Editorial

The proper duration of antibiotic therapy for various infections is a matter of long-standing consternation. For decades, the standard antibiotic course for most acute bacterial infections has been 7 to 14 days, based largely on the fact that the week has 7 days in it.¹ The reason the week has 7 days in it dates back to an edict issued by Constantine the Great in 321 AD.¹ To underscore the absurdity of basing 21st century antibiotic course durations on an ancient Roman Emperor’s decree, I refer to such durations as “Constantine Units.” One Constantine Unit is a 7-day course of antibiotics, and 2 Constantine Units is a 14-day course.

Disclosure: This work was supported by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, grant numbers R01 AI130060, R01 HSO25690, R01 AI1081719, and R21 AI127954. In the last 12 months, BS has consulted for Cempra, The Medicines Company, Medimmune, Tetraphase, AstraZeneca, Merck, Genentech, Forge, and Pfizer and owns equity in BioAIM, Synthetic Biologics, and Mycomed.

The proper duration of antibiotic therapy for various infections is a matter of long-standing consternation. For decades, the standard antibiotic course for most acute bacterial infections has been 7 to 14 days, based largely on the fact that the week has 7 days in it.¹ The reason the week has 7 days in it dates back to an edict issued by Constantine the Great in 321 AD.¹ To underscore the absurdity of basing 21st century antibiotic course durations on an ancient Roman Emperor’s decree, I refer to such durations as “Constantine Units.” One Constantine Unit is a 7-day course of antibiotics, and 2 Constantine Units is a 14-day course.

Disclosure: This work was supported by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, grant numbers R01 AI130060, R01 HSO25690, R01 AI1081719, and R21 AI127954. In the last 12 months, BS has consulted for Cempra, The Medicines Company, Medimmune, Tetraphase, AstraZeneca, Merck, Genentech, Forge, and Pfizer and owns equity in BioAIM, Synthetic Biologics, and Mycomed.

The proper duration of antibiotic therapy for various infections is a matter of long-standing consternation. For decades, the standard antibiotic course for most acute bacterial infections has been 7 to 14 days, based largely on the fact that the week has 7 days in it.¹ The reason the week has 7 days in it dates back to an edict issued by Constantine the Great in 321 AD.¹ To underscore the absurdity of basing 21st century antibiotic course durations on an ancient Roman Emperor’s decree, I refer to such durations as “Constantine Units.” One Constantine Unit is a 7-day course of antibiotics, and 2 Constantine Units is a 14-day course.

Disclosure: This work was supported by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, grant numbers R01 AI130060, R01 HSO25690, R01 AI1081719, and R21 AI127954. In the last 12 months, BS has consulted for Cempra, The Medicines Company, Medimmune, Tetraphase, AstraZeneca, Merck, Genentech, Forge, and Pfizer and owns equity in BioAIM, Synthetic Biologics, and Mycomed.

Communication failures are a leading cause of sentinel events, the most serious adverse events that occur in hospitals.¹ Interventions to improve patient safety have focused on communication between healthcare providers.^2-4 Interventions focusing on communication between providers and families or other patient caregivers are under-studied.^5,6 Given their availability, proximity, historical knowledge, and motivation for a good outcome,⁷ families can play a vital role as “vigilant partners”⁸ in promoting hospital communication and safety.

In this month’s Journal of Hospital Medicine, Solan et al. conducted focus groups and interviews of 61 caregivers of hospitalized pediatric patients at 30 days after discharge to assess their perceptions of communication during hospitalization and discharge home.⁹ They identified several caregiver themes pertaining to communication between the inpatient medical team and families, communication challenges due to the teaching hospital environment, and communication between providers. Caregiver concerns included feeling out of the loop, excessive provider use of medical jargon, confusing messages on rounds, and inadequate communication between inpatient and outpatient providers.

The manuscript serves both to uncover family concerns that may be underappreciated by clinicians and suggest some potential solutions. For instance, caregivers can be apprehensive about whom to call for postdischarge advice because they are sometimes uncertain whether their outpatient providers have sufficient information about the hospitalization to properly advise them. The authors propose using photo “face sheets” to improve caregiver identification of healthcare provider roles, including families in hospital committees, improving transition communication between inpatient and outpatient healthcare providers through timely faxed discharge summaries and telephone calls, and informing families about such communications with their outpatient providers.

These are important suggestions. However, in order to move from promoting communication alone to promoting true partnership in care, there are additional steps that providers can take to fully engage families in hospital and discharge communications.

Meaningful family engagement in hospital communications—eg, during family-centered rounds (FCRs)—has been associated with improved patient safety and experience.^10-12 To further enhance family partnership in care, we would make the following 3 suggestions for hospitals and healthcare providers: (1) focus on health literacy in all communications with families, (2) work towards shared decision making (SDM), and (3) make discharges family-centered.

In order to partner with one another, families and healthcare providers need to speak a common language. A key way to ensure that families and providers speak a common language is for providers to espouse good health literacy principles. Health literacy is the “capacity to obtain, process, and understand basic health information and services to make appropriate health decisions.”¹³ Health literacy is dynamic, varying based on medical problem, provider, and healthcare system.¹⁴ Overall, only 12% of United States adults possess the health literacy skills required to navigate our complex healthcare system.^15,16 Stress, illness, and other factors can compromise the ability of even these individuals to process and utilize health information. Yet health literacy is routinely overestimated by providers.^17-19

To optimize communication with families, providers should use “universal health literacy precautions”¹⁶ with all patients, not just those believed to need extra assistance, in both verbal (eg, FCRs) and written communications (eg, discharge instructions).¹⁶ Providers should speak in plain, nonmedical language, be specific and concrete, and have families engage in “teach-back” (ie, state in their own words their understanding of the plan). They should focus on what families “need to know” rather than what is “good to know.” They should use simpler sentence structure and “chunk and check”²⁰ (ie, provide small, “bite-sized” pieces of information and check for understanding by using teach-back).²¹ In writing, they should use simpler sentence structure, bullet points, active statements, and be cognizant of reading level, medical jargon, and word choice (eg, “has a fever” instead of “febrile”). It is worth recognizing that even highly educated, highly literate families—not least of all those who are physicians and nurses themselves—can benefit from universal health literacy precautions because the ability to process and grasp information is dynamic and can be markedly lower than usual when faced with the illness of a loved one.

At a systematic level, medical schools, nursing schools, residency training programs, and continuing education should include health literacy training in their curricula. While learning to speak the language of medicine is an important part of medical education, the next step is learning to “unspeak” it, a challenging but important charge to promote partnership.

SDM is the process by which providers and patients make decisions together by balancing clinical evidence with patient preferences and values.²² However, despite providers believing they are engaging in SDM,^23,24 families report they are often not as involved in SDM as they would like.^24-26 Indeed, most hospital communications with families, including FCRs and discharge instructions, typically emphasize information sharing, not SDM. SDM tends to be more commonly applied in outpatient settings.²⁷ To encourage SDM in the hospital setting, patients and families should not only understand communication during FCRs and at discharge but should be encouraged to be active participants in developing care plans,²⁶ no matter how minor the decisions involved.²⁸ SDM can be applied to a variety of discussions, both during hospitalization (eg, initiation of antibiotics, transition from intravenous to oral medications, pursuing imaging) and at discharge (eg, assessing discharge readiness, deciding duration of therapy, formulating follow-up recommendations). Providers will benefit from incorporating information from personal and medical histories that only families possess, resulting in more informed and potentially safer care plans that may be more likely to fit into the family’s life at home. SDM can also ensure patient and family “buy-in” and increase the likelihood of compliance with the shared plan.

Discharge processes often involve multiple redundancies and parallel processes that fail to actively involve families or promote transparency.²⁹ Discharge summaries are typically written in medical jargon and intended for the outpatient provider (who may not receive them in a timely fashion), not the family.^30-32 Separate discharge instructions are often provided to families without sufficient attention to health literacy, contingency planning, or individualization (eg, a generic asthma fact sheet).³⁰ Outpatient providers are not always contacted directly about the hospitalization, nor are families always informed when providers are contacted, as Solan et al. describe.

Providers can apply lessons from FCRs to discharge processes, pursuing a similar family-centered, interprofessional approach promoting partnership and transparency. Just as providers engage families during discussions on FCRs, they can engage families in discharge conversations with outpatient providers and nursing colleagues. Indeed, Berry et al. propose a discharge framework that emphasizes involvement of and dialogue between patients, families, and providers as they systematically develop and assess plans for discharge and postdischarge care.³³ To accomplish this, inpatient providers can copy families on discharge summaries and other correspondence with outpatient providers (eg, through secure emails or open-source notes such as OpenNotes^34-36). Moreover, particularly for complex discharges, inpatient providers can call outpatient providers in the family’s presence or invite outpatient providers to join—via telephone or videoconference—day-of-discharge FCRs or discharge huddles. Such efforts require logistical and pragmatic considerations, as well as culture change, but are not insurmountable and may help address many family concerns around peridischarge communication and care. Such efforts may also promote accountability on the part of families and providers alike, thereby ensuring that families are truly engaged as vigilant partners in care.

As one of us (SC) reflected once when considering her experience navigating healthcare as a parent of 2 children with cystic fibrosis, “We have to make it easier for families to be a true part of their children’s care. When patients and families are true members of the medical team, care is more informed, more targeted, and more safe for everyone.”

Disclosure: Dr. Landrigan has consulted with and holds equity in the I-PASS Patient Safety Institute, a company that seeks to train institutions in best handoff practices and aid in their implementation. Dr. Landrigan is supported in part by the Children’s Hospital Association for his work as an Executive Council member of the Pediatric Research in Inpatient Settings (PRIS) network. Dr. Landrigan has also served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation.

Communication failures are a leading cause of sentinel events, the most serious adverse events that occur in hospitals.¹ Interventions to improve patient safety have focused on communication between healthcare providers.^2-4 Interventions focusing on communication between providers and families or other patient caregivers are under-studied.^5,6 Given their availability, proximity, historical knowledge, and motivation for a good outcome,⁷ families can play a vital role as “vigilant partners”⁸ in promoting hospital communication and safety.

In this month’s Journal of Hospital Medicine, Solan et al. conducted focus groups and interviews of 61 caregivers of hospitalized pediatric patients at 30 days after discharge to assess their perceptions of communication during hospitalization and discharge home.⁹ They identified several caregiver themes pertaining to communication between the inpatient medical team and families, communication challenges due to the teaching hospital environment, and communication between providers. Caregiver concerns included feeling out of the loop, excessive provider use of medical jargon, confusing messages on rounds, and inadequate communication between inpatient and outpatient providers.

The manuscript serves both to uncover family concerns that may be underappreciated by clinicians and suggest some potential solutions. For instance, caregivers can be apprehensive about whom to call for postdischarge advice because they are sometimes uncertain whether their outpatient providers have sufficient information about the hospitalization to properly advise them. The authors propose using photo “face sheets” to improve caregiver identification of healthcare provider roles, including families in hospital committees, improving transition communication between inpatient and outpatient healthcare providers through timely faxed discharge summaries and telephone calls, and informing families about such communications with their outpatient providers.

These are important suggestions. However, in order to move from promoting communication alone to promoting true partnership in care, there are additional steps that providers can take to fully engage families in hospital and discharge communications.

Meaningful family engagement in hospital communications—eg, during family-centered rounds (FCRs)—has been associated with improved patient safety and experience.^10-12 To further enhance family partnership in care, we would make the following 3 suggestions for hospitals and healthcare providers: (1) focus on health literacy in all communications with families, (2) work towards shared decision making (SDM), and (3) make discharges family-centered.

In order to partner with one another, families and healthcare providers need to speak a common language. A key way to ensure that families and providers speak a common language is for providers to espouse good health literacy principles. Health literacy is the “capacity to obtain, process, and understand basic health information and services to make appropriate health decisions.”¹³ Health literacy is dynamic, varying based on medical problem, provider, and healthcare system.¹⁴ Overall, only 12% of United States adults possess the health literacy skills required to navigate our complex healthcare system.^15,16 Stress, illness, and other factors can compromise the ability of even these individuals to process and utilize health information. Yet health literacy is routinely overestimated by providers.^17-19

To optimize communication with families, providers should use “universal health literacy precautions”¹⁶ with all patients, not just those believed to need extra assistance, in both verbal (eg, FCRs) and written communications (eg, discharge instructions).¹⁶ Providers should speak in plain, nonmedical language, be specific and concrete, and have families engage in “teach-back” (ie, state in their own words their understanding of the plan). They should focus on what families “need to know” rather than what is “good to know.” They should use simpler sentence structure and “chunk and check”²⁰ (ie, provide small, “bite-sized” pieces of information and check for understanding by using teach-back).²¹ In writing, they should use simpler sentence structure, bullet points, active statements, and be cognizant of reading level, medical jargon, and word choice (eg, “has a fever” instead of “febrile”). It is worth recognizing that even highly educated, highly literate families—not least of all those who are physicians and nurses themselves—can benefit from universal health literacy precautions because the ability to process and grasp information is dynamic and can be markedly lower than usual when faced with the illness of a loved one.

At a systematic level, medical schools, nursing schools, residency training programs, and continuing education should include health literacy training in their curricula. While learning to speak the language of medicine is an important part of medical education, the next step is learning to “unspeak” it, a challenging but important charge to promote partnership.

SDM is the process by which providers and patients make decisions together by balancing clinical evidence with patient preferences and values.²² However, despite providers believing they are engaging in SDM,^23,24 families report they are often not as involved in SDM as they would like.^24-26 Indeed, most hospital communications with families, including FCRs and discharge instructions, typically emphasize information sharing, not SDM. SDM tends to be more commonly applied in outpatient settings.²⁷ To encourage SDM in the hospital setting, patients and families should not only understand communication during FCRs and at discharge but should be encouraged to be active participants in developing care plans,²⁶ no matter how minor the decisions involved.²⁸ SDM can be applied to a variety of discussions, both during hospitalization (eg, initiation of antibiotics, transition from intravenous to oral medications, pursuing imaging) and at discharge (eg, assessing discharge readiness, deciding duration of therapy, formulating follow-up recommendations). Providers will benefit from incorporating information from personal and medical histories that only families possess, resulting in more informed and potentially safer care plans that may be more likely to fit into the family’s life at home. SDM can also ensure patient and family “buy-in” and increase the likelihood of compliance with the shared plan.

Discharge processes often involve multiple redundancies and parallel processes that fail to actively involve families or promote transparency.²⁹ Discharge summaries are typically written in medical jargon and intended for the outpatient provider (who may not receive them in a timely fashion), not the family.^30-32 Separate discharge instructions are often provided to families without sufficient attention to health literacy, contingency planning, or individualization (eg, a generic asthma fact sheet).³⁰ Outpatient providers are not always contacted directly about the hospitalization, nor are families always informed when providers are contacted, as Solan et al. describe.

Providers can apply lessons from FCRs to discharge processes, pursuing a similar family-centered, interprofessional approach promoting partnership and transparency. Just as providers engage families during discussions on FCRs, they can engage families in discharge conversations with outpatient providers and nursing colleagues. Indeed, Berry et al. propose a discharge framework that emphasizes involvement of and dialogue between patients, families, and providers as they systematically develop and assess plans for discharge and postdischarge care.³³ To accomplish this, inpatient providers can copy families on discharge summaries and other correspondence with outpatient providers (eg, through secure emails or open-source notes such as OpenNotes^34-36). Moreover, particularly for complex discharges, inpatient providers can call outpatient providers in the family’s presence or invite outpatient providers to join—via telephone or videoconference—day-of-discharge FCRs or discharge huddles. Such efforts require logistical and pragmatic considerations, as well as culture change, but are not insurmountable and may help address many family concerns around peridischarge communication and care. Such efforts may also promote accountability on the part of families and providers alike, thereby ensuring that families are truly engaged as vigilant partners in care.

As one of us (SC) reflected once when considering her experience navigating healthcare as a parent of 2 children with cystic fibrosis, “We have to make it easier for families to be a true part of their children’s care. When patients and families are true members of the medical team, care is more informed, more targeted, and more safe for everyone.”

Disclosure: Dr. Landrigan has consulted with and holds equity in the I-PASS Patient Safety Institute, a company that seeks to train institutions in best handoff practices and aid in their implementation. Dr. Landrigan is supported in part by the Children’s Hospital Association for his work as an Executive Council member of the Pediatric Research in Inpatient Settings (PRIS) network. Dr. Landrigan has also served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation.

Communication failures are a leading cause of sentinel events, the most serious adverse events that occur in hospitals.¹ Interventions to improve patient safety have focused on communication between healthcare providers.^2-4 Interventions focusing on communication between providers and families or other patient caregivers are under-studied.^5,6 Given their availability, proximity, historical knowledge, and motivation for a good outcome,⁷ families can play a vital role as “vigilant partners”⁸ in promoting hospital communication and safety.

In this month’s Journal of Hospital Medicine, Solan et al. conducted focus groups and interviews of 61 caregivers of hospitalized pediatric patients at 30 days after discharge to assess their perceptions of communication during hospitalization and discharge home.⁹ They identified several caregiver themes pertaining to communication between the inpatient medical team and families, communication challenges due to the teaching hospital environment, and communication between providers. Caregiver concerns included feeling out of the loop, excessive provider use of medical jargon, confusing messages on rounds, and inadequate communication between inpatient and outpatient providers.

The manuscript serves both to uncover family concerns that may be underappreciated by clinicians and suggest some potential solutions. For instance, caregivers can be apprehensive about whom to call for postdischarge advice because they are sometimes uncertain whether their outpatient providers have sufficient information about the hospitalization to properly advise them. The authors propose using photo “face sheets” to improve caregiver identification of healthcare provider roles, including families in hospital committees, improving transition communication between inpatient and outpatient healthcare providers through timely faxed discharge summaries and telephone calls, and informing families about such communications with their outpatient providers.

These are important suggestions. However, in order to move from promoting communication alone to promoting true partnership in care, there are additional steps that providers can take to fully engage families in hospital and discharge communications.

Meaningful family engagement in hospital communications—eg, during family-centered rounds (FCRs)—has been associated with improved patient safety and experience.^10-12 To further enhance family partnership in care, we would make the following 3 suggestions for hospitals and healthcare providers: (1) focus on health literacy in all communications with families, (2) work towards shared decision making (SDM), and (3) make discharges family-centered.

In order to partner with one another, families and healthcare providers need to speak a common language. A key way to ensure that families and providers speak a common language is for providers to espouse good health literacy principles. Health literacy is the “capacity to obtain, process, and understand basic health information and services to make appropriate health decisions.”¹³ Health literacy is dynamic, varying based on medical problem, provider, and healthcare system.¹⁴ Overall, only 12% of United States adults possess the health literacy skills required to navigate our complex healthcare system.^15,16 Stress, illness, and other factors can compromise the ability of even these individuals to process and utilize health information. Yet health literacy is routinely overestimated by providers.^17-19

To optimize communication with families, providers should use “universal health literacy precautions”¹⁶ with all patients, not just those believed to need extra assistance, in both verbal (eg, FCRs) and written communications (eg, discharge instructions).¹⁶ Providers should speak in plain, nonmedical language, be specific and concrete, and have families engage in “teach-back” (ie, state in their own words their understanding of the plan). They should focus on what families “need to know” rather than what is “good to know.” They should use simpler sentence structure and “chunk and check”²⁰ (ie, provide small, “bite-sized” pieces of information and check for understanding by using teach-back).²¹ In writing, they should use simpler sentence structure, bullet points, active statements, and be cognizant of reading level, medical jargon, and word choice (eg, “has a fever” instead of “febrile”). It is worth recognizing that even highly educated, highly literate families—not least of all those who are physicians and nurses themselves—can benefit from universal health literacy precautions because the ability to process and grasp information is dynamic and can be markedly lower than usual when faced with the illness of a loved one.

At a systematic level, medical schools, nursing schools, residency training programs, and continuing education should include health literacy training in their curricula. While learning to speak the language of medicine is an important part of medical education, the next step is learning to “unspeak” it, a challenging but important charge to promote partnership.

SDM is the process by which providers and patients make decisions together by balancing clinical evidence with patient preferences and values.²² However, despite providers believing they are engaging in SDM,^23,24 families report they are often not as involved in SDM as they would like.^24-26 Indeed, most hospital communications with families, including FCRs and discharge instructions, typically emphasize information sharing, not SDM. SDM tends to be more commonly applied in outpatient settings.²⁷ To encourage SDM in the hospital setting, patients and families should not only understand communication during FCRs and at discharge but should be encouraged to be active participants in developing care plans,²⁶ no matter how minor the decisions involved.²⁸ SDM can be applied to a variety of discussions, both during hospitalization (eg, initiation of antibiotics, transition from intravenous to oral medications, pursuing imaging) and at discharge (eg, assessing discharge readiness, deciding duration of therapy, formulating follow-up recommendations). Providers will benefit from incorporating information from personal and medical histories that only families possess, resulting in more informed and potentially safer care plans that may be more likely to fit into the family’s life at home. SDM can also ensure patient and family “buy-in” and increase the likelihood of compliance with the shared plan.

Discharge processes often involve multiple redundancies and parallel processes that fail to actively involve families or promote transparency.²⁹ Discharge summaries are typically written in medical jargon and intended for the outpatient provider (who may not receive them in a timely fashion), not the family.^30-32 Separate discharge instructions are often provided to families without sufficient attention to health literacy, contingency planning, or individualization (eg, a generic asthma fact sheet).³⁰ Outpatient providers are not always contacted directly about the hospitalization, nor are families always informed when providers are contacted, as Solan et al. describe.

Providers can apply lessons from FCRs to discharge processes, pursuing a similar family-centered, interprofessional approach promoting partnership and transparency. Just as providers engage families during discussions on FCRs, they can engage families in discharge conversations with outpatient providers and nursing colleagues. Indeed, Berry et al. propose a discharge framework that emphasizes involvement of and dialogue between patients, families, and providers as they systematically develop and assess plans for discharge and postdischarge care.³³ To accomplish this, inpatient providers can copy families on discharge summaries and other correspondence with outpatient providers (eg, through secure emails or open-source notes such as OpenNotes^34-36). Moreover, particularly for complex discharges, inpatient providers can call outpatient providers in the family’s presence or invite outpatient providers to join—via telephone or videoconference—day-of-discharge FCRs or discharge huddles. Such efforts require logistical and pragmatic considerations, as well as culture change, but are not insurmountable and may help address many family concerns around peridischarge communication and care. Such efforts may also promote accountability on the part of families and providers alike, thereby ensuring that families are truly engaged as vigilant partners in care.

As one of us (SC) reflected once when considering her experience navigating healthcare as a parent of 2 children with cystic fibrosis, “We have to make it easier for families to be a true part of their children’s care. When patients and families are true members of the medical team, care is more informed, more targeted, and more safe for everyone.”

Disclosure: Dr. Landrigan has consulted with and holds equity in the I-PASS Patient Safety Institute, a company that seeks to train institutions in best handoff practices and aid in their implementation. Dr. Landrigan is supported in part by the Children’s Hospital Association for his work as an Executive Council member of the Pediatric Research in Inpatient Settings (PRIS) network. Dr. Landrigan has also served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation.

Despite a marked increase in awareness in recent years surrounding the prevalence and prognosis of frailty in our aging population and its association with cardiovascular disease, itself highly prevalent in elderly cohorts, the exact pathobiological links between the 2 conditions have not been fully elucidated. As a consequence, this has led to difficulty not only in accurately defining cardiovascular risk in vulnerable elderly patients, but also in adequately mitigating against it.

See related article

It is well accepted that cardiovascular disease, whether clinical or subclinical, is associated with an increased risk of developing the frail phenotype.^1,2 Frailty, in turn, has been consistently identified as a universal marker of adverse outcomes in patients at risk of, and in patients with already manifest, cardiovascular disease.^2,3 However, whether or not frailty is its own unique risk factor for cardiovascular disease, independent of co-associated risk markers, or is merely a downstream byproduct indicating a more advanced disease state, has yet to be determined. Furthermore, the question of whether modification of frail status may impact the development and progression of cardiovascular disease has not yet been established.

The article by Orkaby et al⁴ in this issue delves deeper into this question by looking specifically at the interaction between frailty and standard risk factors as they relate to the prevention of cardiovascular disease.

NEEDED: A UNIVERSAL DEFINITION OF FRAILTY

It is important to acknowledge up front that before we can truly examine frailty as a novel risk entity in the assessment and management of cardiovascular risk in older-age patients, we need to agree on an accepted, validated definition of the phenotype as it relates to this population. As acknowledged by Orkaby et al,⁴ lack of such a standardized definition has resulted in highly variable estimates of the prevalence of frailty, ranging from 6.9% in a community-dwelling population in the original Cardiovascular Health Study to as high as 50% in older adults with manifest cardiovascular disease.^1,2

The ideal frailty assessment tool should be a simple, quantitative, objective, and universally accepted method, capable of providing a consistent, valid, reproducible definition that can then be used in real time by the clinician to determine the absolute presence or absence of the phenotype, much like hypertension or diabetes. Whether this optimal tool will turn out to be the traditional or modified version of the Fried Scale,¹ an alternative multicomponent measure such as the Deficit Index,⁵ or even the increasingly popular single-item measures such as gait speed or grip strength, remains to be determined.

Exact choice of tool is perhaps less important than the singular adoption of a universal method that can then be rigorously tried and tested in multicenter studies. Given the bulk of data to date for the original Fried phenotype and its development in an older-age community setting with a typical prevalence of cardiovascular risk factors, the Fried Scale appears a particularly suitable tool to use for this domain of disease prevention. Single-item spin-off measures from this phenotype, including gait speed, may also be useful for their increased feasibility and practicality in certain situations.

A TWO-WAY STREET

Given what we know about the pathophysiological, immunological, and inflammatory processes underlying advancing age that have also been implicated in both frailty and cardiovascular disease syndromes, how can we determine if frailty truly is an independent risk factor for cardiovascular disease or merely an epiphenomenon of the aging process?

We do know that older age is not a prerequisite for frailty, as is evident in studies of the phenotype in middle-aged (and younger) patients with advanced heart failure.⁶ We also know not only that frail populations have a higher age-adjusted prevalence of cardiovascular risk factors including diabetes and hypertension,¹ but also that community-dwellers with prefrailty (as defined in studies using the Fried criteria as 1 or 2 vs 3 present criteria) at baseline have a significantly increased risk of developing incident cardiovascular disease compared with those defined as nonfrail, even after adjustment for traditional risk factors and other biomarkers.³ Exploring the differences between these subgroups at baseline revealed that prefrailty was significantly associated with several subclinical insults that may serve as adverse vascular mediators, including insulin resistance, elevated inflammatory markers, and central adiposity.³

A substudy of the Cardiovascular Health Study also found that in over 1,200 participants without a prior history of a cardiovascular event, the presence of frailty was associated with multiple noninvasive measures of subclinical cardiovascular disease, including electrocardiographic and echocardiographic markers of left ventricular hypertrophy, carotid stenosis, and silent cerebrovascular infarcts on magnetic resonance imaging.⁷

These findings support a mechanistic link between evolving stages of frailty and a gradient of progressive cardiovascular risk, with a multifaceted dysregulation of metabolic processes known to underpin the pathogenesis of the frailty phenotype likely also triggering risk pathways (altered insulin metabolism, inflammation) involved in incident cardiovascular disease. Although the exact pathobiological pathways underlying these complex interlinked relationships between aging, frailty, and cardiovascular disease have yet to be fully elucidated, awareness of the bidirectional relationship between both morbid conditions highlights the absolute importance of modifying risk factors and subclinical conditions that are common to both.

Orkaby et al⁴ nicely lay out the guidelines for standard cardiovascular risk factor modification viewed in light of what is currently known—or not known—about how these recommendations should be interpreted for the older, frail, at-risk population. It is important to note at the outset that clinical trial data both inclusive of this population and incorporating the up-front assessment of frailty to predefine frail-or-not subgroups are sparse, and thereby evidence for how to optimize cardiovascular disease prevention in this important cohort is largely based on smaller observational studies and expert consensus.

Hypertension

However, important subanalyses derived from 2 large randomized controlled trials (Hypertension in the Very Elderly Trial [HYVET] and Systolic Blood Pressure Intervention Trial [SPRINT]) looking specifically at the impact of frail status on blood pressure treatment targets and related outcomes in elderly adults have recently been published.^8,9 Notably, both studies showed the beneficial outcomes of more intensive treatment (to 150/80 mm Hg or 120 mm Hg systolic, respectively) persisted in those characterized as frail (via Rockwood frailty index or slow gait speed).^8,9 Importantly, in the SPRINT analysis, higher event rates were seen with increasing frailty in both treatment groups; across each frailty stratum, absolute event rates were lower for the intensive treatment arm.⁹ These results were evident without a significant difference in the overall rate of serious adverse events⁹ or withdrawal rates⁸ between treatment groups.

Hypertension is the primary domain in which up-to-date clinical trial data have shown benefit for continued aggressive treatment for cardiovascular disease prevention regardless of the presence of frailty. Despite these data, in the real world, the “eyeball” frailty test often leads us to err on the side of caution regarding blood pressure management in the frail older adult. Certainly, the use of antihypertensive therapy in this population requires balanced consideration of the risk for adverse effects; the SPRINT analysis also found higher absolute rates of hypotension, falls, and acute kidney injury in the more intensively treated group.⁹ These adverse effects may be ameliorated not necessarily by modifying the target goal that is required, but by employing alternative strategies in achieving this goal, such as starting with lower doses, uptitrating more slowly, and monitoring with more frequent laboratory testing.

Currently, consensus guidelines in Canada have recommended liberalizing blood pressure treatment goals in those with “advanced frailty” associated with a shorter life expectancy.¹⁰

Dyslipidemia

Regarding the other major vascular risk factors, trials looking at the role of frailty in the targeted treatment of hyperlipidemia with statins in older patients for primary prevention of cardiovascular disease are lacking, although the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial showed a significant positive benefit for statin therapy in adults over age 70 (number needed to treat of 19 to prevent 1 major cardiovascular event, and 29 to prevent 1 cardiovascular death).¹¹ This again may be counterbalanced by the purported increased risk of cognitive and potential adverse functional effects of statins in this age group; however, trial data specific to frail status or not is required to truly assess the benefit-risk ratio in this population.

Hyperglycemia

Meanwhile, recent clinical trials looking at the impact of age, functional impairment, and burden of comorbidities (rather than specific frailty measures) on glucose-lowering targets and cardiovascular outcomes have failed to show a benefit from intensive glycemic control strategies, leading guideline societies to endorse less-stringent hemoglobin A_1c goals in this population.¹² Given the well-documented association between hyperglycemia and cardiovascular disease, as well as the purported dysregulated glucose metabolism underlying the frail phenotype, it is important that future trials looking at optimal hemoglobin A_1c targets incorporate the presence or absence of frailty to better inform specific recommendations for this population.

ONE SIZE MAY NOT FIT ALL

Overall, if both prefrailty and frailty are independent risk factors for, and a consequence of, clinical cardiovascular disease, it is worth bearing in mind that the modification of “intensive” or best practice therapies based on qualitatively assessed frailty may actually contribute to the problem. With best intentions, the negative impact of frailty on cardiovascular outcomes may be augmented by automatically assuming it to reflect a need for “therapy-light.” The adverse downstream consequences of inadequately treated cardiovascular risk factors are not in doubt, and it is important as the role of frailty becomes an increasingly recognized cofactor in the management of older adults with these risk factors that the vicious cycle underlying both syndromes is kept in mind, in order to avoid frailty becoming a harbinger of undertreatment in older, geriatric populations.

What is clear is that more prospective clinical trial data in this population are urgently needed in order to better delineate the exact interactions between frail status and these risk factors and the potential downstream consequences, using prespecified and robust frailty assessment methods.

Perhaps frailty should be seen as a series of stages rather than simply as a binary “there or not there” biomarker; through initial and established stages of the syndrome, which have been independently associated with both clinical events and subclinical surrogates of cardiovascular disease, risk factors should continue to be treated aggressively and according to best available evidence. However, as guideline societies are already beginning to endorse as highlighted above, once the phenotype becomes tethered with a certain threshold burden of comorbidity, cognitive or functional impairment, or more end-stage disease status, then goals for cardiovascular disease prevention may need to be readdressed and modified. If frailty is truly confirmed as a cardiovascular disease equivalent, not only appropriately treating associated cardiovascular risk factors but also seeking therapies that actively target the frailty syndrome itself should be an important goal of future studies seeking to impact the development of both clinical and subclinical cardiovascular disease in this population.

Despite a marked increase in awareness in recent years surrounding the prevalence and prognosis of frailty in our aging population and its association with cardiovascular disease, itself highly prevalent in elderly cohorts, the exact pathobiological links between the 2 conditions have not been fully elucidated. As a consequence, this has led to difficulty not only in accurately defining cardiovascular risk in vulnerable elderly patients, but also in adequately mitigating against it.

See related article

It is well accepted that cardiovascular disease, whether clinical or subclinical, is associated with an increased risk of developing the frail phenotype.^1,2 Frailty, in turn, has been consistently identified as a universal marker of adverse outcomes in patients at risk of, and in patients with already manifest, cardiovascular disease.^2,3 However, whether or not frailty is its own unique risk factor for cardiovascular disease, independent of co-associated risk markers, or is merely a downstream byproduct indicating a more advanced disease state, has yet to be determined. Furthermore, the question of whether modification of frail status may impact the development and progression of cardiovascular disease has not yet been established.

The article by Orkaby et al⁴ in this issue delves deeper into this question by looking specifically at the interaction between frailty and standard risk factors as they relate to the prevention of cardiovascular disease.

NEEDED: A UNIVERSAL DEFINITION OF FRAILTY

It is important to acknowledge up front that before we can truly examine frailty as a novel risk entity in the assessment and management of cardiovascular risk in older-age patients, we need to agree on an accepted, validated definition of the phenotype as it relates to this population. As acknowledged by Orkaby et al,⁴ lack of such a standardized definition has resulted in highly variable estimates of the prevalence of frailty, ranging from 6.9% in a community-dwelling population in the original Cardiovascular Health Study to as high as 50% in older adults with manifest cardiovascular disease.^1,2

The ideal frailty assessment tool should be a simple, quantitative, objective, and universally accepted method, capable of providing a consistent, valid, reproducible definition that can then be used in real time by the clinician to determine the absolute presence or absence of the phenotype, much like hypertension or diabetes. Whether this optimal tool will turn out to be the traditional or modified version of the Fried Scale,¹ an alternative multicomponent measure such as the Deficit Index,⁵ or even the increasingly popular single-item measures such as gait speed or grip strength, remains to be determined.

Exact choice of tool is perhaps less important than the singular adoption of a universal method that can then be rigorously tried and tested in multicenter studies. Given the bulk of data to date for the original Fried phenotype and its development in an older-age community setting with a typical prevalence of cardiovascular risk factors, the Fried Scale appears a particularly suitable tool to use for this domain of disease prevention. Single-item spin-off measures from this phenotype, including gait speed, may also be useful for their increased feasibility and practicality in certain situations.

A TWO-WAY STREET

Given what we know about the pathophysiological, immunological, and inflammatory processes underlying advancing age that have also been implicated in both frailty and cardiovascular disease syndromes, how can we determine if frailty truly is an independent risk factor for cardiovascular disease or merely an epiphenomenon of the aging process?

We do know that older age is not a prerequisite for frailty, as is evident in studies of the phenotype in middle-aged (and younger) patients with advanced heart failure.⁶ We also know not only that frail populations have a higher age-adjusted prevalence of cardiovascular risk factors including diabetes and hypertension,¹ but also that community-dwellers with prefrailty (as defined in studies using the Fried criteria as 1 or 2 vs 3 present criteria) at baseline have a significantly increased risk of developing incident cardiovascular disease compared with those defined as nonfrail, even after adjustment for traditional risk factors and other biomarkers.³ Exploring the differences between these subgroups at baseline revealed that prefrailty was significantly associated with several subclinical insults that may serve as adverse vascular mediators, including insulin resistance, elevated inflammatory markers, and central adiposity.³

A substudy of the Cardiovascular Health Study also found that in over 1,200 participants without a prior history of a cardiovascular event, the presence of frailty was associated with multiple noninvasive measures of subclinical cardiovascular disease, including electrocardiographic and echocardiographic markers of left ventricular hypertrophy, carotid stenosis, and silent cerebrovascular infarcts on magnetic resonance imaging.⁷

These findings support a mechanistic link between evolving stages of frailty and a gradient of progressive cardiovascular risk, with a multifaceted dysregulation of metabolic processes known to underpin the pathogenesis of the frailty phenotype likely also triggering risk pathways (altered insulin metabolism, inflammation) involved in incident cardiovascular disease. Although the exact pathobiological pathways underlying these complex interlinked relationships between aging, frailty, and cardiovascular disease have yet to be fully elucidated, awareness of the bidirectional relationship between both morbid conditions highlights the absolute importance of modifying risk factors and subclinical conditions that are common to both.

Orkaby et al⁴ nicely lay out the guidelines for standard cardiovascular risk factor modification viewed in light of what is currently known—or not known—about how these recommendations should be interpreted for the older, frail, at-risk population. It is important to note at the outset that clinical trial data both inclusive of this population and incorporating the up-front assessment of frailty to predefine frail-or-not subgroups are sparse, and thereby evidence for how to optimize cardiovascular disease prevention in this important cohort is largely based on smaller observational studies and expert consensus.

Hypertension

However, important subanalyses derived from 2 large randomized controlled trials (Hypertension in the Very Elderly Trial [HYVET] and Systolic Blood Pressure Intervention Trial [SPRINT]) looking specifically at the impact of frail status on blood pressure treatment targets and related outcomes in elderly adults have recently been published.^8,9 Notably, both studies showed the beneficial outcomes of more intensive treatment (to 150/80 mm Hg or 120 mm Hg systolic, respectively) persisted in those characterized as frail (via Rockwood frailty index or slow gait speed).^8,9 Importantly, in the SPRINT analysis, higher event rates were seen with increasing frailty in both treatment groups; across each frailty stratum, absolute event rates were lower for the intensive treatment arm.⁹ These results were evident without a significant difference in the overall rate of serious adverse events⁹ or withdrawal rates⁸ between treatment groups.

Hypertension is the primary domain in which up-to-date clinical trial data have shown benefit for continued aggressive treatment for cardiovascular disease prevention regardless of the presence of frailty. Despite these data, in the real world, the “eyeball” frailty test often leads us to err on the side of caution regarding blood pressure management in the frail older adult. Certainly, the use of antihypertensive therapy in this population requires balanced consideration of the risk for adverse effects; the SPRINT analysis also found higher absolute rates of hypotension, falls, and acute kidney injury in the more intensively treated group.⁹ These adverse effects may be ameliorated not necessarily by modifying the target goal that is required, but by employing alternative strategies in achieving this goal, such as starting with lower doses, uptitrating more slowly, and monitoring with more frequent laboratory testing.

Currently, consensus guidelines in Canada have recommended liberalizing blood pressure treatment goals in those with “advanced frailty” associated with a shorter life expectancy.¹⁰

Dyslipidemia

Regarding the other major vascular risk factors, trials looking at the role of frailty in the targeted treatment of hyperlipidemia with statins in older patients for primary prevention of cardiovascular disease are lacking, although the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial showed a significant positive benefit for statin therapy in adults over age 70 (number needed to treat of 19 to prevent 1 major cardiovascular event, and 29 to prevent 1 cardiovascular death).¹¹ This again may be counterbalanced by the purported increased risk of cognitive and potential adverse functional effects of statins in this age group; however, trial data specific to frail status or not is required to truly assess the benefit-risk ratio in this population.

Hyperglycemia

Meanwhile, recent clinical trials looking at the impact of age, functional impairment, and burden of comorbidities (rather than specific frailty measures) on glucose-lowering targets and cardiovascular outcomes have failed to show a benefit from intensive glycemic control strategies, leading guideline societies to endorse less-stringent hemoglobin A_1c goals in this population.¹² Given the well-documented association between hyperglycemia and cardiovascular disease, as well as the purported dysregulated glucose metabolism underlying the frail phenotype, it is important that future trials looking at optimal hemoglobin A_1c targets incorporate the presence or absence of frailty to better inform specific recommendations for this population.

ONE SIZE MAY NOT FIT ALL

Overall, if both prefrailty and frailty are independent risk factors for, and a consequence of, clinical cardiovascular disease, it is worth bearing in mind that the modification of “intensive” or best practice therapies based on qualitatively assessed frailty may actually contribute to the problem. With best intentions, the negative impact of frailty on cardiovascular outcomes may be augmented by automatically assuming it to reflect a need for “therapy-light.” The adverse downstream consequences of inadequately treated cardiovascular risk factors are not in doubt, and it is important as the role of frailty becomes an increasingly recognized cofactor in the management of older adults with these risk factors that the vicious cycle underlying both syndromes is kept in mind, in order to avoid frailty becoming a harbinger of undertreatment in older, geriatric populations.

What is clear is that more prospective clinical trial data in this population are urgently needed in order to better delineate the exact interactions between frail status and these risk factors and the potential downstream consequences, using prespecified and robust frailty assessment methods.

Perhaps frailty should be seen as a series of stages rather than simply as a binary “there or not there” biomarker; through initial and established stages of the syndrome, which have been independently associated with both clinical events and subclinical surrogates of cardiovascular disease, risk factors should continue to be treated aggressively and according to best available evidence. However, as guideline societies are already beginning to endorse as highlighted above, once the phenotype becomes tethered with a certain threshold burden of comorbidity, cognitive or functional impairment, or more end-stage disease status, then goals for cardiovascular disease prevention may need to be readdressed and modified. If frailty is truly confirmed as a cardiovascular disease equivalent, not only appropriately treating associated cardiovascular risk factors but also seeking therapies that actively target the frailty syndrome itself should be an important goal of future studies seeking to impact the development of both clinical and subclinical cardiovascular disease in this population.

Despite a marked increase in awareness in recent years surrounding the prevalence and prognosis of frailty in our aging population and its association with cardiovascular disease, itself highly prevalent in elderly cohorts, the exact pathobiological links between the 2 conditions have not been fully elucidated. As a consequence, this has led to difficulty not only in accurately defining cardiovascular risk in vulnerable elderly patients, but also in adequately mitigating against it.

See related article

It is well accepted that cardiovascular disease, whether clinical or subclinical, is associated with an increased risk of developing the frail phenotype.^1,2 Frailty, in turn, has been consistently identified as a universal marker of adverse outcomes in patients at risk of, and in patients with already manifest, cardiovascular disease.^2,3 However, whether or not frailty is its own unique risk factor for cardiovascular disease, independent of co-associated risk markers, or is merely a downstream byproduct indicating a more advanced disease state, has yet to be determined. Furthermore, the question of whether modification of frail status may impact the development and progression of cardiovascular disease has not yet been established.

The article by Orkaby et al⁴ in this issue delves deeper into this question by looking specifically at the interaction between frailty and standard risk factors as they relate to the prevention of cardiovascular disease.

NEEDED: A UNIVERSAL DEFINITION OF FRAILTY

It is important to acknowledge up front that before we can truly examine frailty as a novel risk entity in the assessment and management of cardiovascular risk in older-age patients, we need to agree on an accepted, validated definition of the phenotype as it relates to this population. As acknowledged by Orkaby et al,⁴ lack of such a standardized definition has resulted in highly variable estimates of the prevalence of frailty, ranging from 6.9% in a community-dwelling population in the original Cardiovascular Health Study to as high as 50% in older adults with manifest cardiovascular disease.^1,2

The ideal frailty assessment tool should be a simple, quantitative, objective, and universally accepted method, capable of providing a consistent, valid, reproducible definition that can then be used in real time by the clinician to determine the absolute presence or absence of the phenotype, much like hypertension or diabetes. Whether this optimal tool will turn out to be the traditional or modified version of the Fried Scale,¹ an alternative multicomponent measure such as the Deficit Index,⁵ or even the increasingly popular single-item measures such as gait speed or grip strength, remains to be determined.

Exact choice of tool is perhaps less important than the singular adoption of a universal method that can then be rigorously tried and tested in multicenter studies. Given the bulk of data to date for the original Fried phenotype and its development in an older-age community setting with a typical prevalence of cardiovascular risk factors, the Fried Scale appears a particularly suitable tool to use for this domain of disease prevention. Single-item spin-off measures from this phenotype, including gait speed, may also be useful for their increased feasibility and practicality in certain situations.

A TWO-WAY STREET

Given what we know about the pathophysiological, immunological, and inflammatory processes underlying advancing age that have also been implicated in both frailty and cardiovascular disease syndromes, how can we determine if frailty truly is an independent risk factor for cardiovascular disease or merely an epiphenomenon of the aging process?

We do know that older age is not a prerequisite for frailty, as is evident in studies of the phenotype in middle-aged (and younger) patients with advanced heart failure.⁶ We also know not only that frail populations have a higher age-adjusted prevalence of cardiovascular risk factors including diabetes and hypertension,¹ but also that community-dwellers with prefrailty (as defined in studies using the Fried criteria as 1 or 2 vs 3 present criteria) at baseline have a significantly increased risk of developing incident cardiovascular disease compared with those defined as nonfrail, even after adjustment for traditional risk factors and other biomarkers.³ Exploring the differences between these subgroups at baseline revealed that prefrailty was significantly associated with several subclinical insults that may serve as adverse vascular mediators, including insulin resistance, elevated inflammatory markers, and central adiposity.³

A substudy of the Cardiovascular Health Study also found that in over 1,200 participants without a prior history of a cardiovascular event, the presence of frailty was associated with multiple noninvasive measures of subclinical cardiovascular disease, including electrocardiographic and echocardiographic markers of left ventricular hypertrophy, carotid stenosis, and silent cerebrovascular infarcts on magnetic resonance imaging.⁷

These findings support a mechanistic link between evolving stages of frailty and a gradient of progressive cardiovascular risk, with a multifaceted dysregulation of metabolic processes known to underpin the pathogenesis of the frailty phenotype likely also triggering risk pathways (altered insulin metabolism, inflammation) involved in incident cardiovascular disease. Although the exact pathobiological pathways underlying these complex interlinked relationships between aging, frailty, and cardiovascular disease have yet to be fully elucidated, awareness of the bidirectional relationship between both morbid conditions highlights the absolute importance of modifying risk factors and subclinical conditions that are common to both.

Orkaby et al⁴ nicely lay out the guidelines for standard cardiovascular risk factor modification viewed in light of what is currently known—or not known—about how these recommendations should be interpreted for the older, frail, at-risk population. It is important to note at the outset that clinical trial data both inclusive of this population and incorporating the up-front assessment of frailty to predefine frail-or-not subgroups are sparse, and thereby evidence for how to optimize cardiovascular disease prevention in this important cohort is largely based on smaller observational studies and expert consensus.

Hypertension

However, important subanalyses derived from 2 large randomized controlled trials (Hypertension in the Very Elderly Trial [HYVET] and Systolic Blood Pressure Intervention Trial [SPRINT]) looking specifically at the impact of frail status on blood pressure treatment targets and related outcomes in elderly adults have recently been published.^8,9 Notably, both studies showed the beneficial outcomes of more intensive treatment (to 150/80 mm Hg or 120 mm Hg systolic, respectively) persisted in those characterized as frail (via Rockwood frailty index or slow gait speed).^8,9 Importantly, in the SPRINT analysis, higher event rates were seen with increasing frailty in both treatment groups; across each frailty stratum, absolute event rates were lower for the intensive treatment arm.⁹ These results were evident without a significant difference in the overall rate of serious adverse events⁹ or withdrawal rates⁸ between treatment groups.

Hypertension is the primary domain in which up-to-date clinical trial data have shown benefit for continued aggressive treatment for cardiovascular disease prevention regardless of the presence of frailty. Despite these data, in the real world, the “eyeball” frailty test often leads us to err on the side of caution regarding blood pressure management in the frail older adult. Certainly, the use of antihypertensive therapy in this population requires balanced consideration of the risk for adverse effects; the SPRINT analysis also found higher absolute rates of hypotension, falls, and acute kidney injury in the more intensively treated group.⁹ These adverse effects may be ameliorated not necessarily by modifying the target goal that is required, but by employing alternative strategies in achieving this goal, such as starting with lower doses, uptitrating more slowly, and monitoring with more frequent laboratory testing.

Currently, consensus guidelines in Canada have recommended liberalizing blood pressure treatment goals in those with “advanced frailty” associated with a shorter life expectancy.¹⁰

Dyslipidemia

Regarding the other major vascular risk factors, trials looking at the role of frailty in the targeted treatment of hyperlipidemia with statins in older patients for primary prevention of cardiovascular disease are lacking, although the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial showed a significant positive benefit for statin therapy in adults over age 70 (number needed to treat of 19 to prevent 1 major cardiovascular event, and 29 to prevent 1 cardiovascular death).¹¹ This again may be counterbalanced by the purported increased risk of cognitive and potential adverse functional effects of statins in this age group; however, trial data specific to frail status or not is required to truly assess the benefit-risk ratio in this population.

Hyperglycemia

Meanwhile, recent clinical trials looking at the impact of age, functional impairment, and burden of comorbidities (rather than specific frailty measures) on glucose-lowering targets and cardiovascular outcomes have failed to show a benefit from intensive glycemic control strategies, leading guideline societies to endorse less-stringent hemoglobin A_1c goals in this population.¹² Given the well-documented association between hyperglycemia and cardiovascular disease, as well as the purported dysregulated glucose metabolism underlying the frail phenotype, it is important that future trials looking at optimal hemoglobin A_1c targets incorporate the presence or absence of frailty to better inform specific recommendations for this population.

ONE SIZE MAY NOT FIT ALL

Overall, if both prefrailty and frailty are independent risk factors for, and a consequence of, clinical cardiovascular disease, it is worth bearing in mind that the modification of “intensive” or best practice therapies based on qualitatively assessed frailty may actually contribute to the problem. With best intentions, the negative impact of frailty on cardiovascular outcomes may be augmented by automatically assuming it to reflect a need for “therapy-light.” The adverse downstream consequences of inadequately treated cardiovascular risk factors are not in doubt, and it is important as the role of frailty becomes an increasingly recognized cofactor in the management of older adults with these risk factors that the vicious cycle underlying both syndromes is kept in mind, in order to avoid frailty becoming a harbinger of undertreatment in older, geriatric populations.

What is clear is that more prospective clinical trial data in this population are urgently needed in order to better delineate the exact interactions between frail status and these risk factors and the potential downstream consequences, using prespecified and robust frailty assessment methods.

Perhaps frailty should be seen as a series of stages rather than simply as a binary “there or not there” biomarker; through initial and established stages of the syndrome, which have been independently associated with both clinical events and subclinical surrogates of cardiovascular disease, risk factors should continue to be treated aggressively and according to best available evidence. However, as guideline societies are already beginning to endorse as highlighted above, once the phenotype becomes tethered with a certain threshold burden of comorbidity, cognitive or functional impairment, or more end-stage disease status, then goals for cardiovascular disease prevention may need to be readdressed and modified. If frailty is truly confirmed as a cardiovascular disease equivalent, not only appropriately treating associated cardiovascular risk factors but also seeking therapies that actively target the frailty syndrome itself should be an important goal of future studies seeking to impact the development of both clinical and subclinical cardiovascular disease in this population.

The urine is the window to the kidney.This oft-repeated adage impresses upon medical students and residents the importance of urine microscopy in the evaluation of patients with renal disorders.

See related article

While this phrase is likely an adaptation of the idea in ancient times that the urine reflected on humors or the quality of the soul, the understanding of the relevance of urine findings to the state of the kidneys likely rests with the pioneers of urine microscopy. As reviewed by Fogazzi and Cameron,^1,2 the origins of direct inspection of urine under a microscope lie in the 17th century, with industrious physicians who used rudimentary microscopes to identify basic structures in the urine and correlated them to clinical presentations.¹ At first, only larger structures could be seen, mostly crystals in patients with nephrolithiasis. As microscopes advanced, smaller structures such as “corpuscles” and “cylinders” could be seen that described cells and casts.¹

In correlating these findings to patient presentations, a rudimentary understanding of renal pathology evolved long before the advent of the kidney biopsy. Lipid droplets were seen¹ in patients swollen from dropsy, and later known to have nephrotic syndromes. In 1872, Harley first described the altered morphology of dysmorphic red blood cells in patients with Bright disease or glomerulonephritis.^1,3 In 1979, Birch and Fairley recognized that the presence of acanthocytes differentiated glomerular from nonglomerular hematuria.⁴

DYSMORPHIC RED BLOOD CELLS: TYPES AND SIGNIFICANCE

The tools used in urine microscopy have advanced significantly since its advent. But not all advances have led to improved patient care. Laboratories have trained technicians to perform urine microscopy. Analyzers can identify basic urinary structures using algorithms to compare them against stored reference images. More important, urine microscopy has been categorized by accreditation and inspection bodies as a “test” rather than a physician-performed competency. As such, definitions of quality in urine microscopy have shifted from the application of urinary findings to the care of the patient to the reproducibility of identifying individual structures in ways that can be documented with quality checks performed by nonclinicians. And since the governing bodies require laboratories to adhere to burdensome procedures to maintain accreditation (eg, the US Food and Drug Administration’s Clinical Laboratory Improvement Amendments), many hospitals have closed nephrologist-based urine laboratories.

This would be acceptable if laboratory-generated reports provided information equivalent to that obtained by the nephrologist. But such reports rarely include anything beyond the most rudimentary findings. In these reports, the red blood cell is not differentiated as dysmorphic or monomorphic. All casts are granular. Crystals are often the highlight of the report, usually an incidental finding of little relevance. Phase contrast and polarization are never performed.

Despite the poor quality of data provided in these reports, because of increasing regulations and time restrictions, a dwindling number of nephrologists perform urine microscopy even at teaching institutions. In an informal 2009 survey of nephrology fellowship program directors, 79% of responding programs relied solely on lab-generated reports for microscopic findings (verbal communication, Perazella, 2017).

There is general concern among medical educators about the surrendering of the physical examination and other techniques to technology.^7,8 However, in many cases, such changes may improve the ability to make a correct diagnosis. When performed properly, urine microscopy can help determine the need for kidney biopsy, differentiate causes of acute kidney injury, and help guide decisions about therapy. Perazella showed that urine microscopy could reliably differentiate acute tubular necrosis from prerenal azotemia.⁹ Further, the severity of findings on urine microscopy has been associated with worse renal outcomes.¹⁰ At our institution, nephrologist-performed urine microscopy resulted in a change in cause of acute kidney injury in 25% of cases and a concrete change in management in 12% of patients (unpublished data).

With this in mind, it is concerning that the only evidence in the literature on this topic demonstrated that laboratory-based urine microscopy is actually a hindrance to its underlying purpose in acute kidney injury, which is to help identify the cause of the injury. Tsai et al¹¹ showed that nephrologists identified the cause of acute kidney injury correctly 90% of the time when they performed their own urine microscopy, but this dropped to 23% when they relied on a laboratory-generated report. Interestingly, knowing the patient’s clinical history when performing the microscopy was important, as the accuracy was 69% when a report of another nephrologist’s microscopy findings was used.¹¹

APPLYING RESULTS TO THE PATIENT

The purpose of urine microscopy in clinical care is to identify and understand the findings as they apply to the patient. When viewed from this perspective, the renal patient is clearly best served when the nephrologist familiar with the case performs urine microscopy, rather than a technician or analyzer in remote parts of the hospital with no connection to the patient.

Advances in technology or streamlining of hospital services do not always produce improvements in patient care, and how we define quality is integral to identifying when this is the case. Quality checklists can serve as guides to safe patient care but should not replace clinical decision-making. Direct physician involvement with our patients has concrete benefits, whether taking a history, performing a physical examination, reviewing radiologic images, or looking at specimens such as urine. It allows us to experience the amazing pathophysiology of human illness and to understand the nuances unique to each of our patients.

But most important, it reinforces the need for the direct bond, both emotional and physical, between us as healers and our patients.

The urine is the window to the kidney.This oft-repeated adage impresses upon medical students and residents the importance of urine microscopy in the evaluation of patients with renal disorders.

See related article

While this phrase is likely an adaptation of the idea in ancient times that the urine reflected on humors or the quality of the soul, the understanding of the relevance of urine findings to the state of the kidneys likely rests with the pioneers of urine microscopy. As reviewed by Fogazzi and Cameron,^1,2 the origins of direct inspection of urine under a microscope lie in the 17th century, with industrious physicians who used rudimentary microscopes to identify basic structures in the urine and correlated them to clinical presentations.¹ At first, only larger structures could be seen, mostly crystals in patients with nephrolithiasis. As microscopes advanced, smaller structures such as “corpuscles” and “cylinders” could be seen that described cells and casts.¹

In correlating these findings to patient presentations, a rudimentary understanding of renal pathology evolved long before the advent of the kidney biopsy. Lipid droplets were seen¹ in patients swollen from dropsy, and later known to have nephrotic syndromes. In 1872, Harley first described the altered morphology of dysmorphic red blood cells in patients with Bright disease or glomerulonephritis.^1,3 In 1979, Birch and Fairley recognized that the presence of acanthocytes differentiated glomerular from nonglomerular hematuria.⁴

DYSMORPHIC RED BLOOD CELLS: TYPES AND SIGNIFICANCE

The tools used in urine microscopy have advanced significantly since its advent. But not all advances have led to improved patient care. Laboratories have trained technicians to perform urine microscopy. Analyzers can identify basic urinary structures using algorithms to compare them against stored reference images. More important, urine microscopy has been categorized by accreditation and inspection bodies as a “test” rather than a physician-performed competency. As such, definitions of quality in urine microscopy have shifted from the application of urinary findings to the care of the patient to the reproducibility of identifying individual structures in ways that can be documented with quality checks performed by nonclinicians. And since the governing bodies require laboratories to adhere to burdensome procedures to maintain accreditation (eg, the US Food and Drug Administration’s Clinical Laboratory Improvement Amendments), many hospitals have closed nephrologist-based urine laboratories.

This would be acceptable if laboratory-generated reports provided information equivalent to that obtained by the nephrologist. But such reports rarely include anything beyond the most rudimentary findings. In these reports, the red blood cell is not differentiated as dysmorphic or monomorphic. All casts are granular. Crystals are often the highlight of the report, usually an incidental finding of little relevance. Phase contrast and polarization are never performed.

Despite the poor quality of data provided in these reports, because of increasing regulations and time restrictions, a dwindling number of nephrologists perform urine microscopy even at teaching institutions. In an informal 2009 survey of nephrology fellowship program directors, 79% of responding programs relied solely on lab-generated reports for microscopic findings (verbal communication, Perazella, 2017).

There is general concern among medical educators about the surrendering of the physical examination and other techniques to technology.^7,8 However, in many cases, such changes may improve the ability to make a correct diagnosis. When performed properly, urine microscopy can help determine the need for kidney biopsy, differentiate causes of acute kidney injury, and help guide decisions about therapy. Perazella showed that urine microscopy could reliably differentiate acute tubular necrosis from prerenal azotemia.⁹ Further, the severity of findings on urine microscopy has been associated with worse renal outcomes.¹⁰ At our institution, nephrologist-performed urine microscopy resulted in a change in cause of acute kidney injury in 25% of cases and a concrete change in management in 12% of patients (unpublished data).

With this in mind, it is concerning that the only evidence in the literature on this topic demonstrated that laboratory-based urine microscopy is actually a hindrance to its underlying purpose in acute kidney injury, which is to help identify the cause of the injury. Tsai et al¹¹ showed that nephrologists identified the cause of acute kidney injury correctly 90% of the time when they performed their own urine microscopy, but this dropped to 23% when they relied on a laboratory-generated report. Interestingly, knowing the patient’s clinical history when performing the microscopy was important, as the accuracy was 69% when a report of another nephrologist’s microscopy findings was used.¹¹

APPLYING RESULTS TO THE PATIENT

The purpose of urine microscopy in clinical care is to identify and understand the findings as they apply to the patient. When viewed from this perspective, the renal patient is clearly best served when the nephrologist familiar with the case performs urine microscopy, rather than a technician or analyzer in remote parts of the hospital with no connection to the patient.

Advances in technology or streamlining of hospital services do not always produce improvements in patient care, and how we define quality is integral to identifying when this is the case. Quality checklists can serve as guides to safe patient care but should not replace clinical decision-making. Direct physician involvement with our patients has concrete benefits, whether taking a history, performing a physical examination, reviewing radiologic images, or looking at specimens such as urine. It allows us to experience the amazing pathophysiology of human illness and to understand the nuances unique to each of our patients.

But most important, it reinforces the need for the direct bond, both emotional and physical, between us as healers and our patients.

The urine is the window to the kidney.This oft-repeated adage impresses upon medical students and residents the importance of urine microscopy in the evaluation of patients with renal disorders.

See related article

While this phrase is likely an adaptation of the idea in ancient times that the urine reflected on humors or the quality of the soul, the understanding of the relevance of urine findings to the state of the kidneys likely rests with the pioneers of urine microscopy. As reviewed by Fogazzi and Cameron,^1,2 the origins of direct inspection of urine under a microscope lie in the 17th century, with industrious physicians who used rudimentary microscopes to identify basic structures in the urine and correlated them to clinical presentations.¹ At first, only larger structures could be seen, mostly crystals in patients with nephrolithiasis. As microscopes advanced, smaller structures such as “corpuscles” and “cylinders” could be seen that described cells and casts.¹

In correlating these findings to patient presentations, a rudimentary understanding of renal pathology evolved long before the advent of the kidney biopsy. Lipid droplets were seen¹ in patients swollen from dropsy, and later known to have nephrotic syndromes. In 1872, Harley first described the altered morphology of dysmorphic red blood cells in patients with Bright disease or glomerulonephritis.^1,3 In 1979, Birch and Fairley recognized that the presence of acanthocytes differentiated glomerular from nonglomerular hematuria.⁴

DYSMORPHIC RED BLOOD CELLS: TYPES AND SIGNIFICANCE

The tools used in urine microscopy have advanced significantly since its advent. But not all advances have led to improved patient care. Laboratories have trained technicians to perform urine microscopy. Analyzers can identify basic urinary structures using algorithms to compare them against stored reference images. More important, urine microscopy has been categorized by accreditation and inspection bodies as a “test” rather than a physician-performed competency. As such, definitions of quality in urine microscopy have shifted from the application of urinary findings to the care of the patient to the reproducibility of identifying individual structures in ways that can be documented with quality checks performed by nonclinicians. And since the governing bodies require laboratories to adhere to burdensome procedures to maintain accreditation (eg, the US Food and Drug Administration’s Clinical Laboratory Improvement Amendments), many hospitals have closed nephrologist-based urine laboratories.

This would be acceptable if laboratory-generated reports provided information equivalent to that obtained by the nephrologist. But such reports rarely include anything beyond the most rudimentary findings. In these reports, the red blood cell is not differentiated as dysmorphic or monomorphic. All casts are granular. Crystals are often the highlight of the report, usually an incidental finding of little relevance. Phase contrast and polarization are never performed.

Despite the poor quality of data provided in these reports, because of increasing regulations and time restrictions, a dwindling number of nephrologists perform urine microscopy even at teaching institutions. In an informal 2009 survey of nephrology fellowship program directors, 79% of responding programs relied solely on lab-generated reports for microscopic findings (verbal communication, Perazella, 2017).

There is general concern among medical educators about the surrendering of the physical examination and other techniques to technology.^7,8 However, in many cases, such changes may improve the ability to make a correct diagnosis. When performed properly, urine microscopy can help determine the need for kidney biopsy, differentiate causes of acute kidney injury, and help guide decisions about therapy. Perazella showed that urine microscopy could reliably differentiate acute tubular necrosis from prerenal azotemia.⁹ Further, the severity of findings on urine microscopy has been associated with worse renal outcomes.¹⁰ At our institution, nephrologist-performed urine microscopy resulted in a change in cause of acute kidney injury in 25% of cases and a concrete change in management in 12% of patients (unpublished data).

With this in mind, it is concerning that the only evidence in the literature on this topic demonstrated that laboratory-based urine microscopy is actually a hindrance to its underlying purpose in acute kidney injury, which is to help identify the cause of the injury. Tsai et al¹¹ showed that nephrologists identified the cause of acute kidney injury correctly 90% of the time when they performed their own urine microscopy, but this dropped to 23% when they relied on a laboratory-generated report. Interestingly, knowing the patient’s clinical history when performing the microscopy was important, as the accuracy was 69% when a report of another nephrologist’s microscopy findings was used.¹¹

APPLYING RESULTS TO THE PATIENT

The purpose of urine microscopy in clinical care is to identify and understand the findings as they apply to the patient. When viewed from this perspective, the renal patient is clearly best served when the nephrologist familiar with the case performs urine microscopy, rather than a technician or analyzer in remote parts of the hospital with no connection to the patient.

Advances in technology or streamlining of hospital services do not always produce improvements in patient care, and how we define quality is integral to identifying when this is the case. Quality checklists can serve as guides to safe patient care but should not replace clinical decision-making. Direct physician involvement with our patients has concrete benefits, whether taking a history, performing a physical examination, reviewing radiologic images, or looking at specimens such as urine. It allows us to experience the amazing pathophysiology of human illness and to understand the nuances unique to each of our patients.

But most important, it reinforces the need for the direct bond, both emotional and physical, between us as healers and our patients.

The transition of care from pediatric to adult providers has drawn increased national attention to the survival of patients with chronic childhood conditions into adulthood.ttps://www.ncbi.nlm.nih.gov/books/NBK11432/ While survival outcomes have improved due to advances in care, many of these patients experience gaps in medical care when they move from pediatric to adult healthcare systems, resulting in age-inappropriate and fragmented care in adulthood.⁴ Many youth with chronic childhood conditions are not prepared to move into adult healthcare, and this lack of transition preparation is associated with poorer health outcomes, including elevated glycosylated hemoglobin and loss of transplanted organs.^5-7 National transition efforts have largely focused on the outpatient setting and there remains a paucity of literature on inpatient transitions of care.^8,9 Although transition-age patients represent a small percentage of patients at children’s hospitals, they accumulate more hospital days and have higher resource utilization compared to their pediatric cohorts.¹⁰ In this issue, Coller et al.¹¹ characterize the current state of pediatric to adult inpatient transitions of care among general pediatric services at US children’s hospitals. Over 50% of children’s hospitals did not have a specific adult-oriented hospital identified to receive transitioning patients. Fewer than half of hospitals (38%) had an explicit inpatient transition policy. Notably only 2% of hospitals could track patient outcomes through transitions; however, 41% had systems in place to address insurance issues. Institutions with combined internal medicine-pediatric (Med-Peds) providers more frequently had inpatient transition initiatives (P = .04). It is clear from Coller et al.¹¹ that the adoption of transition initiatives has been delayed since its introduction at the US Surgeon’s conference in 1989, and much work is needed to bridge this gap.¹²

Coller et al.¹¹ spearhead establishing standardized transition programs using the multidisciplinary Six Core Elements framework and highlight effective techniques from existing inpatient transition processes.¹³ While we encourage providers to utilize existing partnerships in the outpatient community to bridge the gap for this at-risk population, shifting to adult care continues to be disorganized in the face of some key barriers including challenges in addressing psychosocial needs, gaps in insurance, and poor care coordination between pediatric and adult healthcare systems.⁴

We propose several inpatient activities to improve transitions. First, we suggest the development of an inpatient transition or Med-Peds consult service across all hospitals. The Med-Peds consult service would implement the Six Core Elements, including transition readiness, transition planning, and providing insurance and referral resources. A Med-Peds consult service has been well received at our institution as it identifies clear leaders with expertise in transition. Coller et al.11 report only 11% of children’s hospitals surveyed had transition policies that referenced inpatient transitions of care. For those institutions without Med-Peds providers, we recommend establishing a hospital-wide transition policy, and identifying hospitalists trained in transitions, with multidisciplinary approaches to staff their transition consult service.

Tracking and monitoring youth in the inpatient transition process occurred in only 2% of hospitals surveyed. We urge for automatic consults to the transition service for adult aged patients admitted to children’s hospitals. With current electronic health records (EHRs), admission order sets with built-in transition consults for adolescents and young adults would improve the identification and tracking of youths. Assuming care of a pediatric patient with multiple comorbidities can be overwhelming for providers.¹⁴ The transition consult service could alleviate some of this anxiety with clear and concise documentation using standardized, readily available transition templates. These templates would summarize the patient’s past medical history and outline current medical problems, necessary subspecialty referrals, insurance status, limitations in activities of daily living, ancillary services (including physical therapy, occupational therapy, speech therapy, transportation services), and current level of readiness and independence.

In summary, the transition of care from pediatric to adult providers is a particularly vulnerable time for young adults with chronic medical conditions, and efforts focused on inpatient transitions of medical care have overall been limited. Crucial barriers include addressing psychosocial needs, gaps in insurance, and poor communication between pediatric and adult providers.⁴ Coller et al.¹¹ have identified several gaps in inpatient transitions of care as well as multiple areas of focus to improve the patient experience. Based on the findings of this study, we urge children’s hospitals caring for adult patients to identify transition leaders, partner with an adult hospital to foster effective transitions, and to protocolize inpatient and outpatient models of transition. Perhaps the most concerning finding of this study was the widespread inability to track transition outcomes. Our group’s experience has led us to believe that coupling an inpatient transition consult team with EHR-based interventions to identify patients and follow outcomes has the most potential to improve inpatient transitions of care from pediatric to adult providers.

Disclosure

The authors have no conflicts of interests or financial disclosures.

The transition of care from pediatric to adult providers has drawn increased national attention to the survival of patients with chronic childhood conditions into adulthood.ttps://www.ncbi.nlm.nih.gov/books/NBK11432/ While survival outcomes have improved due to advances in care, many of these patients experience gaps in medical care when they move from pediatric to adult healthcare systems, resulting in age-inappropriate and fragmented care in adulthood.⁴ Many youth with chronic childhood conditions are not prepared to move into adult healthcare, and this lack of transition preparation is associated with poorer health outcomes, including elevated glycosylated hemoglobin and loss of transplanted organs.^5-7 National transition efforts have largely focused on the outpatient setting and there remains a paucity of literature on inpatient transitions of care.^8,9 Although transition-age patients represent a small percentage of patients at children’s hospitals, they accumulate more hospital days and have higher resource utilization compared to their pediatric cohorts.¹⁰ In this issue, Coller et al.¹¹ characterize the current state of pediatric to adult inpatient transitions of care among general pediatric services at US children’s hospitals. Over 50% of children’s hospitals did not have a specific adult-oriented hospital identified to receive transitioning patients. Fewer than half of hospitals (38%) had an explicit inpatient transition policy. Notably only 2% of hospitals could track patient outcomes through transitions; however, 41% had systems in place to address insurance issues. Institutions with combined internal medicine-pediatric (Med-Peds) providers more frequently had inpatient transition initiatives (P = .04). It is clear from Coller et al.¹¹ that the adoption of transition initiatives has been delayed since its introduction at the US Surgeon’s conference in 1989, and much work is needed to bridge this gap.¹²

Coller et al.¹¹ spearhead establishing standardized transition programs using the multidisciplinary Six Core Elements framework and highlight effective techniques from existing inpatient transition processes.¹³ While we encourage providers to utilize existing partnerships in the outpatient community to bridge the gap for this at-risk population, shifting to adult care continues to be disorganized in the face of some key barriers including challenges in addressing psychosocial needs, gaps in insurance, and poor care coordination between pediatric and adult healthcare systems.⁴

We propose several inpatient activities to improve transitions. First, we suggest the development of an inpatient transition or Med-Peds consult service across all hospitals. The Med-Peds consult service would implement the Six Core Elements, including transition readiness, transition planning, and providing insurance and referral resources. A Med-Peds consult service has been well received at our institution as it identifies clear leaders with expertise in transition. Coller et al.11 report only 11% of children’s hospitals surveyed had transition policies that referenced inpatient transitions of care. For those institutions without Med-Peds providers, we recommend establishing a hospital-wide transition policy, and identifying hospitalists trained in transitions, with multidisciplinary approaches to staff their transition consult service.

Tracking and monitoring youth in the inpatient transition process occurred in only 2% of hospitals surveyed. We urge for automatic consults to the transition service for adult aged patients admitted to children’s hospitals. With current electronic health records (EHRs), admission order sets with built-in transition consults for adolescents and young adults would improve the identification and tracking of youths. Assuming care of a pediatric patient with multiple comorbidities can be overwhelming for providers.¹⁴ The transition consult service could alleviate some of this anxiety with clear and concise documentation using standardized, readily available transition templates. These templates would summarize the patient’s past medical history and outline current medical problems, necessary subspecialty referrals, insurance status, limitations in activities of daily living, ancillary services (including physical therapy, occupational therapy, speech therapy, transportation services), and current level of readiness and independence.

In summary, the transition of care from pediatric to adult providers is a particularly vulnerable time for young adults with chronic medical conditions, and efforts focused on inpatient transitions of medical care have overall been limited. Crucial barriers include addressing psychosocial needs, gaps in insurance, and poor communication between pediatric and adult providers.⁴ Coller et al.¹¹ have identified several gaps in inpatient transitions of care as well as multiple areas of focus to improve the patient experience. Based on the findings of this study, we urge children’s hospitals caring for adult patients to identify transition leaders, partner with an adult hospital to foster effective transitions, and to protocolize inpatient and outpatient models of transition. Perhaps the most concerning finding of this study was the widespread inability to track transition outcomes. Our group’s experience has led us to believe that coupling an inpatient transition consult team with EHR-based interventions to identify patients and follow outcomes has the most potential to improve inpatient transitions of care from pediatric to adult providers.

Disclosure

The authors have no conflicts of interests or financial disclosures.

The transition of care from pediatric to adult providers has drawn increased national attention to the survival of patients with chronic childhood conditions into adulthood.ttps://www.ncbi.nlm.nih.gov/books/NBK11432/ While survival outcomes have improved due to advances in care, many of these patients experience gaps in medical care when they move from pediatric to adult healthcare systems, resulting in age-inappropriate and fragmented care in adulthood.⁴ Many youth with chronic childhood conditions are not prepared to move into adult healthcare, and this lack of transition preparation is associated with poorer health outcomes, including elevated glycosylated hemoglobin and loss of transplanted organs.^5-7 National transition efforts have largely focused on the outpatient setting and there remains a paucity of literature on inpatient transitions of care.^8,9 Although transition-age patients represent a small percentage of patients at children’s hospitals, they accumulate more hospital days and have higher resource utilization compared to their pediatric cohorts.¹⁰ In this issue, Coller et al.¹¹ characterize the current state of pediatric to adult inpatient transitions of care among general pediatric services at US children’s hospitals. Over 50% of children’s hospitals did not have a specific adult-oriented hospital identified to receive transitioning patients. Fewer than half of hospitals (38%) had an explicit inpatient transition policy. Notably only 2% of hospitals could track patient outcomes through transitions; however, 41% had systems in place to address insurance issues. Institutions with combined internal medicine-pediatric (Med-Peds) providers more frequently had inpatient transition initiatives (P = .04). It is clear from Coller et al.¹¹ that the adoption of transition initiatives has been delayed since its introduction at the US Surgeon’s conference in 1989, and much work is needed to bridge this gap.¹²

Coller et al.¹¹ spearhead establishing standardized transition programs using the multidisciplinary Six Core Elements framework and highlight effective techniques from existing inpatient transition processes.¹³ While we encourage providers to utilize existing partnerships in the outpatient community to bridge the gap for this at-risk population, shifting to adult care continues to be disorganized in the face of some key barriers including challenges in addressing psychosocial needs, gaps in insurance, and poor care coordination between pediatric and adult healthcare systems.⁴

We propose several inpatient activities to improve transitions. First, we suggest the development of an inpatient transition or Med-Peds consult service across all hospitals. The Med-Peds consult service would implement the Six Core Elements, including transition readiness, transition planning, and providing insurance and referral resources. A Med-Peds consult service has been well received at our institution as it identifies clear leaders with expertise in transition. Coller et al.11 report only 11% of children’s hospitals surveyed had transition policies that referenced inpatient transitions of care. For those institutions without Med-Peds providers, we recommend establishing a hospital-wide transition policy, and identifying hospitalists trained in transitions, with multidisciplinary approaches to staff their transition consult service.

Tracking and monitoring youth in the inpatient transition process occurred in only 2% of hospitals surveyed. We urge for automatic consults to the transition service for adult aged patients admitted to children’s hospitals. With current electronic health records (EHRs), admission order sets with built-in transition consults for adolescents and young adults would improve the identification and tracking of youths. Assuming care of a pediatric patient with multiple comorbidities can be overwhelming for providers.¹⁴ The transition consult service could alleviate some of this anxiety with clear and concise documentation using standardized, readily available transition templates. These templates would summarize the patient’s past medical history and outline current medical problems, necessary subspecialty referrals, insurance status, limitations in activities of daily living, ancillary services (including physical therapy, occupational therapy, speech therapy, transportation services), and current level of readiness and independence.

In summary, the transition of care from pediatric to adult providers is a particularly vulnerable time for young adults with chronic medical conditions, and efforts focused on inpatient transitions of medical care have overall been limited. Crucial barriers include addressing psychosocial needs, gaps in insurance, and poor communication between pediatric and adult providers.⁴ Coller et al.¹¹ have identified several gaps in inpatient transitions of care as well as multiple areas of focus to improve the patient experience. Based on the findings of this study, we urge children’s hospitals caring for adult patients to identify transition leaders, partner with an adult hospital to foster effective transitions, and to protocolize inpatient and outpatient models of transition. Perhaps the most concerning finding of this study was the widespread inability to track transition outcomes. Our group’s experience has led us to believe that coupling an inpatient transition consult team with EHR-based interventions to identify patients and follow outcomes has the most potential to improve inpatient transitions of care from pediatric to adult providers.

Disclosure

The authors have no conflicts of interests or financial disclosures.

There is abundant evidence that the use of computed tomography pulmonary angiography (CTPA) is increasing in emergency departments and more patients are being diagnosed with pulmonary embolism (PE).^1,2 The increasing availability and resolution of CTPA technology since the late 1990s has led some to suggest that PE is now being overdiagnosed, which is supported by decreasing PE case–fatality rates and the detection of small, subsegmental clots that do not result in any meaningful right-ventricular dysfunction.^3,4 Indeed, recent guidelines allow that not all small PEs require anticoagulation therapy.⁵ Beyond overdiagnosis, there are potential patient-level harms associated with the liberal use of CTPA imaging, including the consequences of radiation and intravenous contrast exposure.^4,6 At the societal level, excess CTPA use contributes to the growing costs of healthcare.^2,7

Despite the above concerns, CTPA remains the diagnostic test of choice for PE. There are multiple approaches that are suggested to appropriately use CTPA in the workup of suspected PE, the most common of which is endorsed by best practice publications and combines a clinical score (eg, Well’s score) with D-dimer testing, reserving CTPA for those patients with high clinical risk and/or positive D-dimer.^8,9 Despite the professional recommendation, studies have shown that the use of PE diagnostic algorithms in clinical practice is suboptimal, resulting in much practice variation and contributing to the overuse of CTPA.^10,11 In this issue, as a means of clarifying what measures improve adherence with recommended best practices, Deblois and colleagues¹² perform a systematic review of the published interventions that have attempted to reduce CTPA imaging in the diagnosis of PE.

Deblois and colleagues are to be commended for summarizing what is unfortunately a very heterogeneous literature, the limitations of which precluded a formal meta-analysis. The authors report that most of the 17 reviewed studies incorporated either electronic clinical decision support (CDS; usually imbedded into a computerized physician order entry) tools or educational interventions in a retrospective, before-and-after design; only 3 studies were experimental and included a control group. Most of the studies included efficacy, with a few evaluating safety. There was little available evidence regarding cost-effectiveness or barriers to implementation. The most studied approach, CDS, was associated with a decrease in the use of CTPA of between 8.3% and 25.4% along with an increase in PE diagnostic yield of between 3.3% and 4.4%. Likewise, the appropriate use of CTPA (consistent with best practice recommendations) increased with CDS intervention from 18% to 19%. The addition of individual performance feedback seemed to enhance the impact of CDS, although this finding was limited to one investigation. Conversely, educational interventions to improve physician adherence to best practice approaches were less effective than CDS, with only 1 study describing a significant decrease in CTPA use or increase in diagnostic yield. Although safety data were limited, in aggregate, the reported studies did not suggest any increase in mortality with interventions to reduce CTPA use.

As discussed by the authors, CDS was the most studied and most effective intervention to improve appropriate CTPA use, albeit modest in its impact. The lack of contextual details about what factors made CDS effective or not effective makes it difficult to make general recommendations. One cited study did include physician reasons for not embracing CDS, which are not surprising in nature and reflect concerns about impaired efficiency and preference for native clinical judgement over that of electronic tools.

Moving forward, CDS, perhaps coupled with performance feedback, seems to offer the best hope of reducing inappropriate CTPA use. The growing use of electronic medical records, which is accelerated in the United States by the meaningful use provisions of the Health Information Technology for Economic and Clinical Health Act of 2009, implies that CDS tools are going to be implemented across the spectrum of diagnoses, including that of PE.¹³ The goals of CDS interventions, namely improved patient safety, quality, and cost-effectiveness, are more likely to be achieved if those studying and designing these electronic tools understand the day-to-day practice of clinical medicine. As summarized by Bates and colleagues¹⁴ in the “Ten Commandments for Effective Clinical Decision Support,” CDS interventions will be successful in changing physician behavior and promoting the right test or treatment only if they seamlessly fit into the clinical workflow, have no impact on (or improve upon) physician efficiency, and minimize the need for additional information from the user. As suggested by Deblois et al.,¹² future studies of CDS interventions that aim to align CTPA use with recommended best practices should incorporate more rigorous methodological quality, include safety and cost-effectiveness outcomes, and, perhaps most importantly, attempt to understand the environmental and organizational factors that contribute to CDS tool effectiveness.

Disclosure

The authors have declared no conflicts of interest.

There is abundant evidence that the use of computed tomography pulmonary angiography (CTPA) is increasing in emergency departments and more patients are being diagnosed with pulmonary embolism (PE).^1,2 The increasing availability and resolution of CTPA technology since the late 1990s has led some to suggest that PE is now being overdiagnosed, which is supported by decreasing PE case–fatality rates and the detection of small, subsegmental clots that do not result in any meaningful right-ventricular dysfunction.^3,4 Indeed, recent guidelines allow that not all small PEs require anticoagulation therapy.⁵ Beyond overdiagnosis, there are potential patient-level harms associated with the liberal use of CTPA imaging, including the consequences of radiation and intravenous contrast exposure.^4,6 At the societal level, excess CTPA use contributes to the growing costs of healthcare.^2,7

Despite the above concerns, CTPA remains the diagnostic test of choice for PE. There are multiple approaches that are suggested to appropriately use CTPA in the workup of suspected PE, the most common of which is endorsed by best practice publications and combines a clinical score (eg, Well’s score) with D-dimer testing, reserving CTPA for those patients with high clinical risk and/or positive D-dimer.^8,9 Despite the professional recommendation, studies have shown that the use of PE diagnostic algorithms in clinical practice is suboptimal, resulting in much practice variation and contributing to the overuse of CTPA.^10,11 In this issue, as a means of clarifying what measures improve adherence with recommended best practices, Deblois and colleagues¹² perform a systematic review of the published interventions that have attempted to reduce CTPA imaging in the diagnosis of PE.

Deblois and colleagues are to be commended for summarizing what is unfortunately a very heterogeneous literature, the limitations of which precluded a formal meta-analysis. The authors report that most of the 17 reviewed studies incorporated either electronic clinical decision support (CDS; usually imbedded into a computerized physician order entry) tools or educational interventions in a retrospective, before-and-after design; only 3 studies were experimental and included a control group. Most of the studies included efficacy, with a few evaluating safety. There was little available evidence regarding cost-effectiveness or barriers to implementation. The most studied approach, CDS, was associated with a decrease in the use of CTPA of between 8.3% and 25.4% along with an increase in PE diagnostic yield of between 3.3% and 4.4%. Likewise, the appropriate use of CTPA (consistent with best practice recommendations) increased with CDS intervention from 18% to 19%. The addition of individual performance feedback seemed to enhance the impact of CDS, although this finding was limited to one investigation. Conversely, educational interventions to improve physician adherence to best practice approaches were less effective than CDS, with only 1 study describing a significant decrease in CTPA use or increase in diagnostic yield. Although safety data were limited, in aggregate, the reported studies did not suggest any increase in mortality with interventions to reduce CTPA use.

As discussed by the authors, CDS was the most studied and most effective intervention to improve appropriate CTPA use, albeit modest in its impact. The lack of contextual details about what factors made CDS effective or not effective makes it difficult to make general recommendations. One cited study did include physician reasons for not embracing CDS, which are not surprising in nature and reflect concerns about impaired efficiency and preference for native clinical judgement over that of electronic tools.

Moving forward, CDS, perhaps coupled with performance feedback, seems to offer the best hope of reducing inappropriate CTPA use. The growing use of electronic medical records, which is accelerated in the United States by the meaningful use provisions of the Health Information Technology for Economic and Clinical Health Act of 2009, implies that CDS tools are going to be implemented across the spectrum of diagnoses, including that of PE.¹³ The goals of CDS interventions, namely improved patient safety, quality, and cost-effectiveness, are more likely to be achieved if those studying and designing these electronic tools understand the day-to-day practice of clinical medicine. As summarized by Bates and colleagues¹⁴ in the “Ten Commandments for Effective Clinical Decision Support,” CDS interventions will be successful in changing physician behavior and promoting the right test or treatment only if they seamlessly fit into the clinical workflow, have no impact on (or improve upon) physician efficiency, and minimize the need for additional information from the user. As suggested by Deblois et al.,¹² future studies of CDS interventions that aim to align CTPA use with recommended best practices should incorporate more rigorous methodological quality, include safety and cost-effectiveness outcomes, and, perhaps most importantly, attempt to understand the environmental and organizational factors that contribute to CDS tool effectiveness.

Disclosure

The authors have declared no conflicts of interest.

There is abundant evidence that the use of computed tomography pulmonary angiography (CTPA) is increasing in emergency departments and more patients are being diagnosed with pulmonary embolism (PE).^1,2 The increasing availability and resolution of CTPA technology since the late 1990s has led some to suggest that PE is now being overdiagnosed, which is supported by decreasing PE case–fatality rates and the detection of small, subsegmental clots that do not result in any meaningful right-ventricular dysfunction.^3,4 Indeed, recent guidelines allow that not all small PEs require anticoagulation therapy.⁵ Beyond overdiagnosis, there are potential patient-level harms associated with the liberal use of CTPA imaging, including the consequences of radiation and intravenous contrast exposure.^4,6 At the societal level, excess CTPA use contributes to the growing costs of healthcare.^2,7

Despite the above concerns, CTPA remains the diagnostic test of choice for PE. There are multiple approaches that are suggested to appropriately use CTPA in the workup of suspected PE, the most common of which is endorsed by best practice publications and combines a clinical score (eg, Well’s score) with D-dimer testing, reserving CTPA for those patients with high clinical risk and/or positive D-dimer.^8,9 Despite the professional recommendation, studies have shown that the use of PE diagnostic algorithms in clinical practice is suboptimal, resulting in much practice variation and contributing to the overuse of CTPA.^10,11 In this issue, as a means of clarifying what measures improve adherence with recommended best practices, Deblois and colleagues¹² perform a systematic review of the published interventions that have attempted to reduce CTPA imaging in the diagnosis of PE.

Deblois and colleagues are to be commended for summarizing what is unfortunately a very heterogeneous literature, the limitations of which precluded a formal meta-analysis. The authors report that most of the 17 reviewed studies incorporated either electronic clinical decision support (CDS; usually imbedded into a computerized physician order entry) tools or educational interventions in a retrospective, before-and-after design; only 3 studies were experimental and included a control group. Most of the studies included efficacy, with a few evaluating safety. There was little available evidence regarding cost-effectiveness or barriers to implementation. The most studied approach, CDS, was associated with a decrease in the use of CTPA of between 8.3% and 25.4% along with an increase in PE diagnostic yield of between 3.3% and 4.4%. Likewise, the appropriate use of CTPA (consistent with best practice recommendations) increased with CDS intervention from 18% to 19%. The addition of individual performance feedback seemed to enhance the impact of CDS, although this finding was limited to one investigation. Conversely, educational interventions to improve physician adherence to best practice approaches were less effective than CDS, with only 1 study describing a significant decrease in CTPA use or increase in diagnostic yield. Although safety data were limited, in aggregate, the reported studies did not suggest any increase in mortality with interventions to reduce CTPA use.

As discussed by the authors, CDS was the most studied and most effective intervention to improve appropriate CTPA use, albeit modest in its impact. The lack of contextual details about what factors made CDS effective or not effective makes it difficult to make general recommendations. One cited study did include physician reasons for not embracing CDS, which are not surprising in nature and reflect concerns about impaired efficiency and preference for native clinical judgement over that of electronic tools.

Moving forward, CDS, perhaps coupled with performance feedback, seems to offer the best hope of reducing inappropriate CTPA use. The growing use of electronic medical records, which is accelerated in the United States by the meaningful use provisions of the Health Information Technology for Economic and Clinical Health Act of 2009, implies that CDS tools are going to be implemented across the spectrum of diagnoses, including that of PE.¹³ The goals of CDS interventions, namely improved patient safety, quality, and cost-effectiveness, are more likely to be achieved if those studying and designing these electronic tools understand the day-to-day practice of clinical medicine. As summarized by Bates and colleagues¹⁴ in the “Ten Commandments for Effective Clinical Decision Support,” CDS interventions will be successful in changing physician behavior and promoting the right test or treatment only if they seamlessly fit into the clinical workflow, have no impact on (or improve upon) physician efficiency, and minimize the need for additional information from the user. As suggested by Deblois et al.,¹² future studies of CDS interventions that aim to align CTPA use with recommended best practices should incorporate more rigorous methodological quality, include safety and cost-effectiveness outcomes, and, perhaps most importantly, attempt to understand the environmental and organizational factors that contribute to CDS tool effectiveness.

Disclosure

The authors have declared no conflicts of interest.

A new year often comes with resolutions to jettison old tendencies, increase emphasis on what has been successful, and develop new habits. For 2018, the Journal of Hospital Medicine’s year begins with resolutions that span these same areas.

The journal has been incredibly successful over the last 5 years, with a near doubling in the volume of manuscripts we have been receiving; the rise in submissions has been paralleled by the increased quality of submissions. JHM has moved on from our old approach of seeking out authors and research to having great research and authors seek us. In 2018, we expect that the challenges of our startup days will continue to recede into the past.

Many of JHM’s old habits have been incredibly successful, and we recommit ourselves to these areas. JHM is committed to providing the best possible service to its authors in the form of the rapid processing of papers under our charge and, most importantly, the highest quality peer and editorial review. Our internal mantra of “making papers better whether we accept them or not” remains a cornerstone of our efforts. The journal has been innovative in developing new and influential series, such as the Things We Do For No Reason and the Choosing Wisely^®: Next Steps series. JHM’s focus on digital dissemination and social media grew further in 2017, with the #JHMChat Twitter journal clubs engaging hundreds of participants and generating literally millions of impressions.

For 2018, JHM will continue to develop and innovate in areas that reflect the field of Hospital Medicine as well as trends in peer-reviewed publishing. I am particularly excited to see the launch of a new series entitled “In the Hospital,” a series of papers that will highlight the role of connectedness, humanism, and resilience in creating the social fabric of the hospital workplace. We have renewed our relationship with the American Board of Internal Medicine Foundation to support both the Things We Do For No Reason series as well as Choosing Wisely^®: Next Steps, series that will help flesh out aspects of healthcare that remain central to our practice as policies and payment models change.

As our practices become nearly wholly contained within digital workspaces, JHM will begin to highlight digital health papers in newsletters while also developing increased expertise internally. The transition to digital platforms for clinical care will be reflected in the revisiting of JHM’s digital dissemination strategy, in which we will be working to more rapidly publish papers online, often online only and with more frequent accompaniment by blogs, tweets, and the ability for readers to comment.

Our editorial sensibilities will not change; JHM’s goal is to reflect Hospital Medicine’s traditional focus areas on health-systems improvement as a discipline. But beginning in 2018 and for the future, we will also push the field and Hospital Medicine practice by publishing papers that change how we care for patients and suggest fundamental changes in how we manage diseases.

Finally, all of these efforts will be contained within a brilliant new layout and design schema, the first new design for JHM since its first issue more than 12 years ago.

JHM’s past successes and future initiatives are the result of old habits we hope to renew: a deep commitment from JHM’s editors, to whom I am deeply thankful, and from our authors, peer reviewers, and readers who help us put forward a journal that continues to grow in excellence and influence. We look forward to renewing these commitments during 2018 and welcome your help.

A new year often comes with resolutions to jettison old tendencies, increase emphasis on what has been successful, and develop new habits. For 2018, the Journal of Hospital Medicine’s year begins with resolutions that span these same areas.

The journal has been incredibly successful over the last 5 years, with a near doubling in the volume of manuscripts we have been receiving; the rise in submissions has been paralleled by the increased quality of submissions. JHM has moved on from our old approach of seeking out authors and research to having great research and authors seek us. In 2018, we expect that the challenges of our startup days will continue to recede into the past.

Many of JHM’s old habits have been incredibly successful, and we recommit ourselves to these areas. JHM is committed to providing the best possible service to its authors in the form of the rapid processing of papers under our charge and, most importantly, the highest quality peer and editorial review. Our internal mantra of “making papers better whether we accept them or not” remains a cornerstone of our efforts. The journal has been innovative in developing new and influential series, such as the Things We Do For No Reason and the Choosing Wisely^®: Next Steps series. JHM’s focus on digital dissemination and social media grew further in 2017, with the #JHMChat Twitter journal clubs engaging hundreds of participants and generating literally millions of impressions.

For 2018, JHM will continue to develop and innovate in areas that reflect the field of Hospital Medicine as well as trends in peer-reviewed publishing. I am particularly excited to see the launch of a new series entitled “In the Hospital,” a series of papers that will highlight the role of connectedness, humanism, and resilience in creating the social fabric of the hospital workplace. We have renewed our relationship with the American Board of Internal Medicine Foundation to support both the Things We Do For No Reason series as well as Choosing Wisely^®: Next Steps, series that will help flesh out aspects of healthcare that remain central to our practice as policies and payment models change.

As our practices become nearly wholly contained within digital workspaces, JHM will begin to highlight digital health papers in newsletters while also developing increased expertise internally. The transition to digital platforms for clinical care will be reflected in the revisiting of JHM’s digital dissemination strategy, in which we will be working to more rapidly publish papers online, often online only and with more frequent accompaniment by blogs, tweets, and the ability for readers to comment.

Our editorial sensibilities will not change; JHM’s goal is to reflect Hospital Medicine’s traditional focus areas on health-systems improvement as a discipline. But beginning in 2018 and for the future, we will also push the field and Hospital Medicine practice by publishing papers that change how we care for patients and suggest fundamental changes in how we manage diseases.

Finally, all of these efforts will be contained within a brilliant new layout and design schema, the first new design for JHM since its first issue more than 12 years ago.

JHM’s past successes and future initiatives are the result of old habits we hope to renew: a deep commitment from JHM’s editors, to whom I am deeply thankful, and from our authors, peer reviewers, and readers who help us put forward a journal that continues to grow in excellence and influence. We look forward to renewing these commitments during 2018 and welcome your help.

A new year often comes with resolutions to jettison old tendencies, increase emphasis on what has been successful, and develop new habits. For 2018, the Journal of Hospital Medicine’s year begins with resolutions that span these same areas.

The journal has been incredibly successful over the last 5 years, with a near doubling in the volume of manuscripts we have been receiving; the rise in submissions has been paralleled by the increased quality of submissions. JHM has moved on from our old approach of seeking out authors and research to having great research and authors seek us. In 2018, we expect that the challenges of our startup days will continue to recede into the past.

Many of JHM’s old habits have been incredibly successful, and we recommit ourselves to these areas. JHM is committed to providing the best possible service to its authors in the form of the rapid processing of papers under our charge and, most importantly, the highest quality peer and editorial review. Our internal mantra of “making papers better whether we accept them or not” remains a cornerstone of our efforts. The journal has been innovative in developing new and influential series, such as the Things We Do For No Reason and the Choosing Wisely^®: Next Steps series. JHM’s focus on digital dissemination and social media grew further in 2017, with the #JHMChat Twitter journal clubs engaging hundreds of participants and generating literally millions of impressions.

For 2018, JHM will continue to develop and innovate in areas that reflect the field of Hospital Medicine as well as trends in peer-reviewed publishing. I am particularly excited to see the launch of a new series entitled “In the Hospital,” a series of papers that will highlight the role of connectedness, humanism, and resilience in creating the social fabric of the hospital workplace. We have renewed our relationship with the American Board of Internal Medicine Foundation to support both the Things We Do For No Reason series as well as Choosing Wisely^®: Next Steps, series that will help flesh out aspects of healthcare that remain central to our practice as policies and payment models change.

As our practices become nearly wholly contained within digital workspaces, JHM will begin to highlight digital health papers in newsletters while also developing increased expertise internally. The transition to digital platforms for clinical care will be reflected in the revisiting of JHM’s digital dissemination strategy, in which we will be working to more rapidly publish papers online, often online only and with more frequent accompaniment by blogs, tweets, and the ability for readers to comment.

Our editorial sensibilities will not change; JHM’s goal is to reflect Hospital Medicine’s traditional focus areas on health-systems improvement as a discipline. But beginning in 2018 and for the future, we will also push the field and Hospital Medicine practice by publishing papers that change how we care for patients and suggest fundamental changes in how we manage diseases.

Finally, all of these efforts will be contained within a brilliant new layout and design schema, the first new design for JHM since its first issue more than 12 years ago.

JHM’s past successes and future initiatives are the result of old habits we hope to renew: a deep commitment from JHM’s editors, to whom I am deeply thankful, and from our authors, peer reviewers, and readers who help us put forward a journal that continues to grow in excellence and influence. We look forward to renewing these commitments during 2018 and welcome your help.

In the United States, up to 6 million patients are admitted to intensive care units (ICUs) annually at a cost estimated to exceed $80 billion or about 13% of total hospital costs.^1,2 It also appears that as our population ages and illness severity increases, demand for ICU care is increasing.³ Given its importance, the organization and delivery of critical care has been extensively studied. High-intensity physician staffing by an intensivist (all patients managed or comanaged by an intensivist), while inconsistently shown to be associated with improved outcomes, has been endorsed as a high-quality care model by professional societies and the Leapfrog group. Despite its adoption by many hospitals, widespread implementation has been hampered by a national shortage of intensivists that continues to worsen over time. Hospitals, by necessity, look to alternative models to care for critically ill patients, and one such model is the use of hospitalists.

The Society of Hospital Medicine estimates that there are nearly 50,000 hospitalists practicing in the United States, and several studies show they routinely provide care in the nation’s ICUs.⁴ While in some ICUs hospitalists work alongside intensivists, in many, they work without intensivist support, and regardless of the model, they often serve as the primary attending physician. There is good reason to think this model of care would be effective. Most hospitalists are internists, graduating from training programs that tend to emphasize care of acutely ill hospitalized patients. Hospitalists are often present in the hospital 24/7, are comfortable working in multidisciplinary teams, and routinely engage in quality improvement, which are all characteristics common in highly functioning ICUs. Yet, a study in this issue of the Journal of Hospital Medicine raises some concern.

Sweigart and colleagues⁵ surveyed 425 hospitalists to understand the structure and perception of their ICU practices. Consistent with prior studies, 77% provided ICU care with 66% serving as the primary attending. A novel finding is the high level of angst and lack of support hospitalists perceived in caring for these critically ill patients. Among rural hospitalists, 43% reported they were expected to practice beyond their perceived scope of practice, and almost a third reported they never had sufficient intensivist support. Even more concerning is that among hospitalists serving as the primary attending, over two-thirds reported difficulty transferring patients to a higher level of care (Sweigart et al.⁵). While we have concerns over how representative this sample is of hospitalist practice (the survey response rate was only about 10%), it does appear that many hospitalists feel very uncomfortable with the ICU care they are providing and perceive barriers to moving their patients to a potentially safer care setting.

While one might argue more intensivists would solve this problem, calls for more intensivists are shortsighted, as there are compelling reasons to believe that such efforts will do little to address the mismatch between patient need and provider supply. Graduate medical education slots for intensivists cannot be easily and affordably increased, and even if more intensivists could be trained, there are few incentives to encourage them to work where they are needed most. Prioritization of intensivist training also diverts resources from training demands in equally important undersupplied specialties such as primary care.⁶ Finally, simply increasing intensivist supply fails to attend to important issues surrounding the multidisciplinary nature of care in an ICU, which relies heavily on multiple providers communicating and collaborating to provide optimal care. As noted in the study by Sweigart and colleagues,⁵ even in settings where intensivists were available 24 hours per day or made all major decisions, nearly one-third of hospitalists felt they practiced beyond their scope of expertise, suggesting that more intensivists may do little to improve hospitalists’ comfort in caring for patients in the ICU.

In lieu of increasing intensivist numbers, policymakers should consider several strategies that have the potential to improve the quality of care delivered to patients in the ICU without increasing intensivists. Recent data suggest that some ICU patients can be safely managed by physician assistants and nurse practitioners.^7,8 Care models involving such providers may free up overworked intensivists and hospitalists, allowing them to focus their efforts on the sickest patients. ICU telemedicine has also emerged as a promising tool that can bring the expertise of intensivists to hospitals where they are needed. Beyond the additional oversight of routine care practices it provides, telemedicine could allow rapid and real time consultation with intensivists for clinicians at the bedside facing difficult management decisions, potentially saving lives.⁹ The rapid growth of clinically integrated networks, which often include large well-staffed medical centers surrounded by many smaller regional hospitals, might facilitate faster implementation of innovative telemedicine models. Regionalization of care is a third strategy that may improve the quality of care for the critically ill without increasing intensivist supply. Regionalization seeks to selectively transfer the most ill patients to high-volume centers with the greatest expertise in critical care, a practice associated with reduced mortality.¹⁰ Of course, for regionalization to be successful, front-line providers like hospitalists need to be able to orchestrate the transfer to the referral center, a process that, as noted by Sweigart and others, is neither easy nor universally successful.¹¹

A final strategy would be to reduce the demand for intensivists through limiting the number of individuals in an ICU. While policies that explicitly ration ICU beds for individuals who have the greatest ability to benefit are ethically problematic, reductions in ICU beds would force providers to implicitly allocate beds more efficiently. There are a multitude of studies showing that our nation’s ICUs are often filled with patients who derive little benefit from intensive care.^12,13 Further research on ethically sound strategies to avoid ICU admission for patients unlikely to benefit is desperately needed. With fewer patients in an ICU, the busy intensivist could focus on the sickest patients and spend more time communicating with hospitalists about patients they are managing together.

Regardless of the care models that develop, hospitalists will increasingly be called upon to staff ICUs. Hospitalists are necessary, but as the study by Sweigart et al.⁵ suggests, just throwing them into our current ICU models with little support from their critical care colleagues is not sufficient. In the absence of a major influx of new intensivists, hospital medicine and critical care professional societies need to actively collaborate to develop creative training and educational models that provide hospitalists with the necessary skills to care for the critically ill and to lead the multidisciplinary care teams they will work within. More importantly, these professional societies must advocate together for more substantial reform to our current ICU care models. Novel solutions that prioritize the efficient use of existing ICU beds for those individuals with the greatest ability to benefit, but also capitalize on emerging technologies and regional centers of excellence, have great potential to address the mismatch between supply and demand. Given the increasing demand and substantial cost for ICU care, we can’t afford to continue with business as usual.

Disclosure

The authors declared no conflicts of interest.

In the United States, up to 6 million patients are admitted to intensive care units (ICUs) annually at a cost estimated to exceed $80 billion or about 13% of total hospital costs.^1,2 It also appears that as our population ages and illness severity increases, demand for ICU care is increasing.³ Given its importance, the organization and delivery of critical care has been extensively studied. High-intensity physician staffing by an intensivist (all patients managed or comanaged by an intensivist), while inconsistently shown to be associated with improved outcomes, has been endorsed as a high-quality care model by professional societies and the Leapfrog group. Despite its adoption by many hospitals, widespread implementation has been hampered by a national shortage of intensivists that continues to worsen over time. Hospitals, by necessity, look to alternative models to care for critically ill patients, and one such model is the use of hospitalists.

The Society of Hospital Medicine estimates that there are nearly 50,000 hospitalists practicing in the United States, and several studies show they routinely provide care in the nation’s ICUs.⁴ While in some ICUs hospitalists work alongside intensivists, in many, they work without intensivist support, and regardless of the model, they often serve as the primary attending physician. There is good reason to think this model of care would be effective. Most hospitalists are internists, graduating from training programs that tend to emphasize care of acutely ill hospitalized patients. Hospitalists are often present in the hospital 24/7, are comfortable working in multidisciplinary teams, and routinely engage in quality improvement, which are all characteristics common in highly functioning ICUs. Yet, a study in this issue of the Journal of Hospital Medicine raises some concern.

Sweigart and colleagues⁵ surveyed 425 hospitalists to understand the structure and perception of their ICU practices. Consistent with prior studies, 77% provided ICU care with 66% serving as the primary attending. A novel finding is the high level of angst and lack of support hospitalists perceived in caring for these critically ill patients. Among rural hospitalists, 43% reported they were expected to practice beyond their perceived scope of practice, and almost a third reported they never had sufficient intensivist support. Even more concerning is that among hospitalists serving as the primary attending, over two-thirds reported difficulty transferring patients to a higher level of care (Sweigart et al.⁵). While we have concerns over how representative this sample is of hospitalist practice (the survey response rate was only about 10%), it does appear that many hospitalists feel very uncomfortable with the ICU care they are providing and perceive barriers to moving their patients to a potentially safer care setting.

While one might argue more intensivists would solve this problem, calls for more intensivists are shortsighted, as there are compelling reasons to believe that such efforts will do little to address the mismatch between patient need and provider supply. Graduate medical education slots for intensivists cannot be easily and affordably increased, and even if more intensivists could be trained, there are few incentives to encourage them to work where they are needed most. Prioritization of intensivist training also diverts resources from training demands in equally important undersupplied specialties such as primary care.⁶ Finally, simply increasing intensivist supply fails to attend to important issues surrounding the multidisciplinary nature of care in an ICU, which relies heavily on multiple providers communicating and collaborating to provide optimal care. As noted in the study by Sweigart and colleagues,⁵ even in settings where intensivists were available 24 hours per day or made all major decisions, nearly one-third of hospitalists felt they practiced beyond their scope of expertise, suggesting that more intensivists may do little to improve hospitalists’ comfort in caring for patients in the ICU.

In lieu of increasing intensivist numbers, policymakers should consider several strategies that have the potential to improve the quality of care delivered to patients in the ICU without increasing intensivists. Recent data suggest that some ICU patients can be safely managed by physician assistants and nurse practitioners.^7,8 Care models involving such providers may free up overworked intensivists and hospitalists, allowing them to focus their efforts on the sickest patients. ICU telemedicine has also emerged as a promising tool that can bring the expertise of intensivists to hospitals where they are needed. Beyond the additional oversight of routine care practices it provides, telemedicine could allow rapid and real time consultation with intensivists for clinicians at the bedside facing difficult management decisions, potentially saving lives.⁹ The rapid growth of clinically integrated networks, which often include large well-staffed medical centers surrounded by many smaller regional hospitals, might facilitate faster implementation of innovative telemedicine models. Regionalization of care is a third strategy that may improve the quality of care for the critically ill without increasing intensivist supply. Regionalization seeks to selectively transfer the most ill patients to high-volume centers with the greatest expertise in critical care, a practice associated with reduced mortality.¹⁰ Of course, for regionalization to be successful, front-line providers like hospitalists need to be able to orchestrate the transfer to the referral center, a process that, as noted by Sweigart and others, is neither easy nor universally successful.¹¹

A final strategy would be to reduce the demand for intensivists through limiting the number of individuals in an ICU. While policies that explicitly ration ICU beds for individuals who have the greatest ability to benefit are ethically problematic, reductions in ICU beds would force providers to implicitly allocate beds more efficiently. There are a multitude of studies showing that our nation’s ICUs are often filled with patients who derive little benefit from intensive care.^12,13 Further research on ethically sound strategies to avoid ICU admission for patients unlikely to benefit is desperately needed. With fewer patients in an ICU, the busy intensivist could focus on the sickest patients and spend more time communicating with hospitalists about patients they are managing together.

Regardless of the care models that develop, hospitalists will increasingly be called upon to staff ICUs. Hospitalists are necessary, but as the study by Sweigart et al.⁵ suggests, just throwing them into our current ICU models with little support from their critical care colleagues is not sufficient. In the absence of a major influx of new intensivists, hospital medicine and critical care professional societies need to actively collaborate to develop creative training and educational models that provide hospitalists with the necessary skills to care for the critically ill and to lead the multidisciplinary care teams they will work within. More importantly, these professional societies must advocate together for more substantial reform to our current ICU care models. Novel solutions that prioritize the efficient use of existing ICU beds for those individuals with the greatest ability to benefit, but also capitalize on emerging technologies and regional centers of excellence, have great potential to address the mismatch between supply and demand. Given the increasing demand and substantial cost for ICU care, we can’t afford to continue with business as usual.

Disclosure

The authors declared no conflicts of interest.

In the United States, up to 6 million patients are admitted to intensive care units (ICUs) annually at a cost estimated to exceed $80 billion or about 13% of total hospital costs.^1,2 It also appears that as our population ages and illness severity increases, demand for ICU care is increasing.³ Given its importance, the organization and delivery of critical care has been extensively studied. High-intensity physician staffing by an intensivist (all patients managed or comanaged by an intensivist), while inconsistently shown to be associated with improved outcomes, has been endorsed as a high-quality care model by professional societies and the Leapfrog group. Despite its adoption by many hospitals, widespread implementation has been hampered by a national shortage of intensivists that continues to worsen over time. Hospitals, by necessity, look to alternative models to care for critically ill patients, and one such model is the use of hospitalists.

The Society of Hospital Medicine estimates that there are nearly 50,000 hospitalists practicing in the United States, and several studies show they routinely provide care in the nation’s ICUs.⁴ While in some ICUs hospitalists work alongside intensivists, in many, they work without intensivist support, and regardless of the model, they often serve as the primary attending physician. There is good reason to think this model of care would be effective. Most hospitalists are internists, graduating from training programs that tend to emphasize care of acutely ill hospitalized patients. Hospitalists are often present in the hospital 24/7, are comfortable working in multidisciplinary teams, and routinely engage in quality improvement, which are all characteristics common in highly functioning ICUs. Yet, a study in this issue of the Journal of Hospital Medicine raises some concern.

Sweigart and colleagues⁵ surveyed 425 hospitalists to understand the structure and perception of their ICU practices. Consistent with prior studies, 77% provided ICU care with 66% serving as the primary attending. A novel finding is the high level of angst and lack of support hospitalists perceived in caring for these critically ill patients. Among rural hospitalists, 43% reported they were expected to practice beyond their perceived scope of practice, and almost a third reported they never had sufficient intensivist support. Even more concerning is that among hospitalists serving as the primary attending, over two-thirds reported difficulty transferring patients to a higher level of care (Sweigart et al.⁵). While we have concerns over how representative this sample is of hospitalist practice (the survey response rate was only about 10%), it does appear that many hospitalists feel very uncomfortable with the ICU care they are providing and perceive barriers to moving their patients to a potentially safer care setting.

While one might argue more intensivists would solve this problem, calls for more intensivists are shortsighted, as there are compelling reasons to believe that such efforts will do little to address the mismatch between patient need and provider supply. Graduate medical education slots for intensivists cannot be easily and affordably increased, and even if more intensivists could be trained, there are few incentives to encourage them to work where they are needed most. Prioritization of intensivist training also diverts resources from training demands in equally important undersupplied specialties such as primary care.⁶ Finally, simply increasing intensivist supply fails to attend to important issues surrounding the multidisciplinary nature of care in an ICU, which relies heavily on multiple providers communicating and collaborating to provide optimal care. As noted in the study by Sweigart and colleagues,⁵ even in settings where intensivists were available 24 hours per day or made all major decisions, nearly one-third of hospitalists felt they practiced beyond their scope of expertise, suggesting that more intensivists may do little to improve hospitalists’ comfort in caring for patients in the ICU.

In lieu of increasing intensivist numbers, policymakers should consider several strategies that have the potential to improve the quality of care delivered to patients in the ICU without increasing intensivists. Recent data suggest that some ICU patients can be safely managed by physician assistants and nurse practitioners.^7,8 Care models involving such providers may free up overworked intensivists and hospitalists, allowing them to focus their efforts on the sickest patients. ICU telemedicine has also emerged as a promising tool that can bring the expertise of intensivists to hospitals where they are needed. Beyond the additional oversight of routine care practices it provides, telemedicine could allow rapid and real time consultation with intensivists for clinicians at the bedside facing difficult management decisions, potentially saving lives.⁹ The rapid growth of clinically integrated networks, which often include large well-staffed medical centers surrounded by many smaller regional hospitals, might facilitate faster implementation of innovative telemedicine models. Regionalization of care is a third strategy that may improve the quality of care for the critically ill without increasing intensivist supply. Regionalization seeks to selectively transfer the most ill patients to high-volume centers with the greatest expertise in critical care, a practice associated with reduced mortality.¹⁰ Of course, for regionalization to be successful, front-line providers like hospitalists need to be able to orchestrate the transfer to the referral center, a process that, as noted by Sweigart and others, is neither easy nor universally successful.¹¹

A final strategy would be to reduce the demand for intensivists through limiting the number of individuals in an ICU. While policies that explicitly ration ICU beds for individuals who have the greatest ability to benefit are ethically problematic, reductions in ICU beds would force providers to implicitly allocate beds more efficiently. There are a multitude of studies showing that our nation’s ICUs are often filled with patients who derive little benefit from intensive care.^12,13 Further research on ethically sound strategies to avoid ICU admission for patients unlikely to benefit is desperately needed. With fewer patients in an ICU, the busy intensivist could focus on the sickest patients and spend more time communicating with hospitalists about patients they are managing together.

Regardless of the care models that develop, hospitalists will increasingly be called upon to staff ICUs. Hospitalists are necessary, but as the study by Sweigart et al.⁵ suggests, just throwing them into our current ICU models with little support from their critical care colleagues is not sufficient. In the absence of a major influx of new intensivists, hospital medicine and critical care professional societies need to actively collaborate to develop creative training and educational models that provide hospitalists with the necessary skills to care for the critically ill and to lead the multidisciplinary care teams they will work within. More importantly, these professional societies must advocate together for more substantial reform to our current ICU care models. Novel solutions that prioritize the efficient use of existing ICU beds for those individuals with the greatest ability to benefit, but also capitalize on emerging technologies and regional centers of excellence, have great potential to address the mismatch between supply and demand. Given the increasing demand and substantial cost for ICU care, we can’t afford to continue with business as usual.

Disclosure

The authors declared no conflicts of interest.