHP and excited about the opportunity for our research to improve patient care,” says Dr. Hroncich.

The ASHP Research and Education Foundation grant program, sponsored by Sanofi-Aventis, supports research by hospitalists and hospital pharmacists to treat VTE, with a focus on hospitalized patients and post-discharge follow-up. The grants are geared to help hospitalists and pharmacists reduce hospital-acquired VTE, a significant cause of morbidity and mortality in hospitals.

VTE-related treatment costs $1.5 billion a year, according to researchers at the University of Washington School of Pharmacy in Seattle. ASHP statistics indicate VTE affects more than 450,000 hospitalized patients annually. The condition—an amalgam of deep vein thrombosis (DVT) and pulmonary embolism (PE)—affects a range of hospitalized patients. Gynecologic, orthopedic, urologic, vascular, trauma, and cancer patients all are at risk—as are those with other medical conditions such as congestive heart failure, severe respiratory disease, and obesity, or those who are bedridden.

The ASHP grants help pharmacist-hospitalist teams find tools to screen for VTE. Such tools let clinicians intervene early with at-risk patients. Better screening and intervention requires sound clinical, administrative, and IT processes.

The trick is to encourage busy hospitalists to use a consensus-based VTE screening tool for all hospitalized patients.

Rachel Hroncich, PharmD, pharmacy clinical coordinator of Presbyterian Healthcare Service, and Randle Adair, DO, PhD, a PMG hospitalist in adult medicine from Albuquerque, N.M.

While most VTE research involves retrospective chart review of diagnostic codes, Drs. Weibert and Maynard’s grant research goes beyond such studies by identifying patients at risk concurrent with their hospitalizations. Dr. Maynard says the need is urgent: “Hospitals grossly underestimate the risk of VTE. In a 300-bed hospital, at least 150 patients are at risk of hospital-acquired VTE at any time.”

Gregory Maynard, MD, MS, head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego.

The UCSD team hopes to improve VTE screening by integrating an order set into the hospital’s computer physician order entry (CPOE) system. “The literature points to a bundle of best practices for VTE,” says Dr. Maynard, “including baseline lab work, use of compression stockings, using heparin for an optimal time period, patient education for those on anticoagulants, timely follow-up post discharge, the Society of Hospital Medicine collaborative, etc.”

Based on that body of knowledge and the input of its 15 full-time equivalent hospitalists, UCSD stakeholders in VTE screening debate what is practical and workable, conduct small, paper-based pilot projects, and fine-tune the protocol to integrate it with patient flow through admissions. “As we transition fully to a CPOE in our health system, we will incorporate a VTE order set that is doable and user-friendly,” adds Dr. Maynard.

UCSD’s pharmacist-hospitalist collaboration also encourages residents from both disciplines to work together on integrating protocols into clinical care processes. The team hopes that the VTE protocol will go beyond the inpatient stay by wrapping the protocol into the discharge plan. Dr. Weibert’s anticoagulation and pulmonary embolism clinics also help “build on our strengths,” he says.

The second team is led by newcomers to the grant winner’s circle, Drs. Hroncich (pharmacist) and Adair (hospitalist) from Presbyterian Healthcare Services, Albuquerque, N.M. They base their research on this question: Is it more efficient for the system’s 34 hospitalists to screen out those at low risk of VTE than to screen everyone for high risk?

Robert Weibert, PharmD, health sciences clinical professor and director of the Anticoagulation Clinic, School of Pharmacy.

The investigators have been collecting baseline data on compliance with VTE screening since 2003. Hospitalist use of a VTE screening tool on admissions was 60%, improving to 88% with reminders. “The implication is that 12% of the hospitalists didn’t use the screening tool,” says Dr. Adair. “We found that they were resistant to another piece of paper.” PHS data also showed that seven out of 10 patients had some VTE risk, that co-morbidities and hospitalization increase VTE risk, and that the age at which patients fall prey to VTE is dropping to between 50 and 60.

For the ASHP grant, Drs. Hroncich and Adair will monitor VTE screening on admission to all PHS general medical units. All patients 18 or older admitted to those units during a three-month period will be routinely screened on admission for VTE risk. Drs. Hroncich and Adair will make two VTE-related admission order sets available to hospitalists to complete. The current screening tool is designed to identify patients at risk of developing a VTE based on the presence of risk factors. The second, shorter admission order set will contain a screening tool that assumes that all patients need VTE prophylaxis, except low-risk patients and those with VTE prophylaxis contraindications. “The shorter tool should take only one or two minutes to complete,” says Dr. Hroncich.

The PHS team hopes that the shorter screening tool will overcome resistance to VTE screening. Dr. Hroncich says there are many barriers to VTE screening. They include lack of consensus on the best screening tool on admission, the misperception that VTE isn’t a big problem, lack of reliable processes so at-risk patients don’t fall through the cracks, and a misperception that anti-coagulant therapy is dangerous.

“It’s one thing to treat COPD and heart failure,” adds Dr. Adair, “but if I can prevent VTE with less than a 60-second screening, I can prevent a disease state from happening.” TH

Marlene Piturro is a frequent contributor to The Hospitalist.

Delirium—also known as acute confusional state—is a common and potentially serious condition for hospitalized geriatric patients. It is believed to complicate hospital stays for more than 2.3 million older people, account for more than 17.5 million in patient days, and cost more than $4 billion in Medicare expenditures.1

Many experts believe the numbers may be higher because clinical staff too often automatically attribute patients’ symptoms to age-related dementia.

Delirium is many times more likely to occur in older people.2 Because patients older than 65 account for nearly half of all inpatient days, hospitalists must be readily able to identify the signs and symptoms of delirium—as well as what factors put certain patients at an increased risk for developing delirium. Hospitalists with this knowledge and ability will be better equipped to reduce the risk for delirium in their patients and more effectively treat delirium when it occurs.

“Assuming that the patient’s confusion is a normal state for him or her, without speaking to the patient’s family or caregivers to establish the baseline mental status for the patient, is probably the biggest reason delirium is so often misdiagnosed and, consequently, left untreated,” says Sharon Inouye, MD, of the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School.

Define and Diagnose Delirium

Delirium is a temporary state of mental confusion and fluctuating consciousness. Patients are unable to focus their thoughts or pay attention, are confused about their environment and individuals, and unsure about their daily routines. They may exhibit subtle or startling personality changes. Some people may become withdrawn and lethargic, while others become agitated or hyperactive. Some patients experience visual and/or auditory hallucinations and become paranoid.

Changes in sleep patterns are a typical manifestation of delirium. The patient may experience anything from mild insomnia to complete reversal of the sleep-wake cycle. All symptoms may fluctuate in severity as the day progresses, and it is common for delirious patients to become more agitated and confused at night.

Dementia is a chronic problem that develops over time. Delirium is acute—usually developing over hours or days. While patients with pre-existing dementia, brain trauma, cerebrovascular accident, or brain tumor are at higher risk for developing delirium, don’t automatically attribute unusual behavior in a geriatric patient to one of these diagnoses—especially if the behavioral change is sudden.

It is vital to obtain a solid history to determine the patient’s baseline mental status. The patient may not be the most reliable source of information regarding his or her normal level of cognition—particularly if he or she is beginning to show signs that may indicate delirium. Make every effort to question the patient’s family members and caregivers thoroughly to determine the patient’s normal level of functioning.

“The trick is that you have to have a nursing staff you can trust and who is attentive enough to changes in behavior—keeping in mind that they’ve only known the patient for a short time,” says Jonathan Flacker, MD, assistant professor of medicine at Emory University in Atlanta. “You have to rely a lot on the families and caregivers. You have to know whether the patient’s behavior is new or not, and sometimes that’s hard to establish.”

A simple tool nursing staff can use to monitor the patient’s mental status is the Confusion Assessment Method (CAM). The CAM is easy to use and interpret and only takes moments to complete. When staff on each shift use this tool and accurately document the results, it can help identify early changes that may indicate the onset of delirium.3

In addition to the CAM, other tools that can assist in cognitive assessment of the patient can include The Mini-Cog Assessment Instrument for Dementia, The Clock Draw Test, The Short Portable Mental Status Questionnaire (SPMSQ), The Geriatric Depression Scale, The Folstein Mini-Mental Status Exam, and The Digit Span Test.

Identify Etiology

Once the physician has determined that a patient is suffering from delirium, the challenge is to identify and treat the cause.

“It is important to remember that older folks often have atypical presentation of symptoms for medical problems,” says Dr. Inouye. “Physicians and clinical staff need to carefully consider all of the patient’s signs and symptoms, regardless of how insignificant they may seem.”

The physician can then order additional diagnostic tests based on the findings of the physical examination, which may include CBC, serum chemistry group, urinalysis, serum and urine drug screens, and possibly diagnostic radiographic studies as indicated.

Assessment must also include a careful review of the patient’s medications—possibly with input from a pharmacist. To do this, obtain a complete list of medications the patient was taking prior to admission to compare with the medications the patient is taking currently. Consider the possible effects of:

• Medications that have been discontinued;
• New medications;
• Changes in dosage;
• Possible drug interactions; and
• Possible drug toxicities that may require additional lab testing.

Pay attention to psychoactive medications the patient is taking, such as sedative-hypnotic agents, narcotics, and antidepressants. It is important to note whether the patient has recently received anesthesia or pain medications.4 It is also important to determine whether the patient has a history of alcohol or drug dependency.

“The first thing I would think if a patient is not acting right is drugs—some new drug that we’re administering or some drug that he or she is withdrawing from,” says O’Neil Pyke, MD, medical director of the Hamot Hospitalist Group in Erie, Pa. “You have to consider the possibility of side effects, drug interactions, and withdrawals. You also have to recognize polypharmacology as a major risk factor and try to curtail unnecessary medications.”

Dr. Flacker cautions that even once a problem has been identified, the physician must follow through on the complete examination and evaluation of the patient, keeping in mind that the cause for delirium may be multifactorial. “The problem is that like a lot of things in older folks, if you look for ‘the’ cause, you’re likely to be frustrated,” he says. “It’s often a combination of stressors causing the patient’s delirium.”

Treatment

Once the underlying problem or problems have been identified, treat those medical conditions accordingly—by administering antibiotics, fluids, and electrolytes as needed and adjusting or discontinuing medications.

However, resolution of the etiologic cause does not necessarily mean the symptoms of delirium will spontaneously resolve. These symptoms likely will require specific interventions to reorient the patient.

Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.

David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”

To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.

Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.

If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.

If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5

If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.

Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.

“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”

Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.

“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.

While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.

In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:

• Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
• Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
• Early mobilization. Get all patients up and walking three times a day;
• Vision and hearing adaptations;
• Feeding assistance and hydration assistance with encouragement/companionship during meals; and
• Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.

A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.

Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH

Sheri Polley is a frequent contributor to The Hospitalist.

References

1. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
2. Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
3. Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
4. McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
5. Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.

Delirium—also known as acute confusional state—is a common and potentially serious condition for hospitalized geriatric patients. It is believed to complicate hospital stays for more than 2.3 million older people, account for more than 17.5 million in patient days, and cost more than $4 billion in Medicare expenditures.1

Many experts believe the numbers may be higher because clinical staff too often automatically attribute patients’ symptoms to age-related dementia.

Delirium is many times more likely to occur in older people.2 Because patients older than 65 account for nearly half of all inpatient days, hospitalists must be readily able to identify the signs and symptoms of delirium—as well as what factors put certain patients at an increased risk for developing delirium. Hospitalists with this knowledge and ability will be better equipped to reduce the risk for delirium in their patients and more effectively treat delirium when it occurs.

“Assuming that the patient’s confusion is a normal state for him or her, without speaking to the patient’s family or caregivers to establish the baseline mental status for the patient, is probably the biggest reason delirium is so often misdiagnosed and, consequently, left untreated,” says Sharon Inouye, MD, of the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School.

Define and Diagnose Delirium

Delirium is a temporary state of mental confusion and fluctuating consciousness. Patients are unable to focus their thoughts or pay attention, are confused about their environment and individuals, and unsure about their daily routines. They may exhibit subtle or startling personality changes. Some people may become withdrawn and lethargic, while others become agitated or hyperactive. Some patients experience visual and/or auditory hallucinations and become paranoid.

Changes in sleep patterns are a typical manifestation of delirium. The patient may experience anything from mild insomnia to complete reversal of the sleep-wake cycle. All symptoms may fluctuate in severity as the day progresses, and it is common for delirious patients to become more agitated and confused at night.

Dementia is a chronic problem that develops over time. Delirium is acute—usually developing over hours or days. While patients with pre-existing dementia, brain trauma, cerebrovascular accident, or brain tumor are at higher risk for developing delirium, don’t automatically attribute unusual behavior in a geriatric patient to one of these diagnoses—especially if the behavioral change is sudden.

It is vital to obtain a solid history to determine the patient’s baseline mental status. The patient may not be the most reliable source of information regarding his or her normal level of cognition—particularly if he or she is beginning to show signs that may indicate delirium. Make every effort to question the patient’s family members and caregivers thoroughly to determine the patient’s normal level of functioning.

“The trick is that you have to have a nursing staff you can trust and who is attentive enough to changes in behavior—keeping in mind that they’ve only known the patient for a short time,” says Jonathan Flacker, MD, assistant professor of medicine at Emory University in Atlanta. “You have to rely a lot on the families and caregivers. You have to know whether the patient’s behavior is new or not, and sometimes that’s hard to establish.”

A simple tool nursing staff can use to monitor the patient’s mental status is the Confusion Assessment Method (CAM). The CAM is easy to use and interpret and only takes moments to complete. When staff on each shift use this tool and accurately document the results, it can help identify early changes that may indicate the onset of delirium.3

In addition to the CAM, other tools that can assist in cognitive assessment of the patient can include The Mini-Cog Assessment Instrument for Dementia, The Clock Draw Test, The Short Portable Mental Status Questionnaire (SPMSQ), The Geriatric Depression Scale, The Folstein Mini-Mental Status Exam, and The Digit Span Test.

Identify Etiology

Once the physician has determined that a patient is suffering from delirium, the challenge is to identify and treat the cause.

“It is important to remember that older folks often have atypical presentation of symptoms for medical problems,” says Dr. Inouye. “Physicians and clinical staff need to carefully consider all of the patient’s signs and symptoms, regardless of how insignificant they may seem.”

The physician can then order additional diagnostic tests based on the findings of the physical examination, which may include CBC, serum chemistry group, urinalysis, serum and urine drug screens, and possibly diagnostic radiographic studies as indicated.

Assessment must also include a careful review of the patient’s medications—possibly with input from a pharmacist. To do this, obtain a complete list of medications the patient was taking prior to admission to compare with the medications the patient is taking currently. Consider the possible effects of:

• Medications that have been discontinued;
• New medications;
• Changes in dosage;
• Possible drug interactions; and
• Possible drug toxicities that may require additional lab testing.

Pay attention to psychoactive medications the patient is taking, such as sedative-hypnotic agents, narcotics, and antidepressants. It is important to note whether the patient has recently received anesthesia or pain medications.4 It is also important to determine whether the patient has a history of alcohol or drug dependency.

“The first thing I would think if a patient is not acting right is drugs—some new drug that we’re administering or some drug that he or she is withdrawing from,” says O’Neil Pyke, MD, medical director of the Hamot Hospitalist Group in Erie, Pa. “You have to consider the possibility of side effects, drug interactions, and withdrawals. You also have to recognize polypharmacology as a major risk factor and try to curtail unnecessary medications.”

Dr. Flacker cautions that even once a problem has been identified, the physician must follow through on the complete examination and evaluation of the patient, keeping in mind that the cause for delirium may be multifactorial. “The problem is that like a lot of things in older folks, if you look for ‘the’ cause, you’re likely to be frustrated,” he says. “It’s often a combination of stressors causing the patient’s delirium.”

Treatment

Once the underlying problem or problems have been identified, treat those medical conditions accordingly—by administering antibiotics, fluids, and electrolytes as needed and adjusting or discontinuing medications.

However, resolution of the etiologic cause does not necessarily mean the symptoms of delirium will spontaneously resolve. These symptoms likely will require specific interventions to reorient the patient.

Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.

David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”

To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.

Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.

If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.

If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5

If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.

Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.

“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”

Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.

“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.

While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.

In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:

• Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
• Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
• Early mobilization. Get all patients up and walking three times a day;
• Vision and hearing adaptations;
• Feeding assistance and hydration assistance with encouragement/companionship during meals; and
• Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.

A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.

Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH

Sheri Polley is a frequent contributor to The Hospitalist.

References

1. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
2. Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
3. Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
4. McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
5. Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.

Delirium—also known as acute confusional state—is a common and potentially serious condition for hospitalized geriatric patients. It is believed to complicate hospital stays for more than 2.3 million older people, account for more than 17.5 million in patient days, and cost more than $4 billion in Medicare expenditures.1

Many experts believe the numbers may be higher because clinical staff too often automatically attribute patients’ symptoms to age-related dementia.

Delirium is many times more likely to occur in older people.2 Because patients older than 65 account for nearly half of all inpatient days, hospitalists must be readily able to identify the signs and symptoms of delirium—as well as what factors put certain patients at an increased risk for developing delirium. Hospitalists with this knowledge and ability will be better equipped to reduce the risk for delirium in their patients and more effectively treat delirium when it occurs.

“Assuming that the patient’s confusion is a normal state for him or her, without speaking to the patient’s family or caregivers to establish the baseline mental status for the patient, is probably the biggest reason delirium is so often misdiagnosed and, consequently, left untreated,” says Sharon Inouye, MD, of the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School.

Define and Diagnose Delirium

Delirium is a temporary state of mental confusion and fluctuating consciousness. Patients are unable to focus their thoughts or pay attention, are confused about their environment and individuals, and unsure about their daily routines. They may exhibit subtle or startling personality changes. Some people may become withdrawn and lethargic, while others become agitated or hyperactive. Some patients experience visual and/or auditory hallucinations and become paranoid.

Changes in sleep patterns are a typical manifestation of delirium. The patient may experience anything from mild insomnia to complete reversal of the sleep-wake cycle. All symptoms may fluctuate in severity as the day progresses, and it is common for delirious patients to become more agitated and confused at night.

Dementia is a chronic problem that develops over time. Delirium is acute—usually developing over hours or days. While patients with pre-existing dementia, brain trauma, cerebrovascular accident, or brain tumor are at higher risk for developing delirium, don’t automatically attribute unusual behavior in a geriatric patient to one of these diagnoses—especially if the behavioral change is sudden.

It is vital to obtain a solid history to determine the patient’s baseline mental status. The patient may not be the most reliable source of information regarding his or her normal level of cognition—particularly if he or she is beginning to show signs that may indicate delirium. Make every effort to question the patient’s family members and caregivers thoroughly to determine the patient’s normal level of functioning.

“The trick is that you have to have a nursing staff you can trust and who is attentive enough to changes in behavior—keeping in mind that they’ve only known the patient for a short time,” says Jonathan Flacker, MD, assistant professor of medicine at Emory University in Atlanta. “You have to rely a lot on the families and caregivers. You have to know whether the patient’s behavior is new or not, and sometimes that’s hard to establish.”

A simple tool nursing staff can use to monitor the patient’s mental status is the Confusion Assessment Method (CAM). The CAM is easy to use and interpret and only takes moments to complete. When staff on each shift use this tool and accurately document the results, it can help identify early changes that may indicate the onset of delirium.3

In addition to the CAM, other tools that can assist in cognitive assessment of the patient can include The Mini-Cog Assessment Instrument for Dementia, The Clock Draw Test, The Short Portable Mental Status Questionnaire (SPMSQ), The Geriatric Depression Scale, The Folstein Mini-Mental Status Exam, and The Digit Span Test.

Identify Etiology

Once the physician has determined that a patient is suffering from delirium, the challenge is to identify and treat the cause.

“It is important to remember that older folks often have atypical presentation of symptoms for medical problems,” says Dr. Inouye. “Physicians and clinical staff need to carefully consider all of the patient’s signs and symptoms, regardless of how insignificant they may seem.”

The physician can then order additional diagnostic tests based on the findings of the physical examination, which may include CBC, serum chemistry group, urinalysis, serum and urine drug screens, and possibly diagnostic radiographic studies as indicated.

Assessment must also include a careful review of the patient’s medications—possibly with input from a pharmacist. To do this, obtain a complete list of medications the patient was taking prior to admission to compare with the medications the patient is taking currently. Consider the possible effects of:

• Medications that have been discontinued;
• New medications;
• Changes in dosage;
• Possible drug interactions; and
• Possible drug toxicities that may require additional lab testing.

Pay attention to psychoactive medications the patient is taking, such as sedative-hypnotic agents, narcotics, and antidepressants. It is important to note whether the patient has recently received anesthesia or pain medications.4 It is also important to determine whether the patient has a history of alcohol or drug dependency.

“The first thing I would think if a patient is not acting right is drugs—some new drug that we’re administering or some drug that he or she is withdrawing from,” says O’Neil Pyke, MD, medical director of the Hamot Hospitalist Group in Erie, Pa. “You have to consider the possibility of side effects, drug interactions, and withdrawals. You also have to recognize polypharmacology as a major risk factor and try to curtail unnecessary medications.”

Dr. Flacker cautions that even once a problem has been identified, the physician must follow through on the complete examination and evaluation of the patient, keeping in mind that the cause for delirium may be multifactorial. “The problem is that like a lot of things in older folks, if you look for ‘the’ cause, you’re likely to be frustrated,” he says. “It’s often a combination of stressors causing the patient’s delirium.”

Treatment

Once the underlying problem or problems have been identified, treat those medical conditions accordingly—by administering antibiotics, fluids, and electrolytes as needed and adjusting or discontinuing medications.

However, resolution of the etiologic cause does not necessarily mean the symptoms of delirium will spontaneously resolve. These symptoms likely will require specific interventions to reorient the patient.

Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.

David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”

To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.

Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.

If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.

If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5

If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.

Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.

“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”

Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.

“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.

While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.

In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:

• Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
• Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
• Early mobilization. Get all patients up and walking three times a day;
• Vision and hearing adaptations;
• Feeding assistance and hydration assistance with encouragement/companionship during meals; and
• Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.

A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.

Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH

Sheri Polley is a frequent contributor to The Hospitalist.

References

1. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
2. Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
3. Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
4. McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
5. Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.

Bullying, intimidation, verbal abuse—these behaviors negatively affect self-esteem, feelings of competence, and workplace morale. And they can devastate hospital professionals and their patients.

When 2,095 healthcare providers (1,565 nurses, 354 pharmacists, and 176 others) responded to an Institute for Safe Medication Practices (ISMP) survey on intimidation in their healthcare setting, remarkable data were collected.1

Perhaps the most alarming statistic in the 2003-2004 study was that 7% of respondents (n=147) reported they had been involved in a medication error allowed to occur partly because the respondents were afraid to question the prescriber’s decision. At a large urban trauma center in the northeastern United States, nurses listed intimidation as one of the barriers to implementing a sharps safety program.2

click for large version

Nurses’ Perceptions

Research over the past decade has spotlighted intimidation in healthcare.3

“Bullying and harassment still happen in many areas of medicine,” says David M. Pressel, MD, PhD, hospitalist and director, Inpatient Service, Division of General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. “The question is, how do you monitor yourself to make sure you aren’t falling into that hierarchical frame of mind that could intervene in great teaching and learning and great patient care?”

Dr. Pressel and his partner, David I. Rappaport, MD, also a pediatric hospitalist at duPont, have focused on the literature pertaining to nurse-physician relationships. Research shows that intimidation impedes nurse recruitment, retention, and satisfaction. In one study, 90% of nurses reported experiencing at least one episode of verbal abuse.4 A 1997 study examining the effects of intimidation on 35 pediatric nurses over a three-month period found that 25 (71.4%) of them reported being yelled at or loudly admonished. Sixteen (45.7%) had been victims of insults. Thirty (85.7%) were spoken to in a condescending manner. One-third of nurses believed that such behavior was “part of the job.”

Although studies have differed as to the most common source of this abuse—patients and families or physicians—a study of pediatric nurses reported a similar incidence from both sources.5 And, nurses are often guilty of verbally abusing each other.6

When the duPont pediatric hospitalist team began performing more family-centered rounds, they began to appreciate the nurse-physician relationship. “We have worked hard to have a charge nurse and oftentimes the bedside nurse with us when we round,” Dr. Rappaport says. Speculating that rounding with hospitalists allowed nurses to feel more part of the team, Dr. Rappaport says know the medical plan, consolidate efforts such that pages to residents were reduced, and generally improve communication. They heard from participating nurses that it made a tremendous difference. This prompted them to conduct their research.

“Our study looked at the nurse-physician relationship globally, not intimidation or abuse specifically,” says Dr. Rappaport. Along with their nurse colleague Norine Watson, RN, Drs. Pressel and Rappaport are examining the relationship between nurses and different categories of physicians: how nurses perceive interactions between nurses and surgical residents, surgical attendings, community physicians, pediatric residents, and pediatric hospitalists.

“Early data suggest that hospitalists may work more effectively with nurses because they share many of the same goals,” says Dr. Rappaport. “As hospital leaders, hospitalists can also improve working conditions for nurses by providing more accessible, efficient, and effective care. Presumably, improved collaboration will also include decreased intimidation or abuse from physicians and also probably from dissatisfied patients and families.”

Avoiding the trap of communicating in a manner that is too direct and might be construed as abusive requires self-awareness and the realization that people receive information in different ways, says Dr. Pressel. Standard professional behavior is the key. Beyond that, the challenge is giving feedback constructively and in a positive manner.

“Hospitalists [may be] more in tune with the needs of nurses than nonhospitalists,” says Dr. Rappaport. “I think that is one of our strengths. We need to continue to facilitate very strong relationships between nurses and physicians because without good nursing care, hospitalists simply cannot provide good medical care.”

There is another way hospitalists can help address verbal abuse. “Studies consistently show that nurses are hesitant to report episodes of verbal abuse,” Dr. Rappaport says, “whether it is from a family, a patient, a physician, or a fellow nurse. Fewer than one in five nurses reports these episodes. One thing that hospitalists can do is work with hospital administration to create an environment that is more proactive in addressing these concerns and allowing nurses to feel more support in this area.”

Only 60% of respondents to the ISMP survey felt their organization had clearly defined an effective process for handling disagreements with a medication order’s safety. Only about a third felt the process facilitated their bypassing an intimidating prescriber or their own supervisor if necessary. Although 70% of respondents reported that they thought their organization or manager would support them if they reported intimidating behavior, only 39% of respondents believed their organization was dealing effectively with intimidating behavior.

Untapped Source

Perceptions of intimidation also occur among trainees. When 2,884 students from the class of 2003 at 16 U.S. medical schools completed questionnaires at various times during training, 27% reported having been “harassed” by house staff, 21% by faculty, and 25% by patients.7 Further, 71% reported having been “belittled” by house staff, 63% by faculty, and 43% by patients.

Mistreated students were significantly more likely to have suffered stress, be depressed or suicidal, and less likely to report being glad they trained as a physician.

Studies consistently show that nurses are hesitant to report episodes of verbal abuse whether it is from a family, a patient, a physician, or a fellow nurse.

—David I. Rappaport, MD, pediatric hospitalist, Alfred I. Dupont Hospital for Children, Wilmington, Del.

This may have an underlying effect on the potential to monitor for patient safety.8,9 Because errors and near misses often result from miscommunication, medical students may be adept at preventing certain types of errors. Students’ observation skills may be just as keen, if not more so, than their more clinically proficient healthcare teammates.8 In four cases from two U.S. academic health centers reported by medical students Samuel Seiden, Cynthia Galvan, and Ruth Lamm in 2006, medical students demonstrated keen attention to detail and appropriately characterized problematic situations with patients—adding another layer of defense within systems safeguarding against patient harm.8 Yet of the 76% of medical students who had observed a medical error, only about half of the students reported the errors to a resident or an attending, despite having received patient-safety training; only 7% reported having used an electronic medical error reporting system.10

By Example

Some intimidation in medical education may be the result of anger toward students and residents over a lack of medical knowledge, says Jeffery G. Wiese, MD, associate professor of Medicine at Tulane University in New Orleans and member of the SHM Board of Directors. “It is natural to feel [that anger]; people abhor in others what they most detest in themselves,’’ he says. “As physicians, a lack of medical knowledge is what we detest in ourselves. But a student’s ignorance is usually a product of where she is in her training; that’s why she is with you.”

Anger alienates students, absolving them of the guilt of not knowing the information, and demotivating them from learning it. “The lesson to be communicated is that it is OK not to know, but it is not OK to continue to not know,” Dr. Wiese says. “Reprimands should be reserved for the student who does not know, and then after being taught or asked to look it up, continues to not know.”

“The average physician who practices for 30 years will take care of roughly 80,000 people,” estimates Dr. Wiese. “That’s an arithmetic contribution and there is nothing wrong with that. But if you really want to change the world, teaching is the rule. The same 30 years invested in teaching will indirectly affect 400 million people,” he says. “Even better, if you can train your students and residents in the value of coaching their students and residents, well, now you’re talking about 10 billion people that you can affect over the course of a career.”

The question to ask yourself, says Dr. Wiese, is: Do you want to change the world? “If you do, this is the way to do it,” he says.

“For the 30 years in your career, focus on clinical coaching and getting others to clinically coach. That way, especially if you have the right motives in your heart, the right vision for the way you want to see the profession practiced, and the way you want patient care performed, that’s your shot at changing the world.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Institute for Safe Medication Practice. Intimidation: practitioners speak up about this unresolved problem (Part I). Available at w.ismp.org/Newsletters/acutecare/articles/20040311_2.asp. Last accessed June 27, 2007.
2. Hagstrom AM. Perceived barriers to implementation of a successful sharps safety program. AORN J. 2006;83(2):391-7.
3. Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Safety Qual Healthc. 2006 Jul-Aug;3:16-24.
4. Manderino MA, Berkey N. Verbal abuse of staff nurses by physicians. J Prof Nurs. 1997;13(1):48-55.
5. Pejic AR. Verbal abuse: A problem for pediatric nurses. Pediatr Nurs. 2005;31(4):271-279.
6. Rowe MM, Sherlock H. Stress and verbal abuse in nursing: do burned out nurses eat their young? J Nurs Manag. 2005May;13(3):242-248.
7. Frank E, Carrera JS, Stratton T, et al. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ. 2006 Sep 30;333(7570):682.
8. Seiden SC, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care. 2006 Aug;15(4):272-276.
9. Wood DF. Bullying and harassment in medical schools. BMJ. 2006 Sep 30;333(7570):664-665.
10. Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med. 2006 Jan;81(1):94-101.
11. Institute for Safe Medication Practice. Intimidation: Mapping a plan for cultural change in healthcare (Part II). Available at www.ismp.org/Newsletters/acutecare/articles/20040325.asp Last accessed July 2, 2007.

Bullying, intimidation, verbal abuse—these behaviors negatively affect self-esteem, feelings of competence, and workplace morale. And they can devastate hospital professionals and their patients.

When 2,095 healthcare providers (1,565 nurses, 354 pharmacists, and 176 others) responded to an Institute for Safe Medication Practices (ISMP) survey on intimidation in their healthcare setting, remarkable data were collected.1

Perhaps the most alarming statistic in the 2003-2004 study was that 7% of respondents (n=147) reported they had been involved in a medication error allowed to occur partly because the respondents were afraid to question the prescriber’s decision. At a large urban trauma center in the northeastern United States, nurses listed intimidation as one of the barriers to implementing a sharps safety program.2

click for large version

Nurses’ Perceptions

Research over the past decade has spotlighted intimidation in healthcare.3

“Bullying and harassment still happen in many areas of medicine,” says David M. Pressel, MD, PhD, hospitalist and director, Inpatient Service, Division of General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. “The question is, how do you monitor yourself to make sure you aren’t falling into that hierarchical frame of mind that could intervene in great teaching and learning and great patient care?”

Dr. Pressel and his partner, David I. Rappaport, MD, also a pediatric hospitalist at duPont, have focused on the literature pertaining to nurse-physician relationships. Research shows that intimidation impedes nurse recruitment, retention, and satisfaction. In one study, 90% of nurses reported experiencing at least one episode of verbal abuse.4 A 1997 study examining the effects of intimidation on 35 pediatric nurses over a three-month period found that 25 (71.4%) of them reported being yelled at or loudly admonished. Sixteen (45.7%) had been victims of insults. Thirty (85.7%) were spoken to in a condescending manner. One-third of nurses believed that such behavior was “part of the job.”

Although studies have differed as to the most common source of this abuse—patients and families or physicians—a study of pediatric nurses reported a similar incidence from both sources.5 And, nurses are often guilty of verbally abusing each other.6

When the duPont pediatric hospitalist team began performing more family-centered rounds, they began to appreciate the nurse-physician relationship. “We have worked hard to have a charge nurse and oftentimes the bedside nurse with us when we round,” Dr. Rappaport says. Speculating that rounding with hospitalists allowed nurses to feel more part of the team, Dr. Rappaport says know the medical plan, consolidate efforts such that pages to residents were reduced, and generally improve communication. They heard from participating nurses that it made a tremendous difference. This prompted them to conduct their research.

“Our study looked at the nurse-physician relationship globally, not intimidation or abuse specifically,” says Dr. Rappaport. Along with their nurse colleague Norine Watson, RN, Drs. Pressel and Rappaport are examining the relationship between nurses and different categories of physicians: how nurses perceive interactions between nurses and surgical residents, surgical attendings, community physicians, pediatric residents, and pediatric hospitalists.

“Early data suggest that hospitalists may work more effectively with nurses because they share many of the same goals,” says Dr. Rappaport. “As hospital leaders, hospitalists can also improve working conditions for nurses by providing more accessible, efficient, and effective care. Presumably, improved collaboration will also include decreased intimidation or abuse from physicians and also probably from dissatisfied patients and families.”

Avoiding the trap of communicating in a manner that is too direct and might be construed as abusive requires self-awareness and the realization that people receive information in different ways, says Dr. Pressel. Standard professional behavior is the key. Beyond that, the challenge is giving feedback constructively and in a positive manner.

“Hospitalists [may be] more in tune with the needs of nurses than nonhospitalists,” says Dr. Rappaport. “I think that is one of our strengths. We need to continue to facilitate very strong relationships between nurses and physicians because without good nursing care, hospitalists simply cannot provide good medical care.”

There is another way hospitalists can help address verbal abuse. “Studies consistently show that nurses are hesitant to report episodes of verbal abuse,” Dr. Rappaport says, “whether it is from a family, a patient, a physician, or a fellow nurse. Fewer than one in five nurses reports these episodes. One thing that hospitalists can do is work with hospital administration to create an environment that is more proactive in addressing these concerns and allowing nurses to feel more support in this area.”

Only 60% of respondents to the ISMP survey felt their organization had clearly defined an effective process for handling disagreements with a medication order’s safety. Only about a third felt the process facilitated their bypassing an intimidating prescriber or their own supervisor if necessary. Although 70% of respondents reported that they thought their organization or manager would support them if they reported intimidating behavior, only 39% of respondents believed their organization was dealing effectively with intimidating behavior.

Untapped Source

Perceptions of intimidation also occur among trainees. When 2,884 students from the class of 2003 at 16 U.S. medical schools completed questionnaires at various times during training, 27% reported having been “harassed” by house staff, 21% by faculty, and 25% by patients.7 Further, 71% reported having been “belittled” by house staff, 63% by faculty, and 43% by patients.

Mistreated students were significantly more likely to have suffered stress, be depressed or suicidal, and less likely to report being glad they trained as a physician.

Studies consistently show that nurses are hesitant to report episodes of verbal abuse whether it is from a family, a patient, a physician, or a fellow nurse.

—David I. Rappaport, MD, pediatric hospitalist, Alfred I. Dupont Hospital for Children, Wilmington, Del.

This may have an underlying effect on the potential to monitor for patient safety.8,9 Because errors and near misses often result from miscommunication, medical students may be adept at preventing certain types of errors. Students’ observation skills may be just as keen, if not more so, than their more clinically proficient healthcare teammates.8 In four cases from two U.S. academic health centers reported by medical students Samuel Seiden, Cynthia Galvan, and Ruth Lamm in 2006, medical students demonstrated keen attention to detail and appropriately characterized problematic situations with patients—adding another layer of defense within systems safeguarding against patient harm.8 Yet of the 76% of medical students who had observed a medical error, only about half of the students reported the errors to a resident or an attending, despite having received patient-safety training; only 7% reported having used an electronic medical error reporting system.10

By Example

Some intimidation in medical education may be the result of anger toward students and residents over a lack of medical knowledge, says Jeffery G. Wiese, MD, associate professor of Medicine at Tulane University in New Orleans and member of the SHM Board of Directors. “It is natural to feel [that anger]; people abhor in others what they most detest in themselves,’’ he says. “As physicians, a lack of medical knowledge is what we detest in ourselves. But a student’s ignorance is usually a product of where she is in her training; that’s why she is with you.”

Anger alienates students, absolving them of the guilt of not knowing the information, and demotivating them from learning it. “The lesson to be communicated is that it is OK not to know, but it is not OK to continue to not know,” Dr. Wiese says. “Reprimands should be reserved for the student who does not know, and then after being taught or asked to look it up, continues to not know.”

“The average physician who practices for 30 years will take care of roughly 80,000 people,” estimates Dr. Wiese. “That’s an arithmetic contribution and there is nothing wrong with that. But if you really want to change the world, teaching is the rule. The same 30 years invested in teaching will indirectly affect 400 million people,” he says. “Even better, if you can train your students and residents in the value of coaching their students and residents, well, now you’re talking about 10 billion people that you can affect over the course of a career.”

The question to ask yourself, says Dr. Wiese, is: Do you want to change the world? “If you do, this is the way to do it,” he says.

“For the 30 years in your career, focus on clinical coaching and getting others to clinically coach. That way, especially if you have the right motives in your heart, the right vision for the way you want to see the profession practiced, and the way you want patient care performed, that’s your shot at changing the world.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Institute for Safe Medication Practice. Intimidation: practitioners speak up about this unresolved problem (Part I). Available at w.ismp.org/Newsletters/acutecare/articles/20040311_2.asp. Last accessed June 27, 2007.
2. Hagstrom AM. Perceived barriers to implementation of a successful sharps safety program. AORN J. 2006;83(2):391-7.
3. Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Safety Qual Healthc. 2006 Jul-Aug;3:16-24.
4. Manderino MA, Berkey N. Verbal abuse of staff nurses by physicians. J Prof Nurs. 1997;13(1):48-55.
5. Pejic AR. Verbal abuse: A problem for pediatric nurses. Pediatr Nurs. 2005;31(4):271-279.
6. Rowe MM, Sherlock H. Stress and verbal abuse in nursing: do burned out nurses eat their young? J Nurs Manag. 2005May;13(3):242-248.
7. Frank E, Carrera JS, Stratton T, et al. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ. 2006 Sep 30;333(7570):682.
8. Seiden SC, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care. 2006 Aug;15(4):272-276.
9. Wood DF. Bullying and harassment in medical schools. BMJ. 2006 Sep 30;333(7570):664-665.
10. Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med. 2006 Jan;81(1):94-101.
11. Institute for Safe Medication Practice. Intimidation: Mapping a plan for cultural change in healthcare (Part II). Available at www.ismp.org/Newsletters/acutecare/articles/20040325.asp Last accessed July 2, 2007.

Bullying, intimidation, verbal abuse—these behaviors negatively affect self-esteem, feelings of competence, and workplace morale. And they can devastate hospital professionals and their patients.

When 2,095 healthcare providers (1,565 nurses, 354 pharmacists, and 176 others) responded to an Institute for Safe Medication Practices (ISMP) survey on intimidation in their healthcare setting, remarkable data were collected.1

Perhaps the most alarming statistic in the 2003-2004 study was that 7% of respondents (n=147) reported they had been involved in a medication error allowed to occur partly because the respondents were afraid to question the prescriber’s decision. At a large urban trauma center in the northeastern United States, nurses listed intimidation as one of the barriers to implementing a sharps safety program.2

click for large version

Nurses’ Perceptions

Research over the past decade has spotlighted intimidation in healthcare.3

“Bullying and harassment still happen in many areas of medicine,” says David M. Pressel, MD, PhD, hospitalist and director, Inpatient Service, Division of General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. “The question is, how do you monitor yourself to make sure you aren’t falling into that hierarchical frame of mind that could intervene in great teaching and learning and great patient care?”

Dr. Pressel and his partner, David I. Rappaport, MD, also a pediatric hospitalist at duPont, have focused on the literature pertaining to nurse-physician relationships. Research shows that intimidation impedes nurse recruitment, retention, and satisfaction. In one study, 90% of nurses reported experiencing at least one episode of verbal abuse.4 A 1997 study examining the effects of intimidation on 35 pediatric nurses over a three-month period found that 25 (71.4%) of them reported being yelled at or loudly admonished. Sixteen (45.7%) had been victims of insults. Thirty (85.7%) were spoken to in a condescending manner. One-third of nurses believed that such behavior was “part of the job.”

Although studies have differed as to the most common source of this abuse—patients and families or physicians—a study of pediatric nurses reported a similar incidence from both sources.5 And, nurses are often guilty of verbally abusing each other.6

When the duPont pediatric hospitalist team began performing more family-centered rounds, they began to appreciate the nurse-physician relationship. “We have worked hard to have a charge nurse and oftentimes the bedside nurse with us when we round,” Dr. Rappaport says. Speculating that rounding with hospitalists allowed nurses to feel more part of the team, Dr. Rappaport says know the medical plan, consolidate efforts such that pages to residents were reduced, and generally improve communication. They heard from participating nurses that it made a tremendous difference. This prompted them to conduct their research.

“Our study looked at the nurse-physician relationship globally, not intimidation or abuse specifically,” says Dr. Rappaport. Along with their nurse colleague Norine Watson, RN, Drs. Pressel and Rappaport are examining the relationship between nurses and different categories of physicians: how nurses perceive interactions between nurses and surgical residents, surgical attendings, community physicians, pediatric residents, and pediatric hospitalists.

“Early data suggest that hospitalists may work more effectively with nurses because they share many of the same goals,” says Dr. Rappaport. “As hospital leaders, hospitalists can also improve working conditions for nurses by providing more accessible, efficient, and effective care. Presumably, improved collaboration will also include decreased intimidation or abuse from physicians and also probably from dissatisfied patients and families.”

Avoiding the trap of communicating in a manner that is too direct and might be construed as abusive requires self-awareness and the realization that people receive information in different ways, says Dr. Pressel. Standard professional behavior is the key. Beyond that, the challenge is giving feedback constructively and in a positive manner.

“Hospitalists [may be] more in tune with the needs of nurses than nonhospitalists,” says Dr. Rappaport. “I think that is one of our strengths. We need to continue to facilitate very strong relationships between nurses and physicians because without good nursing care, hospitalists simply cannot provide good medical care.”

There is another way hospitalists can help address verbal abuse. “Studies consistently show that nurses are hesitant to report episodes of verbal abuse,” Dr. Rappaport says, “whether it is from a family, a patient, a physician, or a fellow nurse. Fewer than one in five nurses reports these episodes. One thing that hospitalists can do is work with hospital administration to create an environment that is more proactive in addressing these concerns and allowing nurses to feel more support in this area.”

Only 60% of respondents to the ISMP survey felt their organization had clearly defined an effective process for handling disagreements with a medication order’s safety. Only about a third felt the process facilitated their bypassing an intimidating prescriber or their own supervisor if necessary. Although 70% of respondents reported that they thought their organization or manager would support them if they reported intimidating behavior, only 39% of respondents believed their organization was dealing effectively with intimidating behavior.

Untapped Source

Perceptions of intimidation also occur among trainees. When 2,884 students from the class of 2003 at 16 U.S. medical schools completed questionnaires at various times during training, 27% reported having been “harassed” by house staff, 21% by faculty, and 25% by patients.7 Further, 71% reported having been “belittled” by house staff, 63% by faculty, and 43% by patients.

Mistreated students were significantly more likely to have suffered stress, be depressed or suicidal, and less likely to report being glad they trained as a physician.

Studies consistently show that nurses are hesitant to report episodes of verbal abuse whether it is from a family, a patient, a physician, or a fellow nurse.

—David I. Rappaport, MD, pediatric hospitalist, Alfred I. Dupont Hospital for Children, Wilmington, Del.

This may have an underlying effect on the potential to monitor for patient safety.8,9 Because errors and near misses often result from miscommunication, medical students may be adept at preventing certain types of errors. Students’ observation skills may be just as keen, if not more so, than their more clinically proficient healthcare teammates.8 In four cases from two U.S. academic health centers reported by medical students Samuel Seiden, Cynthia Galvan, and Ruth Lamm in 2006, medical students demonstrated keen attention to detail and appropriately characterized problematic situations with patients—adding another layer of defense within systems safeguarding against patient harm.8 Yet of the 76% of medical students who had observed a medical error, only about half of the students reported the errors to a resident or an attending, despite having received patient-safety training; only 7% reported having used an electronic medical error reporting system.10

By Example

Some intimidation in medical education may be the result of anger toward students and residents over a lack of medical knowledge, says Jeffery G. Wiese, MD, associate professor of Medicine at Tulane University in New Orleans and member of the SHM Board of Directors. “It is natural to feel [that anger]; people abhor in others what they most detest in themselves,’’ he says. “As physicians, a lack of medical knowledge is what we detest in ourselves. But a student’s ignorance is usually a product of where she is in her training; that’s why she is with you.”

Anger alienates students, absolving them of the guilt of not knowing the information, and demotivating them from learning it. “The lesson to be communicated is that it is OK not to know, but it is not OK to continue to not know,” Dr. Wiese says. “Reprimands should be reserved for the student who does not know, and then after being taught or asked to look it up, continues to not know.”

“The average physician who practices for 30 years will take care of roughly 80,000 people,” estimates Dr. Wiese. “That’s an arithmetic contribution and there is nothing wrong with that. But if you really want to change the world, teaching is the rule. The same 30 years invested in teaching will indirectly affect 400 million people,” he says. “Even better, if you can train your students and residents in the value of coaching their students and residents, well, now you’re talking about 10 billion people that you can affect over the course of a career.”

The question to ask yourself, says Dr. Wiese, is: Do you want to change the world? “If you do, this is the way to do it,” he says.

“For the 30 years in your career, focus on clinical coaching and getting others to clinically coach. That way, especially if you have the right motives in your heart, the right vision for the way you want to see the profession practiced, and the way you want patient care performed, that’s your shot at changing the world.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Institute for Safe Medication Practice. Intimidation: practitioners speak up about this unresolved problem (Part I). Available at w.ismp.org/Newsletters/acutecare/articles/20040311_2.asp. Last accessed June 27, 2007.
2. Hagstrom AM. Perceived barriers to implementation of a successful sharps safety program. AORN J. 2006;83(2):391-7.
3. Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Safety Qual Healthc. 2006 Jul-Aug;3:16-24.
4. Manderino MA, Berkey N. Verbal abuse of staff nurses by physicians. J Prof Nurs. 1997;13(1):48-55.
5. Pejic AR. Verbal abuse: A problem for pediatric nurses. Pediatr Nurs. 2005;31(4):271-279.
6. Rowe MM, Sherlock H. Stress and verbal abuse in nursing: do burned out nurses eat their young? J Nurs Manag. 2005May;13(3):242-248.
7. Frank E, Carrera JS, Stratton T, et al. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ. 2006 Sep 30;333(7570):682.
8. Seiden SC, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care. 2006 Aug;15(4):272-276.
9. Wood DF. Bullying and harassment in medical schools. BMJ. 2006 Sep 30;333(7570):664-665.
10. Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med. 2006 Jan;81(1):94-101.
11. Institute for Safe Medication Practice. Intimidation: Mapping a plan for cultural change in healthcare (Part II). Available at www.ismp.org/Newsletters/acutecare/articles/20040325.asp Last accessed July 2, 2007.

In reflecting on the history of pediatric hospital medicine (HM), I have identified a widening schism between inpatient and outpatient pediatrics as the major threat to HM. Here, I follow Bob Wachter’s lead from SHM’s May annual meeting and detail key steps for pediatric HM in the upcoming 10 years.

Define the field: The SHM Pediatric Committee and the Ambulatory Pediatric Association’s (APA) hospital medicine special interest group are collaborating to publish a list of core clinical procedural and systems domains for pediatric hospital medicine.

This will provide a blueprint of how we have defined our field and supply a framework for pediatric acute care residency tracks, hospitalist electives, hospitalist fellowships, and maintenance of certification (MOC). Related characterizations of the field are available through pediatric hospital medicine textbooks. The Pediatric Research in Inpatient Settings (PRIS) network is studying the epidemiology of pediatric HM practice to provide an evidence basis for these expert decrees.

Individual programs should use these resources to help develop program-specific hospitalist privilege materials based on documented patient acuity, volume, and hospital medicine CME activities. The specific criteria and privileges will differ based on differences in job description between and within tertiary care centers and community hospitals—but all will include the general pediatric ward.

Develop MOC Appropriate for Pediatric Hospitalists: The American Board of Internal Medicine has officially approved the creation of a Focused Recognition of Hospital Medicine through its MOC system. A final decision rests with the American Board of Medical Specialties.

Pediatric hospitalists will do well to wait several years to examine the results of these efforts before deciding whether to pursue a similar designation from the American Board of Pediatrics. In the meantime, we should be on a fast track to create specific pediatric HM materials that will meet the 2010 MOC requirements.

There are at least 1,500 practicing pediatric hospitalists. This is equal to the number of board-certified pediatric ED physicians (1,446) and considerably more than the number of pulmonologists (821). Certainly these numbers merit development of MOC materials specifical to pediatric HM. The American Academy of Pediatrics (AAP) is developing an inpatient Education in Quality Improvement for Pediatric Practice (eQIPP) asthma model. SHM may be able to develop a transitions-of-care personal information manager and/or self-evaluation program (SEP) module appropriate for adult and pediatric hospitalists.

The only things missing are a comprehensive inpatient SEP and a closed-book exam. Pediatric hospitalists are here to stay. The American Board of Pediatrics (ABP) will best fulfill its responsibility to the public by creating an MOC program germane to pediatric HM. The actual designation on the MOC doesn’t need to be changed in 2010, but hospitalists recertifying in 2010 should be participating in relevant activities.

Expand pediatric HM (post-) graduate medical education: The increasing number of hospitalists will undoubtedly influence pediatric graduate medical education.

The ABP’s Residency Review and Redesign in Pediatrics project, which looks at global reform of pediatric residency training, should allow for acute care pediatric residency tracks. These would be amenable to pediatricians planning careers in HM, emergency medicine, and critical care.

Overall, most pediatric hospitalists will continue to begin their careers directly out of residency. Although pediatric hospitalist fellowship programs are likely to increase in number, formal fellowship training will not be required for one to practice as a pediatric hospitalist. These programs will benefit individuals choosing either an academic or administrative career. Frontline hospitalists should be able to gain suitable experience through appropriately mentored and supported clinical practice and focused CME activities—much as a new office-based pediatrician matures during his or her initial years in practice.

Publish, publish, publish: Success within the academic and research environment is crucial to being viewed as equal among subspecialties.

Perceptions of our field improve with each paper published in Pediatrics and the Journal of Hospital Medicine and each plenary presentation at a national meeting. Within our professional community, writing articles for The Hospitalist and the AAP Section on Hospital Medicine newsletter and presenting our work in poster form or hospitalist platform presentation advances knowledge and creates group identity.

Additionally, these activities promote the pediatric HM group and the authors. Some of us have made a career out of LISTSERV postings.

Continue to grow PRIS: We must all contribute to the growth of PRIS over the next decade.

Ultimately, PRIS promises to answer clinical questions faced by hospitalists the same way the Vermont Oxford Network helps neonatology and the Pediatric Emergency Care Applied Research Network helps pediatric emergency medicine. Academic hospitalists can use PRIS to pursue their research interests. Community hospitalists can pick and choose from available projects to identify a study relevant and suitable for them. We all must participate.

My hope is that in 10 to 20 years PRIS will coordinate randomized, controlled clinical trials and universal, integrated, HIPPA-compliant, electronic medical record systems that facilitate real-time analysis of outcomes and practice variation.

Own our diseases: Defining The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, creating a research base, and publishing must lead to the recognition of pediatric hospitalists as the experts for a core set of illnesses.

Potential starting points include bronchiolitis, the ruling out of sepsis in less than 30 days, apparent life-threatening events (ALTE), and the medically complex/technologically dependent child. We’ll know we’ve hit it big when the nationally recognized speakers and authors on these topics identify themselves as hospitalists rather than infectious disease physicians or pulmonologists. For this to occur, hospitalists must participate in research efforts, speak at regional and national meetings, and participate on national consensus panels.

On a purely local program level, individual physicians within a hospital medicine group should cultivate areas of clinical, administrative, and educational expertise. This is particularly valuable in community hospital settings where pediatric infectious disease or pulmonary specialists may not be available—but is equally important to career development in larger academic centers where hospitalists are ideal for quality improvement, safety, and educational roles.

Identify and publicly report national benchmarks: Our adult colleagues suffer and benefit from the public reporting mandated by the Centers for Medicare and Medicaid Services. One hopes the adult tribulations with data collection, attribution, and risk adjustment will make pediatric public reporting easier.

The wide variation in management of ALTE, osteomyelitis, and complicated pneumonias documented by Pediatric Health Information System researchers at the Toronto Pediatric Academic Societies meetings is a clarion call for evidence-based medicine. Parents have a right to make an informed choice about where and how their child is treated based on reliable data. Rational expenditure of limited State Children’s Health Insurance Program (SCHIP) funds requires practicing evidence-based medicine

Pediatric quality measures and standards are being developed through the National Quality Forum as well as the Alliance for Pediatric Quality. This movement will significantly affect pediatric HM. On the positive side, reporting will require that more resources be devoted to pediatric quality improvement (QI) efforts. Pediatric hospitalists are ideally suited to lead inpatient QI efforts. Creation of a hospitalist physician specialty identification code will facilitate comparison of hospitalist with non-hospitalist care in large multicenter data sets. These studies will be key descriptors of the cost and quality outcomes of pediatric HM programs.

Public reporting will highlight variation among hospitals, programs, and, possibly, physicians. Parents and payers will vote with their feet. Overall, this will create less variation in care as best practices are identified and adopted. Shortcomings will be revealed in programs that fail to practice state-of-the-art pediatrics or that are inadequately staffed from either the physician or nursing perspective. This likely will result in a consolidation of pediatric care. Smaller units closer to larger pediatric centers probably will close or become affiliates of the referral center. Geographic proximity will be a secondary concern to outcomes for parents and office-based pediatricians.

The methodological and political considerations of pay for performance are beyond most of us. Nonetheless, we in pediatric HM can begin to prepare for these changes by identifying the benchmarks that highlight our successes and failures as hospitalists, groups, hospitals, and the field as a whole. Potential clinical, quality, economic, and logistic metrics include severity-adjusted lengths of stay (LOS) for asthma and bronchiolitis, readmission rates, time to antibiotics for ruling out sepsis less than 30 days, patient and referring physician satisfaction, and coordination of transitions of care.

Expand children’s health insurance: SCHIP and universal insurance for children enjoys significant support.

The AAP’s efforts in this area deserve praise and demand continued support. As noted previously, large public expenditures on SCHIP likely will be linked to public reporting of outcomes. It is crucial to the economic viability of pediatrics that SCHIP reimbursement is equivalent to Medicare reimbursement on a code-for-code basis. It is indefensible to suggest that we as a nation value the care of children less than the care of the elderly.

Ultimately, SCHIP and state Medicaid programs would do well to move beyond a per diem-based system of reimbursement for pediatric inpatient care to a system based either on diagnosis-related groups (DRGs) or disease episodes. This would benefit HM programs by rewarding hospitals that can shorten LOS while providing the same high-quality outcomes. Current per diem reimbursement paradigms at best fail to maximally encourage efficiency and at worst create perverse incentives to prolong LOS.

Relentlessly pursue career satisfaction: Many programs are asking pediatric hospitalists to work at a clinical pace not sustainable over a 20- to 30-year career. Particularly efficient programs can produce burnout in one to three years of excessive workloads and call obligations.

SHM’s “A White Paper on Hospitalist Career Satisfaction” identifies four pillars: reward/recognition, workload/schedule, autonomy/control, and community/environment. (Each pillar has been featured in the “Career Development” section, starting with the June issue.) In pediatrics we can turn to neonatology, pediatric critical care, and (pediatric) emergency medicine for help in establishing realistic guidelines for clinical hours in house.

The harder question to answer is: What is a reasonable number of patients for a hospitalist to cover at a time? This depends on patient acuity, patient and family expectations, teaching responsibilities, hospitalist responsibilities outside the ward, and physician style. It is unlikely that prospective randomized controlled trials will be conducted to answer this question. The answer is likely to come from individual programs, hospitalists, and—regrettably—patients suffering the consequences of pushing the limits too far. We will learn from our mistakes. Failed models will not be repeated. To the extent that quality rather than economics becomes the overriding driver for HM programs, I favor 15 encounters per hospitalist per day over 20.

Hospitalists also must diversify beyond pure clinical practice for long-term career satisfaction. Focusing on a specific clinical interest, subspecialty, or practice environment can provide some variety.

Teaching and research is another source of career satisfaction. Each hospitalist within a group should be involved in at least one QI project and/or committee—if only to appreciate the importance and complexity of a systems approach to improving overall outcomes. Job descriptions must include protected time for these nonclinical activities. Career growth and satisfaction will be stifled without these additional outlets.

Expand beyond traditional roles: The push for improved quality will lead to expanded roles for pediatric hospitalists—some of which may be unwelcome.

In particular, larger programs will move to 24/7 in-house hospitalist presence. Given the acuity and complexity of the patients we care for, particularly in tertiary care centers, the quality argument for 24/7 in-house coverage will quickly trump the economic argument against it. The choice is obvious in terms of quality and safety and from the perspective of the most important “decider” when it comes to healthcare—the patient.

As educators exploit the opportunities of 24/7 coverage, resident teaching will increase and academic hospitalists will master the art of promoting autonomy 24/7 while providing appropriate supervision. If we learned to teach with family-centered rounds, we can learn to teach at 3 a.m.

In addition to expanded hours, we will follow the lead of adult hospitalists and increase our co-management role beyond the traditional general medical patient on the hospitalist service. This will include surgical and subspecialty patients. From the patient’s and family’s perspective the improved care that can result is valuable. It may not be necessary for every patient or for every surgeon or subspecialist, but on the whole hospitalists provide added value.

Within individual programs and among various physicians, the rules of engagement will need to be defined to promote collegial, respectful relationships with clear lines of communication and defined clinical responsibilities. “Inappropriate behavior” from “difficult” physicians (surgeons, subspecialists, and hospitalists) will need to be addressed. Specific arrangements will need to be defined (co-management versus specialist/surgeon attending with hospitalist consultation or hospitalist attending with specialist/surgeon consultant). But once the rules of engagement are established and appropriate resources allotted, it becomes impossible for hospitalists to argue that it’s not within our job description to contribute to improved quality of care for hospitalized patients. Improving patient care is not scutwork.

In particular, given the limited availability of pediatric sub-specialists and surgeons, to the extent that we as hospitalists can increase the efficiency of our subspecialty and surgical colleagues, we can improve access to pediatric subspecialty care within both the inpatient and outpatient settings These manpower issues will also drive involvement of pediatric hospitalists into other parts of the hospital such as sedation services, the ED, the NICU, and PICU. As these other services become vocal advocates for pediatric hospitalists, the economic viability of pediatric hospital medicine programs will increase.

Make the economic argument for value-added services: Pediatric hospitalists must do better at the economic arguments of value-added services.

Until pediatric inpatient stays are reimbursed on a DRG basis or physician charges are based on a global fee, we most move beyond the simple formulation of decreased costs for inpatient stays. We must highlight the value of our critical roles in coordination of care; quality and safety; 24/7 coverage; improved throughput in the emergency department (ED), ward, and PICU; and increased efficiency for surgeons and subspecialists.

Success for pediatric HM in these arenas will come only at the cost of failed individual programs. As implied above, it is only natural for non-hospitalist administrators and department leaders to push the limits of hospitalist programs to the maximum. Programs that place excessive demands on hospitalists will implode. Good hospitalists will leave for positions that offer them respect, autonomy, and a reasonable workload and lifestyle. Small community programs with low-volume services may not be economically viable. As we develop a history of successful programs and failed programs, hospitalists and administrators will have more realistic expectations of the ingredients of success.

Conclusion

Programs that meet the above challenges will succeed. Pediatric HM is a tremendously rewarding and challenging field. National recognition of pediatric HM as a unique field combined with the respect of local pediatricians, subspecialists, and surgeons will create the pride and ownership among hospitalists necessary for us to raise the bar for standards of inpatient care.

Public reporting will provide the external pull for the same high-quality outcomes. Divisions of HM led by hospitalists in which each hospitalist has an additional clinical, administrative, or academic focus will create the workload, autonomy, and diversity necessary for long-term career satisfaction and support the research and QI activities necessary for the evidence-based practice of high-quality pediatric inpatient care by hospitalists and non-hospitalists alike. Universal access, economic parity with Medicare, and a full understanding of the value-added nature of pediatric hospital medicine practice will provide the margin necessary for this mission. It will be a challenging but rewarding 10 years. TH

Dr. Percelay is SHM’s treasurer and a pediatric hospitalist.

In reflecting on the history of pediatric hospital medicine (HM), I have identified a widening schism between inpatient and outpatient pediatrics as the major threat to HM. Here, I follow Bob Wachter’s lead from SHM’s May annual meeting and detail key steps for pediatric HM in the upcoming 10 years.

Define the field: The SHM Pediatric Committee and the Ambulatory Pediatric Association’s (APA) hospital medicine special interest group are collaborating to publish a list of core clinical procedural and systems domains for pediatric hospital medicine.

This will provide a blueprint of how we have defined our field and supply a framework for pediatric acute care residency tracks, hospitalist electives, hospitalist fellowships, and maintenance of certification (MOC). Related characterizations of the field are available through pediatric hospital medicine textbooks. The Pediatric Research in Inpatient Settings (PRIS) network is studying the epidemiology of pediatric HM practice to provide an evidence basis for these expert decrees.

Individual programs should use these resources to help develop program-specific hospitalist privilege materials based on documented patient acuity, volume, and hospital medicine CME activities. The specific criteria and privileges will differ based on differences in job description between and within tertiary care centers and community hospitals—but all will include the general pediatric ward.

Develop MOC Appropriate for Pediatric Hospitalists: The American Board of Internal Medicine has officially approved the creation of a Focused Recognition of Hospital Medicine through its MOC system. A final decision rests with the American Board of Medical Specialties.

Pediatric hospitalists will do well to wait several years to examine the results of these efforts before deciding whether to pursue a similar designation from the American Board of Pediatrics. In the meantime, we should be on a fast track to create specific pediatric HM materials that will meet the 2010 MOC requirements.

There are at least 1,500 practicing pediatric hospitalists. This is equal to the number of board-certified pediatric ED physicians (1,446) and considerably more than the number of pulmonologists (821). Certainly these numbers merit development of MOC materials specifical to pediatric HM. The American Academy of Pediatrics (AAP) is developing an inpatient Education in Quality Improvement for Pediatric Practice (eQIPP) asthma model. SHM may be able to develop a transitions-of-care personal information manager and/or self-evaluation program (SEP) module appropriate for adult and pediatric hospitalists.

The only things missing are a comprehensive inpatient SEP and a closed-book exam. Pediatric hospitalists are here to stay. The American Board of Pediatrics (ABP) will best fulfill its responsibility to the public by creating an MOC program germane to pediatric HM. The actual designation on the MOC doesn’t need to be changed in 2010, but hospitalists recertifying in 2010 should be participating in relevant activities.

Expand pediatric HM (post-) graduate medical education: The increasing number of hospitalists will undoubtedly influence pediatric graduate medical education.

The ABP’s Residency Review and Redesign in Pediatrics project, which looks at global reform of pediatric residency training, should allow for acute care pediatric residency tracks. These would be amenable to pediatricians planning careers in HM, emergency medicine, and critical care.

Overall, most pediatric hospitalists will continue to begin their careers directly out of residency. Although pediatric hospitalist fellowship programs are likely to increase in number, formal fellowship training will not be required for one to practice as a pediatric hospitalist. These programs will benefit individuals choosing either an academic or administrative career. Frontline hospitalists should be able to gain suitable experience through appropriately mentored and supported clinical practice and focused CME activities—much as a new office-based pediatrician matures during his or her initial years in practice.

Publish, publish, publish: Success within the academic and research environment is crucial to being viewed as equal among subspecialties.

Perceptions of our field improve with each paper published in Pediatrics and the Journal of Hospital Medicine and each plenary presentation at a national meeting. Within our professional community, writing articles for The Hospitalist and the AAP Section on Hospital Medicine newsletter and presenting our work in poster form or hospitalist platform presentation advances knowledge and creates group identity.

Additionally, these activities promote the pediatric HM group and the authors. Some of us have made a career out of LISTSERV postings.

Continue to grow PRIS: We must all contribute to the growth of PRIS over the next decade.

Ultimately, PRIS promises to answer clinical questions faced by hospitalists the same way the Vermont Oxford Network helps neonatology and the Pediatric Emergency Care Applied Research Network helps pediatric emergency medicine. Academic hospitalists can use PRIS to pursue their research interests. Community hospitalists can pick and choose from available projects to identify a study relevant and suitable for them. We all must participate.

My hope is that in 10 to 20 years PRIS will coordinate randomized, controlled clinical trials and universal, integrated, HIPPA-compliant, electronic medical record systems that facilitate real-time analysis of outcomes and practice variation.

Own our diseases: Defining The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, creating a research base, and publishing must lead to the recognition of pediatric hospitalists as the experts for a core set of illnesses.

Potential starting points include bronchiolitis, the ruling out of sepsis in less than 30 days, apparent life-threatening events (ALTE), and the medically complex/technologically dependent child. We’ll know we’ve hit it big when the nationally recognized speakers and authors on these topics identify themselves as hospitalists rather than infectious disease physicians or pulmonologists. For this to occur, hospitalists must participate in research efforts, speak at regional and national meetings, and participate on national consensus panels.

On a purely local program level, individual physicians within a hospital medicine group should cultivate areas of clinical, administrative, and educational expertise. This is particularly valuable in community hospital settings where pediatric infectious disease or pulmonary specialists may not be available—but is equally important to career development in larger academic centers where hospitalists are ideal for quality improvement, safety, and educational roles.

Identify and publicly report national benchmarks: Our adult colleagues suffer and benefit from the public reporting mandated by the Centers for Medicare and Medicaid Services. One hopes the adult tribulations with data collection, attribution, and risk adjustment will make pediatric public reporting easier.

The wide variation in management of ALTE, osteomyelitis, and complicated pneumonias documented by Pediatric Health Information System researchers at the Toronto Pediatric Academic Societies meetings is a clarion call for evidence-based medicine. Parents have a right to make an informed choice about where and how their child is treated based on reliable data. Rational expenditure of limited State Children’s Health Insurance Program (SCHIP) funds requires practicing evidence-based medicine

Pediatric quality measures and standards are being developed through the National Quality Forum as well as the Alliance for Pediatric Quality. This movement will significantly affect pediatric HM. On the positive side, reporting will require that more resources be devoted to pediatric quality improvement (QI) efforts. Pediatric hospitalists are ideally suited to lead inpatient QI efforts. Creation of a hospitalist physician specialty identification code will facilitate comparison of hospitalist with non-hospitalist care in large multicenter data sets. These studies will be key descriptors of the cost and quality outcomes of pediatric HM programs.

Public reporting will highlight variation among hospitals, programs, and, possibly, physicians. Parents and payers will vote with their feet. Overall, this will create less variation in care as best practices are identified and adopted. Shortcomings will be revealed in programs that fail to practice state-of-the-art pediatrics or that are inadequately staffed from either the physician or nursing perspective. This likely will result in a consolidation of pediatric care. Smaller units closer to larger pediatric centers probably will close or become affiliates of the referral center. Geographic proximity will be a secondary concern to outcomes for parents and office-based pediatricians.

The methodological and political considerations of pay for performance are beyond most of us. Nonetheless, we in pediatric HM can begin to prepare for these changes by identifying the benchmarks that highlight our successes and failures as hospitalists, groups, hospitals, and the field as a whole. Potential clinical, quality, economic, and logistic metrics include severity-adjusted lengths of stay (LOS) for asthma and bronchiolitis, readmission rates, time to antibiotics for ruling out sepsis less than 30 days, patient and referring physician satisfaction, and coordination of transitions of care.

Expand children’s health insurance: SCHIP and universal insurance for children enjoys significant support.

The AAP’s efforts in this area deserve praise and demand continued support. As noted previously, large public expenditures on SCHIP likely will be linked to public reporting of outcomes. It is crucial to the economic viability of pediatrics that SCHIP reimbursement is equivalent to Medicare reimbursement on a code-for-code basis. It is indefensible to suggest that we as a nation value the care of children less than the care of the elderly.

Ultimately, SCHIP and state Medicaid programs would do well to move beyond a per diem-based system of reimbursement for pediatric inpatient care to a system based either on diagnosis-related groups (DRGs) or disease episodes. This would benefit HM programs by rewarding hospitals that can shorten LOS while providing the same high-quality outcomes. Current per diem reimbursement paradigms at best fail to maximally encourage efficiency and at worst create perverse incentives to prolong LOS.

Relentlessly pursue career satisfaction: Many programs are asking pediatric hospitalists to work at a clinical pace not sustainable over a 20- to 30-year career. Particularly efficient programs can produce burnout in one to three years of excessive workloads and call obligations.

SHM’s “A White Paper on Hospitalist Career Satisfaction” identifies four pillars: reward/recognition, workload/schedule, autonomy/control, and community/environment. (Each pillar has been featured in the “Career Development” section, starting with the June issue.) In pediatrics we can turn to neonatology, pediatric critical care, and (pediatric) emergency medicine for help in establishing realistic guidelines for clinical hours in house.

The harder question to answer is: What is a reasonable number of patients for a hospitalist to cover at a time? This depends on patient acuity, patient and family expectations, teaching responsibilities, hospitalist responsibilities outside the ward, and physician style. It is unlikely that prospective randomized controlled trials will be conducted to answer this question. The answer is likely to come from individual programs, hospitalists, and—regrettably—patients suffering the consequences of pushing the limits too far. We will learn from our mistakes. Failed models will not be repeated. To the extent that quality rather than economics becomes the overriding driver for HM programs, I favor 15 encounters per hospitalist per day over 20.

Hospitalists also must diversify beyond pure clinical practice for long-term career satisfaction. Focusing on a specific clinical interest, subspecialty, or practice environment can provide some variety.

Teaching and research is another source of career satisfaction. Each hospitalist within a group should be involved in at least one QI project and/or committee—if only to appreciate the importance and complexity of a systems approach to improving overall outcomes. Job descriptions must include protected time for these nonclinical activities. Career growth and satisfaction will be stifled without these additional outlets.

Expand beyond traditional roles: The push for improved quality will lead to expanded roles for pediatric hospitalists—some of which may be unwelcome.

In particular, larger programs will move to 24/7 in-house hospitalist presence. Given the acuity and complexity of the patients we care for, particularly in tertiary care centers, the quality argument for 24/7 in-house coverage will quickly trump the economic argument against it. The choice is obvious in terms of quality and safety and from the perspective of the most important “decider” when it comes to healthcare—the patient.

As educators exploit the opportunities of 24/7 coverage, resident teaching will increase and academic hospitalists will master the art of promoting autonomy 24/7 while providing appropriate supervision. If we learned to teach with family-centered rounds, we can learn to teach at 3 a.m.

In addition to expanded hours, we will follow the lead of adult hospitalists and increase our co-management role beyond the traditional general medical patient on the hospitalist service. This will include surgical and subspecialty patients. From the patient’s and family’s perspective the improved care that can result is valuable. It may not be necessary for every patient or for every surgeon or subspecialist, but on the whole hospitalists provide added value.

Within individual programs and among various physicians, the rules of engagement will need to be defined to promote collegial, respectful relationships with clear lines of communication and defined clinical responsibilities. “Inappropriate behavior” from “difficult” physicians (surgeons, subspecialists, and hospitalists) will need to be addressed. Specific arrangements will need to be defined (co-management versus specialist/surgeon attending with hospitalist consultation or hospitalist attending with specialist/surgeon consultant). But once the rules of engagement are established and appropriate resources allotted, it becomes impossible for hospitalists to argue that it’s not within our job description to contribute to improved quality of care for hospitalized patients. Improving patient care is not scutwork.

In particular, given the limited availability of pediatric sub-specialists and surgeons, to the extent that we as hospitalists can increase the efficiency of our subspecialty and surgical colleagues, we can improve access to pediatric subspecialty care within both the inpatient and outpatient settings These manpower issues will also drive involvement of pediatric hospitalists into other parts of the hospital such as sedation services, the ED, the NICU, and PICU. As these other services become vocal advocates for pediatric hospitalists, the economic viability of pediatric hospital medicine programs will increase.

Make the economic argument for value-added services: Pediatric hospitalists must do better at the economic arguments of value-added services.

Until pediatric inpatient stays are reimbursed on a DRG basis or physician charges are based on a global fee, we most move beyond the simple formulation of decreased costs for inpatient stays. We must highlight the value of our critical roles in coordination of care; quality and safety; 24/7 coverage; improved throughput in the emergency department (ED), ward, and PICU; and increased efficiency for surgeons and subspecialists.

Success for pediatric HM in these arenas will come only at the cost of failed individual programs. As implied above, it is only natural for non-hospitalist administrators and department leaders to push the limits of hospitalist programs to the maximum. Programs that place excessive demands on hospitalists will implode. Good hospitalists will leave for positions that offer them respect, autonomy, and a reasonable workload and lifestyle. Small community programs with low-volume services may not be economically viable. As we develop a history of successful programs and failed programs, hospitalists and administrators will have more realistic expectations of the ingredients of success.

Conclusion

Programs that meet the above challenges will succeed. Pediatric HM is a tremendously rewarding and challenging field. National recognition of pediatric HM as a unique field combined with the respect of local pediatricians, subspecialists, and surgeons will create the pride and ownership among hospitalists necessary for us to raise the bar for standards of inpatient care.

Public reporting will provide the external pull for the same high-quality outcomes. Divisions of HM led by hospitalists in which each hospitalist has an additional clinical, administrative, or academic focus will create the workload, autonomy, and diversity necessary for long-term career satisfaction and support the research and QI activities necessary for the evidence-based practice of high-quality pediatric inpatient care by hospitalists and non-hospitalists alike. Universal access, economic parity with Medicare, and a full understanding of the value-added nature of pediatric hospital medicine practice will provide the margin necessary for this mission. It will be a challenging but rewarding 10 years. TH

Dr. Percelay is SHM’s treasurer and a pediatric hospitalist.

In reflecting on the history of pediatric hospital medicine (HM), I have identified a widening schism between inpatient and outpatient pediatrics as the major threat to HM. Here, I follow Bob Wachter’s lead from SHM’s May annual meeting and detail key steps for pediatric HM in the upcoming 10 years.

Define the field: The SHM Pediatric Committee and the Ambulatory Pediatric Association’s (APA) hospital medicine special interest group are collaborating to publish a list of core clinical procedural and systems domains for pediatric hospital medicine.

This will provide a blueprint of how we have defined our field and supply a framework for pediatric acute care residency tracks, hospitalist electives, hospitalist fellowships, and maintenance of certification (MOC). Related characterizations of the field are available through pediatric hospital medicine textbooks. The Pediatric Research in Inpatient Settings (PRIS) network is studying the epidemiology of pediatric HM practice to provide an evidence basis for these expert decrees.

Individual programs should use these resources to help develop program-specific hospitalist privilege materials based on documented patient acuity, volume, and hospital medicine CME activities. The specific criteria and privileges will differ based on differences in job description between and within tertiary care centers and community hospitals—but all will include the general pediatric ward.

Develop MOC Appropriate for Pediatric Hospitalists: The American Board of Internal Medicine has officially approved the creation of a Focused Recognition of Hospital Medicine through its MOC system. A final decision rests with the American Board of Medical Specialties.

Pediatric hospitalists will do well to wait several years to examine the results of these efforts before deciding whether to pursue a similar designation from the American Board of Pediatrics. In the meantime, we should be on a fast track to create specific pediatric HM materials that will meet the 2010 MOC requirements.

There are at least 1,500 practicing pediatric hospitalists. This is equal to the number of board-certified pediatric ED physicians (1,446) and considerably more than the number of pulmonologists (821). Certainly these numbers merit development of MOC materials specifical to pediatric HM. The American Academy of Pediatrics (AAP) is developing an inpatient Education in Quality Improvement for Pediatric Practice (eQIPP) asthma model. SHM may be able to develop a transitions-of-care personal information manager and/or self-evaluation program (SEP) module appropriate for adult and pediatric hospitalists.

The only things missing are a comprehensive inpatient SEP and a closed-book exam. Pediatric hospitalists are here to stay. The American Board of Pediatrics (ABP) will best fulfill its responsibility to the public by creating an MOC program germane to pediatric HM. The actual designation on the MOC doesn’t need to be changed in 2010, but hospitalists recertifying in 2010 should be participating in relevant activities.

Expand pediatric HM (post-) graduate medical education: The increasing number of hospitalists will undoubtedly influence pediatric graduate medical education.

The ABP’s Residency Review and Redesign in Pediatrics project, which looks at global reform of pediatric residency training, should allow for acute care pediatric residency tracks. These would be amenable to pediatricians planning careers in HM, emergency medicine, and critical care.

Overall, most pediatric hospitalists will continue to begin their careers directly out of residency. Although pediatric hospitalist fellowship programs are likely to increase in number, formal fellowship training will not be required for one to practice as a pediatric hospitalist. These programs will benefit individuals choosing either an academic or administrative career. Frontline hospitalists should be able to gain suitable experience through appropriately mentored and supported clinical practice and focused CME activities—much as a new office-based pediatrician matures during his or her initial years in practice.

Publish, publish, publish: Success within the academic and research environment is crucial to being viewed as equal among subspecialties.

Perceptions of our field improve with each paper published in Pediatrics and the Journal of Hospital Medicine and each plenary presentation at a national meeting. Within our professional community, writing articles for The Hospitalist and the AAP Section on Hospital Medicine newsletter and presenting our work in poster form or hospitalist platform presentation advances knowledge and creates group identity.

Additionally, these activities promote the pediatric HM group and the authors. Some of us have made a career out of LISTSERV postings.

Continue to grow PRIS: We must all contribute to the growth of PRIS over the next decade.

Ultimately, PRIS promises to answer clinical questions faced by hospitalists the same way the Vermont Oxford Network helps neonatology and the Pediatric Emergency Care Applied Research Network helps pediatric emergency medicine. Academic hospitalists can use PRIS to pursue their research interests. Community hospitalists can pick and choose from available projects to identify a study relevant and suitable for them. We all must participate.

My hope is that in 10 to 20 years PRIS will coordinate randomized, controlled clinical trials and universal, integrated, HIPPA-compliant, electronic medical record systems that facilitate real-time analysis of outcomes and practice variation.

Own our diseases: Defining The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, creating a research base, and publishing must lead to the recognition of pediatric hospitalists as the experts for a core set of illnesses.

Potential starting points include bronchiolitis, the ruling out of sepsis in less than 30 days, apparent life-threatening events (ALTE), and the medically complex/technologically dependent child. We’ll know we’ve hit it big when the nationally recognized speakers and authors on these topics identify themselves as hospitalists rather than infectious disease physicians or pulmonologists. For this to occur, hospitalists must participate in research efforts, speak at regional and national meetings, and participate on national consensus panels.

On a purely local program level, individual physicians within a hospital medicine group should cultivate areas of clinical, administrative, and educational expertise. This is particularly valuable in community hospital settings where pediatric infectious disease or pulmonary specialists may not be available—but is equally important to career development in larger academic centers where hospitalists are ideal for quality improvement, safety, and educational roles.

Identify and publicly report national benchmarks: Our adult colleagues suffer and benefit from the public reporting mandated by the Centers for Medicare and Medicaid Services. One hopes the adult tribulations with data collection, attribution, and risk adjustment will make pediatric public reporting easier.

The wide variation in management of ALTE, osteomyelitis, and complicated pneumonias documented by Pediatric Health Information System researchers at the Toronto Pediatric Academic Societies meetings is a clarion call for evidence-based medicine. Parents have a right to make an informed choice about where and how their child is treated based on reliable data. Rational expenditure of limited State Children’s Health Insurance Program (SCHIP) funds requires practicing evidence-based medicine

Pediatric quality measures and standards are being developed through the National Quality Forum as well as the Alliance for Pediatric Quality. This movement will significantly affect pediatric HM. On the positive side, reporting will require that more resources be devoted to pediatric quality improvement (QI) efforts. Pediatric hospitalists are ideally suited to lead inpatient QI efforts. Creation of a hospitalist physician specialty identification code will facilitate comparison of hospitalist with non-hospitalist care in large multicenter data sets. These studies will be key descriptors of the cost and quality outcomes of pediatric HM programs.

Public reporting will highlight variation among hospitals, programs, and, possibly, physicians. Parents and payers will vote with their feet. Overall, this will create less variation in care as best practices are identified and adopted. Shortcomings will be revealed in programs that fail to practice state-of-the-art pediatrics or that are inadequately staffed from either the physician or nursing perspective. This likely will result in a consolidation of pediatric care. Smaller units closer to larger pediatric centers probably will close or become affiliates of the referral center. Geographic proximity will be a secondary concern to outcomes for parents and office-based pediatricians.

The methodological and political considerations of pay for performance are beyond most of us. Nonetheless, we in pediatric HM can begin to prepare for these changes by identifying the benchmarks that highlight our successes and failures as hospitalists, groups, hospitals, and the field as a whole. Potential clinical, quality, economic, and logistic metrics include severity-adjusted lengths of stay (LOS) for asthma and bronchiolitis, readmission rates, time to antibiotics for ruling out sepsis less than 30 days, patient and referring physician satisfaction, and coordination of transitions of care.

Expand children’s health insurance: SCHIP and universal insurance for children enjoys significant support.

The AAP’s efforts in this area deserve praise and demand continued support. As noted previously, large public expenditures on SCHIP likely will be linked to public reporting of outcomes. It is crucial to the economic viability of pediatrics that SCHIP reimbursement is equivalent to Medicare reimbursement on a code-for-code basis. It is indefensible to suggest that we as a nation value the care of children less than the care of the elderly.

Ultimately, SCHIP and state Medicaid programs would do well to move beyond a per diem-based system of reimbursement for pediatric inpatient care to a system based either on diagnosis-related groups (DRGs) or disease episodes. This would benefit HM programs by rewarding hospitals that can shorten LOS while providing the same high-quality outcomes. Current per diem reimbursement paradigms at best fail to maximally encourage efficiency and at worst create perverse incentives to prolong LOS.

Relentlessly pursue career satisfaction: Many programs are asking pediatric hospitalists to work at a clinical pace not sustainable over a 20- to 30-year career. Particularly efficient programs can produce burnout in one to three years of excessive workloads and call obligations.

SHM’s “A White Paper on Hospitalist Career Satisfaction” identifies four pillars: reward/recognition, workload/schedule, autonomy/control, and community/environment. (Each pillar has been featured in the “Career Development” section, starting with the June issue.) In pediatrics we can turn to neonatology, pediatric critical care, and (pediatric) emergency medicine for help in establishing realistic guidelines for clinical hours in house.

The harder question to answer is: What is a reasonable number of patients for a hospitalist to cover at a time? This depends on patient acuity, patient and family expectations, teaching responsibilities, hospitalist responsibilities outside the ward, and physician style. It is unlikely that prospective randomized controlled trials will be conducted to answer this question. The answer is likely to come from individual programs, hospitalists, and—regrettably—patients suffering the consequences of pushing the limits too far. We will learn from our mistakes. Failed models will not be repeated. To the extent that quality rather than economics becomes the overriding driver for HM programs, I favor 15 encounters per hospitalist per day over 20.

Hospitalists also must diversify beyond pure clinical practice for long-term career satisfaction. Focusing on a specific clinical interest, subspecialty, or practice environment can provide some variety.

Teaching and research is another source of career satisfaction. Each hospitalist within a group should be involved in at least one QI project and/or committee—if only to appreciate the importance and complexity of a systems approach to improving overall outcomes. Job descriptions must include protected time for these nonclinical activities. Career growth and satisfaction will be stifled without these additional outlets.

Expand beyond traditional roles: The push for improved quality will lead to expanded roles for pediatric hospitalists—some of which may be unwelcome.

In particular, larger programs will move to 24/7 in-house hospitalist presence. Given the acuity and complexity of the patients we care for, particularly in tertiary care centers, the quality argument for 24/7 in-house coverage will quickly trump the economic argument against it. The choice is obvious in terms of quality and safety and from the perspective of the most important “decider” when it comes to healthcare—the patient.

As educators exploit the opportunities of 24/7 coverage, resident teaching will increase and academic hospitalists will master the art of promoting autonomy 24/7 while providing appropriate supervision. If we learned to teach with family-centered rounds, we can learn to teach at 3 a.m.

In addition to expanded hours, we will follow the lead of adult hospitalists and increase our co-management role beyond the traditional general medical patient on the hospitalist service. This will include surgical and subspecialty patients. From the patient’s and family’s perspective the improved care that can result is valuable. It may not be necessary for every patient or for every surgeon or subspecialist, but on the whole hospitalists provide added value.

Within individual programs and among various physicians, the rules of engagement will need to be defined to promote collegial, respectful relationships with clear lines of communication and defined clinical responsibilities. “Inappropriate behavior” from “difficult” physicians (surgeons, subspecialists, and hospitalists) will need to be addressed. Specific arrangements will need to be defined (co-management versus specialist/surgeon attending with hospitalist consultation or hospitalist attending with specialist/surgeon consultant). But once the rules of engagement are established and appropriate resources allotted, it becomes impossible for hospitalists to argue that it’s not within our job description to contribute to improved quality of care for hospitalized patients. Improving patient care is not scutwork.

In particular, given the limited availability of pediatric sub-specialists and surgeons, to the extent that we as hospitalists can increase the efficiency of our subspecialty and surgical colleagues, we can improve access to pediatric subspecialty care within both the inpatient and outpatient settings These manpower issues will also drive involvement of pediatric hospitalists into other parts of the hospital such as sedation services, the ED, the NICU, and PICU. As these other services become vocal advocates for pediatric hospitalists, the economic viability of pediatric hospital medicine programs will increase.

Make the economic argument for value-added services: Pediatric hospitalists must do better at the economic arguments of value-added services.

Until pediatric inpatient stays are reimbursed on a DRG basis or physician charges are based on a global fee, we most move beyond the simple formulation of decreased costs for inpatient stays. We must highlight the value of our critical roles in coordination of care; quality and safety; 24/7 coverage; improved throughput in the emergency department (ED), ward, and PICU; and increased efficiency for surgeons and subspecialists.

Success for pediatric HM in these arenas will come only at the cost of failed individual programs. As implied above, it is only natural for non-hospitalist administrators and department leaders to push the limits of hospitalist programs to the maximum. Programs that place excessive demands on hospitalists will implode. Good hospitalists will leave for positions that offer them respect, autonomy, and a reasonable workload and lifestyle. Small community programs with low-volume services may not be economically viable. As we develop a history of successful programs and failed programs, hospitalists and administrators will have more realistic expectations of the ingredients of success.

Conclusion

Programs that meet the above challenges will succeed. Pediatric HM is a tremendously rewarding and challenging field. National recognition of pediatric HM as a unique field combined with the respect of local pediatricians, subspecialists, and surgeons will create the pride and ownership among hospitalists necessary for us to raise the bar for standards of inpatient care.

Public reporting will provide the external pull for the same high-quality outcomes. Divisions of HM led by hospitalists in which each hospitalist has an additional clinical, administrative, or academic focus will create the workload, autonomy, and diversity necessary for long-term career satisfaction and support the research and QI activities necessary for the evidence-based practice of high-quality pediatric inpatient care by hospitalists and non-hospitalists alike. Universal access, economic parity with Medicare, and a full understanding of the value-added nature of pediatric hospital medicine practice will provide the margin necessary for this mission. It will be a challenging but rewarding 10 years. TH

Dr. Percelay is SHM’s treasurer and a pediatric hospitalist.