A60‐year‐old man presented with agitation and a forehead mass (Figs. 1 and 2). His wife had noticed its rapid growth over several weeks and said he had recently become extremely confused and hostile. He had a history of smoking and exposures to silica and Agent Orange. His vitals and oxygen saturation were normal. He was cachectic but in no distress, and although he was uncooperative, his examination did not demonstrate an obvious neurological deficit. Routine electrolytes were within normal limits.

Figure 1

Figure 2

Noncontrast computed tomography of the skull revealed a 5.5 5.4 7.7cm frontal soft‐tissue density eroding his frontal bone and extending intracranially, with extensive displacement of both frontal lobes and invasion into his superior sagittal sinus (Fig. 3) and possible involvement of the brain parenchyma. A subsequent CT scan of the chest demonstrated a 7.8 7.9cm right mass in the lower lobe of the lung encasing the right pulmonary artery and 2 left renal masses.

Figure 3

Biopsy of the forehead mass demonstrated a necrotic, poorly differentiated carcinoma with focal clear‐cell features. Immunohistochemical staining was consistent with squamous cell carcinoma.

The forehead mass was painless, and the lung mass unresectable. His behavioral changes persisted and were attributed to the tumor compressing and possibly invading both frontal lobes. At his wife's request, he was discharged on dexamethasone with home hospice and died 2 weeks later.

Although there is little literature on the epidemiology of skull metastases, the most common malignancies to metastasize to the skull are breast and lung carcinomas. Others include prostate, thyroid, myeloma, and melanoma. Symptomatic metastases, including neurological findings, are unusual, except for tumors that metastasize to the skull base and cause cranial nerve deficits. Skeletal metastasis as the first manifestation of lung cancer occurs in about 2% of lung cancer patients and is a marker of poor prognosis. Received 2 November 2006; revision received 15 December 2006; accepted 16 January 2007.

A60‐year‐old man presented with agitation and a forehead mass (Figs. 1 and 2). His wife had noticed its rapid growth over several weeks and said he had recently become extremely confused and hostile. He had a history of smoking and exposures to silica and Agent Orange. His vitals and oxygen saturation were normal. He was cachectic but in no distress, and although he was uncooperative, his examination did not demonstrate an obvious neurological deficit. Routine electrolytes were within normal limits.

Figure 1

Figure 2

Noncontrast computed tomography of the skull revealed a 5.5 5.4 7.7cm frontal soft‐tissue density eroding his frontal bone and extending intracranially, with extensive displacement of both frontal lobes and invasion into his superior sagittal sinus (Fig. 3) and possible involvement of the brain parenchyma. A subsequent CT scan of the chest demonstrated a 7.8 7.9cm right mass in the lower lobe of the lung encasing the right pulmonary artery and 2 left renal masses.

Figure 3

Biopsy of the forehead mass demonstrated a necrotic, poorly differentiated carcinoma with focal clear‐cell features. Immunohistochemical staining was consistent with squamous cell carcinoma.

The forehead mass was painless, and the lung mass unresectable. His behavioral changes persisted and were attributed to the tumor compressing and possibly invading both frontal lobes. At his wife's request, he was discharged on dexamethasone with home hospice and died 2 weeks later.

Although there is little literature on the epidemiology of skull metastases, the most common malignancies to metastasize to the skull are breast and lung carcinomas. Others include prostate, thyroid, myeloma, and melanoma. Symptomatic metastases, including neurological findings, are unusual, except for tumors that metastasize to the skull base and cause cranial nerve deficits. Skeletal metastasis as the first manifestation of lung cancer occurs in about 2% of lung cancer patients and is a marker of poor prognosis. Received 2 November 2006; revision received 15 December 2006; accepted 16 January 2007.

A60‐year‐old man presented with agitation and a forehead mass (Figs. 1 and 2). His wife had noticed its rapid growth over several weeks and said he had recently become extremely confused and hostile. He had a history of smoking and exposures to silica and Agent Orange. His vitals and oxygen saturation were normal. He was cachectic but in no distress, and although he was uncooperative, his examination did not demonstrate an obvious neurological deficit. Routine electrolytes were within normal limits.

Figure 1

Figure 2

Noncontrast computed tomography of the skull revealed a 5.5 5.4 7.7cm frontal soft‐tissue density eroding his frontal bone and extending intracranially, with extensive displacement of both frontal lobes and invasion into his superior sagittal sinus (Fig. 3) and possible involvement of the brain parenchyma. A subsequent CT scan of the chest demonstrated a 7.8 7.9cm right mass in the lower lobe of the lung encasing the right pulmonary artery and 2 left renal masses.

Figure 3

Biopsy of the forehead mass demonstrated a necrotic, poorly differentiated carcinoma with focal clear‐cell features. Immunohistochemical staining was consistent with squamous cell carcinoma.

The forehead mass was painless, and the lung mass unresectable. His behavioral changes persisted and were attributed to the tumor compressing and possibly invading both frontal lobes. At his wife's request, he was discharged on dexamethasone with home hospice and died 2 weeks later.

Although there is little literature on the epidemiology of skull metastases, the most common malignancies to metastasize to the skull are breast and lung carcinomas. Others include prostate, thyroid, myeloma, and melanoma. Symptomatic metastases, including neurological findings, are unusual, except for tumors that metastasize to the skull base and cause cranial nerve deficits. Skeletal metastasis as the first manifestation of lung cancer occurs in about 2% of lung cancer patients and is a marker of poor prognosis. Received 2 November 2006; revision received 15 December 2006; accepted 16 January 2007.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Venous thromboembolism prophylaxis (VTE PX) has been identified as an area of primary importance to improve patient safety in research and clinical practice.13 Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common, often preventable life‐threatening condition for hospitalized patients.4 Up to half of patients admitted to the hospital are admitted from the emergency department (ED). Most of these patients are acutely ill with multiple risk factors for VTE. To reduce the incidence of VTE, these patients require routine evaluation to determine if thromboprophylaxis is needed, and when indicated, therapy should be started promptly on admission. The Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy outlines recommendations for VTE PX that reduce the development of DVT and PE.3 Despite there being effective VTE PX and the current focus on increasing its utilization to improve patient safety, VTE PX is underutilized. In particular, the subgroup of patients admitted from the ED, a group at high risk for VTE, has been neglected in the literature.

Our hypothesis was that VTE PX is underutilized in patients admitted through the ED. The specific objective of this study was to measure the rate at which hospitalized patients admitted though the ED received VTE PX.

METHODS

The study was conducted with the approval of and in accordance with the ethical standards of the Institutional Review Board of Baylor College of Medicine and Affiliated Hospitals. Prior to initiating chart review, passive consent was sought from physicians who were identified through the hospital medical records system as having admitted patients to this hospital through the ED in the preceding 6 months. Physicians were contacted twice in writing in a 1‐month period prior to study inception. Those who objected to their charts being reviewed were to notify the investigators. Otherwise, they were assumed to have consented to chart review. Fifteen percent of physicians declined chart review. Physicians were not informed of the particulars of the study, only that medication use in the ED was being evaluated.

This study was conducted at a private 900‐bed urban teaching hospital. The ED evaluates approximately 31,000 patients per year, predominantly a medical population. During the previous year, the ED had admitted roughly 30 patients per day, or 36% of all patients examined. Approximately 29% of admissions to this hospital (800/month) are admitted through the ED.

A convenience sample of every other hospital admission through the ED during 1 month was prospectively identified for inclusion in the study and chart review. Data were abstracted by a single reviewer on admission and at the time of discharge. The following data were collected: demographic characteristics, anticoagulant use or existing IVC filter, diagnoses, indications for full‐dose anticoagulation, indications for VTE PX (ie, immobilization, respiratory failure, congestive heart failure, limb trauma, surgery, or stroke), whether therapeutic anticoagulation or VTE PX was given, and date of initiation of this regimen, contraindications to anticoagulation, primary physician, and use of a standard order set. Patients were excluded if the attending physician declined chart review via the passive consent process. Other exclusion criteria were: receiving full‐dose anticoagulants before presentation to the ED, presence of an inferior vena cava (IVC) filter, indication for full‐dose anticoagulation (presented with DVT, PE, acute coronary syndrome), renal failure requiring hemodialysis (controversial risk for VTE59), length of stay (LOS) less than 2 days, and admission for psychiatric evaluation or treatment.

A modified Caprini's Risk Assessment Model for Surgical and Nonsurgical Patients was used to classify VTE risk.10 This tool assigns points to VTE risk factors so that risk and the need for VTE PX can be determined. For example, major surgery, central venous access, age older than 60 years, and bed rest for more than 72 hours are each assigned 2 points; higher‐risk factors such as hip or leg fractures or stroke are each assigned 5 points. This tool is generally in accord with the ACCP guidelines. Modifications made to this tool were to assign 3 points to patients in respiratory failure on ventilators and 5 points to patients who were critically ill on vasopressor medication. Decreased venous return associated with mechanical ventilation and peripheral vasoconstriction associated with the use of vasopressor medication justified the addition of these risk factors.11, 12 Patients were assigned to one of these risk categories: no risk (0 points), low risk (1 point), moderate risk (2 points), high risk (3‐4 points), or very high risk (5 or more points). As indicated by this risk assessment tool, those with moderate, high, or very high risk were considered in need of VTE PX.

Appropriate VTE PX was defined as any currently accepted medical (unfractionated heparin, low‐molecular‐weight heparin, or warfarin for orthopedic patients) or mechanical methods of VTE PX (sequential compression devices, and graduated compression stockings) for those in need and no VTE PX if none indicated. Aspirin, clopidogrel, or a combination of the 2 was not considered sufficient VTE PX.3 In addition, we established whether VTE PX as determined by the modified Caprini score was in line with ACCP guidelines, taking into account contraindications to anticoagulation. Preprinted order sets were divided into those that included VTE PX and those that did not. Order sets that included options for VTE PX were defined as standard order sets.

The primary objective of this study was to determine how frequently VTE PX was implemented in ED admissions. Secondary objectives were determining factors associated with correct VTE PX decision making and the proximity of orders for VTE PX to the time of admission.

RESULTS

Four hundred and fourteen charts of patient admissions were reviewed, of which 254 met the inclusion criteria. One‐hundred and sixty patients were excluded because they received full‐dose anticoagulation or had an existing IVC filter prior to admission (49 patients), received treatment with full‐dose anticoagulation in the ED (42 patients), had a LOS of less than 2 days (39 patients), or had end‐stage renal disease requiring hemodialysis (30 patients; Fig. 1).

Figure 1

Eighty percent of patients were admitted for medical problems, and 20% were admitted for surgery (Table 1). The most frequent admitting diagnoses were abdominal pain, congestive heart failure, chronic obstructive pulmonary disease, altered mental status, cerebral vascular accident, and pneumonia. The average patient had 5 comorbid conditions, the most frequently noted were hypertension, diabetes mellitus, anemia, urinary tract infections, and coronary artery disease. The principal admitting services were general medicine, pulmonary, cardiology, hematology‐oncology, neurology, surgery, and gastroenterology. Six patients died (2.4%), and 2 patients were diagnosed with pulmonary emboli (0.8%). The study group's average length of stay was 6.7 days (range 2‐52 days), 48.8% were male, and average age was 61 19.7 years. Overall, the correct VTE PX decision making occurred in 44.9% of patients admitted, including the 49 of 254 patients who did not require and did not receive VTE PX. Of the 254 patients, 201 (79%) had indications for VTE PX, 65 of whom (32.3%) received it (Table 2). For those receiving VTE PX, 78% of orders were written within the first day of hospitalization.

When the data were reanalyzed per ACCP guidelines using the modified Caprini's risk assessment tool, the results were consistent with the initial findings. Overall, 46% of all patients (116 of 254) received prophylaxis in compliance with ACCP guidelines. In this group, 52 of 116 patients (44.8%) did not require and did not receive VTE PX. Sixty‐four patients (32% of those with indications for prophylaxis) had indications for VTE PX, were in compliance with ACCP guidelines, and received the indicated prophylaxis (30 patients received mechanical prophylaxis, 19 patients received medical prophylaxis, and 15 patients received both medical and mechanical prophylaxis). The difference between the assessments was explained by high‐risk patients with no contraindications to medical prophylaxis who received only mechanical prophylaxis but required medical prophylaxis through ACCP guidelines. Note, the Caprini tool recommended medical prophylaxis for these high‐risk patients; however, our original application was simply to assess if prophylaxis was employed. In addition, several patients with a prolonged INR suggestive of bleeding risk or autoprophylaxis were reclassified as compliant and not needing prophylaxis.

Fifty‐five patients with indications for VTE prophylaxis had contraindications to medical prophylaxis: 44 had bleeding risk, 8 had spine injury or surgery, and 3 had brain metastases and thrombocytopenia. Twenty of the 55 patients (36%) received mechanical prophylaxis; they were considered in compliance with ACCP guidelines and were included in the appropriate decisions regarding VTE PX count. Prophylaxed patients at moderate to high risk were more likely to receive mechanical prophylaxis, whereas two‐thirds of those prophylaxed patients who were at very high risk received medical prophylaxis or a combination of medical and mechanical prophylaxis.

Standard order sets increased the likelihood of appropriate VTE PX. Increasing age and a primary cardiovascular diagnosis (chest pain, congestive heart failure, syncope/near‐syncope, chronic ischemic heart disease, sinus tachycardia) decreased the likelihood of VTE PX (Table 3). VTE PX was not significantly related to bed rest (OR = 1.46, P = .14). In 26 of the 254 patient admissions, standard order sets that included VTE PX were utilized. Of these 26 patients, 69.2% (18; P = .01) received appropriate VTE PX compared with the overall rate of 44.9% receiving appropriate VTE PX. The use of VTE PX was significantly associated with level of risk: from 0% in patients at no or low risk of VTE to 47% in patients at very high risk (P = .0001). This significance persisted when controlling for age greater than 60 years (Table 4).

Aspirin and other antiplatelet medications (clopidogrel, dipyridamole, and cilostazol) were ordered for 22 and 5 patients, respectively, of the 39 patients with primary cardiovascular diagnosis who had indications for VTE PX but did not receive it. Forty‐seven percent (17 of 36 with activity orders) of those in our cardiovascular at‐risk but not prophylaxed group had activity orders of ambulatory ad lib or had physical therapy ordered.

DISCUSSION

An estimated 200,000‐300,000 cases of VTE with 60,000‐200,000 fatal pulmonary emboli occur annually.1316 The inpatient fatality rate due to PE is estimated to be 12%.13 The frequency of VTE varies with risk that relates to the population studied and the diagnosis. VTE rates range from 3%‐55% for medical patients to 80% for patients who receive total hip replacement or have multiple trauma, though the higher numbers cited are based on studies using fibrinogen uptake scanning or venography, with the true rates probably between the extremes noted.3, 4, 17, 18 Many of these acutely ill patients are admitted through the ED. Though VTE is common in patients admitted through the ED, with respect to VTE PX, this population is understudied.

In this study, the first to our knowledge to focus on VTE PX in an unselected cohort of ED admissions, the most significant findings were: 79% of ED admissions had indications for VTE PX, yet only 32% of those received it, and 78% of these orders were written within the first day of hospitalization. We also noted a direct association of the use of VTE PX with the level of risk, which increased from 9% in the moderate‐risk group to 23% for high‐risk patients and 47% for very‐high‐risk patients (P < .0001; Table 4.). Thus, most of our patients, including those at highest risk for VTE never received prophylaxis at any time during their hospitalization. Also explored in this study was the relationship of risk factors for VTE with the use of prophylaxis. These risk factors were age, cardiovascular diagnosis, and use of standard order sets. Increasing age and having a primary cardiovascular diagnosis (ie, congestive heart failure, atrial fibrillation) were the risk factors that increased the likelihood of receiving VTE. Therefore, it was expected that the rate of VTE PX would be higher for patients who were older or had these diagnoses. However, in the current study, increasing age alone did not influence the likelihood of physicians ordering VTE PX. In addition, we found markedly decreased rates of VTE PX in cardiac patients.

Other investigators have reported similar findings in selected groups of hospitalized patients.1922 A retrospective chart review of internal medicine discharges from 2 Italian hospitals determined that VTE PX was prescribed in 46.4% and 58.3% of at‐risk patients in nonteaching and teaching hospitals, respectively.20 In a retrospective study of surgical patients in 20 hospitals, 38% of patients received VTE PX.21 Similar results were found in a registry of hospitalized patients who developed VTE, in which only 42% of patients who developed VTE received VTE PX within 30 days prior to diagnosis.23

Bosson et al. reported no increased use of VTE PX in patients with myocardial infarction, similar to that in the current study, though they did find VTE PX administered more frequently to patients with congestive heart failure.22 Antiplatelet medications and activity orders are commonly prescribed for cardiac patients. According to reports that indicated a degree of protection from antiplatelet agents,24, 25 frequent use of activity orders, and the belief that ambulation eliminates the risk of VTE, it is possible physicians believed patients were sufficiently prophylaxed. However, although early ambulation and antiplatelet medications decrease risk of VTE, neither is sufficient to prevent it.3 The administration of aspirin and other antiplatelet medications implies that in our study group bleeding risk was not the primary deterrent to ordering VTE PX. Furthermore, bleeding risk would not be a deterrent to mechanical VTE PX.

In the current study, use of standard order sets was associated with correct decision making and increased use of VTE PX. Risk of VTE might be decreased through the use of standard order sets that result in increased utilization of VTE PX. However, despite evidence that standard order sets can successfully modify prescribing patterns,2629 Cook et al. found that only 5 of 29 Canadian ICU directors surveyed for their approach to VTE prevention and diagnosis in critically ill patients used preprinted orders.30

The present study had several limitations. First, determination of VTE was not an end point. As a single‐center study of prospectively selected subjects, this would have required too large a sample to be feasible. Our data may be biased by not including patients admitted by physicians who declined to allow their charts to be reviewed. However, although physicians were informed that we were examining drug use of patients admitted through the ED, they were not aware that the study focused on VTE PX. Our results are consistent with results of inpatient studies citing inadequate VTE PX.19, 21, 31, 32 Using the modified Caprini Scoring System, we found that only 32% of patients with indications for VTE PX received it. This result was unchanged when stratifying using ACCP guidelines. Finally, we found that prophylaxed patients who were at moderate to high risk were more likely to receive mechanical prophylaxis, whereas two‐thirds of patients who received prophylaxis who were at very high risk received medical prophylaxis or a combination of medical and mechanical prophylaxis.

CONCLUSIONS

Most patients needing VTE PX did not receive it, and those who did receive VTE PX usually had it prescribed in the first 24 hours. As risk factors increased, patients were more often prophylaxed, though fewer than 50% of those in the very‐high‐risk group received VTE PX. This study suggests that in hospital systems similar to ours with 30% or more of hospital admissions coming from the ED implementing a standard order set for patients admitted through the ED may increase VTE PX, which, in turn, could have a major impact on their course. Future studies need to determine the best way to implement these changes.

Venous thromboembolism prophylaxis (VTE PX) has been identified as an area of primary importance to improve patient safety in research and clinical practice.13 Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common, often preventable life‐threatening condition for hospitalized patients.4 Up to half of patients admitted to the hospital are admitted from the emergency department (ED). Most of these patients are acutely ill with multiple risk factors for VTE. To reduce the incidence of VTE, these patients require routine evaluation to determine if thromboprophylaxis is needed, and when indicated, therapy should be started promptly on admission. The Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy outlines recommendations for VTE PX that reduce the development of DVT and PE.3 Despite there being effective VTE PX and the current focus on increasing its utilization to improve patient safety, VTE PX is underutilized. In particular, the subgroup of patients admitted from the ED, a group at high risk for VTE, has been neglected in the literature.

Our hypothesis was that VTE PX is underutilized in patients admitted through the ED. The specific objective of this study was to measure the rate at which hospitalized patients admitted though the ED received VTE PX.

METHODS

The study was conducted with the approval of and in accordance with the ethical standards of the Institutional Review Board of Baylor College of Medicine and Affiliated Hospitals. Prior to initiating chart review, passive consent was sought from physicians who were identified through the hospital medical records system as having admitted patients to this hospital through the ED in the preceding 6 months. Physicians were contacted twice in writing in a 1‐month period prior to study inception. Those who objected to their charts being reviewed were to notify the investigators. Otherwise, they were assumed to have consented to chart review. Fifteen percent of physicians declined chart review. Physicians were not informed of the particulars of the study, only that medication use in the ED was being evaluated.

This study was conducted at a private 900‐bed urban teaching hospital. The ED evaluates approximately 31,000 patients per year, predominantly a medical population. During the previous year, the ED had admitted roughly 30 patients per day, or 36% of all patients examined. Approximately 29% of admissions to this hospital (800/month) are admitted through the ED.

A convenience sample of every other hospital admission through the ED during 1 month was prospectively identified for inclusion in the study and chart review. Data were abstracted by a single reviewer on admission and at the time of discharge. The following data were collected: demographic characteristics, anticoagulant use or existing IVC filter, diagnoses, indications for full‐dose anticoagulation, indications for VTE PX (ie, immobilization, respiratory failure, congestive heart failure, limb trauma, surgery, or stroke), whether therapeutic anticoagulation or VTE PX was given, and date of initiation of this regimen, contraindications to anticoagulation, primary physician, and use of a standard order set. Patients were excluded if the attending physician declined chart review via the passive consent process. Other exclusion criteria were: receiving full‐dose anticoagulants before presentation to the ED, presence of an inferior vena cava (IVC) filter, indication for full‐dose anticoagulation (presented with DVT, PE, acute coronary syndrome), renal failure requiring hemodialysis (controversial risk for VTE59), length of stay (LOS) less than 2 days, and admission for psychiatric evaluation or treatment.

A modified Caprini's Risk Assessment Model for Surgical and Nonsurgical Patients was used to classify VTE risk.10 This tool assigns points to VTE risk factors so that risk and the need for VTE PX can be determined. For example, major surgery, central venous access, age older than 60 years, and bed rest for more than 72 hours are each assigned 2 points; higher‐risk factors such as hip or leg fractures or stroke are each assigned 5 points. This tool is generally in accord with the ACCP guidelines. Modifications made to this tool were to assign 3 points to patients in respiratory failure on ventilators and 5 points to patients who were critically ill on vasopressor medication. Decreased venous return associated with mechanical ventilation and peripheral vasoconstriction associated with the use of vasopressor medication justified the addition of these risk factors.11, 12 Patients were assigned to one of these risk categories: no risk (0 points), low risk (1 point), moderate risk (2 points), high risk (3‐4 points), or very high risk (5 or more points). As indicated by this risk assessment tool, those with moderate, high, or very high risk were considered in need of VTE PX.

Appropriate VTE PX was defined as any currently accepted medical (unfractionated heparin, low‐molecular‐weight heparin, or warfarin for orthopedic patients) or mechanical methods of VTE PX (sequential compression devices, and graduated compression stockings) for those in need and no VTE PX if none indicated. Aspirin, clopidogrel, or a combination of the 2 was not considered sufficient VTE PX.3 In addition, we established whether VTE PX as determined by the modified Caprini score was in line with ACCP guidelines, taking into account contraindications to anticoagulation. Preprinted order sets were divided into those that included VTE PX and those that did not. Order sets that included options for VTE PX were defined as standard order sets.

The primary objective of this study was to determine how frequently VTE PX was implemented in ED admissions. Secondary objectives were determining factors associated with correct VTE PX decision making and the proximity of orders for VTE PX to the time of admission.

RESULTS

Four hundred and fourteen charts of patient admissions were reviewed, of which 254 met the inclusion criteria. One‐hundred and sixty patients were excluded because they received full‐dose anticoagulation or had an existing IVC filter prior to admission (49 patients), received treatment with full‐dose anticoagulation in the ED (42 patients), had a LOS of less than 2 days (39 patients), or had end‐stage renal disease requiring hemodialysis (30 patients; Fig. 1).

Figure 1

Eighty percent of patients were admitted for medical problems, and 20% were admitted for surgery (Table 1). The most frequent admitting diagnoses were abdominal pain, congestive heart failure, chronic obstructive pulmonary disease, altered mental status, cerebral vascular accident, and pneumonia. The average patient had 5 comorbid conditions, the most frequently noted were hypertension, diabetes mellitus, anemia, urinary tract infections, and coronary artery disease. The principal admitting services were general medicine, pulmonary, cardiology, hematology‐oncology, neurology, surgery, and gastroenterology. Six patients died (2.4%), and 2 patients were diagnosed with pulmonary emboli (0.8%). The study group's average length of stay was 6.7 days (range 2‐52 days), 48.8% were male, and average age was 61 19.7 years. Overall, the correct VTE PX decision making occurred in 44.9% of patients admitted, including the 49 of 254 patients who did not require and did not receive VTE PX. Of the 254 patients, 201 (79%) had indications for VTE PX, 65 of whom (32.3%) received it (Table 2). For those receiving VTE PX, 78% of orders were written within the first day of hospitalization.

When the data were reanalyzed per ACCP guidelines using the modified Caprini's risk assessment tool, the results were consistent with the initial findings. Overall, 46% of all patients (116 of 254) received prophylaxis in compliance with ACCP guidelines. In this group, 52 of 116 patients (44.8%) did not require and did not receive VTE PX. Sixty‐four patients (32% of those with indications for prophylaxis) had indications for VTE PX, were in compliance with ACCP guidelines, and received the indicated prophylaxis (30 patients received mechanical prophylaxis, 19 patients received medical prophylaxis, and 15 patients received both medical and mechanical prophylaxis). The difference between the assessments was explained by high‐risk patients with no contraindications to medical prophylaxis who received only mechanical prophylaxis but required medical prophylaxis through ACCP guidelines. Note, the Caprini tool recommended medical prophylaxis for these high‐risk patients; however, our original application was simply to assess if prophylaxis was employed. In addition, several patients with a prolonged INR suggestive of bleeding risk or autoprophylaxis were reclassified as compliant and not needing prophylaxis.

Fifty‐five patients with indications for VTE prophylaxis had contraindications to medical prophylaxis: 44 had bleeding risk, 8 had spine injury or surgery, and 3 had brain metastases and thrombocytopenia. Twenty of the 55 patients (36%) received mechanical prophylaxis; they were considered in compliance with ACCP guidelines and were included in the appropriate decisions regarding VTE PX count. Prophylaxed patients at moderate to high risk were more likely to receive mechanical prophylaxis, whereas two‐thirds of those prophylaxed patients who were at very high risk received medical prophylaxis or a combination of medical and mechanical prophylaxis.

Standard order sets increased the likelihood of appropriate VTE PX. Increasing age and a primary cardiovascular diagnosis (chest pain, congestive heart failure, syncope/near‐syncope, chronic ischemic heart disease, sinus tachycardia) decreased the likelihood of VTE PX (Table 3). VTE PX was not significantly related to bed rest (OR = 1.46, P = .14). In 26 of the 254 patient admissions, standard order sets that included VTE PX were utilized. Of these 26 patients, 69.2% (18; P = .01) received appropriate VTE PX compared with the overall rate of 44.9% receiving appropriate VTE PX. The use of VTE PX was significantly associated with level of risk: from 0% in patients at no or low risk of VTE to 47% in patients at very high risk (P = .0001). This significance persisted when controlling for age greater than 60 years (Table 4).

Aspirin and other antiplatelet medications (clopidogrel, dipyridamole, and cilostazol) were ordered for 22 and 5 patients, respectively, of the 39 patients with primary cardiovascular diagnosis who had indications for VTE PX but did not receive it. Forty‐seven percent (17 of 36 with activity orders) of those in our cardiovascular at‐risk but not prophylaxed group had activity orders of ambulatory ad lib or had physical therapy ordered.

DISCUSSION

An estimated 200,000‐300,000 cases of VTE with 60,000‐200,000 fatal pulmonary emboli occur annually.1316 The inpatient fatality rate due to PE is estimated to be 12%.13 The frequency of VTE varies with risk that relates to the population studied and the diagnosis. VTE rates range from 3%‐55% for medical patients to 80% for patients who receive total hip replacement or have multiple trauma, though the higher numbers cited are based on studies using fibrinogen uptake scanning or venography, with the true rates probably between the extremes noted.3, 4, 17, 18 Many of these acutely ill patients are admitted through the ED. Though VTE is common in patients admitted through the ED, with respect to VTE PX, this population is understudied.

In this study, the first to our knowledge to focus on VTE PX in an unselected cohort of ED admissions, the most significant findings were: 79% of ED admissions had indications for VTE PX, yet only 32% of those received it, and 78% of these orders were written within the first day of hospitalization. We also noted a direct association of the use of VTE PX with the level of risk, which increased from 9% in the moderate‐risk group to 23% for high‐risk patients and 47% for very‐high‐risk patients (P < .0001; Table 4.). Thus, most of our patients, including those at highest risk for VTE never received prophylaxis at any time during their hospitalization. Also explored in this study was the relationship of risk factors for VTE with the use of prophylaxis. These risk factors were age, cardiovascular diagnosis, and use of standard order sets. Increasing age and having a primary cardiovascular diagnosis (ie, congestive heart failure, atrial fibrillation) were the risk factors that increased the likelihood of receiving VTE. Therefore, it was expected that the rate of VTE PX would be higher for patients who were older or had these diagnoses. However, in the current study, increasing age alone did not influence the likelihood of physicians ordering VTE PX. In addition, we found markedly decreased rates of VTE PX in cardiac patients.

Other investigators have reported similar findings in selected groups of hospitalized patients.1922 A retrospective chart review of internal medicine discharges from 2 Italian hospitals determined that VTE PX was prescribed in 46.4% and 58.3% of at‐risk patients in nonteaching and teaching hospitals, respectively.20 In a retrospective study of surgical patients in 20 hospitals, 38% of patients received VTE PX.21 Similar results were found in a registry of hospitalized patients who developed VTE, in which only 42% of patients who developed VTE received VTE PX within 30 days prior to diagnosis.23

Bosson et al. reported no increased use of VTE PX in patients with myocardial infarction, similar to that in the current study, though they did find VTE PX administered more frequently to patients with congestive heart failure.22 Antiplatelet medications and activity orders are commonly prescribed for cardiac patients. According to reports that indicated a degree of protection from antiplatelet agents,24, 25 frequent use of activity orders, and the belief that ambulation eliminates the risk of VTE, it is possible physicians believed patients were sufficiently prophylaxed. However, although early ambulation and antiplatelet medications decrease risk of VTE, neither is sufficient to prevent it.3 The administration of aspirin and other antiplatelet medications implies that in our study group bleeding risk was not the primary deterrent to ordering VTE PX. Furthermore, bleeding risk would not be a deterrent to mechanical VTE PX.

In the current study, use of standard order sets was associated with correct decision making and increased use of VTE PX. Risk of VTE might be decreased through the use of standard order sets that result in increased utilization of VTE PX. However, despite evidence that standard order sets can successfully modify prescribing patterns,2629 Cook et al. found that only 5 of 29 Canadian ICU directors surveyed for their approach to VTE prevention and diagnosis in critically ill patients used preprinted orders.30

The present study had several limitations. First, determination of VTE was not an end point. As a single‐center study of prospectively selected subjects, this would have required too large a sample to be feasible. Our data may be biased by not including patients admitted by physicians who declined to allow their charts to be reviewed. However, although physicians were informed that we were examining drug use of patients admitted through the ED, they were not aware that the study focused on VTE PX. Our results are consistent with results of inpatient studies citing inadequate VTE PX.19, 21, 31, 32 Using the modified Caprini Scoring System, we found that only 32% of patients with indications for VTE PX received it. This result was unchanged when stratifying using ACCP guidelines. Finally, we found that prophylaxed patients who were at moderate to high risk were more likely to receive mechanical prophylaxis, whereas two‐thirds of patients who received prophylaxis who were at very high risk received medical prophylaxis or a combination of medical and mechanical prophylaxis.

CONCLUSIONS

Most patients needing VTE PX did not receive it, and those who did receive VTE PX usually had it prescribed in the first 24 hours. As risk factors increased, patients were more often prophylaxed, though fewer than 50% of those in the very‐high‐risk group received VTE PX. This study suggests that in hospital systems similar to ours with 30% or more of hospital admissions coming from the ED implementing a standard order set for patients admitted through the ED may increase VTE PX, which, in turn, could have a major impact on their course. Future studies need to determine the best way to implement these changes.

Venous thromboembolism prophylaxis (VTE PX) has been identified as an area of primary importance to improve patient safety in research and clinical practice.13 Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common, often preventable life‐threatening condition for hospitalized patients.4 Up to half of patients admitted to the hospital are admitted from the emergency department (ED). Most of these patients are acutely ill with multiple risk factors for VTE. To reduce the incidence of VTE, these patients require routine evaluation to determine if thromboprophylaxis is needed, and when indicated, therapy should be started promptly on admission. The Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy outlines recommendations for VTE PX that reduce the development of DVT and PE.3 Despite there being effective VTE PX and the current focus on increasing its utilization to improve patient safety, VTE PX is underutilized. In particular, the subgroup of patients admitted from the ED, a group at high risk for VTE, has been neglected in the literature.

Our hypothesis was that VTE PX is underutilized in patients admitted through the ED. The specific objective of this study was to measure the rate at which hospitalized patients admitted though the ED received VTE PX.

METHODS

The study was conducted with the approval of and in accordance with the ethical standards of the Institutional Review Board of Baylor College of Medicine and Affiliated Hospitals. Prior to initiating chart review, passive consent was sought from physicians who were identified through the hospital medical records system as having admitted patients to this hospital through the ED in the preceding 6 months. Physicians were contacted twice in writing in a 1‐month period prior to study inception. Those who objected to their charts being reviewed were to notify the investigators. Otherwise, they were assumed to have consented to chart review. Fifteen percent of physicians declined chart review. Physicians were not informed of the particulars of the study, only that medication use in the ED was being evaluated.

This study was conducted at a private 900‐bed urban teaching hospital. The ED evaluates approximately 31,000 patients per year, predominantly a medical population. During the previous year, the ED had admitted roughly 30 patients per day, or 36% of all patients examined. Approximately 29% of admissions to this hospital (800/month) are admitted through the ED.

A convenience sample of every other hospital admission through the ED during 1 month was prospectively identified for inclusion in the study and chart review. Data were abstracted by a single reviewer on admission and at the time of discharge. The following data were collected: demographic characteristics, anticoagulant use or existing IVC filter, diagnoses, indications for full‐dose anticoagulation, indications for VTE PX (ie, immobilization, respiratory failure, congestive heart failure, limb trauma, surgery, or stroke), whether therapeutic anticoagulation or VTE PX was given, and date of initiation of this regimen, contraindications to anticoagulation, primary physician, and use of a standard order set. Patients were excluded if the attending physician declined chart review via the passive consent process. Other exclusion criteria were: receiving full‐dose anticoagulants before presentation to the ED, presence of an inferior vena cava (IVC) filter, indication for full‐dose anticoagulation (presented with DVT, PE, acute coronary syndrome), renal failure requiring hemodialysis (controversial risk for VTE59), length of stay (LOS) less than 2 days, and admission for psychiatric evaluation or treatment.

A modified Caprini's Risk Assessment Model for Surgical and Nonsurgical Patients was used to classify VTE risk.10 This tool assigns points to VTE risk factors so that risk and the need for VTE PX can be determined. For example, major surgery, central venous access, age older than 60 years, and bed rest for more than 72 hours are each assigned 2 points; higher‐risk factors such as hip or leg fractures or stroke are each assigned 5 points. This tool is generally in accord with the ACCP guidelines. Modifications made to this tool were to assign 3 points to patients in respiratory failure on ventilators and 5 points to patients who were critically ill on vasopressor medication. Decreased venous return associated with mechanical ventilation and peripheral vasoconstriction associated with the use of vasopressor medication justified the addition of these risk factors.11, 12 Patients were assigned to one of these risk categories: no risk (0 points), low risk (1 point), moderate risk (2 points), high risk (3‐4 points), or very high risk (5 or more points). As indicated by this risk assessment tool, those with moderate, high, or very high risk were considered in need of VTE PX.

Appropriate VTE PX was defined as any currently accepted medical (unfractionated heparin, low‐molecular‐weight heparin, or warfarin for orthopedic patients) or mechanical methods of VTE PX (sequential compression devices, and graduated compression stockings) for those in need and no VTE PX if none indicated. Aspirin, clopidogrel, or a combination of the 2 was not considered sufficient VTE PX.3 In addition, we established whether VTE PX as determined by the modified Caprini score was in line with ACCP guidelines, taking into account contraindications to anticoagulation. Preprinted order sets were divided into those that included VTE PX and those that did not. Order sets that included options for VTE PX were defined as standard order sets.

The primary objective of this study was to determine how frequently VTE PX was implemented in ED admissions. Secondary objectives were determining factors associated with correct VTE PX decision making and the proximity of orders for VTE PX to the time of admission.

RESULTS

Four hundred and fourteen charts of patient admissions were reviewed, of which 254 met the inclusion criteria. One‐hundred and sixty patients were excluded because they received full‐dose anticoagulation or had an existing IVC filter prior to admission (49 patients), received treatment with full‐dose anticoagulation in the ED (42 patients), had a LOS of less than 2 days (39 patients), or had end‐stage renal disease requiring hemodialysis (30 patients; Fig. 1).

Figure 1

Eighty percent of patients were admitted for medical problems, and 20% were admitted for surgery (Table 1). The most frequent admitting diagnoses were abdominal pain, congestive heart failure, chronic obstructive pulmonary disease, altered mental status, cerebral vascular accident, and pneumonia. The average patient had 5 comorbid conditions, the most frequently noted were hypertension, diabetes mellitus, anemia, urinary tract infections, and coronary artery disease. The principal admitting services were general medicine, pulmonary, cardiology, hematology‐oncology, neurology, surgery, and gastroenterology. Six patients died (2.4%), and 2 patients were diagnosed with pulmonary emboli (0.8%). The study group's average length of stay was 6.7 days (range 2‐52 days), 48.8% were male, and average age was 61 19.7 years. Overall, the correct VTE PX decision making occurred in 44.9% of patients admitted, including the 49 of 254 patients who did not require and did not receive VTE PX. Of the 254 patients, 201 (79%) had indications for VTE PX, 65 of whom (32.3%) received it (Table 2). For those receiving VTE PX, 78% of orders were written within the first day of hospitalization.

When the data were reanalyzed per ACCP guidelines using the modified Caprini's risk assessment tool, the results were consistent with the initial findings. Overall, 46% of all patients (116 of 254) received prophylaxis in compliance with ACCP guidelines. In this group, 52 of 116 patients (44.8%) did not require and did not receive VTE PX. Sixty‐four patients (32% of those with indications for prophylaxis) had indications for VTE PX, were in compliance with ACCP guidelines, and received the indicated prophylaxis (30 patients received mechanical prophylaxis, 19 patients received medical prophylaxis, and 15 patients received both medical and mechanical prophylaxis). The difference between the assessments was explained by high‐risk patients with no contraindications to medical prophylaxis who received only mechanical prophylaxis but required medical prophylaxis through ACCP guidelines. Note, the Caprini tool recommended medical prophylaxis for these high‐risk patients; however, our original application was simply to assess if prophylaxis was employed. In addition, several patients with a prolonged INR suggestive of bleeding risk or autoprophylaxis were reclassified as compliant and not needing prophylaxis.

Fifty‐five patients with indications for VTE prophylaxis had contraindications to medical prophylaxis: 44 had bleeding risk, 8 had spine injury or surgery, and 3 had brain metastases and thrombocytopenia. Twenty of the 55 patients (36%) received mechanical prophylaxis; they were considered in compliance with ACCP guidelines and were included in the appropriate decisions regarding VTE PX count. Prophylaxed patients at moderate to high risk were more likely to receive mechanical prophylaxis, whereas two‐thirds of those prophylaxed patients who were at very high risk received medical prophylaxis or a combination of medical and mechanical prophylaxis.

Standard order sets increased the likelihood of appropriate VTE PX. Increasing age and a primary cardiovascular diagnosis (chest pain, congestive heart failure, syncope/near‐syncope, chronic ischemic heart disease, sinus tachycardia) decreased the likelihood of VTE PX (Table 3). VTE PX was not significantly related to bed rest (OR = 1.46, P = .14). In 26 of the 254 patient admissions, standard order sets that included VTE PX were utilized. Of these 26 patients, 69.2% (18; P = .01) received appropriate VTE PX compared with the overall rate of 44.9% receiving appropriate VTE PX. The use of VTE PX was significantly associated with level of risk: from 0% in patients at no or low risk of VTE to 47% in patients at very high risk (P = .0001). This significance persisted when controlling for age greater than 60 years (Table 4).

Aspirin and other antiplatelet medications (clopidogrel, dipyridamole, and cilostazol) were ordered for 22 and 5 patients, respectively, of the 39 patients with primary cardiovascular diagnosis who had indications for VTE PX but did not receive it. Forty‐seven percent (17 of 36 with activity orders) of those in our cardiovascular at‐risk but not prophylaxed group had activity orders of ambulatory ad lib or had physical therapy ordered.

DISCUSSION

An estimated 200,000‐300,000 cases of VTE with 60,000‐200,000 fatal pulmonary emboli occur annually.1316 The inpatient fatality rate due to PE is estimated to be 12%.13 The frequency of VTE varies with risk that relates to the population studied and the diagnosis. VTE rates range from 3%‐55% for medical patients to 80% for patients who receive total hip replacement or have multiple trauma, though the higher numbers cited are based on studies using fibrinogen uptake scanning or venography, with the true rates probably between the extremes noted.3, 4, 17, 18 Many of these acutely ill patients are admitted through the ED. Though VTE is common in patients admitted through the ED, with respect to VTE PX, this population is understudied.

In this study, the first to our knowledge to focus on VTE PX in an unselected cohort of ED admissions, the most significant findings were: 79% of ED admissions had indications for VTE PX, yet only 32% of those received it, and 78% of these orders were written within the first day of hospitalization. We also noted a direct association of the use of VTE PX with the level of risk, which increased from 9% in the moderate‐risk group to 23% for high‐risk patients and 47% for very‐high‐risk patients (P < .0001; Table 4.). Thus, most of our patients, including those at highest risk for VTE never received prophylaxis at any time during their hospitalization. Also explored in this study was the relationship of risk factors for VTE with the use of prophylaxis. These risk factors were age, cardiovascular diagnosis, and use of standard order sets. Increasing age and having a primary cardiovascular diagnosis (ie, congestive heart failure, atrial fibrillation) were the risk factors that increased the likelihood of receiving VTE. Therefore, it was expected that the rate of VTE PX would be higher for patients who were older or had these diagnoses. However, in the current study, increasing age alone did not influence the likelihood of physicians ordering VTE PX. In addition, we found markedly decreased rates of VTE PX in cardiac patients.

Other investigators have reported similar findings in selected groups of hospitalized patients.1922 A retrospective chart review of internal medicine discharges from 2 Italian hospitals determined that VTE PX was prescribed in 46.4% and 58.3% of at‐risk patients in nonteaching and teaching hospitals, respectively.20 In a retrospective study of surgical patients in 20 hospitals, 38% of patients received VTE PX.21 Similar results were found in a registry of hospitalized patients who developed VTE, in which only 42% of patients who developed VTE received VTE PX within 30 days prior to diagnosis.23

Bosson et al. reported no increased use of VTE PX in patients with myocardial infarction, similar to that in the current study, though they did find VTE PX administered more frequently to patients with congestive heart failure.22 Antiplatelet medications and activity orders are commonly prescribed for cardiac patients. According to reports that indicated a degree of protection from antiplatelet agents,24, 25 frequent use of activity orders, and the belief that ambulation eliminates the risk of VTE, it is possible physicians believed patients were sufficiently prophylaxed. However, although early ambulation and antiplatelet medications decrease risk of VTE, neither is sufficient to prevent it.3 The administration of aspirin and other antiplatelet medications implies that in our study group bleeding risk was not the primary deterrent to ordering VTE PX. Furthermore, bleeding risk would not be a deterrent to mechanical VTE PX.

In the current study, use of standard order sets was associated with correct decision making and increased use of VTE PX. Risk of VTE might be decreased through the use of standard order sets that result in increased utilization of VTE PX. However, despite evidence that standard order sets can successfully modify prescribing patterns,2629 Cook et al. found that only 5 of 29 Canadian ICU directors surveyed for their approach to VTE prevention and diagnosis in critically ill patients used preprinted orders.30

The present study had several limitations. First, determination of VTE was not an end point. As a single‐center study of prospectively selected subjects, this would have required too large a sample to be feasible. Our data may be biased by not including patients admitted by physicians who declined to allow their charts to be reviewed. However, although physicians were informed that we were examining drug use of patients admitted through the ED, they were not aware that the study focused on VTE PX. Our results are consistent with results of inpatient studies citing inadequate VTE PX.19, 21, 31, 32 Using the modified Caprini Scoring System, we found that only 32% of patients with indications for VTE PX received it. This result was unchanged when stratifying using ACCP guidelines. Finally, we found that prophylaxed patients who were at moderate to high risk were more likely to receive mechanical prophylaxis, whereas two‐thirds of patients who received prophylaxis who were at very high risk received medical prophylaxis or a combination of medical and mechanical prophylaxis.

CONCLUSIONS

Most patients needing VTE PX did not receive it, and those who did receive VTE PX usually had it prescribed in the first 24 hours. As risk factors increased, patients were more often prophylaxed, though fewer than 50% of those in the very‐high‐risk group received VTE PX. This study suggests that in hospital systems similar to ours with 30% or more of hospital admissions coming from the ED implementing a standard order set for patients admitted through the ED may increase VTE PX, which, in turn, could have a major impact on their course. Future studies need to determine the best way to implement these changes.

Patients suffering from a critical life‐threatening illness have long been known to have an increased risk of spontaneous upper gastrointestinal bleeding, even in the absence of previously known gastrointestinal pathology. This phenomenon is generally known as the stress‐ulcer syndrome or stress‐related mucosal disease. Although the incidence in critically ill patients has declined in recent years to less than 10%, the mortality rate in patients experiencing bleeding is often considered to be nearly 50%.1, 2 Various pathophysiological processes including respiratory failure, sepsis, coagulopathy, burns, and severe trauma have been implicated in the development of stress ulcers in critically ill patients.1, 3 The administration of acid‐suppressing medications such as histamine‐2 receptor antagonists, proton‐pump inhibitors, and sucralfate has been shown to decrease the risk of stress‐related gastrointestinal bleeding in these patients.46 As a result, it is standard practice in many intensive care units to use such medications, commonly referred to as stress‐ulcer prophylaxis, to reduce the production of gastric acid and raise intragastric pH. Many intensivists prescribe stress‐ulcer prophylaxis to all ICU patients, including those without risk factors.7

Patients admitted to general medical wards also experience gastrointestinal bleeding. There appears to be an association between stress‐ulcer bleeding in general medical patients and overall severity of illness, similar to that in critically ill patients. Risk factors may include ischemic heart disease, chronic renal failure, and a prior intensive care unit stay or mechanical ventilation.8, 9 Studies in limited populations found that 3% of patients admitted with acute stroke and 13% of patients admitted with renal failure have experienced bleeding. However, only about half these episodes were clinically significant.10, 11 A more recent review that included a much larger and medically diverse population found a rate of less than 1%. In this study mortality did not differ between patients with and without bleeding.12 An older report found that mortality in a set of 125 hospitalized patients with secondary gastrointestinal bleeding was 28%, but only a small fraction of the deaths was directly attributable to the bleeding episode.13

Widespread use of acid‐suppressive therapy for stress‐ulcer prophylaxis in general medical settings has been recognized, especially among patients cared for by medical residents. However, this practice has been significantly less well characterized than the use of stress‐ulcer prophylaxis in critical care settings.1416 This article reports a systematic review of the literature to answer 2 questions: (1) What is the frequency of prescription of acid‐suppressive therapy for stress‐ulcer prophylaxis among adult general medical inpatients? (2) What evidence exists to support this practice?

METHODS

RESULTS

The search criteria identified 3979 citations from the electronic databases and 106 references from the included studies. After eliminating non‐English‐language articles and articles that did not have human subjects, 2912 articles were examined. Of these, only 5 citations met the inclusion criteria (Fig. 1).

Figure 1

DISCUSSION

To our knowledge, this is the first systematic review of the literature that examined the use of acid‐suppressing medications as stress‐ulcer bleeding prophylaxis among general medical patients. Results indicate that there is widespread use of these medications among general medical patients, but little evidence demonstrating a reduction in clinically important gastrointestinal bleeding.

Nardino et al., Parente et al., and Gullota et al. indicated that acid‐suppressive therapies are prescribed to 29%‐54% of hospitalized inpatients. The most common indication for such therapy is stress‐ulcer prophylaxis in patients believed to be at low or no risk, which was true for 20%‐25% of all such patients. Interestingly, both Nardino et al. and Parente et al. assumed there were risk factors that place some general medical patients in a higher‐risk category. In their assessment, these patients warrant prophylaxis. This is somewhat problematic though, as such risk factors have yet to be firmly established. All studies were localized, and results should be confirmed in a larger series that spans multiple institutions. Widespread use of stress‐ulcer prophylaxis may be driven by fear of the previously reported high mortality rates associated with stress‐ulcer bleeding. This fear may be largely unjustified, as overall rates of bleeding episodes appear low.12 Furthermore, patients who die with stress‐ulcer‐related bleeding likely die from their underlying severe illness rather than the bleed itself.

We identified only 2 studies that tested the effectiveness of stress‐ulcer prophylaxis in general medical populations. Both indicated a relatively low risk of gastrointestinal bleeding in patients receiving prophylaxis. Most notably, the work by Estruch et al. comparing an antacid regimen (magaldrate) to placebo showed a significant reduction in bleeding in the active treatment group. However, these trials possess characteristics that limit their applicability to a broad medical population. In particular, these trials were designed to represent only patients with severe illness, many of whom possessed presumed risk factors for stress‐ulcer bleeding. Although all the patients in these 2 series were managed on a general medical ward, many (eg, heart failure patients requiring inotropic support) would likely qualify for intensive care at some institutions. The rate of minor gastrointestinal hemorrhages in the placebo group of the magaldrate trial was significantly higher than in previous observational trials, further suggesting that this population had greater severity of illness than a typical medical population. In addition, although the studies contributed some useful information about severely ill patients, both controlled trials had design limitations. Neither study described why the respective populations were chosen or how the sample sizes were derived. More important, neither was double‐blinded. In sum, given the small number of trials, the limited generalizability to more severely ill patients, and design limitations, the existing literature provides minimal guidance about stress‐ulcer prophylaxis in a diverse inpatient service.

There were no major drug‐related adverse effects reported in these trials, and all the acid‐suppressive drugs currently available are considered relatively safe. However, widespread prophylaxis could result in adverse outcomes on balance. For example, in intensive care populations, there is evidence of an increased risk of nosocomial pneumonia associated with universal acid suppression.27 Many of these patients, however, have other risk factors for pneumonia such as mechanical ventilation.28, 29 Similarly, there has been an association between proton‐pump inhibitor use and increased risk for Clostridium difficileassociated diarrhea.30, 31 Also, H2 receptor antagonists have been implicated in thrombocytopenia, but this is still somewhat controversial.32 Whether these or any other adverse events occur commonly in general medical patients is unclear. Finally, every medication prescribed to inpatients increases the cost of the hospitalization and places a further strain on the financial resources of many already troubled health care delivery systems. For example, a 1997 study found that the use of ranitidine for stress‐ulcer prophylaxis cost $84.81 per day and omeprazole cost $39.52 per day, and those costs would presumably be higher today.33 These costs increase more if patients are continued on such medications after discharge. Clinicians have an obligation to ensure that the therapies they prescribe do not result in increased cost or harm, unless there is at least a reasonable expectation for average net benefit. More information is needed to guide such judgments for stress‐ulcer prophylaxis in non‐ICU patients.

As with all reviews, this one had some limitations. Although we searched a wide body of medical literature, some relevant work may not have been considered. Any published work not indexed by the Medline database or not listed in the Cochrane database of controlled trials would not have been part of this review. In addition, articles written in a language other than English and unpublished works were not examined. Therefore, it is possible that others have investigated this topic and collected information that would alter our results. However, this seems unlikely given the paucity of relevant studies in the wide body of literature that was examined. Finally, the primary author was exclusively responsible for identifying which studies met the inclusion criteria. It is conceivable that additional reviewers would have considered other studies to be relevant to the analysis.

Because stress‐ulcer prophylaxis appears to be widely used in patients hospitalized outside the intensive care unit, it is necessary to determine the efficacy and safety of this practice. Unfortunately, research in this area is sparse. The only 2 trials evaluating this topic, although suggesting a benefit for prophylaxis in selected higher‐risk populations, did not provide guidance for prophylaxis among a broad population of hospitalized medical patients. The present body of evidence does not clearly support or refute the use of stress‐ulcer prophylaxis in a general medical population. An appropriately powered randomized, controlled trial in a diverse population of general medical patients would clarify this issue.

Patients suffering from a critical life‐threatening illness have long been known to have an increased risk of spontaneous upper gastrointestinal bleeding, even in the absence of previously known gastrointestinal pathology. This phenomenon is generally known as the stress‐ulcer syndrome or stress‐related mucosal disease. Although the incidence in critically ill patients has declined in recent years to less than 10%, the mortality rate in patients experiencing bleeding is often considered to be nearly 50%.1, 2 Various pathophysiological processes including respiratory failure, sepsis, coagulopathy, burns, and severe trauma have been implicated in the development of stress ulcers in critically ill patients.1, 3 The administration of acid‐suppressing medications such as histamine‐2 receptor antagonists, proton‐pump inhibitors, and sucralfate has been shown to decrease the risk of stress‐related gastrointestinal bleeding in these patients.46 As a result, it is standard practice in many intensive care units to use such medications, commonly referred to as stress‐ulcer prophylaxis, to reduce the production of gastric acid and raise intragastric pH. Many intensivists prescribe stress‐ulcer prophylaxis to all ICU patients, including those without risk factors.7

Patients admitted to general medical wards also experience gastrointestinal bleeding. There appears to be an association between stress‐ulcer bleeding in general medical patients and overall severity of illness, similar to that in critically ill patients. Risk factors may include ischemic heart disease, chronic renal failure, and a prior intensive care unit stay or mechanical ventilation.8, 9 Studies in limited populations found that 3% of patients admitted with acute stroke and 13% of patients admitted with renal failure have experienced bleeding. However, only about half these episodes were clinically significant.10, 11 A more recent review that included a much larger and medically diverse population found a rate of less than 1%. In this study mortality did not differ between patients with and without bleeding.12 An older report found that mortality in a set of 125 hospitalized patients with secondary gastrointestinal bleeding was 28%, but only a small fraction of the deaths was directly attributable to the bleeding episode.13

Widespread use of acid‐suppressive therapy for stress‐ulcer prophylaxis in general medical settings has been recognized, especially among patients cared for by medical residents. However, this practice has been significantly less well characterized than the use of stress‐ulcer prophylaxis in critical care settings.1416 This article reports a systematic review of the literature to answer 2 questions: (1) What is the frequency of prescription of acid‐suppressive therapy for stress‐ulcer prophylaxis among adult general medical inpatients? (2) What evidence exists to support this practice?

METHODS

RESULTS

The search criteria identified 3979 citations from the electronic databases and 106 references from the included studies. After eliminating non‐English‐language articles and articles that did not have human subjects, 2912 articles were examined. Of these, only 5 citations met the inclusion criteria (Fig. 1).

Figure 1

DISCUSSION

To our knowledge, this is the first systematic review of the literature that examined the use of acid‐suppressing medications as stress‐ulcer bleeding prophylaxis among general medical patients. Results indicate that there is widespread use of these medications among general medical patients, but little evidence demonstrating a reduction in clinically important gastrointestinal bleeding.

Nardino et al., Parente et al., and Gullota et al. indicated that acid‐suppressive therapies are prescribed to 29%‐54% of hospitalized inpatients. The most common indication for such therapy is stress‐ulcer prophylaxis in patients believed to be at low or no risk, which was true for 20%‐25% of all such patients. Interestingly, both Nardino et al. and Parente et al. assumed there were risk factors that place some general medical patients in a higher‐risk category. In their assessment, these patients warrant prophylaxis. This is somewhat problematic though, as such risk factors have yet to be firmly established. All studies were localized, and results should be confirmed in a larger series that spans multiple institutions. Widespread use of stress‐ulcer prophylaxis may be driven by fear of the previously reported high mortality rates associated with stress‐ulcer bleeding. This fear may be largely unjustified, as overall rates of bleeding episodes appear low.12 Furthermore, patients who die with stress‐ulcer‐related bleeding likely die from their underlying severe illness rather than the bleed itself.

We identified only 2 studies that tested the effectiveness of stress‐ulcer prophylaxis in general medical populations. Both indicated a relatively low risk of gastrointestinal bleeding in patients receiving prophylaxis. Most notably, the work by Estruch et al. comparing an antacid regimen (magaldrate) to placebo showed a significant reduction in bleeding in the active treatment group. However, these trials possess characteristics that limit their applicability to a broad medical population. In particular, these trials were designed to represent only patients with severe illness, many of whom possessed presumed risk factors for stress‐ulcer bleeding. Although all the patients in these 2 series were managed on a general medical ward, many (eg, heart failure patients requiring inotropic support) would likely qualify for intensive care at some institutions. The rate of minor gastrointestinal hemorrhages in the placebo group of the magaldrate trial was significantly higher than in previous observational trials, further suggesting that this population had greater severity of illness than a typical medical population. In addition, although the studies contributed some useful information about severely ill patients, both controlled trials had design limitations. Neither study described why the respective populations were chosen or how the sample sizes were derived. More important, neither was double‐blinded. In sum, given the small number of trials, the limited generalizability to more severely ill patients, and design limitations, the existing literature provides minimal guidance about stress‐ulcer prophylaxis in a diverse inpatient service.

There were no major drug‐related adverse effects reported in these trials, and all the acid‐suppressive drugs currently available are considered relatively safe. However, widespread prophylaxis could result in adverse outcomes on balance. For example, in intensive care populations, there is evidence of an increased risk of nosocomial pneumonia associated with universal acid suppression.27 Many of these patients, however, have other risk factors for pneumonia such as mechanical ventilation.28, 29 Similarly, there has been an association between proton‐pump inhibitor use and increased risk for Clostridium difficileassociated diarrhea.30, 31 Also, H2 receptor antagonists have been implicated in thrombocytopenia, but this is still somewhat controversial.32 Whether these or any other adverse events occur commonly in general medical patients is unclear. Finally, every medication prescribed to inpatients increases the cost of the hospitalization and places a further strain on the financial resources of many already troubled health care delivery systems. For example, a 1997 study found that the use of ranitidine for stress‐ulcer prophylaxis cost $84.81 per day and omeprazole cost $39.52 per day, and those costs would presumably be higher today.33 These costs increase more if patients are continued on such medications after discharge. Clinicians have an obligation to ensure that the therapies they prescribe do not result in increased cost or harm, unless there is at least a reasonable expectation for average net benefit. More information is needed to guide such judgments for stress‐ulcer prophylaxis in non‐ICU patients.

As with all reviews, this one had some limitations. Although we searched a wide body of medical literature, some relevant work may not have been considered. Any published work not indexed by the Medline database or not listed in the Cochrane database of controlled trials would not have been part of this review. In addition, articles written in a language other than English and unpublished works were not examined. Therefore, it is possible that others have investigated this topic and collected information that would alter our results. However, this seems unlikely given the paucity of relevant studies in the wide body of literature that was examined. Finally, the primary author was exclusively responsible for identifying which studies met the inclusion criteria. It is conceivable that additional reviewers would have considered other studies to be relevant to the analysis.

Because stress‐ulcer prophylaxis appears to be widely used in patients hospitalized outside the intensive care unit, it is necessary to determine the efficacy and safety of this practice. Unfortunately, research in this area is sparse. The only 2 trials evaluating this topic, although suggesting a benefit for prophylaxis in selected higher‐risk populations, did not provide guidance for prophylaxis among a broad population of hospitalized medical patients. The present body of evidence does not clearly support or refute the use of stress‐ulcer prophylaxis in a general medical population. An appropriately powered randomized, controlled trial in a diverse population of general medical patients would clarify this issue.

Patients suffering from a critical life‐threatening illness have long been known to have an increased risk of spontaneous upper gastrointestinal bleeding, even in the absence of previously known gastrointestinal pathology. This phenomenon is generally known as the stress‐ulcer syndrome or stress‐related mucosal disease. Although the incidence in critically ill patients has declined in recent years to less than 10%, the mortality rate in patients experiencing bleeding is often considered to be nearly 50%.1, 2 Various pathophysiological processes including respiratory failure, sepsis, coagulopathy, burns, and severe trauma have been implicated in the development of stress ulcers in critically ill patients.1, 3 The administration of acid‐suppressing medications such as histamine‐2 receptor antagonists, proton‐pump inhibitors, and sucralfate has been shown to decrease the risk of stress‐related gastrointestinal bleeding in these patients.46 As a result, it is standard practice in many intensive care units to use such medications, commonly referred to as stress‐ulcer prophylaxis, to reduce the production of gastric acid and raise intragastric pH. Many intensivists prescribe stress‐ulcer prophylaxis to all ICU patients, including those without risk factors.7

Patients admitted to general medical wards also experience gastrointestinal bleeding. There appears to be an association between stress‐ulcer bleeding in general medical patients and overall severity of illness, similar to that in critically ill patients. Risk factors may include ischemic heart disease, chronic renal failure, and a prior intensive care unit stay or mechanical ventilation.8, 9 Studies in limited populations found that 3% of patients admitted with acute stroke and 13% of patients admitted with renal failure have experienced bleeding. However, only about half these episodes were clinically significant.10, 11 A more recent review that included a much larger and medically diverse population found a rate of less than 1%. In this study mortality did not differ between patients with and without bleeding.12 An older report found that mortality in a set of 125 hospitalized patients with secondary gastrointestinal bleeding was 28%, but only a small fraction of the deaths was directly attributable to the bleeding episode.13

Widespread use of acid‐suppressive therapy for stress‐ulcer prophylaxis in general medical settings has been recognized, especially among patients cared for by medical residents. However, this practice has been significantly less well characterized than the use of stress‐ulcer prophylaxis in critical care settings.1416 This article reports a systematic review of the literature to answer 2 questions: (1) What is the frequency of prescription of acid‐suppressive therapy for stress‐ulcer prophylaxis among adult general medical inpatients? (2) What evidence exists to support this practice?

METHODS

RESULTS

The search criteria identified 3979 citations from the electronic databases and 106 references from the included studies. After eliminating non‐English‐language articles and articles that did not have human subjects, 2912 articles were examined. Of these, only 5 citations met the inclusion criteria (Fig. 1).

Figure 1

DISCUSSION

To our knowledge, this is the first systematic review of the literature that examined the use of acid‐suppressing medications as stress‐ulcer bleeding prophylaxis among general medical patients. Results indicate that there is widespread use of these medications among general medical patients, but little evidence demonstrating a reduction in clinically important gastrointestinal bleeding.

Nardino et al., Parente et al., and Gullota et al. indicated that acid‐suppressive therapies are prescribed to 29%‐54% of hospitalized inpatients. The most common indication for such therapy is stress‐ulcer prophylaxis in patients believed to be at low or no risk, which was true for 20%‐25% of all such patients. Interestingly, both Nardino et al. and Parente et al. assumed there were risk factors that place some general medical patients in a higher‐risk category. In their assessment, these patients warrant prophylaxis. This is somewhat problematic though, as such risk factors have yet to be firmly established. All studies were localized, and results should be confirmed in a larger series that spans multiple institutions. Widespread use of stress‐ulcer prophylaxis may be driven by fear of the previously reported high mortality rates associated with stress‐ulcer bleeding. This fear may be largely unjustified, as overall rates of bleeding episodes appear low.12 Furthermore, patients who die with stress‐ulcer‐related bleeding likely die from their underlying severe illness rather than the bleed itself.

We identified only 2 studies that tested the effectiveness of stress‐ulcer prophylaxis in general medical populations. Both indicated a relatively low risk of gastrointestinal bleeding in patients receiving prophylaxis. Most notably, the work by Estruch et al. comparing an antacid regimen (magaldrate) to placebo showed a significant reduction in bleeding in the active treatment group. However, these trials possess characteristics that limit their applicability to a broad medical population. In particular, these trials were designed to represent only patients with severe illness, many of whom possessed presumed risk factors for stress‐ulcer bleeding. Although all the patients in these 2 series were managed on a general medical ward, many (eg, heart failure patients requiring inotropic support) would likely qualify for intensive care at some institutions. The rate of minor gastrointestinal hemorrhages in the placebo group of the magaldrate trial was significantly higher than in previous observational trials, further suggesting that this population had greater severity of illness than a typical medical population. In addition, although the studies contributed some useful information about severely ill patients, both controlled trials had design limitations. Neither study described why the respective populations were chosen or how the sample sizes were derived. More important, neither was double‐blinded. In sum, given the small number of trials, the limited generalizability to more severely ill patients, and design limitations, the existing literature provides minimal guidance about stress‐ulcer prophylaxis in a diverse inpatient service.

There were no major drug‐related adverse effects reported in these trials, and all the acid‐suppressive drugs currently available are considered relatively safe. However, widespread prophylaxis could result in adverse outcomes on balance. For example, in intensive care populations, there is evidence of an increased risk of nosocomial pneumonia associated with universal acid suppression.27 Many of these patients, however, have other risk factors for pneumonia such as mechanical ventilation.28, 29 Similarly, there has been an association between proton‐pump inhibitor use and increased risk for Clostridium difficileassociated diarrhea.30, 31 Also, H2 receptor antagonists have been implicated in thrombocytopenia, but this is still somewhat controversial.32 Whether these or any other adverse events occur commonly in general medical patients is unclear. Finally, every medication prescribed to inpatients increases the cost of the hospitalization and places a further strain on the financial resources of many already troubled health care delivery systems. For example, a 1997 study found that the use of ranitidine for stress‐ulcer prophylaxis cost $84.81 per day and omeprazole cost $39.52 per day, and those costs would presumably be higher today.33 These costs increase more if patients are continued on such medications after discharge. Clinicians have an obligation to ensure that the therapies they prescribe do not result in increased cost or harm, unless there is at least a reasonable expectation for average net benefit. More information is needed to guide such judgments for stress‐ulcer prophylaxis in non‐ICU patients.

As with all reviews, this one had some limitations. Although we searched a wide body of medical literature, some relevant work may not have been considered. Any published work not indexed by the Medline database or not listed in the Cochrane database of controlled trials would not have been part of this review. In addition, articles written in a language other than English and unpublished works were not examined. Therefore, it is possible that others have investigated this topic and collected information that would alter our results. However, this seems unlikely given the paucity of relevant studies in the wide body of literature that was examined. Finally, the primary author was exclusively responsible for identifying which studies met the inclusion criteria. It is conceivable that additional reviewers would have considered other studies to be relevant to the analysis.

Because stress‐ulcer prophylaxis appears to be widely used in patients hospitalized outside the intensive care unit, it is necessary to determine the efficacy and safety of this practice. Unfortunately, research in this area is sparse. The only 2 trials evaluating this topic, although suggesting a benefit for prophylaxis in selected higher‐risk populations, did not provide guidance for prophylaxis among a broad population of hospitalized medical patients. The present body of evidence does not clearly support or refute the use of stress‐ulcer prophylaxis in a general medical population. An appropriately powered randomized, controlled trial in a diverse population of general medical patients would clarify this issue.

In 10 short years, the explosive growth in the number of hospitalists has made hospital medicine programs the cornerstone of many innovations that support the institutions they serve: expanded inpatient care, developing consultative and comanagement services, hospital capacity management, improved patient quality and safety practices, and more. Hospitalist teams have demonstrated a genuine commitment to improving the hospital system, with literature supporting that hospitalists can positively affect cost, length of stay, quality of care, and, at academic institutions, education.1 To the casual observer, these hospitalist groups and the solutions they bring may seem fairly uniform; however, to the discerning eye, nothing could be farther from the truth. Hospital medicine programs, and their innovations, are as varied as the hospitals they serve.

Although the challenges encountered in hospital systems have clear, institution‐specific elements, common themes are often encountered by clinicians that parallel those seen at other facilities. Unfortunately, widely disseminated articles from peer‐reviewed journals on hospital‐based innovations have not been available for other hospitalists to use and glean ideas from for use at their home institutionsuntil now. The Journal of Hospital Medicine is pleased to announce the creation of that opportunity.

This year, the Journal of Hospital Medicine will publish articles on and later a supplement dedicated to innovations in hospital medicine. We invite authors to submit manuscripts related to any successful innovation they initiated in their hospital. We will consider any original work that pertains to hospital medicine, including but not limited to clinical innovations, educational programs, quality and safety initiatives, and administrative or academic issues. When available and appropriate, we encourage outcomes to be reported.

To be able to publish articles on a significant number of innovations, we request manuscripts be a maximum of 1500 words with no more than 2 tables or figures and fewer than 15 references. The deadline for submissions is August 1, 2007. All submitted manuscripts will undergo both editorial review by JHM staff and peer review. Authors should consult JHM's instructions for authors2 for guidelines on manuscript submission and preparation.

In 10 short years, the explosive growth in the number of hospitalists has made hospital medicine programs the cornerstone of many innovations that support the institutions they serve: expanded inpatient care, developing consultative and comanagement services, hospital capacity management, improved patient quality and safety practices, and more. Hospitalist teams have demonstrated a genuine commitment to improving the hospital system, with literature supporting that hospitalists can positively affect cost, length of stay, quality of care, and, at academic institutions, education.1 To the casual observer, these hospitalist groups and the solutions they bring may seem fairly uniform; however, to the discerning eye, nothing could be farther from the truth. Hospital medicine programs, and their innovations, are as varied as the hospitals they serve.

Although the challenges encountered in hospital systems have clear, institution‐specific elements, common themes are often encountered by clinicians that parallel those seen at other facilities. Unfortunately, widely disseminated articles from peer‐reviewed journals on hospital‐based innovations have not been available for other hospitalists to use and glean ideas from for use at their home institutionsuntil now. The Journal of Hospital Medicine is pleased to announce the creation of that opportunity.

This year, the Journal of Hospital Medicine will publish articles on and later a supplement dedicated to innovations in hospital medicine. We invite authors to submit manuscripts related to any successful innovation they initiated in their hospital. We will consider any original work that pertains to hospital medicine, including but not limited to clinical innovations, educational programs, quality and safety initiatives, and administrative or academic issues. When available and appropriate, we encourage outcomes to be reported.

To be able to publish articles on a significant number of innovations, we request manuscripts be a maximum of 1500 words with no more than 2 tables or figures and fewer than 15 references. The deadline for submissions is August 1, 2007. All submitted manuscripts will undergo both editorial review by JHM staff and peer review. Authors should consult JHM's instructions for authors2 for guidelines on manuscript submission and preparation.

In 10 short years, the explosive growth in the number of hospitalists has made hospital medicine programs the cornerstone of many innovations that support the institutions they serve: expanded inpatient care, developing consultative and comanagement services, hospital capacity management, improved patient quality and safety practices, and more. Hospitalist teams have demonstrated a genuine commitment to improving the hospital system, with literature supporting that hospitalists can positively affect cost, length of stay, quality of care, and, at academic institutions, education.1 To the casual observer, these hospitalist groups and the solutions they bring may seem fairly uniform; however, to the discerning eye, nothing could be farther from the truth. Hospital medicine programs, and their innovations, are as varied as the hospitals they serve.

Although the challenges encountered in hospital systems have clear, institution‐specific elements, common themes are often encountered by clinicians that parallel those seen at other facilities. Unfortunately, widely disseminated articles from peer‐reviewed journals on hospital‐based innovations have not been available for other hospitalists to use and glean ideas from for use at their home institutionsuntil now. The Journal of Hospital Medicine is pleased to announce the creation of that opportunity.

This year, the Journal of Hospital Medicine will publish articles on and later a supplement dedicated to innovations in hospital medicine. We invite authors to submit manuscripts related to any successful innovation they initiated in their hospital. We will consider any original work that pertains to hospital medicine, including but not limited to clinical innovations, educational programs, quality and safety initiatives, and administrative or academic issues. When available and appropriate, we encourage outcomes to be reported.

To be able to publish articles on a significant number of innovations, we request manuscripts be a maximum of 1500 words with no more than 2 tables or figures and fewer than 15 references. The deadline for submissions is August 1, 2007. All submitted manuscripts will undergo both editorial review by JHM staff and peer review. Authors should consult JHM's instructions for authors2 for guidelines on manuscript submission and preparation.

The field of hospital medicine came into being in response to numerous factors involving physicians, patients, and hospitals themselves1 Now, years later, hospital medicine is a specialty that is growing, both in size and sophistication such that the role of the hospitalist is constantly evolving.2 A compelling function that has not yet been clearly articulated is the opportunity for hospitalists to serve as public health practitioners in their unique clinical environment. There is precedence for the power of collaboration between medicine and public health as has been seen with emergency medicine's willingness to embrace opportunities to advance public health.35

In public health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities vary with changing technology and social values, but the goals remain the same: to reduce the amount of disease, premature death, and disease‐associated discomfort and disability in the population.6 The authors of a leading textbook of public health, Scutchfield and Keck, contend that the most important skill for public health practice is the capacity to visualize the potential for health that exists in a community.6

Hospitalists care for a distinct subset of the general populationinpatients, only a small percentage of society in a given year. Yet over time hospitalists affect a substantial subset of the larger population that uses considerable health care resources.79 Furthermore, hospitalization can be a sentinel event with public health implications (eg, newly diagnosed HIV infection or acute myocardial infarction in a patient with an extended family of cigarette smokers). This presents an opportunity to educate and counsel both the patient and the patient's social network. One model of public health practice by hospitalists is to influence the patient, his or her family, and the community by touching and inspiring the hospitalized patient.

Hospitalists are already involved in many of the core functions of public health (assessment, assurance, and policy development; Fig. 1).10 Achieving ongoing success in this arena means developing hospitalists who are consciously in tune with their roles as public health practitioners.

Figure 1

In this article we define the specific public health contributions that hospitalists have made and describe the possibilities for further innovative advances. To this end, we outline specific public health roles under the broad categories of assessment, assurance, and policy. We point to advances in public health accomplished by hospitalists as well as those being performed by nonhospitalists in the hospital setting. We conclude by describing some of the barriers to and implications of hospitalists taking on public health roles.

ASSESSMENT

Assessment is the systematic collection, analysis, and dissemination of health status information.10 These activities include disease surveillance and investigation of acute outbreaks or changes in the epidemiology of chronic diseases. Assessment also involves understanding the health of a population and the key determinants of a population's health from a variety of perspectives: physical, biological, behavioral, social, cultural, and spiritual.6 Human health has been defined as a state characterized by anatomic integrity; ability to perform personally valued family work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well‐being; and freedom from the risk of disease and untimely death.6 Hospitalists interact with individuals at times of stress and acute illness and thus have a unique opportunity to assess the strength, viability, and resources available to individuals. Key roles that may fall within the auspices of assessment in hospital medicine are infection control, epidemic recognition, disaster response, preventive care, substance abuse treatment, and chronic disease management.

ASSURANCE

Assurance is the provision of access to necessary health services. It entails efforts to solve problems that threaten the health of populations and empowers individuals to maintain their own health. This is accomplished by either encouraging action, delegating to other entities (private or public sector), mandating specific requirements through regulation, or providing services directly.10 Hospitalist teams aim to ensure that the high‐quality services needed to protect the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. The few studies to date that have directly examined the quality of care that hospitalists provide38 have done so using evidence‐based measures believed to correlate with improved health care outcomes.38 The ambiguities in assessing quality may in part limit such studies.39 Specific hospitalist roles that fall under the assurance umbrella include antibiotic optimization, palliative care, patient safety, and medical error management.

POLICY

Policy development defines health control goals and objectives and develops implementation plans for those goals.10 By necessity, it operates at the intersection of legislative, political, and regulatory processes.10 At many institutions, hospitalists have been involved in the development of policies ensuring that the core functions of assessment and assurance are addressed and maintained. In fact, hospitalists report that development of quality assurance and practice guidelines accounts for most of their nonclinical time.56 This role of hospitalists is supported by anecdotal reports rather than published empiric evidence.57 For example, at Johns Hopkins Bayview Medical Center, hospitalist‐led teams have developed triage and patient handoff policies designed to improve patient safety. Parameters for admission to the general medicine ward have been elaborated and are periodically refined by the hospitalist team.

Another area that falls within the genre of policy is development of clinical practice guidelines. Guidelines for the treatment of pneumonia, congestive heart failure, deep‐vein thrombosis prophylaxis, alcohol and drug withdrawal, pain management, delirium, and chronic obstructive pulmonary disease have been developed by nonhospitalists.58, 59 These areas are considered core competencies in hospital medicine, and as such, hospitalists have an obligation to review and refine these guidelines to ensure the best provision of care to our patients.59

Hospitalists have been engaged in upholding guidelines that affect community practice. For example, in a study comparing treatment of patients admitted with congestive heart failure by hospitalists compared with that by nonhospitalists, hospitalists were found to be more likely to document left ventricular function, a core measure of quality as defined by JCAHO.39, 60 Knowledge about cardiac function can direct future care for patients when they return to the community and into the care of their primary care providers. In another example, Rifkin found that patients with community‐acquired pneumonia treated by hospitalists were more rapidly converted to oral antibiotics from intravenous antibiotics, facilitating a shorter length of stay,61 which reduced the opportunity for nosocomial infections to propagate. Because hospitalists are skilled at following guidelines,59 it follows that they should seize the opportunity to develop more of them.

As the hospitalist movement continues to grow, hospitalists will likely be engaged in implementing citywide, statewide, and even national policies that ensure optimal care of the hospitalized patient.

BARRIERS TO HOSPITALISTS FOCUSING ON PUBLIC HEALTH

Hospitalists are involved in public health activities even though they may not recognize the extent of this involvement. However, there may be some drawbacks to hospitalists viewing each patient encounter as an opportunity for a public health intervention. First, in viewing a patient as part of a cohort, the individual needs of the patient may be overlooked. There is inherent tension between population‐based and individual‐based care, which is a challenge. Second, hospitalists are busy clinicians who may be most highly valued because of their focus on efficiency and cost savings in the acute care setting. This factor alone may prevent substantive involvement by hospitalists in public health practice. Moving beyond the management of an acute illness may interfere with this efficiency and cost effectiveness from the hospital's perspective. However, interventions that promote health and prevent or reduce rehospitalizations may be cost effective to society in the long run. Third, current billing systems do not adequately reward or reimburse providers for the extra time that may be necessary to engage in public health practice. Fourth, hospitalists may not have the awareness, interest, training, or commitment to engage in public health practice. Finally, there may not be effective collaboration and communication systems between primary care providers and hospitalists. This barrier limits or hinders many possibilities for the effective execution of several public health initiatives.

CONCLUSIONS AND IMPLICATIONS

Hospitalists and the specialty of hospital medicine materialized because of myriad economic forces and the need to provide safe, high‐quality care to hospitalized patients. In this article we have described the ways in which hospitalists can be explicitly involved in public health practice. Traditionally, physicians caring for hospitalized patients have collected information through histories and physical examinations, interpreted laboratory data and tests, and formulated assessments and plans of care. To become public health practitioners, hospitalists have to go beyond these tasks and consider public health thought processes, such as problem‐solving paradigms and theories of behavior change. In adopting this public health perspective, hospitalists may begin to think of a patient in the context of the larger community in order to define the problems facing the community, not just the patient, determine the magnitude of such problems, identify key stakeholders, create intervention/prevention strategies, set priorities and recommend interventions, and implement and evaluate those interventions. This approach forces providers to move beyond the physicianpatient model and draw on public health models to invoke change. Hopefully, future research will further convince hospitalists of the benefits of this approach. Although it may be easier to defer care and management decisions to an outpatient physician, data suggest that intervening when patients are in the hospital may be most effective.62, 63 For example, is it possible that patients are more likely to quit smoking when they are sick in the hospital than when they are in their usual state of health on a routine visit at their primary care provider's office?64 Further, although deferring care to a primary care provider (PCP) may be easier, it is not always possible given these barriers: (1) some patients are routinely rehospitalized, precluding primary care visits, (2) some recommendations may not be received by PCPs, and (3) PCPpatient encounters are brief and the agendas full, and there are limited resources to address recommendations from the hospital.

As hospitalists become more involved in public health practice, their collaboration with physicians and researchers in other fields, nurses, policymakers, and administrators will expand. Succeeding in this arena requires integrity, motivation, capacity, understanding, knowledge, and experience.65 It is hoped that hospitalists will embrace the opportunity and master the requisite skill set necessary to practice in and advance this field. As hospitalist fellowship programs are developed, public health practice skills could be incorporated into the curriculum. Currently 6 of 16 fellowship programs offer either a master of public health degree or public health courses.66 Public health skills can also be taught at Society of Hospital Medicine meetings and other continuing medical education events.

With the evolution of hospital medicine, hospitalists have to be malleable in order to optimally meet the needs of the population they serve. The possibilities are endless.