Respect for patient autonomy is a primary ethical principle guiding the practice of medicine in the United States.1. The Patient Self‐Determination Act (PSDA), enacted to enhance autonomy at the end of life, has not fulfilled its promise for a number of reasons.24 No state mandates that on admission, hospitalized patients be asked to provide informed consent for end‐of‐life procedures. Despite informed consent being a requirement for all other invasive procedures when there is sufficient opportunity to obtain it (eg, in nonemergent situations with a capable patient),5 cardiopulmonary resuscitation (CPR) and mechanical ventilation are assumed, until otherwise stipulated, to be procedures that all patients want. It also has been assumed that patients would believe that a request for informed consent for such procedures on hospital admission implied they had significant risk of cardiopulmonary failure and that this would discourage or disturb acutely ill patients.6 Another impediment to obtaining informed consent is that many physicians may not have sufficient time or level of comfort to be able to routinely approach end‐of‐life discussions. In this prospective study, we hypothesized that acutely ill medical patients would be willing to provide informed consent for CPR and mechanical ventilation and to create written advance directives.

METHODS

This study was approved by the hospital's institutional review board. Patients admitted to the Department of Medicine from December 2003 through February 2004 were candidates for this study. Patients admitted for cardiac catheterization (and similar same‐day medical procedures) or critical illness (admitted to intensive care units) were excluded from the study. In our hospital, all patients are asked by admitting personnel (clerk and nurse) whether they already have advance directives. Some patients are also queried by their physicians about whether they wish to have CPR in the event of cardiopulmonary arrest during hospitalization. Patients who are not asked are assumed to be full codes, that is, they are to receive CPR and mechanical ventilation in the event of cardiac and respiratory failure. For those who are asked, there are generally 3 possible outcomes: (1) the patient chooses to accept CPR and mechanical ventilation, and nothing further is documented; (2) the patient chooses a code status, and it is documented in the admission orders and/or a formal code designation form with a progress note describing the discussion; or (3) the patient defers the decision.

Our data processing department generated a daily list of the patients admitted to the hospital on the previous day. Patients satisfying inclusion criteria were randomized (by a random number generator) to the intervention or the control group. Medical records of all patients were examined to ascertain demographic information, admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, primary diagnosis, number of comorbid illnesses, and documentation of whether the patient had a preexisting advance directive or wishes regarding CPR and mechanical ventilation for that admission.

Patients in the control group were not approached by study personnel, but medical records were surveyed for their in‐hospital outcomes and changes in code or advance directive status. Patients randomized to the intervention arm were approached by 1 of 4 study physicians, who read from a script detailed information about life‐sustaining therapies and advance directives (see Appendix). This script was developed with hospital clinician‐experts and approved by members of the Department of Medicine.

Patients whose primary language was not English were interviewed through in‐house or 3‐way telephone (remote) translators. All patients in the treatment group were assessed during the scripted intervention to ascertain whether they had the capacity to make informed decisions, which was determined based on their ability: (a) to understand the information presented, (b) to consider the information in relation to their personal values, and (c) to communicate their wishes. If personnel doubted an individual's capacity in any of these 3 areas, then he or she was not included in the study (ie, excluded after randomization). In the control group, patients with documented dementia or delirium were also excluded.

As specified in the script, patients in the intervention group were asked at the end of the interview whether they wished to choose their in‐hospital CPR status for that admission. If a patient definitely wanted to change the status indicated in the hospital record, study personnel would communicate the patient's wishes to the admitting physician. Attending physicians were given the opportunity to speak with their patients before changing a code status, but if the physicians agreed with the change, study personnel would document it in the formal orders. Patients were also asked whether they wished to create advance directives; if so, staff from the hospital's patient relations department would meet with them to draft the documents.

The following outcomes were measured: 1) willingness of patients assigned to the intervention group to listen to the script about end‐of‐life/life‐sustaining therapies; 2) opinions of patients about whether the information in the intervention was useful versus whether it was disturbing; 3) the frequency with which patients who had proactively received the information chose or changed their code status; and 4) the frequency with which patients without a preexisting advance directive created one while hospitalized. Simple proportions of each of these variables (ie, observed number divided by total number) in the intervention and control groups were compared using software that calculates the significance of the difference between two percentages (Statistica). The demographics of the patients were compared using the unpaired Student's t test. A P value of < .05 was considered statistically significant.

RESULTS

A total of 585 patients admitted to the Department of Medicine between December 2003 and February 2004 were randomized for the study. Patients were excluded if they had insufficient capacity (133) or if they were rapidly discharged from the hospital (155). Patients who were excluded tended to be more ill (APACHE 8.1 vs. 7.3, P = .06) and were more likely to die while hospitalized (8% vs. 4%, P = .04). A total of 297 patients were included in the study, 136 in the intervention group and 161 in the control group. Baseline characteristics were similar between the 2 groups (see Table 1).

Did Patients Who Received the Intervention Clarify Their CPR Preference?

Of the 136 patients in the intervention arm, 49 (36%) had explicit documentation of their code status on admission, compared to 55 of the 161 patients in the control group (34%; P = .7). Documentation included listing the CPR status in the admission orders or in a completed code designation form. After receiving the intervention, 125 of the 136 patients in the intervention arm (92%) clarified their preferences about CPR and mechanical ventilation.

Of the 49 patients in the intervention group who had documented CPR status on admission, 48 were listed as full code (both CPR and mechanical ventilation), and 1 was documented as refusing both CPR and mechanical ventilation. Of the 48 patients who were full codes, 3 stated they did not want CPR and mechanical ventilation under any circumstances after the intervention. Their preferences were subsequently documented as formal orders. The remaining 45 (94%) stayed full codes (see Figure 1).

Figure 1

Of the 87 patients in the intervention group who had no explicit documentation of CPR status on hospital admission, 76 clarified their preference and 11 did not. Of the 76 patients, 71 wished to receive both CPR and mechanical ventilation, and 5 wanted neither. The status of the latter as no code, no ventilator was subsequently documented in the medical record with the consent of their attending physicians. One of these 5 patients became increasingly ill during hospitalization, with reduced capacity, and family members later asked that he receive only comfort care.

Of the 161 patients in the control group, 55 (34%) had documentation of their code status (ie, to receive CPR if needed) in the admission hospital record. By the end of hospitalization, 1 patient requested no CPR and no mechanical ventilation, and 2 received comfort care with cessation of other active life‐prolonging interventions. Of the 106 without initial code documentation, 4 were later documented as being no code, no ventilator and 2 as being comfort care (see Figure 1).

DISCUSSION

This study demonstrates that most (95%) hospitalized medical patients welcomed the opportunity to provide prospective informed consent for CPR and mechanical ventilation. Although only a small minority (4%) opted out of CPR/mechanical ventilation, a majority (92%) of those who received the educational intervention chose to accept those therapies if required. This study also demonstrates that hospitalization can be one point‐of‐care where patients can consider and create advance directives. The results of this study are consistent with those of the SUPPORT group4 and other7 studies about patient interest in making choices on CPR. Our study suggests that physicians can elicit patients' wishes about and record formal orders on CPR around the time of hospital admission.

The default action has been to administer CPR and mechanical ventilation after cardiopulmonary failure or arrest, that is, patients receive these procedures unless they state explicitly that they do not want them. Unlike with all other invasive procedures, no national regulation mandates obtaining informed consent prospectively, when possible, for these treatments, because it is assumed that patients would want these therapies rather than the alternative (ie, death). Indeed, it is appropriate to perform lifesaving procedures in emergencies without consent if the patient lacks capacity and a surrogate decision maker cannot be contacted quickly. This clinical approach is consistent with medical ethics: to err on the side of life when a patient's wishes are unknown or unclear. Nonetheless, having a full code as the default action denies patients the opportunity to provide informed consent for these highly invasive procedures because there often is ample opportunity to ask their permission. If patient self‐determination is the categorical imperative of American medicine, then current practice violates that principle at the moment when it may be most important, that is, when a patient's decision about whether to risk life‐sustaining therapies could promote survival or prolong dying. Our study demonstrates that a simple interventionsimply askingpromotes a decision and therefore patient autonomy in most cases.

When patients have opted for life‐sustaining therapies that subsequently have been administered or when patients have received such therapies by default, physicians and patients can be left in 2 situations. In one outcome the patient retains capacity, and the dialogue about life‐sustaining therapies can continue between patient and physician. In the second, frequent scenario, the patient is incapacitated. Until patient capacity can be restored, the physician must work with surrogate decision makers and preexisting advance directives to infer a patient's wishes about continuation of life‐sustaining care. Our data demonstrate that hospital admission is one point‐of‐care at which patients can be offered and can complete, albeit in small numbers, advance directives.8 Previous work with our patients demonstrated that many patients misunderstood advance directives and the degree of effort required to create them.9 We reasoned that more patients might create advance directives if we offered the service for free during hospitalization. We were very surprised at how infrequently patients created advance directives in this study, although this finding is consistent with others in the published literature.8 It is speculated that hospitalized patients may feel too ill to exert themselves and/or are not psychologically prepared to consider end‐of‐life directives (ie, I came to the hospital to get better, not to consider what should be done when I'm terminal ). Some patients may not trust physicians to use advance directives reliably.4, 10

Our study had several important limitations. First, and most important, not all patients who were randomized were enrolled in the study. The most common reasons for exclusion were rapid discharge from the hospital and mental status change calling into question a patient's capacity to make end‐of‐life decisions. Nonetheless, it is only competent patients who can be engaged to decide these questions for themselves. Surrogates (ie, loved ones), guided by advance directives, are left to address resuscitation decisions for those lacking capacity. In addition, patients' predilections may change with time,11 especially as death becomes more imminent. However, insofar as many patients have several hospital admissions as they approach the end of life and are more likely to possess capacity to consider CPR decisions during early admissions, their choices can be recorded repeatedly over time (with each admission or even as status changes during an admission) to inform decisions if they develop incapacity. Little more can be done to enhance autonomy regarding CPR beyond repeatedly educating and asking, as disease and specific illnesses progress. It can be argued that this intervention had little real overall effectmost patients who would have received CPR by default did in fact want it when informed and asked. This is an ethically problematic position for two reasons: it neglects the right of patients to decide for themselves, and it potentially subjects the small group of patients who would reject CPR if asked to an unwanted risky procedure (ie, one that may prolong dying). Another limitation of the present study is that patients were approached by doctors‐in‐training with whom they had had no prior therapeutic relationship. Although it would have been optimal for patients to be approached by their primary care physicians, this was not feasible. Even if we could have convinced all of our medical staff members to implement the intervention, it is unlikely that all would have adhered to a study script, which is what enabled standardization of the information shared with patients. Some physicians may disagree with the script's content. But the goal of this study was not to determine if specific information would affect outcomes; rather, it was to determine if patients were receptive to discussing these issues and making proactive choices regarding life‐sustaining therapies during hospitalization for acute illness. It is possible that using different scripts delivered by different personnel, ideally the patients' own doctors, might have elicited even greater rates of consent and proactive decision making. Finally, the degree to which these results can be generalized may vary based on the population sampled. White and well‐educated patients are more likely to engage in end‐of‐life decision making than non‐White and poorly educated patients.9, 12

In conclusion, this study suggests that capable patients hospitalized for medical problems are willing to give informed consent for (or reject) CPR and mechanical ventilation in the event of cardiopulmonary failure. The approach of the study was very simple. It took roughly 510 minutes to inform patients and elicit their choices. Allowing patients to choose, rather than assuming that CPR is the choice of patients by default, strenuously honors patient autonomy. If these findings are replicated in larger cohorts and at different centers, there would be little justification for not informing patients about and asking them to choose their CPR preferences for each hospitalization. In the meantime, caregivers might consider the appropriateness of addressing these issues when they admit acutely ill patients to the hospital.

Respect for patient autonomy is a primary ethical principle guiding the practice of medicine in the United States.1. The Patient Self‐Determination Act (PSDA), enacted to enhance autonomy at the end of life, has not fulfilled its promise for a number of reasons.24 No state mandates that on admission, hospitalized patients be asked to provide informed consent for end‐of‐life procedures. Despite informed consent being a requirement for all other invasive procedures when there is sufficient opportunity to obtain it (eg, in nonemergent situations with a capable patient),5 cardiopulmonary resuscitation (CPR) and mechanical ventilation are assumed, until otherwise stipulated, to be procedures that all patients want. It also has been assumed that patients would believe that a request for informed consent for such procedures on hospital admission implied they had significant risk of cardiopulmonary failure and that this would discourage or disturb acutely ill patients.6 Another impediment to obtaining informed consent is that many physicians may not have sufficient time or level of comfort to be able to routinely approach end‐of‐life discussions. In this prospective study, we hypothesized that acutely ill medical patients would be willing to provide informed consent for CPR and mechanical ventilation and to create written advance directives.

METHODS

This study was approved by the hospital's institutional review board. Patients admitted to the Department of Medicine from December 2003 through February 2004 were candidates for this study. Patients admitted for cardiac catheterization (and similar same‐day medical procedures) or critical illness (admitted to intensive care units) were excluded from the study. In our hospital, all patients are asked by admitting personnel (clerk and nurse) whether they already have advance directives. Some patients are also queried by their physicians about whether they wish to have CPR in the event of cardiopulmonary arrest during hospitalization. Patients who are not asked are assumed to be full codes, that is, they are to receive CPR and mechanical ventilation in the event of cardiac and respiratory failure. For those who are asked, there are generally 3 possible outcomes: (1) the patient chooses to accept CPR and mechanical ventilation, and nothing further is documented; (2) the patient chooses a code status, and it is documented in the admission orders and/or a formal code designation form with a progress note describing the discussion; or (3) the patient defers the decision.

Our data processing department generated a daily list of the patients admitted to the hospital on the previous day. Patients satisfying inclusion criteria were randomized (by a random number generator) to the intervention or the control group. Medical records of all patients were examined to ascertain demographic information, admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, primary diagnosis, number of comorbid illnesses, and documentation of whether the patient had a preexisting advance directive or wishes regarding CPR and mechanical ventilation for that admission.

Patients in the control group were not approached by study personnel, but medical records were surveyed for their in‐hospital outcomes and changes in code or advance directive status. Patients randomized to the intervention arm were approached by 1 of 4 study physicians, who read from a script detailed information about life‐sustaining therapies and advance directives (see Appendix). This script was developed with hospital clinician‐experts and approved by members of the Department of Medicine.

Patients whose primary language was not English were interviewed through in‐house or 3‐way telephone (remote) translators. All patients in the treatment group were assessed during the scripted intervention to ascertain whether they had the capacity to make informed decisions, which was determined based on their ability: (a) to understand the information presented, (b) to consider the information in relation to their personal values, and (c) to communicate their wishes. If personnel doubted an individual's capacity in any of these 3 areas, then he or she was not included in the study (ie, excluded after randomization). In the control group, patients with documented dementia or delirium were also excluded.

As specified in the script, patients in the intervention group were asked at the end of the interview whether they wished to choose their in‐hospital CPR status for that admission. If a patient definitely wanted to change the status indicated in the hospital record, study personnel would communicate the patient's wishes to the admitting physician. Attending physicians were given the opportunity to speak with their patients before changing a code status, but if the physicians agreed with the change, study personnel would document it in the formal orders. Patients were also asked whether they wished to create advance directives; if so, staff from the hospital's patient relations department would meet with them to draft the documents.

The following outcomes were measured: 1) willingness of patients assigned to the intervention group to listen to the script about end‐of‐life/life‐sustaining therapies; 2) opinions of patients about whether the information in the intervention was useful versus whether it was disturbing; 3) the frequency with which patients who had proactively received the information chose or changed their code status; and 4) the frequency with which patients without a preexisting advance directive created one while hospitalized. Simple proportions of each of these variables (ie, observed number divided by total number) in the intervention and control groups were compared using software that calculates the significance of the difference between two percentages (Statistica). The demographics of the patients were compared using the unpaired Student's t test. A P value of < .05 was considered statistically significant.

RESULTS

A total of 585 patients admitted to the Department of Medicine between December 2003 and February 2004 were randomized for the study. Patients were excluded if they had insufficient capacity (133) or if they were rapidly discharged from the hospital (155). Patients who were excluded tended to be more ill (APACHE 8.1 vs. 7.3, P = .06) and were more likely to die while hospitalized (8% vs. 4%, P = .04). A total of 297 patients were included in the study, 136 in the intervention group and 161 in the control group. Baseline characteristics were similar between the 2 groups (see Table 1).

Did Patients Who Received the Intervention Clarify Their CPR Preference?

Of the 136 patients in the intervention arm, 49 (36%) had explicit documentation of their code status on admission, compared to 55 of the 161 patients in the control group (34%; P = .7). Documentation included listing the CPR status in the admission orders or in a completed code designation form. After receiving the intervention, 125 of the 136 patients in the intervention arm (92%) clarified their preferences about CPR and mechanical ventilation.

Of the 49 patients in the intervention group who had documented CPR status on admission, 48 were listed as full code (both CPR and mechanical ventilation), and 1 was documented as refusing both CPR and mechanical ventilation. Of the 48 patients who were full codes, 3 stated they did not want CPR and mechanical ventilation under any circumstances after the intervention. Their preferences were subsequently documented as formal orders. The remaining 45 (94%) stayed full codes (see Figure 1).

Figure 1

Of the 87 patients in the intervention group who had no explicit documentation of CPR status on hospital admission, 76 clarified their preference and 11 did not. Of the 76 patients, 71 wished to receive both CPR and mechanical ventilation, and 5 wanted neither. The status of the latter as no code, no ventilator was subsequently documented in the medical record with the consent of their attending physicians. One of these 5 patients became increasingly ill during hospitalization, with reduced capacity, and family members later asked that he receive only comfort care.

Of the 161 patients in the control group, 55 (34%) had documentation of their code status (ie, to receive CPR if needed) in the admission hospital record. By the end of hospitalization, 1 patient requested no CPR and no mechanical ventilation, and 2 received comfort care with cessation of other active life‐prolonging interventions. Of the 106 without initial code documentation, 4 were later documented as being no code, no ventilator and 2 as being comfort care (see Figure 1).

DISCUSSION

This study demonstrates that most (95%) hospitalized medical patients welcomed the opportunity to provide prospective informed consent for CPR and mechanical ventilation. Although only a small minority (4%) opted out of CPR/mechanical ventilation, a majority (92%) of those who received the educational intervention chose to accept those therapies if required. This study also demonstrates that hospitalization can be one point‐of‐care where patients can consider and create advance directives. The results of this study are consistent with those of the SUPPORT group4 and other7 studies about patient interest in making choices on CPR. Our study suggests that physicians can elicit patients' wishes about and record formal orders on CPR around the time of hospital admission.

The default action has been to administer CPR and mechanical ventilation after cardiopulmonary failure or arrest, that is, patients receive these procedures unless they state explicitly that they do not want them. Unlike with all other invasive procedures, no national regulation mandates obtaining informed consent prospectively, when possible, for these treatments, because it is assumed that patients would want these therapies rather than the alternative (ie, death). Indeed, it is appropriate to perform lifesaving procedures in emergencies without consent if the patient lacks capacity and a surrogate decision maker cannot be contacted quickly. This clinical approach is consistent with medical ethics: to err on the side of life when a patient's wishes are unknown or unclear. Nonetheless, having a full code as the default action denies patients the opportunity to provide informed consent for these highly invasive procedures because there often is ample opportunity to ask their permission. If patient self‐determination is the categorical imperative of American medicine, then current practice violates that principle at the moment when it may be most important, that is, when a patient's decision about whether to risk life‐sustaining therapies could promote survival or prolong dying. Our study demonstrates that a simple interventionsimply askingpromotes a decision and therefore patient autonomy in most cases.

When patients have opted for life‐sustaining therapies that subsequently have been administered or when patients have received such therapies by default, physicians and patients can be left in 2 situations. In one outcome the patient retains capacity, and the dialogue about life‐sustaining therapies can continue between patient and physician. In the second, frequent scenario, the patient is incapacitated. Until patient capacity can be restored, the physician must work with surrogate decision makers and preexisting advance directives to infer a patient's wishes about continuation of life‐sustaining care. Our data demonstrate that hospital admission is one point‐of‐care at which patients can be offered and can complete, albeit in small numbers, advance directives.8 Previous work with our patients demonstrated that many patients misunderstood advance directives and the degree of effort required to create them.9 We reasoned that more patients might create advance directives if we offered the service for free during hospitalization. We were very surprised at how infrequently patients created advance directives in this study, although this finding is consistent with others in the published literature.8 It is speculated that hospitalized patients may feel too ill to exert themselves and/or are not psychologically prepared to consider end‐of‐life directives (ie, I came to the hospital to get better, not to consider what should be done when I'm terminal ). Some patients may not trust physicians to use advance directives reliably.4, 10

Our study had several important limitations. First, and most important, not all patients who were randomized were enrolled in the study. The most common reasons for exclusion were rapid discharge from the hospital and mental status change calling into question a patient's capacity to make end‐of‐life decisions. Nonetheless, it is only competent patients who can be engaged to decide these questions for themselves. Surrogates (ie, loved ones), guided by advance directives, are left to address resuscitation decisions for those lacking capacity. In addition, patients' predilections may change with time,11 especially as death becomes more imminent. However, insofar as many patients have several hospital admissions as they approach the end of life and are more likely to possess capacity to consider CPR decisions during early admissions, their choices can be recorded repeatedly over time (with each admission or even as status changes during an admission) to inform decisions if they develop incapacity. Little more can be done to enhance autonomy regarding CPR beyond repeatedly educating and asking, as disease and specific illnesses progress. It can be argued that this intervention had little real overall effectmost patients who would have received CPR by default did in fact want it when informed and asked. This is an ethically problematic position for two reasons: it neglects the right of patients to decide for themselves, and it potentially subjects the small group of patients who would reject CPR if asked to an unwanted risky procedure (ie, one that may prolong dying). Another limitation of the present study is that patients were approached by doctors‐in‐training with whom they had had no prior therapeutic relationship. Although it would have been optimal for patients to be approached by their primary care physicians, this was not feasible. Even if we could have convinced all of our medical staff members to implement the intervention, it is unlikely that all would have adhered to a study script, which is what enabled standardization of the information shared with patients. Some physicians may disagree with the script's content. But the goal of this study was not to determine if specific information would affect outcomes; rather, it was to determine if patients were receptive to discussing these issues and making proactive choices regarding life‐sustaining therapies during hospitalization for acute illness. It is possible that using different scripts delivered by different personnel, ideally the patients' own doctors, might have elicited even greater rates of consent and proactive decision making. Finally, the degree to which these results can be generalized may vary based on the population sampled. White and well‐educated patients are more likely to engage in end‐of‐life decision making than non‐White and poorly educated patients.9, 12

In conclusion, this study suggests that capable patients hospitalized for medical problems are willing to give informed consent for (or reject) CPR and mechanical ventilation in the event of cardiopulmonary failure. The approach of the study was very simple. It took roughly 510 minutes to inform patients and elicit their choices. Allowing patients to choose, rather than assuming that CPR is the choice of patients by default, strenuously honors patient autonomy. If these findings are replicated in larger cohorts and at different centers, there would be little justification for not informing patients about and asking them to choose their CPR preferences for each hospitalization. In the meantime, caregivers might consider the appropriateness of addressing these issues when they admit acutely ill patients to the hospital.

Respect for patient autonomy is a primary ethical principle guiding the practice of medicine in the United States.1. The Patient Self‐Determination Act (PSDA), enacted to enhance autonomy at the end of life, has not fulfilled its promise for a number of reasons.24 No state mandates that on admission, hospitalized patients be asked to provide informed consent for end‐of‐life procedures. Despite informed consent being a requirement for all other invasive procedures when there is sufficient opportunity to obtain it (eg, in nonemergent situations with a capable patient),5 cardiopulmonary resuscitation (CPR) and mechanical ventilation are assumed, until otherwise stipulated, to be procedures that all patients want. It also has been assumed that patients would believe that a request for informed consent for such procedures on hospital admission implied they had significant risk of cardiopulmonary failure and that this would discourage or disturb acutely ill patients.6 Another impediment to obtaining informed consent is that many physicians may not have sufficient time or level of comfort to be able to routinely approach end‐of‐life discussions. In this prospective study, we hypothesized that acutely ill medical patients would be willing to provide informed consent for CPR and mechanical ventilation and to create written advance directives.

METHODS

This study was approved by the hospital's institutional review board. Patients admitted to the Department of Medicine from December 2003 through February 2004 were candidates for this study. Patients admitted for cardiac catheterization (and similar same‐day medical procedures) or critical illness (admitted to intensive care units) were excluded from the study. In our hospital, all patients are asked by admitting personnel (clerk and nurse) whether they already have advance directives. Some patients are also queried by their physicians about whether they wish to have CPR in the event of cardiopulmonary arrest during hospitalization. Patients who are not asked are assumed to be full codes, that is, they are to receive CPR and mechanical ventilation in the event of cardiac and respiratory failure. For those who are asked, there are generally 3 possible outcomes: (1) the patient chooses to accept CPR and mechanical ventilation, and nothing further is documented; (2) the patient chooses a code status, and it is documented in the admission orders and/or a formal code designation form with a progress note describing the discussion; or (3) the patient defers the decision.

Our data processing department generated a daily list of the patients admitted to the hospital on the previous day. Patients satisfying inclusion criteria were randomized (by a random number generator) to the intervention or the control group. Medical records of all patients were examined to ascertain demographic information, admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, primary diagnosis, number of comorbid illnesses, and documentation of whether the patient had a preexisting advance directive or wishes regarding CPR and mechanical ventilation for that admission.

Patients in the control group were not approached by study personnel, but medical records were surveyed for their in‐hospital outcomes and changes in code or advance directive status. Patients randomized to the intervention arm were approached by 1 of 4 study physicians, who read from a script detailed information about life‐sustaining therapies and advance directives (see Appendix). This script was developed with hospital clinician‐experts and approved by members of the Department of Medicine.

Patients whose primary language was not English were interviewed through in‐house or 3‐way telephone (remote) translators. All patients in the treatment group were assessed during the scripted intervention to ascertain whether they had the capacity to make informed decisions, which was determined based on their ability: (a) to understand the information presented, (b) to consider the information in relation to their personal values, and (c) to communicate their wishes. If personnel doubted an individual's capacity in any of these 3 areas, then he or she was not included in the study (ie, excluded after randomization). In the control group, patients with documented dementia or delirium were also excluded.

As specified in the script, patients in the intervention group were asked at the end of the interview whether they wished to choose their in‐hospital CPR status for that admission. If a patient definitely wanted to change the status indicated in the hospital record, study personnel would communicate the patient's wishes to the admitting physician. Attending physicians were given the opportunity to speak with their patients before changing a code status, but if the physicians agreed with the change, study personnel would document it in the formal orders. Patients were also asked whether they wished to create advance directives; if so, staff from the hospital's patient relations department would meet with them to draft the documents.

The following outcomes were measured: 1) willingness of patients assigned to the intervention group to listen to the script about end‐of‐life/life‐sustaining therapies; 2) opinions of patients about whether the information in the intervention was useful versus whether it was disturbing; 3) the frequency with which patients who had proactively received the information chose or changed their code status; and 4) the frequency with which patients without a preexisting advance directive created one while hospitalized. Simple proportions of each of these variables (ie, observed number divided by total number) in the intervention and control groups were compared using software that calculates the significance of the difference between two percentages (Statistica). The demographics of the patients were compared using the unpaired Student's t test. A P value of < .05 was considered statistically significant.

RESULTS

A total of 585 patients admitted to the Department of Medicine between December 2003 and February 2004 were randomized for the study. Patients were excluded if they had insufficient capacity (133) or if they were rapidly discharged from the hospital (155). Patients who were excluded tended to be more ill (APACHE 8.1 vs. 7.3, P = .06) and were more likely to die while hospitalized (8% vs. 4%, P = .04). A total of 297 patients were included in the study, 136 in the intervention group and 161 in the control group. Baseline characteristics were similar between the 2 groups (see Table 1).

Did Patients Who Received the Intervention Clarify Their CPR Preference?

Of the 136 patients in the intervention arm, 49 (36%) had explicit documentation of their code status on admission, compared to 55 of the 161 patients in the control group (34%; P = .7). Documentation included listing the CPR status in the admission orders or in a completed code designation form. After receiving the intervention, 125 of the 136 patients in the intervention arm (92%) clarified their preferences about CPR and mechanical ventilation.

Of the 49 patients in the intervention group who had documented CPR status on admission, 48 were listed as full code (both CPR and mechanical ventilation), and 1 was documented as refusing both CPR and mechanical ventilation. Of the 48 patients who were full codes, 3 stated they did not want CPR and mechanical ventilation under any circumstances after the intervention. Their preferences were subsequently documented as formal orders. The remaining 45 (94%) stayed full codes (see Figure 1).

Figure 1

Of the 87 patients in the intervention group who had no explicit documentation of CPR status on hospital admission, 76 clarified their preference and 11 did not. Of the 76 patients, 71 wished to receive both CPR and mechanical ventilation, and 5 wanted neither. The status of the latter as no code, no ventilator was subsequently documented in the medical record with the consent of their attending physicians. One of these 5 patients became increasingly ill during hospitalization, with reduced capacity, and family members later asked that he receive only comfort care.

Of the 161 patients in the control group, 55 (34%) had documentation of their code status (ie, to receive CPR if needed) in the admission hospital record. By the end of hospitalization, 1 patient requested no CPR and no mechanical ventilation, and 2 received comfort care with cessation of other active life‐prolonging interventions. Of the 106 without initial code documentation, 4 were later documented as being no code, no ventilator and 2 as being comfort care (see Figure 1).

DISCUSSION

This study demonstrates that most (95%) hospitalized medical patients welcomed the opportunity to provide prospective informed consent for CPR and mechanical ventilation. Although only a small minority (4%) opted out of CPR/mechanical ventilation, a majority (92%) of those who received the educational intervention chose to accept those therapies if required. This study also demonstrates that hospitalization can be one point‐of‐care where patients can consider and create advance directives. The results of this study are consistent with those of the SUPPORT group4 and other7 studies about patient interest in making choices on CPR. Our study suggests that physicians can elicit patients' wishes about and record formal orders on CPR around the time of hospital admission.

The default action has been to administer CPR and mechanical ventilation after cardiopulmonary failure or arrest, that is, patients receive these procedures unless they state explicitly that they do not want them. Unlike with all other invasive procedures, no national regulation mandates obtaining informed consent prospectively, when possible, for these treatments, because it is assumed that patients would want these therapies rather than the alternative (ie, death). Indeed, it is appropriate to perform lifesaving procedures in emergencies without consent if the patient lacks capacity and a surrogate decision maker cannot be contacted quickly. This clinical approach is consistent with medical ethics: to err on the side of life when a patient's wishes are unknown or unclear. Nonetheless, having a full code as the default action denies patients the opportunity to provide informed consent for these highly invasive procedures because there often is ample opportunity to ask their permission. If patient self‐determination is the categorical imperative of American medicine, then current practice violates that principle at the moment when it may be most important, that is, when a patient's decision about whether to risk life‐sustaining therapies could promote survival or prolong dying. Our study demonstrates that a simple interventionsimply askingpromotes a decision and therefore patient autonomy in most cases.

When patients have opted for life‐sustaining therapies that subsequently have been administered or when patients have received such therapies by default, physicians and patients can be left in 2 situations. In one outcome the patient retains capacity, and the dialogue about life‐sustaining therapies can continue between patient and physician. In the second, frequent scenario, the patient is incapacitated. Until patient capacity can be restored, the physician must work with surrogate decision makers and preexisting advance directives to infer a patient's wishes about continuation of life‐sustaining care. Our data demonstrate that hospital admission is one point‐of‐care at which patients can be offered and can complete, albeit in small numbers, advance directives.8 Previous work with our patients demonstrated that many patients misunderstood advance directives and the degree of effort required to create them.9 We reasoned that more patients might create advance directives if we offered the service for free during hospitalization. We were very surprised at how infrequently patients created advance directives in this study, although this finding is consistent with others in the published literature.8 It is speculated that hospitalized patients may feel too ill to exert themselves and/or are not psychologically prepared to consider end‐of‐life directives (ie, I came to the hospital to get better, not to consider what should be done when I'm terminal ). Some patients may not trust physicians to use advance directives reliably.4, 10

Our study had several important limitations. First, and most important, not all patients who were randomized were enrolled in the study. The most common reasons for exclusion were rapid discharge from the hospital and mental status change calling into question a patient's capacity to make end‐of‐life decisions. Nonetheless, it is only competent patients who can be engaged to decide these questions for themselves. Surrogates (ie, loved ones), guided by advance directives, are left to address resuscitation decisions for those lacking capacity. In addition, patients' predilections may change with time,11 especially as death becomes more imminent. However, insofar as many patients have several hospital admissions as they approach the end of life and are more likely to possess capacity to consider CPR decisions during early admissions, their choices can be recorded repeatedly over time (with each admission or even as status changes during an admission) to inform decisions if they develop incapacity. Little more can be done to enhance autonomy regarding CPR beyond repeatedly educating and asking, as disease and specific illnesses progress. It can be argued that this intervention had little real overall effectmost patients who would have received CPR by default did in fact want it when informed and asked. This is an ethically problematic position for two reasons: it neglects the right of patients to decide for themselves, and it potentially subjects the small group of patients who would reject CPR if asked to an unwanted risky procedure (ie, one that may prolong dying). Another limitation of the present study is that patients were approached by doctors‐in‐training with whom they had had no prior therapeutic relationship. Although it would have been optimal for patients to be approached by their primary care physicians, this was not feasible. Even if we could have convinced all of our medical staff members to implement the intervention, it is unlikely that all would have adhered to a study script, which is what enabled standardization of the information shared with patients. Some physicians may disagree with the script's content. But the goal of this study was not to determine if specific information would affect outcomes; rather, it was to determine if patients were receptive to discussing these issues and making proactive choices regarding life‐sustaining therapies during hospitalization for acute illness. It is possible that using different scripts delivered by different personnel, ideally the patients' own doctors, might have elicited even greater rates of consent and proactive decision making. Finally, the degree to which these results can be generalized may vary based on the population sampled. White and well‐educated patients are more likely to engage in end‐of‐life decision making than non‐White and poorly educated patients.9, 12

In conclusion, this study suggests that capable patients hospitalized for medical problems are willing to give informed consent for (or reject) CPR and mechanical ventilation in the event of cardiopulmonary failure. The approach of the study was very simple. It took roughly 510 minutes to inform patients and elicit their choices. Allowing patients to choose, rather than assuming that CPR is the choice of patients by default, strenuously honors patient autonomy. If these findings are replicated in larger cohorts and at different centers, there would be little justification for not informing patients about and asking them to choose their CPR preferences for each hospitalization. In the meantime, caregivers might consider the appropriateness of addressing these issues when they admit acutely ill patients to the hospital.

Persons with diabetes have a greater risk of being hospitalized than do nondiabetic persons,1 and hospitalization was a major contributor to health care utilization and costs of patients with diabetes. In 1997, diabetes was the fourth most common comorbid condition in hospitalized patients nationwide. In 2001 in the United States, 562,000 hospital discharges listed diabetes as a principal diagnosis, and more than 4 million discharges listed diabetes in any diagnostic field.24 Nearly one third of diabetes patients may require 2 or more hospitalizations a year,5 and inpatient stays are the largest expense incurred by persons with this disease.6, 7 A substantial number of hospitalized persons are found to have unrecognized diabetes or to develop hyperglycemia during an inpatient stay.8, 9

The severity of hyperglycemia in the hospital has been linked to numerous adverse outcomes in various clinical situations, and recent studies have demonstrated the potential benefits of achieving good glucose control in the inpatient setting.10, 11 Moreover, specific inpatient‐directed interventions can improve the delivery of diabetes care.1216

Unlike the quality of outpatient diabetes care, which has been extensively profiled,1723 little is actually known about inpatient management. However, earlier reports suggested that hyperglycemia is frequently overlooked by health care personnel.8, 24 To develop intervention and educational programs will require insight into how diabetes is being addressed in the hospital. Thus, we undertook a retrospective chart review of inpatients with a discharge diagnosis of diabetes or hyperglycemia in order to assess whether these conditions were being documented and whether glucose management was being addressed.

METHODS

RESULTS

Documentation of Diabetes

Of the 90 patients whose records were reviewed, 81 had preexisting diabetes, 3 had a diagnosis of metabolic syndrome or abnormal glucose tolerance, and 6 had hyperglycemia that developed during the admission hospitalization. When admission notes of persons with known diabetes or abnormal glucose tolerance were examined (Fig. 1), diabetes was documented in 96%. In the daily progress notes of the primary service, 62% of patients had diabetes documented at least once during their hospitalization, whereas the records of 38% had no mention of diabetes. When only those patients with known diabetes or evidence of inpatient hyperglycemia were considered, documentation of the diabetic condition was made in 60% of discharge summaries, and the need for follow‐up was noted in just 20% (Fig. 1).

Figure 1

Fifty‐seven percent (n = 51) of the 90 patients whose records were sampled had had some type of consultant involved with their care, but only 13% had had an endocrinology consultation. For 27 patients (30% of all 90 cases), diabetes or hyperglycemia was documented in a consultant's note; thus, there was evidence that the issue of glucose management was being addressed by someone other than a member of the primary team and that someone was not necessarily an endocrinologist. When excluding those patients whose consultant addressed diabetes or hyperglycemia, only 53% had documentation of the problems recorded in the daily progress notes (data not shown).

Recording and Assessment of Glucose Values

Most of the 90 patients whose records were reviewed (86%; n = 79) had documentation in physician orders for bedside glucose monitoring during their hospital stay (Fig. 2), and 53% had bedside glucose levels recorded in at least one daily progress note, whereas documentation was absent in 47%. A written assessment of glucose control was found in the records of 52% of the hospitalized patients; 48% lacked any evaluation of the severity of their hyperglycemia (Fig. 2). Excluding data listed from consultants, bedside glucose data was recorded for 53% of patients, and an assessment of glycemic control was made for 41%.

Figure 2

Glycemic Control

The average daily number of bedside glucose measurements was 4, while the daily frequency of blood glucose tests was only 1; an average of 10 bedside readings were obtained per patient. The mean bedside glucose value (averaged over the length of stay) was 170 mg/dL. At the time of admission, 33% of patients had a bedside glucose value >200 mg/dL (Fig 3, top panel), and 27% had a value >200 mg/dL before discharge (Fig 3, middle panel). Based on the bedside glucose averaged over the length of stay, 29% of patients had persistent hyperglycemia (Fig. 3, bottom panel).

Figure 3

Hypoglycemia was rare. Only 11% of patients had at least one bedside measurement that was <70 mg/dL; 5% a measurement of <60 mg/dL, 4% a measurement of <50 mg/dL, and 1% a measurement of <40 mg/dL (Fig. 4). The frequency of values <70 mg/dL was 1.1 per person per 100 measurements; of values <60 mg/dL, 0.66; of values <50 mg/dL, 0.18; and of values <40 mg/dL, 0.08. In contrast, hyperglycemia was common: 71% of patients had at least one value >200 mg/dL; 43% at least one value >250 mg/dLl 24% at least one value >300 mg/dL; 20% at least one value >350 mg/dL; and 9% at least one value >400 mg/dL (Fig. 4). The frequency of hyperglycemic events was 28.2 per person per 100 measurements for values >200 mg/dL, 11.2 for values >250 mg/dL, 5.3 for values >300 mg/dL, 2.4 for values >350 mg/dL, and 1.1 for values >400 mg/dL.

Figure 4

Changes in Therapy

Overall, changes were made in the hyperglycemia therapy of only 34% of patients. Treatment was changed for 50% of patients who had at least one glucose reading >200 mg/dL, and 89% of patients who had at least one glucose reading <70 mg/dL. Figure 5 shows whether changes in treatment occurred by tertiles of average bedside glucose. The percentage of patients with a change in therapy increased with worse hyperglycemia, although 32% in the third tertile still had not had a change in treatment. The odds of those in the second tertile having a change in therapy (compared with those in the first tertile) were 1.9 (95% confidence interval 0.556.25, P = .32), but were 5.6 (95% confidence interval 1.6818.7, P = .005) for patients in the third tertile. The frequency of glucose values <70 mg/dL was 1.8 per person per 100 measurements for patients in the first tertile, 1.1 for patients in the second tertile, but only 0.29 per person per 100 measurements for patients in the third tertile. The average number of glucose measurements >200 mg/dL per person was 2.9 per 100 measurements for patients in the first tertile, 22.7 for patients in the second tertile, and 60.0 for patients in the third tertile (not shown).

Figure 5

DISCUSSION

Just as clinical trials in the outpatient setting have demonstrated the benefits of good glycemic control,2830 recent studies have also suggested that treatment of hyperglycemia during hospitalization can improve outcomes.10, 11 Consequently, there has been increased attention to the management of glucose in the hospital, with recognition of the need for inpatient‐specific standards for diabetes care.10, 11, 31 Optimization of management and of education about diabetes and hyperglycemia in the hospital requires better understanding of current care practices in order to determine where to direct interventions.

Nearly all the 90 patients whose records we reviewed had preexisting diabetes or a known potential glucose abnormality that was documented either at the time of, or just prior to, hospital admission. The observation that most patients had orders for bedside glucose monitoring also indicated that practitioners were aware of the diagnosis when the patient was admitted. Although clinicians seemed to be aware of the potential problem of glucoseand the majority of clinicians did some trackinga substantial number of hospitalizations (nearly 40%) had no documentation of diabetes or hyperglycemia after admission. If diabetes was not the principal reason for hospitalization, it is possible that the primary team did not focus on managing hyperglycemia. Nonetheless, the hospital encounter does represent an opportunity to address glucose management and perhaps improve care and outcomes, even if the patient was admitted for an unrelated condition.32 Because the average length of stay was almost 5 days, there should have been sufficient time to address diabetes in most patients.

Although most patients had the condition of their diabetes documented in their discharge notes, a substantial proportion of the discharge notes did not mention an outpatient plan to follow up on the diabetes or hyperglycemia. A recent study suggested that direct referral for outpatient diabetes services increased the chances of patient follow‐up.33 Educating practitioners about the need to emphasize to patients the importance of diabetes postdischarge care is a program that could be developed and implemented in the hospital setting.

Although bedside glucose monitoring was appropriately ordered in most instances, the actual recording of values and the assessment of glucose control were documented in the records of only about half the patients during their hospitalizations. Moreover, even among patients who had high bedside glucose levels, changes in therapy often did not occur. Clinician concern about inducing hypoglycemia in hospitalized patients has been cited as a factor limiting the intensification of treatment for diabetes.34 The frequency in our facility of documented low blood glucose values was small, although there may have been unrecognized episodes. However, missed events were probably unusual, given the daily average of 4 bedside glucose measurements per patient, ongoing nursing staff contact with patients, and a formal policy to document and treat hypoglycemia. We found that hyperglycemia was far more common than hypoglycemia and that there were likely many opportunities to control blood glucose more rigorously.

Practitioners appeared to be responding to hypoglycemia, as a large proportion of the patients with a glucose reading of <70 mg/dL had a change in therapy. However, the response to hyperglycemia was delayedthe odds of therapy being changed were significant only for patients whose glucose levels were in the third tertile. Despite evidence of hyperglycemia and the low frequency of hypoglycemia of those whose glucose levels were in the second and third tertiles, a substantial proportion of patients did not have their therapy changed. Combined with the observation that glucose data and diabetes were often not documented, our data suggest that there may be a problem of clinical inertia in the inpatient setting. Clinical inertia has been defined as not initiating or intensifying therapy when doing so is indicated.35, 36 Other reports have also documented clinical inertia in the outpatient environment.23, 3741 Overcoming clinical inertia, at least in regard to diabetes management, can improve glycemic control in patients.35 To improve the management of hyperglycemia in the hospital, educational interventions must be developed to teach health care practitioners effective strategies for glucose reduction. We did not quantify the changes in therapy (eg, how much insulin was changed or in what direction), only whether a change had been made. The observation that the proportion of cases on insulin at discharge was less than on admission day suggests that there may actually have been deintensification of therapy taking placesome of the cases in which therapy was changed, therefore, likely included instances of negative therapeutic momentum despite evidence of hyperglycemia. The control of inpatient hyperglycemia will likely require frequent changes in therapy, as it does in the outpatient setting, and detailed information about treatment strategies actually employed will be necessary to design educational programs.

One limitation of our analysis was that the study was retrospective, which did not allow assessment of the reasons underlying the behavior of the clinicians, such as why they did not document diabetes or change therapy. We selected a 5% sample for our study as per common methods.20, 25, 26 Thus, although the 90 patients making up the sample were randomly selected and were not different demographically from the larger population of patients admitted with diabetes, the number of cases we reviewed was small compared with the actual number of discharged patients with diabetes. Cases were diagnosed by diagnosis codes; therefore, it is likely that some diabetes cases were missed, and other patients with hyperglycemia may not have had the diagnosis even documented.8, 24 Our study design and sample size precluded a comparison of outcomes between cases with in which a consultant was involved with those in which a consultant was not involved or a comparison of cases according to type of consultant involved.1216 Finally, our study focused on noncritically ill patients; thus, our findings cannot be generalized to care provided in the intensive care unit.

There are no definitive guidelines on what method (ie, blood or bedside glucose) should be used to evaluate glycemic control in the hospital. The methods we used here can serve as means to benchmark and track improvement in glycemic control. The observations that most patients had bedside glucose monitoring ordered and that the frequency of these measurements was high compared with the frequency of actual blood glucose assessments support the idea that practitioners favored this method to evaluate the level of glycemic control in the hospital. In practice, it is bedside glucose evaluation that clinicians use to make decisions about day‐to‐day treatment of hyperglycemia. In our facility, the method for bedside glucose monitoring is standardized and is part of a quality assurance program. Moreover, the high average frequency of bedside blood glucose determination increased the chance of detecting hyper‐ and hypoglycemic events.

Current guidelines provide suggestions about target pre‐ and postprandial glucose levels for noncritically ill patients.11 However, these targets are not universally recognized.42 For instance, the Institutes for Healthcare Improvement's Prevent Surgical Site Infections initiative defines a glucose level of <200 mg/dL as its target perioperative glucose control level.43 In practice, it can be difficult to assess glucose control in terms of pre‐ and postprandial categories. Although bedside glucose monitoring in our facility is typically ordered before meals and at bedtime, in many cases prolonged periods of patient fasting, disrupted meal schedules, mismatching insulin with meals, and use of continuous parental and enteral nutritional support all make it difficult to assess pre‐ and postprandial glycemic control retrospectively. Hence, we used as our measures the value of the bedside glucose averaged over the length of the hospital stay and the number of hyper‐ and hypoglycemic events.

In general, our study was hampered by a lack of hospital‐specific process measures to evaluate the quality of inpatient diabetes care. Process measures such as the frequency of hemoglobin A1c monitoring or performance of ophthalmologic examinations,1723 which are commonly used to assess quality of diabetes care in the outpatient arena, may not be optimal variables for evaluating care in the hospital. New methods to guide efforts to improve the quality of inpatient management of diabetes and hyperglycemia are needed.

Despite these limitations, our analysis was helpful in providing direction about how to enhance the care of hospitalized patients with hyperglycemia or known diabetes. Constructing institution‐specific management guidelines for the care of inpatient diabetes and hyperglycemia would provide a yardstick against which to measure the care provided by both the hospital and the individual clinician. Educational programs can be developed to increase awareness among practitioners of the importance of inpatient glucose control and of the need to improve ongoing documentation of the problem. Exploring practitioner barriers to treatment of inpatient hyperglycemia should be an essential component of this educational process. Finally, consensus strategies on when to initiate and change therapy should be designed so that hyperglycemia in the hospital can be managed more effectively. All these areas must be addressed to assure delivery of the highest‐quality inpatient care to patients with diabetes.

Persons with diabetes have a greater risk of being hospitalized than do nondiabetic persons,1 and hospitalization was a major contributor to health care utilization and costs of patients with diabetes. In 1997, diabetes was the fourth most common comorbid condition in hospitalized patients nationwide. In 2001 in the United States, 562,000 hospital discharges listed diabetes as a principal diagnosis, and more than 4 million discharges listed diabetes in any diagnostic field.24 Nearly one third of diabetes patients may require 2 or more hospitalizations a year,5 and inpatient stays are the largest expense incurred by persons with this disease.6, 7 A substantial number of hospitalized persons are found to have unrecognized diabetes or to develop hyperglycemia during an inpatient stay.8, 9

The severity of hyperglycemia in the hospital has been linked to numerous adverse outcomes in various clinical situations, and recent studies have demonstrated the potential benefits of achieving good glucose control in the inpatient setting.10, 11 Moreover, specific inpatient‐directed interventions can improve the delivery of diabetes care.1216

Unlike the quality of outpatient diabetes care, which has been extensively profiled,1723 little is actually known about inpatient management. However, earlier reports suggested that hyperglycemia is frequently overlooked by health care personnel.8, 24 To develop intervention and educational programs will require insight into how diabetes is being addressed in the hospital. Thus, we undertook a retrospective chart review of inpatients with a discharge diagnosis of diabetes or hyperglycemia in order to assess whether these conditions were being documented and whether glucose management was being addressed.

METHODS

RESULTS

Documentation of Diabetes

Of the 90 patients whose records were reviewed, 81 had preexisting diabetes, 3 had a diagnosis of metabolic syndrome or abnormal glucose tolerance, and 6 had hyperglycemia that developed during the admission hospitalization. When admission notes of persons with known diabetes or abnormal glucose tolerance were examined (Fig. 1), diabetes was documented in 96%. In the daily progress notes of the primary service, 62% of patients had diabetes documented at least once during their hospitalization, whereas the records of 38% had no mention of diabetes. When only those patients with known diabetes or evidence of inpatient hyperglycemia were considered, documentation of the diabetic condition was made in 60% of discharge summaries, and the need for follow‐up was noted in just 20% (Fig. 1).

Figure 1

Fifty‐seven percent (n = 51) of the 90 patients whose records were sampled had had some type of consultant involved with their care, but only 13% had had an endocrinology consultation. For 27 patients (30% of all 90 cases), diabetes or hyperglycemia was documented in a consultant's note; thus, there was evidence that the issue of glucose management was being addressed by someone other than a member of the primary team and that someone was not necessarily an endocrinologist. When excluding those patients whose consultant addressed diabetes or hyperglycemia, only 53% had documentation of the problems recorded in the daily progress notes (data not shown).

Recording and Assessment of Glucose Values

Most of the 90 patients whose records were reviewed (86%; n = 79) had documentation in physician orders for bedside glucose monitoring during their hospital stay (Fig. 2), and 53% had bedside glucose levels recorded in at least one daily progress note, whereas documentation was absent in 47%. A written assessment of glucose control was found in the records of 52% of the hospitalized patients; 48% lacked any evaluation of the severity of their hyperglycemia (Fig. 2). Excluding data listed from consultants, bedside glucose data was recorded for 53% of patients, and an assessment of glycemic control was made for 41%.

Figure 2

Glycemic Control

The average daily number of bedside glucose measurements was 4, while the daily frequency of blood glucose tests was only 1; an average of 10 bedside readings were obtained per patient. The mean bedside glucose value (averaged over the length of stay) was 170 mg/dL. At the time of admission, 33% of patients had a bedside glucose value >200 mg/dL (Fig 3, top panel), and 27% had a value >200 mg/dL before discharge (Fig 3, middle panel). Based on the bedside glucose averaged over the length of stay, 29% of patients had persistent hyperglycemia (Fig. 3, bottom panel).

Figure 3

Hypoglycemia was rare. Only 11% of patients had at least one bedside measurement that was <70 mg/dL; 5% a measurement of <60 mg/dL, 4% a measurement of <50 mg/dL, and 1% a measurement of <40 mg/dL (Fig. 4). The frequency of values <70 mg/dL was 1.1 per person per 100 measurements; of values <60 mg/dL, 0.66; of values <50 mg/dL, 0.18; and of values <40 mg/dL, 0.08. In contrast, hyperglycemia was common: 71% of patients had at least one value >200 mg/dL; 43% at least one value >250 mg/dLl 24% at least one value >300 mg/dL; 20% at least one value >350 mg/dL; and 9% at least one value >400 mg/dL (Fig. 4). The frequency of hyperglycemic events was 28.2 per person per 100 measurements for values >200 mg/dL, 11.2 for values >250 mg/dL, 5.3 for values >300 mg/dL, 2.4 for values >350 mg/dL, and 1.1 for values >400 mg/dL.

Figure 4

Changes in Therapy

Overall, changes were made in the hyperglycemia therapy of only 34% of patients. Treatment was changed for 50% of patients who had at least one glucose reading >200 mg/dL, and 89% of patients who had at least one glucose reading <70 mg/dL. Figure 5 shows whether changes in treatment occurred by tertiles of average bedside glucose. The percentage of patients with a change in therapy increased with worse hyperglycemia, although 32% in the third tertile still had not had a change in treatment. The odds of those in the second tertile having a change in therapy (compared with those in the first tertile) were 1.9 (95% confidence interval 0.556.25, P = .32), but were 5.6 (95% confidence interval 1.6818.7, P = .005) for patients in the third tertile. The frequency of glucose values <70 mg/dL was 1.8 per person per 100 measurements for patients in the first tertile, 1.1 for patients in the second tertile, but only 0.29 per person per 100 measurements for patients in the third tertile. The average number of glucose measurements >200 mg/dL per person was 2.9 per 100 measurements for patients in the first tertile, 22.7 for patients in the second tertile, and 60.0 for patients in the third tertile (not shown).

Figure 5

DISCUSSION

Just as clinical trials in the outpatient setting have demonstrated the benefits of good glycemic control,2830 recent studies have also suggested that treatment of hyperglycemia during hospitalization can improve outcomes.10, 11 Consequently, there has been increased attention to the management of glucose in the hospital, with recognition of the need for inpatient‐specific standards for diabetes care.10, 11, 31 Optimization of management and of education about diabetes and hyperglycemia in the hospital requires better understanding of current care practices in order to determine where to direct interventions.

Nearly all the 90 patients whose records we reviewed had preexisting diabetes or a known potential glucose abnormality that was documented either at the time of, or just prior to, hospital admission. The observation that most patients had orders for bedside glucose monitoring also indicated that practitioners were aware of the diagnosis when the patient was admitted. Although clinicians seemed to be aware of the potential problem of glucoseand the majority of clinicians did some trackinga substantial number of hospitalizations (nearly 40%) had no documentation of diabetes or hyperglycemia after admission. If diabetes was not the principal reason for hospitalization, it is possible that the primary team did not focus on managing hyperglycemia. Nonetheless, the hospital encounter does represent an opportunity to address glucose management and perhaps improve care and outcomes, even if the patient was admitted for an unrelated condition.32 Because the average length of stay was almost 5 days, there should have been sufficient time to address diabetes in most patients.

Although most patients had the condition of their diabetes documented in their discharge notes, a substantial proportion of the discharge notes did not mention an outpatient plan to follow up on the diabetes or hyperglycemia. A recent study suggested that direct referral for outpatient diabetes services increased the chances of patient follow‐up.33 Educating practitioners about the need to emphasize to patients the importance of diabetes postdischarge care is a program that could be developed and implemented in the hospital setting.

Although bedside glucose monitoring was appropriately ordered in most instances, the actual recording of values and the assessment of glucose control were documented in the records of only about half the patients during their hospitalizations. Moreover, even among patients who had high bedside glucose levels, changes in therapy often did not occur. Clinician concern about inducing hypoglycemia in hospitalized patients has been cited as a factor limiting the intensification of treatment for diabetes.34 The frequency in our facility of documented low blood glucose values was small, although there may have been unrecognized episodes. However, missed events were probably unusual, given the daily average of 4 bedside glucose measurements per patient, ongoing nursing staff contact with patients, and a formal policy to document and treat hypoglycemia. We found that hyperglycemia was far more common than hypoglycemia and that there were likely many opportunities to control blood glucose more rigorously.

Practitioners appeared to be responding to hypoglycemia, as a large proportion of the patients with a glucose reading of <70 mg/dL had a change in therapy. However, the response to hyperglycemia was delayedthe odds of therapy being changed were significant only for patients whose glucose levels were in the third tertile. Despite evidence of hyperglycemia and the low frequency of hypoglycemia of those whose glucose levels were in the second and third tertiles, a substantial proportion of patients did not have their therapy changed. Combined with the observation that glucose data and diabetes were often not documented, our data suggest that there may be a problem of clinical inertia in the inpatient setting. Clinical inertia has been defined as not initiating or intensifying therapy when doing so is indicated.35, 36 Other reports have also documented clinical inertia in the outpatient environment.23, 3741 Overcoming clinical inertia, at least in regard to diabetes management, can improve glycemic control in patients.35 To improve the management of hyperglycemia in the hospital, educational interventions must be developed to teach health care practitioners effective strategies for glucose reduction. We did not quantify the changes in therapy (eg, how much insulin was changed or in what direction), only whether a change had been made. The observation that the proportion of cases on insulin at discharge was less than on admission day suggests that there may actually have been deintensification of therapy taking placesome of the cases in which therapy was changed, therefore, likely included instances of negative therapeutic momentum despite evidence of hyperglycemia. The control of inpatient hyperglycemia will likely require frequent changes in therapy, as it does in the outpatient setting, and detailed information about treatment strategies actually employed will be necessary to design educational programs.

One limitation of our analysis was that the study was retrospective, which did not allow assessment of the reasons underlying the behavior of the clinicians, such as why they did not document diabetes or change therapy. We selected a 5% sample for our study as per common methods.20, 25, 26 Thus, although the 90 patients making up the sample were randomly selected and were not different demographically from the larger population of patients admitted with diabetes, the number of cases we reviewed was small compared with the actual number of discharged patients with diabetes. Cases were diagnosed by diagnosis codes; therefore, it is likely that some diabetes cases were missed, and other patients with hyperglycemia may not have had the diagnosis even documented.8, 24 Our study design and sample size precluded a comparison of outcomes between cases with in which a consultant was involved with those in which a consultant was not involved or a comparison of cases according to type of consultant involved.1216 Finally, our study focused on noncritically ill patients; thus, our findings cannot be generalized to care provided in the intensive care unit.

There are no definitive guidelines on what method (ie, blood or bedside glucose) should be used to evaluate glycemic control in the hospital. The methods we used here can serve as means to benchmark and track improvement in glycemic control. The observations that most patients had bedside glucose monitoring ordered and that the frequency of these measurements was high compared with the frequency of actual blood glucose assessments support the idea that practitioners favored this method to evaluate the level of glycemic control in the hospital. In practice, it is bedside glucose evaluation that clinicians use to make decisions about day‐to‐day treatment of hyperglycemia. In our facility, the method for bedside glucose monitoring is standardized and is part of a quality assurance program. Moreover, the high average frequency of bedside blood glucose determination increased the chance of detecting hyper‐ and hypoglycemic events.

Current guidelines provide suggestions about target pre‐ and postprandial glucose levels for noncritically ill patients.11 However, these targets are not universally recognized.42 For instance, the Institutes for Healthcare Improvement's Prevent Surgical Site Infections initiative defines a glucose level of <200 mg/dL as its target perioperative glucose control level.43 In practice, it can be difficult to assess glucose control in terms of pre‐ and postprandial categories. Although bedside glucose monitoring in our facility is typically ordered before meals and at bedtime, in many cases prolonged periods of patient fasting, disrupted meal schedules, mismatching insulin with meals, and use of continuous parental and enteral nutritional support all make it difficult to assess pre‐ and postprandial glycemic control retrospectively. Hence, we used as our measures the value of the bedside glucose averaged over the length of the hospital stay and the number of hyper‐ and hypoglycemic events.

In general, our study was hampered by a lack of hospital‐specific process measures to evaluate the quality of inpatient diabetes care. Process measures such as the frequency of hemoglobin A1c monitoring or performance of ophthalmologic examinations,1723 which are commonly used to assess quality of diabetes care in the outpatient arena, may not be optimal variables for evaluating care in the hospital. New methods to guide efforts to improve the quality of inpatient management of diabetes and hyperglycemia are needed.

Despite these limitations, our analysis was helpful in providing direction about how to enhance the care of hospitalized patients with hyperglycemia or known diabetes. Constructing institution‐specific management guidelines for the care of inpatient diabetes and hyperglycemia would provide a yardstick against which to measure the care provided by both the hospital and the individual clinician. Educational programs can be developed to increase awareness among practitioners of the importance of inpatient glucose control and of the need to improve ongoing documentation of the problem. Exploring practitioner barriers to treatment of inpatient hyperglycemia should be an essential component of this educational process. Finally, consensus strategies on when to initiate and change therapy should be designed so that hyperglycemia in the hospital can be managed more effectively. All these areas must be addressed to assure delivery of the highest‐quality inpatient care to patients with diabetes.

Persons with diabetes have a greater risk of being hospitalized than do nondiabetic persons,1 and hospitalization was a major contributor to health care utilization and costs of patients with diabetes. In 1997, diabetes was the fourth most common comorbid condition in hospitalized patients nationwide. In 2001 in the United States, 562,000 hospital discharges listed diabetes as a principal diagnosis, and more than 4 million discharges listed diabetes in any diagnostic field.24 Nearly one third of diabetes patients may require 2 or more hospitalizations a year,5 and inpatient stays are the largest expense incurred by persons with this disease.6, 7 A substantial number of hospitalized persons are found to have unrecognized diabetes or to develop hyperglycemia during an inpatient stay.8, 9

The severity of hyperglycemia in the hospital has been linked to numerous adverse outcomes in various clinical situations, and recent studies have demonstrated the potential benefits of achieving good glucose control in the inpatient setting.10, 11 Moreover, specific inpatient‐directed interventions can improve the delivery of diabetes care.1216

Unlike the quality of outpatient diabetes care, which has been extensively profiled,1723 little is actually known about inpatient management. However, earlier reports suggested that hyperglycemia is frequently overlooked by health care personnel.8, 24 To develop intervention and educational programs will require insight into how diabetes is being addressed in the hospital. Thus, we undertook a retrospective chart review of inpatients with a discharge diagnosis of diabetes or hyperglycemia in order to assess whether these conditions were being documented and whether glucose management was being addressed.

METHODS

RESULTS

Documentation of Diabetes

Of the 90 patients whose records were reviewed, 81 had preexisting diabetes, 3 had a diagnosis of metabolic syndrome or abnormal glucose tolerance, and 6 had hyperglycemia that developed during the admission hospitalization. When admission notes of persons with known diabetes or abnormal glucose tolerance were examined (Fig. 1), diabetes was documented in 96%. In the daily progress notes of the primary service, 62% of patients had diabetes documented at least once during their hospitalization, whereas the records of 38% had no mention of diabetes. When only those patients with known diabetes or evidence of inpatient hyperglycemia were considered, documentation of the diabetic condition was made in 60% of discharge summaries, and the need for follow‐up was noted in just 20% (Fig. 1).

Figure 1

Fifty‐seven percent (n = 51) of the 90 patients whose records were sampled had had some type of consultant involved with their care, but only 13% had had an endocrinology consultation. For 27 patients (30% of all 90 cases), diabetes or hyperglycemia was documented in a consultant's note; thus, there was evidence that the issue of glucose management was being addressed by someone other than a member of the primary team and that someone was not necessarily an endocrinologist. When excluding those patients whose consultant addressed diabetes or hyperglycemia, only 53% had documentation of the problems recorded in the daily progress notes (data not shown).

Recording and Assessment of Glucose Values

Most of the 90 patients whose records were reviewed (86%; n = 79) had documentation in physician orders for bedside glucose monitoring during their hospital stay (Fig. 2), and 53% had bedside glucose levels recorded in at least one daily progress note, whereas documentation was absent in 47%. A written assessment of glucose control was found in the records of 52% of the hospitalized patients; 48% lacked any evaluation of the severity of their hyperglycemia (Fig. 2). Excluding data listed from consultants, bedside glucose data was recorded for 53% of patients, and an assessment of glycemic control was made for 41%.

Figure 2

Glycemic Control

The average daily number of bedside glucose measurements was 4, while the daily frequency of blood glucose tests was only 1; an average of 10 bedside readings were obtained per patient. The mean bedside glucose value (averaged over the length of stay) was 170 mg/dL. At the time of admission, 33% of patients had a bedside glucose value >200 mg/dL (Fig 3, top panel), and 27% had a value >200 mg/dL before discharge (Fig 3, middle panel). Based on the bedside glucose averaged over the length of stay, 29% of patients had persistent hyperglycemia (Fig. 3, bottom panel).

Figure 3

Hypoglycemia was rare. Only 11% of patients had at least one bedside measurement that was <70 mg/dL; 5% a measurement of <60 mg/dL, 4% a measurement of <50 mg/dL, and 1% a measurement of <40 mg/dL (Fig. 4). The frequency of values <70 mg/dL was 1.1 per person per 100 measurements; of values <60 mg/dL, 0.66; of values <50 mg/dL, 0.18; and of values <40 mg/dL, 0.08. In contrast, hyperglycemia was common: 71% of patients had at least one value >200 mg/dL; 43% at least one value >250 mg/dLl 24% at least one value >300 mg/dL; 20% at least one value >350 mg/dL; and 9% at least one value >400 mg/dL (Fig. 4). The frequency of hyperglycemic events was 28.2 per person per 100 measurements for values >200 mg/dL, 11.2 for values >250 mg/dL, 5.3 for values >300 mg/dL, 2.4 for values >350 mg/dL, and 1.1 for values >400 mg/dL.

Figure 4

Changes in Therapy

Overall, changes were made in the hyperglycemia therapy of only 34% of patients. Treatment was changed for 50% of patients who had at least one glucose reading >200 mg/dL, and 89% of patients who had at least one glucose reading <70 mg/dL. Figure 5 shows whether changes in treatment occurred by tertiles of average bedside glucose. The percentage of patients with a change in therapy increased with worse hyperglycemia, although 32% in the third tertile still had not had a change in treatment. The odds of those in the second tertile having a change in therapy (compared with those in the first tertile) were 1.9 (95% confidence interval 0.556.25, P = .32), but were 5.6 (95% confidence interval 1.6818.7, P = .005) for patients in the third tertile. The frequency of glucose values <70 mg/dL was 1.8 per person per 100 measurements for patients in the first tertile, 1.1 for patients in the second tertile, but only 0.29 per person per 100 measurements for patients in the third tertile. The average number of glucose measurements >200 mg/dL per person was 2.9 per 100 measurements for patients in the first tertile, 22.7 for patients in the second tertile, and 60.0 for patients in the third tertile (not shown).

Figure 5

DISCUSSION

Just as clinical trials in the outpatient setting have demonstrated the benefits of good glycemic control,2830 recent studies have also suggested that treatment of hyperglycemia during hospitalization can improve outcomes.10, 11 Consequently, there has been increased attention to the management of glucose in the hospital, with recognition of the need for inpatient‐specific standards for diabetes care.10, 11, 31 Optimization of management and of education about diabetes and hyperglycemia in the hospital requires better understanding of current care practices in order to determine where to direct interventions.

Nearly all the 90 patients whose records we reviewed had preexisting diabetes or a known potential glucose abnormality that was documented either at the time of, or just prior to, hospital admission. The observation that most patients had orders for bedside glucose monitoring also indicated that practitioners were aware of the diagnosis when the patient was admitted. Although clinicians seemed to be aware of the potential problem of glucoseand the majority of clinicians did some trackinga substantial number of hospitalizations (nearly 40%) had no documentation of diabetes or hyperglycemia after admission. If diabetes was not the principal reason for hospitalization, it is possible that the primary team did not focus on managing hyperglycemia. Nonetheless, the hospital encounter does represent an opportunity to address glucose management and perhaps improve care and outcomes, even if the patient was admitted for an unrelated condition.32 Because the average length of stay was almost 5 days, there should have been sufficient time to address diabetes in most patients.

Although most patients had the condition of their diabetes documented in their discharge notes, a substantial proportion of the discharge notes did not mention an outpatient plan to follow up on the diabetes or hyperglycemia. A recent study suggested that direct referral for outpatient diabetes services increased the chances of patient follow‐up.33 Educating practitioners about the need to emphasize to patients the importance of diabetes postdischarge care is a program that could be developed and implemented in the hospital setting.

Although bedside glucose monitoring was appropriately ordered in most instances, the actual recording of values and the assessment of glucose control were documented in the records of only about half the patients during their hospitalizations. Moreover, even among patients who had high bedside glucose levels, changes in therapy often did not occur. Clinician concern about inducing hypoglycemia in hospitalized patients has been cited as a factor limiting the intensification of treatment for diabetes.34 The frequency in our facility of documented low blood glucose values was small, although there may have been unrecognized episodes. However, missed events were probably unusual, given the daily average of 4 bedside glucose measurements per patient, ongoing nursing staff contact with patients, and a formal policy to document and treat hypoglycemia. We found that hyperglycemia was far more common than hypoglycemia and that there were likely many opportunities to control blood glucose more rigorously.

Practitioners appeared to be responding to hypoglycemia, as a large proportion of the patients with a glucose reading of <70 mg/dL had a change in therapy. However, the response to hyperglycemia was delayedthe odds of therapy being changed were significant only for patients whose glucose levels were in the third tertile. Despite evidence of hyperglycemia and the low frequency of hypoglycemia of those whose glucose levels were in the second and third tertiles, a substantial proportion of patients did not have their therapy changed. Combined with the observation that glucose data and diabetes were often not documented, our data suggest that there may be a problem of clinical inertia in the inpatient setting. Clinical inertia has been defined as not initiating or intensifying therapy when doing so is indicated.35, 36 Other reports have also documented clinical inertia in the outpatient environment.23, 3741 Overcoming clinical inertia, at least in regard to diabetes management, can improve glycemic control in patients.35 To improve the management of hyperglycemia in the hospital, educational interventions must be developed to teach health care practitioners effective strategies for glucose reduction. We did not quantify the changes in therapy (eg, how much insulin was changed or in what direction), only whether a change had been made. The observation that the proportion of cases on insulin at discharge was less than on admission day suggests that there may actually have been deintensification of therapy taking placesome of the cases in which therapy was changed, therefore, likely included instances of negative therapeutic momentum despite evidence of hyperglycemia. The control of inpatient hyperglycemia will likely require frequent changes in therapy, as it does in the outpatient setting, and detailed information about treatment strategies actually employed will be necessary to design educational programs.

One limitation of our analysis was that the study was retrospective, which did not allow assessment of the reasons underlying the behavior of the clinicians, such as why they did not document diabetes or change therapy. We selected a 5% sample for our study as per common methods.20, 25, 26 Thus, although the 90 patients making up the sample were randomly selected and were not different demographically from the larger population of patients admitted with diabetes, the number of cases we reviewed was small compared with the actual number of discharged patients with diabetes. Cases were diagnosed by diagnosis codes; therefore, it is likely that some diabetes cases were missed, and other patients with hyperglycemia may not have had the diagnosis even documented.8, 24 Our study design and sample size precluded a comparison of outcomes between cases with in which a consultant was involved with those in which a consultant was not involved or a comparison of cases according to type of consultant involved.1216 Finally, our study focused on noncritically ill patients; thus, our findings cannot be generalized to care provided in the intensive care unit.

There are no definitive guidelines on what method (ie, blood or bedside glucose) should be used to evaluate glycemic control in the hospital. The methods we used here can serve as means to benchmark and track improvement in glycemic control. The observations that most patients had bedside glucose monitoring ordered and that the frequency of these measurements was high compared with the frequency of actual blood glucose assessments support the idea that practitioners favored this method to evaluate the level of glycemic control in the hospital. In practice, it is bedside glucose evaluation that clinicians use to make decisions about day‐to‐day treatment of hyperglycemia. In our facility, the method for bedside glucose monitoring is standardized and is part of a quality assurance program. Moreover, the high average frequency of bedside blood glucose determination increased the chance of detecting hyper‐ and hypoglycemic events.

Current guidelines provide suggestions about target pre‐ and postprandial glucose levels for noncritically ill patients.11 However, these targets are not universally recognized.42 For instance, the Institutes for Healthcare Improvement's Prevent Surgical Site Infections initiative defines a glucose level of <200 mg/dL as its target perioperative glucose control level.43 In practice, it can be difficult to assess glucose control in terms of pre‐ and postprandial categories. Although bedside glucose monitoring in our facility is typically ordered before meals and at bedtime, in many cases prolonged periods of patient fasting, disrupted meal schedules, mismatching insulin with meals, and use of continuous parental and enteral nutritional support all make it difficult to assess pre‐ and postprandial glycemic control retrospectively. Hence, we used as our measures the value of the bedside glucose averaged over the length of the hospital stay and the number of hyper‐ and hypoglycemic events.

In general, our study was hampered by a lack of hospital‐specific process measures to evaluate the quality of inpatient diabetes care. Process measures such as the frequency of hemoglobin A1c monitoring or performance of ophthalmologic examinations,1723 which are commonly used to assess quality of diabetes care in the outpatient arena, may not be optimal variables for evaluating care in the hospital. New methods to guide efforts to improve the quality of inpatient management of diabetes and hyperglycemia are needed.

Despite these limitations, our analysis was helpful in providing direction about how to enhance the care of hospitalized patients with hyperglycemia or known diabetes. Constructing institution‐specific management guidelines for the care of inpatient diabetes and hyperglycemia would provide a yardstick against which to measure the care provided by both the hospital and the individual clinician. Educational programs can be developed to increase awareness among practitioners of the importance of inpatient glucose control and of the need to improve ongoing documentation of the problem. Exploring practitioner barriers to treatment of inpatient hyperglycemia should be an essential component of this educational process. Finally, consensus strategies on when to initiate and change therapy should be designed so that hyperglycemia in the hospital can be managed more effectively. All these areas must be addressed to assure delivery of the highest‐quality inpatient care to patients with diabetes.

Insanity: doing the same thing over and over again and expecting different results.Albert Einstein

Diabetes is one of the most common diagnoses in hospitalized patients.1 A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes.2 The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome.38 In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) short‐ and long‐term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization.7, 911

The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death.12, 13 In general‐surgical patients, serum glucose > 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital‐acquired infection.14 A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18‐fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5‐fold increase in mortality in patients with known diabetes compared with controls.2 A meta‐analysis of 26 studies identified an association of admission glucose > 110 mg/dL with the increased mortality of patients hospitalized for acute stroke.15 More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia.16, 17

In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and published glycemic targets and recommendations for inpatient management of hyperglycemia.18 The American Diabetes Association (ADA) subsequently published an excellent technical review evaluating the evidence and outlining treatment, monitoring, and educational strategies13 for the hospitalized patient, and these recommendations were largely incorporated into the 2005 ADA Clinical Practice Guidelines for Hospitalized Patients.19 The recommended glycemic targets for hospitalized patients in the intensive care unit are between 80 and 110 mg/dL. In noncritical care settings a preprandial glucose of 90130 mg/dL (midpoint 110 mg/dL) and a postprandial or random glucose of less than 180 mg/dL are the recommended glycemic targets. Physiologic and safe insulin regimen strategies for virtually all patient situations were succinctly presented. Although there have been modest (and occasionally dramatic) improvements in glycemic control in several institutions, the reviews and guidelines have not yet resulted in widespread change in clinical practice on the inpatient wards.

Two retrospective studies from prestigious medical institutions reported in this issue of the Journal of Hospital Medicine dramatically illustrate that glycemic control and insulin‐ordering practices in general medicine services continue to be deficient and underscore the contribution of physician inertia in the management of hyperglycemia in noncritically ill patients.20, 21 From their findings and experiences in our institutions, you should expect the following at your institution unless you have embarked on an organized program to improve noncritical care inpatient glycemic control.

• Around one third of your patients with hyperglycemia have a mean glucose of more than 200 mg/dL during their hospital stay.

• Despite these out‐of‐control values, 60% of your inpatients will remain on a static regimen of sliding‐scale insulin over the duration of their stay. Unfortunately, this degree of hyperglycemia is not protective for hypoglycemic episodes.

• Around 10% of your monitored ward inpatients will have at least one hypoglycemic episode during their stay. Many of these episodes will be precipitated by poor coordination of nutrition and insulin administration and nonsensical insulin regimens that lead to insulin stacking.

• Discharge summaries and plans will include mention and follow‐up of hyperglycemia only a minority of the time.

• Your nursing and medical staffs are unevenly educated about the proper use of insulin, even though insulin errors are very common, and insulin is one of the top 3 drugs involved in adverse drug events in your institution.

• Transitions in care will lead to an inconsistent approach to glycemic control, leaving some of your patients confused and others just plain angry.

The ubiquitous use of the insulin sliding scale as the single routine response for controlling hyperglycemia in inpatients has been discredited for a long time.2224 Strong terms have been used the condemnation of this method: mindless medicine, paralysis of thought, and action without benefit, for example.25, 26 Yet this remains the most popular default regimen in most institutions across the country. Clinical inertia is defined as not initiating or intensifying therapy when doing so is indicated,27, 28 and that term certainly applies to glycemic control practices and the continued heavy use of sliding‐scale insulin across the nation.

Why is clinical inertia so strong in this area? Why have well‐done practice guidelines and reviews not eradicated the use of sliding‐scale insulin? First, hyperglycemia is rarely the focus of care during the hospital stay, as the overwhelming majority of hospitalizations of patients with hyperglycemia occur for comorbid conditions.2, 29 Second, fear of hypoglycemia constitutes a major barrier to efforts to improve glycemic control in hospitalized patients, especially in those with poor caloric intake.13, 30 Third, practitioners initiate sliding‐scale insulin regimens, even though this has been a thoroughly discredited approach, simply because it is the easiest thing to do in their current practice environment.31

How do we break this inertia and redesign our practice environment in such a way that using a more physiologic and sensible insulin regimen is the easiest thing to do? It starts with local physician leadership. On noncritical care wards, hospitalists and endocrinologists are the natural candidates to own the issue of inpatient diabetes care. These physician leaders need to garner appropriate institutional support, form a multidisciplinary steering committee or team, and formulate interventions.

Implementing a standardized subcutaneous insulin order set promoting the use of scheduled insulin therapy is a key intervention in the inpatient management of diabetes. These order sets should encourage basal replacement insulin therapy (ie, NPH, glargine, detemir) and scheduled nutritional/prandial short‐/rapid‐acting insulin (ie, regular, aspart, lispro, glulisine). The order set should also state the glycemic target, eliminate improper abbreviations and notations, incorporate a hypoglycemia protocol, and provide a range of default correction insulin dosage scales appropriate for varied levels of insulin sensitivity. Examples of such order sets are widely available.13, 32 This simple intervention can result in a tripling of insulin regimens including scheduled basal insulin, substantial subsequent improvement in glycemic control on the hospital floor, and significant reduction in hypoglycemic event rates.

The standardized order set can be much more effective when it is complemented by institution‐specific algorithms, protocols, and policies that support their effective use. These tools must not merely exist; they must be widely disseminated and used and, if possible, embedded in the order set. They should outline the calculation of insulin dosages, define recommended insulin regimens for patients with different forms of nutritional intake, guide transitions from insulin infusion to subcutaneous regimens, and enhance discharge planning and education.

The SHM, AACE, ADA, and other organizations are partnering to create a compendium of tested tools and strategies to assist hospitalists and their hospitals in these and other interventions and to assist them in devising reliable and practical metrics to gauge the impact of their efforts. These tools and a guidebook to walk teams through the improvement process step by step should be available on the SHM (www.hospitalmedicine.org) and other Web sites in the fall of 2006.

Look around and take stock. Does your hospital have standardized subcutaneous insulin order sets, algorithms and protocols supporting the order set, a multidisciplinary team tasked with improving insulin safety and glycemic control, and metrics to gauge whether your efforts are making a difference? Expecting better results without these essential elements is not only foolhardy but fits Einstein's definition of insanity: doing the same thing over and over again and expecting different results. Let's stop this sliding‐scale insulin insanity now.

Insanity: doing the same thing over and over again and expecting different results.Albert Einstein

Diabetes is one of the most common diagnoses in hospitalized patients.1 A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes.2 The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome.38 In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) short‐ and long‐term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization.7, 911

The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death.12, 13 In general‐surgical patients, serum glucose > 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital‐acquired infection.14 A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18‐fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5‐fold increase in mortality in patients with known diabetes compared with controls.2 A meta‐analysis of 26 studies identified an association of admission glucose > 110 mg/dL with the increased mortality of patients hospitalized for acute stroke.15 More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia.16, 17

In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and published glycemic targets and recommendations for inpatient management of hyperglycemia.18 The American Diabetes Association (ADA) subsequently published an excellent technical review evaluating the evidence and outlining treatment, monitoring, and educational strategies13 for the hospitalized patient, and these recommendations were largely incorporated into the 2005 ADA Clinical Practice Guidelines for Hospitalized Patients.19 The recommended glycemic targets for hospitalized patients in the intensive care unit are between 80 and 110 mg/dL. In noncritical care settings a preprandial glucose of 90130 mg/dL (midpoint 110 mg/dL) and a postprandial or random glucose of less than 180 mg/dL are the recommended glycemic targets. Physiologic and safe insulin regimen strategies for virtually all patient situations were succinctly presented. Although there have been modest (and occasionally dramatic) improvements in glycemic control in several institutions, the reviews and guidelines have not yet resulted in widespread change in clinical practice on the inpatient wards.

Two retrospective studies from prestigious medical institutions reported in this issue of the Journal of Hospital Medicine dramatically illustrate that glycemic control and insulin‐ordering practices in general medicine services continue to be deficient and underscore the contribution of physician inertia in the management of hyperglycemia in noncritically ill patients.20, 21 From their findings and experiences in our institutions, you should expect the following at your institution unless you have embarked on an organized program to improve noncritical care inpatient glycemic control.

• Around one third of your patients with hyperglycemia have a mean glucose of more than 200 mg/dL during their hospital stay.

• Despite these out‐of‐control values, 60% of your inpatients will remain on a static regimen of sliding‐scale insulin over the duration of their stay. Unfortunately, this degree of hyperglycemia is not protective for hypoglycemic episodes.

• Around 10% of your monitored ward inpatients will have at least one hypoglycemic episode during their stay. Many of these episodes will be precipitated by poor coordination of nutrition and insulin administration and nonsensical insulin regimens that lead to insulin stacking.

• Discharge summaries and plans will include mention and follow‐up of hyperglycemia only a minority of the time.

• Your nursing and medical staffs are unevenly educated about the proper use of insulin, even though insulin errors are very common, and insulin is one of the top 3 drugs involved in adverse drug events in your institution.

• Transitions in care will lead to an inconsistent approach to glycemic control, leaving some of your patients confused and others just plain angry.

The ubiquitous use of the insulin sliding scale as the single routine response for controlling hyperglycemia in inpatients has been discredited for a long time.2224 Strong terms have been used the condemnation of this method: mindless medicine, paralysis of thought, and action without benefit, for example.25, 26 Yet this remains the most popular default regimen in most institutions across the country. Clinical inertia is defined as not initiating or intensifying therapy when doing so is indicated,27, 28 and that term certainly applies to glycemic control practices and the continued heavy use of sliding‐scale insulin across the nation.

Why is clinical inertia so strong in this area? Why have well‐done practice guidelines and reviews not eradicated the use of sliding‐scale insulin? First, hyperglycemia is rarely the focus of care during the hospital stay, as the overwhelming majority of hospitalizations of patients with hyperglycemia occur for comorbid conditions.2, 29 Second, fear of hypoglycemia constitutes a major barrier to efforts to improve glycemic control in hospitalized patients, especially in those with poor caloric intake.13, 30 Third, practitioners initiate sliding‐scale insulin regimens, even though this has been a thoroughly discredited approach, simply because it is the easiest thing to do in their current practice environment.31

How do we break this inertia and redesign our practice environment in such a way that using a more physiologic and sensible insulin regimen is the easiest thing to do? It starts with local physician leadership. On noncritical care wards, hospitalists and endocrinologists are the natural candidates to own the issue of inpatient diabetes care. These physician leaders need to garner appropriate institutional support, form a multidisciplinary steering committee or team, and formulate interventions.

Implementing a standardized subcutaneous insulin order set promoting the use of scheduled insulin therapy is a key intervention in the inpatient management of diabetes. These order sets should encourage basal replacement insulin therapy (ie, NPH, glargine, detemir) and scheduled nutritional/prandial short‐/rapid‐acting insulin (ie, regular, aspart, lispro, glulisine). The order set should also state the glycemic target, eliminate improper abbreviations and notations, incorporate a hypoglycemia protocol, and provide a range of default correction insulin dosage scales appropriate for varied levels of insulin sensitivity. Examples of such order sets are widely available.13, 32 This simple intervention can result in a tripling of insulin regimens including scheduled basal insulin, substantial subsequent improvement in glycemic control on the hospital floor, and significant reduction in hypoglycemic event rates.

The standardized order set can be much more effective when it is complemented by institution‐specific algorithms, protocols, and policies that support their effective use. These tools must not merely exist; they must be widely disseminated and used and, if possible, embedded in the order set. They should outline the calculation of insulin dosages, define recommended insulin regimens for patients with different forms of nutritional intake, guide transitions from insulin infusion to subcutaneous regimens, and enhance discharge planning and education.

The SHM, AACE, ADA, and other organizations are partnering to create a compendium of tested tools and strategies to assist hospitalists and their hospitals in these and other interventions and to assist them in devising reliable and practical metrics to gauge the impact of their efforts. These tools and a guidebook to walk teams through the improvement process step by step should be available on the SHM (www.hospitalmedicine.org) and other Web sites in the fall of 2006.

Look around and take stock. Does your hospital have standardized subcutaneous insulin order sets, algorithms and protocols supporting the order set, a multidisciplinary team tasked with improving insulin safety and glycemic control, and metrics to gauge whether your efforts are making a difference? Expecting better results without these essential elements is not only foolhardy but fits Einstein's definition of insanity: doing the same thing over and over again and expecting different results. Let's stop this sliding‐scale insulin insanity now.

Insanity: doing the same thing over and over again and expecting different results.Albert Einstein

Diabetes is one of the most common diagnoses in hospitalized patients.1 A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes.2 The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome.38 In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) short‐ and long‐term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization.7, 911

The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death.12, 13 In general‐surgical patients, serum glucose > 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital‐acquired infection.14 A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18‐fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5‐fold increase in mortality in patients with known diabetes compared with controls.2 A meta‐analysis of 26 studies identified an association of admission glucose > 110 mg/dL with the increased mortality of patients hospitalized for acute stroke.15 More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia.16, 17

In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and published glycemic targets and recommendations for inpatient management of hyperglycemia.18 The American Diabetes Association (ADA) subsequently published an excellent technical review evaluating the evidence and outlining treatment, monitoring, and educational strategies13 for the hospitalized patient, and these recommendations were largely incorporated into the 2005 ADA Clinical Practice Guidelines for Hospitalized Patients.19 The recommended glycemic targets for hospitalized patients in the intensive care unit are between 80 and 110 mg/dL. In noncritical care settings a preprandial glucose of 90130 mg/dL (midpoint 110 mg/dL) and a postprandial or random glucose of less than 180 mg/dL are the recommended glycemic targets. Physiologic and safe insulin regimen strategies for virtually all patient situations were succinctly presented. Although there have been modest (and occasionally dramatic) improvements in glycemic control in several institutions, the reviews and guidelines have not yet resulted in widespread change in clinical practice on the inpatient wards.

Two retrospective studies from prestigious medical institutions reported in this issue of the Journal of Hospital Medicine dramatically illustrate that glycemic control and insulin‐ordering practices in general medicine services continue to be deficient and underscore the contribution of physician inertia in the management of hyperglycemia in noncritically ill patients.20, 21 From their findings and experiences in our institutions, you should expect the following at your institution unless you have embarked on an organized program to improve noncritical care inpatient glycemic control.

• Around one third of your patients with hyperglycemia have a mean glucose of more than 200 mg/dL during their hospital stay.

• Despite these out‐of‐control values, 60% of your inpatients will remain on a static regimen of sliding‐scale insulin over the duration of their stay. Unfortunately, this degree of hyperglycemia is not protective for hypoglycemic episodes.

• Around 10% of your monitored ward inpatients will have at least one hypoglycemic episode during their stay. Many of these episodes will be precipitated by poor coordination of nutrition and insulin administration and nonsensical insulin regimens that lead to insulin stacking.

• Discharge summaries and plans will include mention and follow‐up of hyperglycemia only a minority of the time.

• Your nursing and medical staffs are unevenly educated about the proper use of insulin, even though insulin errors are very common, and insulin is one of the top 3 drugs involved in adverse drug events in your institution.

• Transitions in care will lead to an inconsistent approach to glycemic control, leaving some of your patients confused and others just plain angry.

The ubiquitous use of the insulin sliding scale as the single routine response for controlling hyperglycemia in inpatients has been discredited for a long time.2224 Strong terms have been used the condemnation of this method: mindless medicine, paralysis of thought, and action without benefit, for example.25, 26 Yet this remains the most popular default regimen in most institutions across the country. Clinical inertia is defined as not initiating or intensifying therapy when doing so is indicated,27, 28 and that term certainly applies to glycemic control practices and the continued heavy use of sliding‐scale insulin across the nation.

Why is clinical inertia so strong in this area? Why have well‐done practice guidelines and reviews not eradicated the use of sliding‐scale insulin? First, hyperglycemia is rarely the focus of care during the hospital stay, as the overwhelming majority of hospitalizations of patients with hyperglycemia occur for comorbid conditions.2, 29 Second, fear of hypoglycemia constitutes a major barrier to efforts to improve glycemic control in hospitalized patients, especially in those with poor caloric intake.13, 30 Third, practitioners initiate sliding‐scale insulin regimens, even though this has been a thoroughly discredited approach, simply because it is the easiest thing to do in their current practice environment.31

How do we break this inertia and redesign our practice environment in such a way that using a more physiologic and sensible insulin regimen is the easiest thing to do? It starts with local physician leadership. On noncritical care wards, hospitalists and endocrinologists are the natural candidates to own the issue of inpatient diabetes care. These physician leaders need to garner appropriate institutional support, form a multidisciplinary steering committee or team, and formulate interventions.

Implementing a standardized subcutaneous insulin order set promoting the use of scheduled insulin therapy is a key intervention in the inpatient management of diabetes. These order sets should encourage basal replacement insulin therapy (ie, NPH, glargine, detemir) and scheduled nutritional/prandial short‐/rapid‐acting insulin (ie, regular, aspart, lispro, glulisine). The order set should also state the glycemic target, eliminate improper abbreviations and notations, incorporate a hypoglycemia protocol, and provide a range of default correction insulin dosage scales appropriate for varied levels of insulin sensitivity. Examples of such order sets are widely available.13, 32 This simple intervention can result in a tripling of insulin regimens including scheduled basal insulin, substantial subsequent improvement in glycemic control on the hospital floor, and significant reduction in hypoglycemic event rates.

The standardized order set can be much more effective when it is complemented by institution‐specific algorithms, protocols, and policies that support their effective use. These tools must not merely exist; they must be widely disseminated and used and, if possible, embedded in the order set. They should outline the calculation of insulin dosages, define recommended insulin regimens for patients with different forms of nutritional intake, guide transitions from insulin infusion to subcutaneous regimens, and enhance discharge planning and education.

The SHM, AACE, ADA, and other organizations are partnering to create a compendium of tested tools and strategies to assist hospitalists and their hospitals in these and other interventions and to assist them in devising reliable and practical metrics to gauge the impact of their efforts. These tools and a guidebook to walk teams through the improvement process step by step should be available on the SHM (www.hospitalmedicine.org) and other Web sites in the fall of 2006.

Look around and take stock. Does your hospital have standardized subcutaneous insulin order sets, algorithms and protocols supporting the order set, a multidisciplinary team tasked with improving insulin safety and glycemic control, and metrics to gauge whether your efforts are making a difference? Expecting better results without these essential elements is not only foolhardy but fits Einstein's definition of insanity: doing the same thing over and over again and expecting different results. Let's stop this sliding‐scale insulin insanity now.

Several groups of medical patients at risk for venous thromboembolism (VTE) while hospitalized have been identified. These include patients with certain acute medical illnesses such as acute myocardial infarction, stroke, or chronic obstructive pulmonary disease and those with acute medical illness combined with additional risk factors including advanced age, cancer, obesity, or prior VTE.13

Heparin‐induced thrombocytopenia (HIT) and heparin‐induced thrombocytopenia with thrombosis (HITT), a spectrum of disease also known as type 2 HIT, are potentially devastating hematologic consequences of VTE prophylaxis that result from heparin binding to platelet factor IV, leading to IgG antibodymediated platelet activation.46 These complications manifest along a spectrum from thrombocytopenia alone (HIT) to more severe sequelae that include death, amputation, venous and arterial thrombosis. Unfractionated heparin (UFH) has traditionally been used for VTE prophylaxis in these populations at risk. More recently, evidence has indicated that enoxaparin, a low‐molecular‐weight heparin, is at least as effective for VTE prophylaxis1, 7 and carries a significantly lower risk for the development of the complications of HIT and HITT. Despite the superior side‐effect profile of enoxaparin, many institutions encourage the use of heparin for DVT prophylaxis because of its lower price. However, when the costs of treating these complications are considered, using unfractionated heparin may actually be more costly.

Two studies of the cost effectiveness of heparin compared with enoxaparin when used for VTE prophylaxis in medical inpatients have recently been published.8, 9 However, one of these studies focused only on pharmacy‐related costs and did not consider patient‐related outcomes, and the other was published by a for‐profit research company. Studies of treatment with enoxaparin versus UFH in other medical settings, including non‐Q‐wave myocardial infarction10 and treatment of acute deep‐vein thrombosis,11 suggest that enoxaparin is more cost effective. Studies of prophylaxis of surgical patients have been contradictory. Data suggest that in orthopedic patients the use of enoxaparin is more cost effective for both short‐ and long‐term VTE prophylaxis,1214 but low‐dose heparin appeared more cost effective for patients undergoing colorectal surgery, in large part because of an assumption of a smaller risk of bleeding.15

The purpose of this analysis was to determine the cost utility of heparin compared with enoxaparin for VTE prophylaxis for medical inpatients at risk. In such an analysis, it is important to consider the possibly different meanings that entities may attach to cost utility and effectiveness according to their different roles in the health care system. Individual institutions pay inpatient medication costs, but they often do not directly bear the costs of complications of treatment and may actually receive reimbursements for them. In contrast, payers must provide that reimbursement. For this reason, costs were analyzed from 2 perspectives, that of a payer (Medicare) and that of a health care system or institution.

METHODS

This protocol was declared exempt by the Institutional Review Board at the University of Texas Health Science Center at San Antonio.

RESULTS

The decision tree used for the base‐case analysis is shown in Figure 1. The gain in quality‐adjusted life years (QALYs) for medical patients who used enoxaparin rather than heparin for VTE prophylaxis was 0.00629 (approximately 55 hours). This was based on the decrease in HITT‐related premature death resulting from the use of enoxaparin. From a payer perspective, the daily cost of enoxaparin is $3.58, compared with $32.18 for heparin. The difference is a savings of $28.61, leading to a savings/QALY of $4550.17. Therefore, the use of enoxaparin is both more effective and less costly.

Figure 1

Sensitivity analysis showed that from a payer perspective, enoxaparin remained both less costly and more effective in all cases. The factors that had the largest impact on cost/QALY were incidence of HIT and rate of thrombosis among those with HIT. Decreasing length of stay to 0 for patients with HIT, decreasing reimbursement to $0 for both HIT and HITT, and billing at a high or low level did not change the general finding. Decreasing the cost of enoxaparin or heparin also did not affect these findings. The results of the sensitivity analysis are summarized in Table 3.

From an institutional perspective, the effect of considering the costs of HIT and HITT did not necessarily make enoxaparin a more attractive choice. When potential reimbursement for drug‐related complications was considered, an institution actually make $7.27/day by choosing heparin, whereas the cost of enoxaparin decreases only minimally from $84.00 to $82.75/day (Table 4). Factoring opportunity costs into the analysis showed that an institution does not make money by using heparin, but heparin still costs less on a daily basis. This finding changes only at rates of HIT over 4%.

Sensitivity analyses of institutional costs are summarized in Table 4. These analyses demonstrated that potential increases in length of stay for patients with HIT or HITT could make heparin less attractive when opportunity costs to the hospital are considered. If the additional length of stay for patients with HIT increased to greater than 1.75 days or the additional length of stay for those with HITT increased to more than 9 days, heparin becomes a less attractive choice. Loss of reimbursement for HIT or HITT alone does not make enoxaparin less costly than heparin.

Sensitivity analysis also demonstrated that variation in the price of enoxaparin could potentially make heparin less attractive. If the price of heparin were held constant at $4.00/day, enoxaparin would become less costly at a price of $37.00. If the price of heparin were to decrease to as low as $0.50/day, the price at which enoxaparin would be more attractive decreased to $33.00. These prices are only applicable when the opportunity costs of having occupied beds are consideredthat is, only when an institution is operating at full capacity. When this is not the case, enoxaparin would have to cost less than $1.00 to be more financially attractive than heparin. In practical terms, unless a hospital is at full capacity and needs hospital beds for other patients, the cost of enoxaparin would have to be less than $1 for an institution to choose it instead of heparin.

DISCUSSION

This study demonstrates that from a payer perspective, there is greater cost utility in the use of enoxaparin in place of heparin for the prevention of venous thromboembolism in at‐risk medical patients. This benefit is based on a single advantage of enoxaparin: its decreased tendency to cause HIT/T. Despite the simplicity of this assumption, it is well supported by published data. Sensitivity analyses supported the finding that enoxaparin was a superior choice in all scenarios modeled. This payer data can be extrapolated to a societal level because the costs used were based on Medicare reimbursements.

The benefit of using enoxaparin when expressed in an absolute number of quality‐adjusted life years was small, approximately 55 hours. This reflects that although the effects of HIT and HITT are potentially devastating, they occur infrequently. However, our calculation was conservative in several respects. We calculated the highest possible average age for a medical inpatient based on the available statistics. This was done to ensure that we were not overestimating the number of QALYs saved by preventing death secondary to HITT. We also considered only 2 outcomes of HITT: death and recovery. This underestimates the significant potential thrombotic complications, notably amputation or other loss of function, which would increase the number of QALYs saved by using enoxaparin. The inclusion of these complications would only strengthen this finding. Finally, we assumed equal efficacy for heparin and enoxaparin. The inclusion of superior efficacy of enoxaparin in subpopulations of medical inpatients would again only strengthen this finding.

Apart from the price of the medication, the incidence of HIT had the largest impact on costs and QALYs saved in the sensitivity analysis. Studies specific to VTE prophylaxis in medical inpatients could better define the incidence of HIT/T in this population, but this would not change our overall finding.

From an institutional perspective, the choice of heparin or enoxaparin is more complicated. In most but not all scenarios, the use of heparin appears to be more financially attractive. The prices of enoxaparin and heparin, the additional length of stay required to care for patients with HIT and HITT, and the percentage of total beds occupied all affect this decision. Several pieces of cost data, specifically those related to medication and laboratory testing, were specific to an MIHCS health care system, the type considered in the analysis and could potentially limit the applicability of this study to other institutions. However, the sensitivity analysis demonstrated that the cost of enoxaparin would have to be at least 60% lower, below $33/day, before affecting our conclusion, and then only if an institution were at full capacity. Thus, we expect that our results are generally applicable.

The potential limitations of this study are related to the assumptions required. However, our efficacy assumptions were conservatively based on published data. It is possible that a decrease in the rate of thrombosis if all cases of HIT were treated with argatroban could affect our findings. However, in the study by Lewis et al., the complication rate for those with HIT in the treatment group was 28% (versus 38.8% in the untreated group), consistent with rates used in our sensitivity analysis. DRG and physician reimbursements are based on published Medicare data. The greatest variation is likely to be in drug cost, as different institutions may negotiate lower prices. From a payer perspective, drug costs do not affect the conclusions; from an institutional perspective, drug cost may make the choice a complicated one. One factor not included in our analysis that may affect this decision is the possible impact of legal action on the medications institutions choose for VTE prophylaxis. Because the potential consequences of HITT can be so devastating, an institution could have difficulty defending the choice of heparin when an equally effective alternative with fewer adverse events was available. A settlement of $1 million could potentially pay for prophylaxis with enoxaparin for at least 2500 patients.

This analysis has highlighted one of the unfortunate paradoxes caused by the different, potentially competing incentives in our health care system. Payers and institutions often face different financial incentives. From a hospital's perspective, it may cost less to use an intervention that can potentially cause a greater number of complications and higher payer costs. We believe that for VTE prophylaxis for medical inpatients, improved patient outcomes coupled with decreased payer/societal costs argue strongly for the use of enoxaparin over unfractionated heparin and outweigh any institutional benefits.

Several groups of medical patients at risk for venous thromboembolism (VTE) while hospitalized have been identified. These include patients with certain acute medical illnesses such as acute myocardial infarction, stroke, or chronic obstructive pulmonary disease and those with acute medical illness combined with additional risk factors including advanced age, cancer, obesity, or prior VTE.13

Heparin‐induced thrombocytopenia (HIT) and heparin‐induced thrombocytopenia with thrombosis (HITT), a spectrum of disease also known as type 2 HIT, are potentially devastating hematologic consequences of VTE prophylaxis that result from heparin binding to platelet factor IV, leading to IgG antibodymediated platelet activation.46 These complications manifest along a spectrum from thrombocytopenia alone (HIT) to more severe sequelae that include death, amputation, venous and arterial thrombosis. Unfractionated heparin (UFH) has traditionally been used for VTE prophylaxis in these populations at risk. More recently, evidence has indicated that enoxaparin, a low‐molecular‐weight heparin, is at least as effective for VTE prophylaxis1, 7 and carries a significantly lower risk for the development of the complications of HIT and HITT. Despite the superior side‐effect profile of enoxaparin, many institutions encourage the use of heparin for DVT prophylaxis because of its lower price. However, when the costs of treating these complications are considered, using unfractionated heparin may actually be more costly.

Two studies of the cost effectiveness of heparin compared with enoxaparin when used for VTE prophylaxis in medical inpatients have recently been published.8, 9 However, one of these studies focused only on pharmacy‐related costs and did not consider patient‐related outcomes, and the other was published by a for‐profit research company. Studies of treatment with enoxaparin versus UFH in other medical settings, including non‐Q‐wave myocardial infarction10 and treatment of acute deep‐vein thrombosis,11 suggest that enoxaparin is more cost effective. Studies of prophylaxis of surgical patients have been contradictory. Data suggest that in orthopedic patients the use of enoxaparin is more cost effective for both short‐ and long‐term VTE prophylaxis,1214 but low‐dose heparin appeared more cost effective for patients undergoing colorectal surgery, in large part because of an assumption of a smaller risk of bleeding.15

The purpose of this analysis was to determine the cost utility of heparin compared with enoxaparin for VTE prophylaxis for medical inpatients at risk. In such an analysis, it is important to consider the possibly different meanings that entities may attach to cost utility and effectiveness according to their different roles in the health care system. Individual institutions pay inpatient medication costs, but they often do not directly bear the costs of complications of treatment and may actually receive reimbursements for them. In contrast, payers must provide that reimbursement. For this reason, costs were analyzed from 2 perspectives, that of a payer (Medicare) and that of a health care system or institution.

METHODS

This protocol was declared exempt by the Institutional Review Board at the University of Texas Health Science Center at San Antonio.

RESULTS

The decision tree used for the base‐case analysis is shown in Figure 1. The gain in quality‐adjusted life years (QALYs) for medical patients who used enoxaparin rather than heparin for VTE prophylaxis was 0.00629 (approximately 55 hours). This was based on the decrease in HITT‐related premature death resulting from the use of enoxaparin. From a payer perspective, the daily cost of enoxaparin is $3.58, compared with $32.18 for heparin. The difference is a savings of $28.61, leading to a savings/QALY of $4550.17. Therefore, the use of enoxaparin is both more effective and less costly.

Figure 1

Sensitivity analysis showed that from a payer perspective, enoxaparin remained both less costly and more effective in all cases. The factors that had the largest impact on cost/QALY were incidence of HIT and rate of thrombosis among those with HIT. Decreasing length of stay to 0 for patients with HIT, decreasing reimbursement to $0 for both HIT and HITT, and billing at a high or low level did not change the general finding. Decreasing the cost of enoxaparin or heparin also did not affect these findings. The results of the sensitivity analysis are summarized in Table 3.

From an institutional perspective, the effect of considering the costs of HIT and HITT did not necessarily make enoxaparin a more attractive choice. When potential reimbursement for drug‐related complications was considered, an institution actually make $7.27/day by choosing heparin, whereas the cost of enoxaparin decreases only minimally from $84.00 to $82.75/day (Table 4). Factoring opportunity costs into the analysis showed that an institution does not make money by using heparin, but heparin still costs less on a daily basis. This finding changes only at rates of HIT over 4%.

Sensitivity analyses of institutional costs are summarized in Table 4. These analyses demonstrated that potential increases in length of stay for patients with HIT or HITT could make heparin less attractive when opportunity costs to the hospital are considered. If the additional length of stay for patients with HIT increased to greater than 1.75 days or the additional length of stay for those with HITT increased to more than 9 days, heparin becomes a less attractive choice. Loss of reimbursement for HIT or HITT alone does not make enoxaparin less costly than heparin.

Sensitivity analysis also demonstrated that variation in the price of enoxaparin could potentially make heparin less attractive. If the price of heparin were held constant at $4.00/day, enoxaparin would become less costly at a price of $37.00. If the price of heparin were to decrease to as low as $0.50/day, the price at which enoxaparin would be more attractive decreased to $33.00. These prices are only applicable when the opportunity costs of having occupied beds are consideredthat is, only when an institution is operating at full capacity. When this is not the case, enoxaparin would have to cost less than $1.00 to be more financially attractive than heparin. In practical terms, unless a hospital is at full capacity and needs hospital beds for other patients, the cost of enoxaparin would have to be less than $1 for an institution to choose it instead of heparin.

DISCUSSION

This study demonstrates that from a payer perspective, there is greater cost utility in the use of enoxaparin in place of heparin for the prevention of venous thromboembolism in at‐risk medical patients. This benefit is based on a single advantage of enoxaparin: its decreased tendency to cause HIT/T. Despite the simplicity of this assumption, it is well supported by published data. Sensitivity analyses supported the finding that enoxaparin was a superior choice in all scenarios modeled. This payer data can be extrapolated to a societal level because the costs used were based on Medicare reimbursements.

The benefit of using enoxaparin when expressed in an absolute number of quality‐adjusted life years was small, approximately 55 hours. This reflects that although the effects of HIT and HITT are potentially devastating, they occur infrequently. However, our calculation was conservative in several respects. We calculated the highest possible average age for a medical inpatient based on the available statistics. This was done to ensure that we were not overestimating the number of QALYs saved by preventing death secondary to HITT. We also considered only 2 outcomes of HITT: death and recovery. This underestimates the significant potential thrombotic complications, notably amputation or other loss of function, which would increase the number of QALYs saved by using enoxaparin. The inclusion of these complications would only strengthen this finding. Finally, we assumed equal efficacy for heparin and enoxaparin. The inclusion of superior efficacy of enoxaparin in subpopulations of medical inpatients would again only strengthen this finding.

Apart from the price of the medication, the incidence of HIT had the largest impact on costs and QALYs saved in the sensitivity analysis. Studies specific to VTE prophylaxis in medical inpatients could better define the incidence of HIT/T in this population, but this would not change our overall finding.

From an institutional perspective, the choice of heparin or enoxaparin is more complicated. In most but not all scenarios, the use of heparin appears to be more financially attractive. The prices of enoxaparin and heparin, the additional length of stay required to care for patients with HIT and HITT, and the percentage of total beds occupied all affect this decision. Several pieces of cost data, specifically those related to medication and laboratory testing, were specific to an MIHCS health care system, the type considered in the analysis and could potentially limit the applicability of this study to other institutions. However, the sensitivity analysis demonstrated that the cost of enoxaparin would have to be at least 60% lower, below $33/day, before affecting our conclusion, and then only if an institution were at full capacity. Thus, we expect that our results are generally applicable.

The potential limitations of this study are related to the assumptions required. However, our efficacy assumptions were conservatively based on published data. It is possible that a decrease in the rate of thrombosis if all cases of HIT were treated with argatroban could affect our findings. However, in the study by Lewis et al., the complication rate for those with HIT in the treatment group was 28% (versus 38.8% in the untreated group), consistent with rates used in our sensitivity analysis. DRG and physician reimbursements are based on published Medicare data. The greatest variation is likely to be in drug cost, as different institutions may negotiate lower prices. From a payer perspective, drug costs do not affect the conclusions; from an institutional perspective, drug cost may make the choice a complicated one. One factor not included in our analysis that may affect this decision is the possible impact of legal action on the medications institutions choose for VTE prophylaxis. Because the potential consequences of HITT can be so devastating, an institution could have difficulty defending the choice of heparin when an equally effective alternative with fewer adverse events was available. A settlement of $1 million could potentially pay for prophylaxis with enoxaparin for at least 2500 patients.

This analysis has highlighted one of the unfortunate paradoxes caused by the different, potentially competing incentives in our health care system. Payers and institutions often face different financial incentives. From a hospital's perspective, it may cost less to use an intervention that can potentially cause a greater number of complications and higher payer costs. We believe that for VTE prophylaxis for medical inpatients, improved patient outcomes coupled with decreased payer/societal costs argue strongly for the use of enoxaparin over unfractionated heparin and outweigh any institutional benefits.

Several groups of medical patients at risk for venous thromboembolism (VTE) while hospitalized have been identified. These include patients with certain acute medical illnesses such as acute myocardial infarction, stroke, or chronic obstructive pulmonary disease and those with acute medical illness combined with additional risk factors including advanced age, cancer, obesity, or prior VTE.13

Heparin‐induced thrombocytopenia (HIT) and heparin‐induced thrombocytopenia with thrombosis (HITT), a spectrum of disease also known as type 2 HIT, are potentially devastating hematologic consequences of VTE prophylaxis that result from heparin binding to platelet factor IV, leading to IgG antibodymediated platelet activation.46 These complications manifest along a spectrum from thrombocytopenia alone (HIT) to more severe sequelae that include death, amputation, venous and arterial thrombosis. Unfractionated heparin (UFH) has traditionally been used for VTE prophylaxis in these populations at risk. More recently, evidence has indicated that enoxaparin, a low‐molecular‐weight heparin, is at least as effective for VTE prophylaxis1, 7 and carries a significantly lower risk for the development of the complications of HIT and HITT. Despite the superior side‐effect profile of enoxaparin, many institutions encourage the use of heparin for DVT prophylaxis because of its lower price. However, when the costs of treating these complications are considered, using unfractionated heparin may actually be more costly.

Two studies of the cost effectiveness of heparin compared with enoxaparin when used for VTE prophylaxis in medical inpatients have recently been published.8, 9 However, one of these studies focused only on pharmacy‐related costs and did not consider patient‐related outcomes, and the other was published by a for‐profit research company. Studies of treatment with enoxaparin versus UFH in other medical settings, including non‐Q‐wave myocardial infarction10 and treatment of acute deep‐vein thrombosis,11 suggest that enoxaparin is more cost effective. Studies of prophylaxis of surgical patients have been contradictory. Data suggest that in orthopedic patients the use of enoxaparin is more cost effective for both short‐ and long‐term VTE prophylaxis,1214 but low‐dose heparin appeared more cost effective for patients undergoing colorectal surgery, in large part because of an assumption of a smaller risk of bleeding.15

The purpose of this analysis was to determine the cost utility of heparin compared with enoxaparin for VTE prophylaxis for medical inpatients at risk. In such an analysis, it is important to consider the possibly different meanings that entities may attach to cost utility and effectiveness according to their different roles in the health care system. Individual institutions pay inpatient medication costs, but they often do not directly bear the costs of complications of treatment and may actually receive reimbursements for them. In contrast, payers must provide that reimbursement. For this reason, costs were analyzed from 2 perspectives, that of a payer (Medicare) and that of a health care system or institution.

METHODS

This protocol was declared exempt by the Institutional Review Board at the University of Texas Health Science Center at San Antonio.

RESULTS

The decision tree used for the base‐case analysis is shown in Figure 1. The gain in quality‐adjusted life years (QALYs) for medical patients who used enoxaparin rather than heparin for VTE prophylaxis was 0.00629 (approximately 55 hours). This was based on the decrease in HITT‐related premature death resulting from the use of enoxaparin. From a payer perspective, the daily cost of enoxaparin is $3.58, compared with $32.18 for heparin. The difference is a savings of $28.61, leading to a savings/QALY of $4550.17. Therefore, the use of enoxaparin is both more effective and less costly.

Figure 1

Sensitivity analysis showed that from a payer perspective, enoxaparin remained both less costly and more effective in all cases. The factors that had the largest impact on cost/QALY were incidence of HIT and rate of thrombosis among those with HIT. Decreasing length of stay to 0 for patients with HIT, decreasing reimbursement to $0 for both HIT and HITT, and billing at a high or low level did not change the general finding. Decreasing the cost of enoxaparin or heparin also did not affect these findings. The results of the sensitivity analysis are summarized in Table 3.

From an institutional perspective, the effect of considering the costs of HIT and HITT did not necessarily make enoxaparin a more attractive choice. When potential reimbursement for drug‐related complications was considered, an institution actually make $7.27/day by choosing heparin, whereas the cost of enoxaparin decreases only minimally from $84.00 to $82.75/day (Table 4). Factoring opportunity costs into the analysis showed that an institution does not make money by using heparin, but heparin still costs less on a daily basis. This finding changes only at rates of HIT over 4%.

Sensitivity analyses of institutional costs are summarized in Table 4. These analyses demonstrated that potential increases in length of stay for patients with HIT or HITT could make heparin less attractive when opportunity costs to the hospital are considered. If the additional length of stay for patients with HIT increased to greater than 1.75 days or the additional length of stay for those with HITT increased to more than 9 days, heparin becomes a less attractive choice. Loss of reimbursement for HIT or HITT alone does not make enoxaparin less costly than heparin.

Sensitivity analysis also demonstrated that variation in the price of enoxaparin could potentially make heparin less attractive. If the price of heparin were held constant at $4.00/day, enoxaparin would become less costly at a price of $37.00. If the price of heparin were to decrease to as low as $0.50/day, the price at which enoxaparin would be more attractive decreased to $33.00. These prices are only applicable when the opportunity costs of having occupied beds are consideredthat is, only when an institution is operating at full capacity. When this is not the case, enoxaparin would have to cost less than $1.00 to be more financially attractive than heparin. In practical terms, unless a hospital is at full capacity and needs hospital beds for other patients, the cost of enoxaparin would have to be less than $1 for an institution to choose it instead of heparin.

DISCUSSION

This study demonstrates that from a payer perspective, there is greater cost utility in the use of enoxaparin in place of heparin for the prevention of venous thromboembolism in at‐risk medical patients. This benefit is based on a single advantage of enoxaparin: its decreased tendency to cause HIT/T. Despite the simplicity of this assumption, it is well supported by published data. Sensitivity analyses supported the finding that enoxaparin was a superior choice in all scenarios modeled. This payer data can be extrapolated to a societal level because the costs used were based on Medicare reimbursements.

The benefit of using enoxaparin when expressed in an absolute number of quality‐adjusted life years was small, approximately 55 hours. This reflects that although the effects of HIT and HITT are potentially devastating, they occur infrequently. However, our calculation was conservative in several respects. We calculated the highest possible average age for a medical inpatient based on the available statistics. This was done to ensure that we were not overestimating the number of QALYs saved by preventing death secondary to HITT. We also considered only 2 outcomes of HITT: death and recovery. This underestimates the significant potential thrombotic complications, notably amputation or other loss of function, which would increase the number of QALYs saved by using enoxaparin. The inclusion of these complications would only strengthen this finding. Finally, we assumed equal efficacy for heparin and enoxaparin. The inclusion of superior efficacy of enoxaparin in subpopulations of medical inpatients would again only strengthen this finding.

Apart from the price of the medication, the incidence of HIT had the largest impact on costs and QALYs saved in the sensitivity analysis. Studies specific to VTE prophylaxis in medical inpatients could better define the incidence of HIT/T in this population, but this would not change our overall finding.

From an institutional perspective, the choice of heparin or enoxaparin is more complicated. In most but not all scenarios, the use of heparin appears to be more financially attractive. The prices of enoxaparin and heparin, the additional length of stay required to care for patients with HIT and HITT, and the percentage of total beds occupied all affect this decision. Several pieces of cost data, specifically those related to medication and laboratory testing, were specific to an MIHCS health care system, the type considered in the analysis and could potentially limit the applicability of this study to other institutions. However, the sensitivity analysis demonstrated that the cost of enoxaparin would have to be at least 60% lower, below $33/day, before affecting our conclusion, and then only if an institution were at full capacity. Thus, we expect that our results are generally applicable.

The potential limitations of this study are related to the assumptions required. However, our efficacy assumptions were conservatively based on published data. It is possible that a decrease in the rate of thrombosis if all cases of HIT were treated with argatroban could affect our findings. However, in the study by Lewis et al., the complication rate for those with HIT in the treatment group was 28% (versus 38.8% in the untreated group), consistent with rates used in our sensitivity analysis. DRG and physician reimbursements are based on published Medicare data. The greatest variation is likely to be in drug cost, as different institutions may negotiate lower prices. From a payer perspective, drug costs do not affect the conclusions; from an institutional perspective, drug cost may make the choice a complicated one. One factor not included in our analysis that may affect this decision is the possible impact of legal action on the medications institutions choose for VTE prophylaxis. Because the potential consequences of HITT can be so devastating, an institution could have difficulty defending the choice of heparin when an equally effective alternative with fewer adverse events was available. A settlement of $1 million could potentially pay for prophylaxis with enoxaparin for at least 2500 patients.

This analysis has highlighted one of the unfortunate paradoxes caused by the different, potentially competing incentives in our health care system. Payers and institutions often face different financial incentives. From a hospital's perspective, it may cost less to use an intervention that can potentially cause a greater number of complications and higher payer costs. We believe that for VTE prophylaxis for medical inpatients, improved patient outcomes coupled with decreased payer/societal costs argue strongly for the use of enoxaparin over unfractionated heparin and outweigh any institutional benefits.

Being a hospitalist provides us with many rewards in life: a secure job, decent income, intellectually stimulating experiences at work, and gratification from helping the patients we encounter. Importantly, without patients none of this would be possible. Their role in our work lives and their personal experience in the hospital vary dramatically from ours, and that experience may be relatively invisible to many of us. Be honesthave you fully recognized the apprehension and even terror experienced by some patients when nightfall sweeps through the hospital wards and the commotion and attention of the day shift dissipates?1 Have you been fully aware of the desperate need of patients or their family members for timely communication of understandable information in the midst of critical illness?2 We willingly believe what we wishpatients and their families are having a comforting experience while hospitalized, and we are doing wonderful jobs as hospitalists caring for them. However, the lay press indicates that the patient's perception may differ radically from this reassuring point of view.3

To comprehend fully the hospital experience of patients and their families, we can benefit from them telling us their stories. The narrative stories from a patient1 and the wife of a patient2 clearly convey the apprehension and fear both patients and their loved ones suffer. Without this appreciation, we cannot empathetically deliver the care patients deserve. Not surprisingly, as medical technology guides physicians to focus more on the disease instead of the person, a backlash of an increasing emphasis on patient‐centered care is emerging.4, 5 Through short essays on illuminating experiences of physicians, patients, or families of patients, I hope to bring the patient's perspective to the forefront of hospital medicine care. View from the Hospital Bed can educate us about patients' perspectives on the experience of being hospitalized. We can also learn from the families of patients in View from the Hospital Room. The next time you recognize that a patient or family member has a potent story to tell (good or bad), encourage them to send it to us at the Journal of Hospital Medicine.

Being a hospitalist provides us with many rewards in life: a secure job, decent income, intellectually stimulating experiences at work, and gratification from helping the patients we encounter. Importantly, without patients none of this would be possible. Their role in our work lives and their personal experience in the hospital vary dramatically from ours, and that experience may be relatively invisible to many of us. Be honesthave you fully recognized the apprehension and even terror experienced by some patients when nightfall sweeps through the hospital wards and the commotion and attention of the day shift dissipates?1 Have you been fully aware of the desperate need of patients or their family members for timely communication of understandable information in the midst of critical illness?2 We willingly believe what we wishpatients and their families are having a comforting experience while hospitalized, and we are doing wonderful jobs as hospitalists caring for them. However, the lay press indicates that the patient's perception may differ radically from this reassuring point of view.3

To comprehend fully the hospital experience of patients and their families, we can benefit from them telling us their stories. The narrative stories from a patient1 and the wife of a patient2 clearly convey the apprehension and fear both patients and their loved ones suffer. Without this appreciation, we cannot empathetically deliver the care patients deserve. Not surprisingly, as medical technology guides physicians to focus more on the disease instead of the person, a backlash of an increasing emphasis on patient‐centered care is emerging.4, 5 Through short essays on illuminating experiences of physicians, patients, or families of patients, I hope to bring the patient's perspective to the forefront of hospital medicine care. View from the Hospital Bed can educate us about patients' perspectives on the experience of being hospitalized. We can also learn from the families of patients in View from the Hospital Room. The next time you recognize that a patient or family member has a potent story to tell (good or bad), encourage them to send it to us at the Journal of Hospital Medicine.

Being a hospitalist provides us with many rewards in life: a secure job, decent income, intellectually stimulating experiences at work, and gratification from helping the patients we encounter. Importantly, without patients none of this would be possible. Their role in our work lives and their personal experience in the hospital vary dramatically from ours, and that experience may be relatively invisible to many of us. Be honesthave you fully recognized the apprehension and even terror experienced by some patients when nightfall sweeps through the hospital wards and the commotion and attention of the day shift dissipates?1 Have you been fully aware of the desperate need of patients or their family members for timely communication of understandable information in the midst of critical illness?2 We willingly believe what we wishpatients and their families are having a comforting experience while hospitalized, and we are doing wonderful jobs as hospitalists caring for them. However, the lay press indicates that the patient's perception may differ radically from this reassuring point of view.3

To comprehend fully the hospital experience of patients and their families, we can benefit from them telling us their stories. The narrative stories from a patient1 and the wife of a patient2 clearly convey the apprehension and fear both patients and their loved ones suffer. Without this appreciation, we cannot empathetically deliver the care patients deserve. Not surprisingly, as medical technology guides physicians to focus more on the disease instead of the person, a backlash of an increasing emphasis on patient‐centered care is emerging.4, 5 Through short essays on illuminating experiences of physicians, patients, or families of patients, I hope to bring the patient's perspective to the forefront of hospital medicine care. View from the Hospital Bed can educate us about patients' perspectives on the experience of being hospitalized. We can also learn from the families of patients in View from the Hospital Room. The next time you recognize that a patient or family member has a potent story to tell (good or bad), encourage them to send it to us at the Journal of Hospital Medicine.