Editorial

Thrombotic disorders, such as venous thromboembolism (VTE) and acute ischemic stroke, are highly prevalent,¹ morbid, and anxiety-provoking conditions for patients, their families, and providers.² Often, a clear cause for these thrombotic events cannot be found, leading to diagnoses of “cryptogenic stroke” or “idiopathic VTE.” In response, many patients and clinicians search for a cause with thrombophilia testing.

However, evaluation for thrombophilia is rarely clinically useful in hospitalized patients. Test results are often inaccurate in the setting of acute thrombosis or active anticoagulation. Even when thrombophilia results are reliable, they seldom alter immediate management of the underlying condition, especially for the inherited forms.³ An important exception is when there is high clinical suspicion for the antiphospholipid syndrome (APS), because APS test results may affect both short-term and long-term drug choices and international normalized ratio target range. Despite the broad recommendations against routine use of thrombophilia testing (including the Choosing Wisely campaign),⁴ patterns and cost of testing for inpatient thrombophilia evaluation have not been well reported.

In this issue of Journal of Hospital Medicine, Cox et al.⁵ and Mou et al.⁶ retrospectively review the appropriateness and impact of inpatient thrombophilia testing at 2 academic centers. In the report by Mou and colleagues, nearly half of all thrombophilia tests were felt to be inappropriate at an excess cost of over $40,000. Cox and colleagues identified that 77% of patients received 1 or more thrombophilia tests with minimal clinical utility. Perhaps most striking, Cox and colleagues report that management was affected in only 2 of 163 patients (1.2%) that received thrombophilia testing; both had cryptogenic stroke and both were started on anticoagulation after testing positive for multiple coagulation defects.

These studies confirm 2 key findings: first, that 43%-63% of tests are potentially inaccurate or of low utility, and second, that inpatient thrombophilia testing can be costly. Importantly, the costs of inappropriate testing were likely underestimated. For example, Mou et al. excluded 16.6% of tests that were performed for reasons that could not always be easily justified—such as “tests ordered with no documentation or justification” or “work-up sent solely on suspicion of possible thrombotic event without diagnostic confirmation.” Additionally, Mou et al. defined appropriateness more generously than current guidelines; for example, “recurrent provoked VTE” was listed as an appropriate indication for thrombophilia testing, although this is not supported by current guidelines for inherited thrombophilia evaluation. Similarly, Cox et al included cryptogenic stroke as an appropriate indication to perform thrombophilia testing; however, current American Heart Association and American Stroke Association guidelines state that usefulness of screening for hypercoagulable states in such patients is unknown.⁷ Furthermore, APS testing is not recommended in all cases of cryptogenic stroke in the absence of other clinical manifestations of APS.⁷

It remains puzzling why physicians continue to order inpatient thrombophilia testing despite their low clinical utility and inaccurate results. Cox and colleagues suggested that a lack of clinician and patient education may explain part of this reason. Likewise, easy access to “thrombophilia panels” make it easy for any clinician to order a number of tests that appear to be expert endorsed due to their inclusion in the panel. Cox et al. found that 79% of all thrombophilia tests were ordered as a part of a panel. Finally, patients and clinicians are continually searching for a reason why the thromboembolic event occurred. The thrombophilia test results (even if potentially inaccurate), may lead to a false sense of relief for both parties, no matter the results. If a thrombophilia is found, then patients and clinicians often have a sense for why the thrombotic event occurred. If the testing is negative, there may be a false sense of reassurance that “no genetic” cause for thrombosis exists.⁸

How can we improve care in this regard? Given the magnitude of financial and psychological cost of inappropriate inpatient thrombophilia testing,⁹ a robust deimplementation effort is needed.^10,11 Electronic-medical-record–based solutions may be the most effective tool to educate physicians at the point of care while simultaneously deterring inappropriate ordering. Examples include eliminating tests without evidence of clinical utility in the inpatient setting (ie, methylenetetrahydrofolate reductase); using hard stops to prevent unintentional duplicative tests¹²; and preventing providers from ordering tests that are not reliable in certain settings—such as protein S activity when patients are receiving warfarin. The latter intervention would have prevented 16% of tests (on 44% of the patients) performed in the Cox et al study. Other promising efforts include embedding guidelines into order sets and requiring the provider to choose a guideline-based reason before being allowed to order such a test. Finally, eliminating thrombophilia “panels” may reduce unnecessary duplicate testing and avoid giving a false sense of clinical validation to ordering providers who may not be familiar with the indications or nuances of each individual test.

In light of mounting evidence, including the 2 important studies discussed above, it is no longer appropriate or wise to allow unfettered access to thrombophilia testing in hospitalized patients. The evidence suggests that these tests are often ordered without regard to expense, utility, or accuracy in hospital-based settings. Deimplementation efforts that provide hard stops, education, and limited access to such testing in the electronic medical ordering system when ordering thrombophilia workups now appear necessary.

Disclosure

Lauren Heidemann and Christopher Petrilli have no conflicts of interest to report. Geoffrey Barnes reports the following conflicts of interest: Research funding from NIH/NHLBI (K01 HL135392), Blue Cross-Blue Shield of Michigan, and BMS/Pfizer. Consulting from BMS/Pfizer and Portola.

Thrombotic disorders, such as venous thromboembolism (VTE) and acute ischemic stroke, are highly prevalent,¹ morbid, and anxiety-provoking conditions for patients, their families, and providers.² Often, a clear cause for these thrombotic events cannot be found, leading to diagnoses of “cryptogenic stroke” or “idiopathic VTE.” In response, many patients and clinicians search for a cause with thrombophilia testing.

However, evaluation for thrombophilia is rarely clinically useful in hospitalized patients. Test results are often inaccurate in the setting of acute thrombosis or active anticoagulation. Even when thrombophilia results are reliable, they seldom alter immediate management of the underlying condition, especially for the inherited forms.³ An important exception is when there is high clinical suspicion for the antiphospholipid syndrome (APS), because APS test results may affect both short-term and long-term drug choices and international normalized ratio target range. Despite the broad recommendations against routine use of thrombophilia testing (including the Choosing Wisely campaign),⁴ patterns and cost of testing for inpatient thrombophilia evaluation have not been well reported.

In this issue of Journal of Hospital Medicine, Cox et al.⁵ and Mou et al.⁶ retrospectively review the appropriateness and impact of inpatient thrombophilia testing at 2 academic centers. In the report by Mou and colleagues, nearly half of all thrombophilia tests were felt to be inappropriate at an excess cost of over $40,000. Cox and colleagues identified that 77% of patients received 1 or more thrombophilia tests with minimal clinical utility. Perhaps most striking, Cox and colleagues report that management was affected in only 2 of 163 patients (1.2%) that received thrombophilia testing; both had cryptogenic stroke and both were started on anticoagulation after testing positive for multiple coagulation defects.

These studies confirm 2 key findings: first, that 43%-63% of tests are potentially inaccurate or of low utility, and second, that inpatient thrombophilia testing can be costly. Importantly, the costs of inappropriate testing were likely underestimated. For example, Mou et al. excluded 16.6% of tests that were performed for reasons that could not always be easily justified—such as “tests ordered with no documentation or justification” or “work-up sent solely on suspicion of possible thrombotic event without diagnostic confirmation.” Additionally, Mou et al. defined appropriateness more generously than current guidelines; for example, “recurrent provoked VTE” was listed as an appropriate indication for thrombophilia testing, although this is not supported by current guidelines for inherited thrombophilia evaluation. Similarly, Cox et al included cryptogenic stroke as an appropriate indication to perform thrombophilia testing; however, current American Heart Association and American Stroke Association guidelines state that usefulness of screening for hypercoagulable states in such patients is unknown.⁷ Furthermore, APS testing is not recommended in all cases of cryptogenic stroke in the absence of other clinical manifestations of APS.⁷

It remains puzzling why physicians continue to order inpatient thrombophilia testing despite their low clinical utility and inaccurate results. Cox and colleagues suggested that a lack of clinician and patient education may explain part of this reason. Likewise, easy access to “thrombophilia panels” make it easy for any clinician to order a number of tests that appear to be expert endorsed due to their inclusion in the panel. Cox et al. found that 79% of all thrombophilia tests were ordered as a part of a panel. Finally, patients and clinicians are continually searching for a reason why the thromboembolic event occurred. The thrombophilia test results (even if potentially inaccurate), may lead to a false sense of relief for both parties, no matter the results. If a thrombophilia is found, then patients and clinicians often have a sense for why the thrombotic event occurred. If the testing is negative, there may be a false sense of reassurance that “no genetic” cause for thrombosis exists.⁸

How can we improve care in this regard? Given the magnitude of financial and psychological cost of inappropriate inpatient thrombophilia testing,⁹ a robust deimplementation effort is needed.^10,11 Electronic-medical-record–based solutions may be the most effective tool to educate physicians at the point of care while simultaneously deterring inappropriate ordering. Examples include eliminating tests without evidence of clinical utility in the inpatient setting (ie, methylenetetrahydrofolate reductase); using hard stops to prevent unintentional duplicative tests¹²; and preventing providers from ordering tests that are not reliable in certain settings—such as protein S activity when patients are receiving warfarin. The latter intervention would have prevented 16% of tests (on 44% of the patients) performed in the Cox et al study. Other promising efforts include embedding guidelines into order sets and requiring the provider to choose a guideline-based reason before being allowed to order such a test. Finally, eliminating thrombophilia “panels” may reduce unnecessary duplicate testing and avoid giving a false sense of clinical validation to ordering providers who may not be familiar with the indications or nuances of each individual test.

In light of mounting evidence, including the 2 important studies discussed above, it is no longer appropriate or wise to allow unfettered access to thrombophilia testing in hospitalized patients. The evidence suggests that these tests are often ordered without regard to expense, utility, or accuracy in hospital-based settings. Deimplementation efforts that provide hard stops, education, and limited access to such testing in the electronic medical ordering system when ordering thrombophilia workups now appear necessary.

Disclosure

Lauren Heidemann and Christopher Petrilli have no conflicts of interest to report. Geoffrey Barnes reports the following conflicts of interest: Research funding from NIH/NHLBI (K01 HL135392), Blue Cross-Blue Shield of Michigan, and BMS/Pfizer. Consulting from BMS/Pfizer and Portola.

Thrombotic disorders, such as venous thromboembolism (VTE) and acute ischemic stroke, are highly prevalent,¹ morbid, and anxiety-provoking conditions for patients, their families, and providers.² Often, a clear cause for these thrombotic events cannot be found, leading to diagnoses of “cryptogenic stroke” or “idiopathic VTE.” In response, many patients and clinicians search for a cause with thrombophilia testing.

However, evaluation for thrombophilia is rarely clinically useful in hospitalized patients. Test results are often inaccurate in the setting of acute thrombosis or active anticoagulation. Even when thrombophilia results are reliable, they seldom alter immediate management of the underlying condition, especially for the inherited forms.³ An important exception is when there is high clinical suspicion for the antiphospholipid syndrome (APS), because APS test results may affect both short-term and long-term drug choices and international normalized ratio target range. Despite the broad recommendations against routine use of thrombophilia testing (including the Choosing Wisely campaign),⁴ patterns and cost of testing for inpatient thrombophilia evaluation have not been well reported.

In this issue of Journal of Hospital Medicine, Cox et al.⁵ and Mou et al.⁶ retrospectively review the appropriateness and impact of inpatient thrombophilia testing at 2 academic centers. In the report by Mou and colleagues, nearly half of all thrombophilia tests were felt to be inappropriate at an excess cost of over $40,000. Cox and colleagues identified that 77% of patients received 1 or more thrombophilia tests with minimal clinical utility. Perhaps most striking, Cox and colleagues report that management was affected in only 2 of 163 patients (1.2%) that received thrombophilia testing; both had cryptogenic stroke and both were started on anticoagulation after testing positive for multiple coagulation defects.

These studies confirm 2 key findings: first, that 43%-63% of tests are potentially inaccurate or of low utility, and second, that inpatient thrombophilia testing can be costly. Importantly, the costs of inappropriate testing were likely underestimated. For example, Mou et al. excluded 16.6% of tests that were performed for reasons that could not always be easily justified—such as “tests ordered with no documentation or justification” or “work-up sent solely on suspicion of possible thrombotic event without diagnostic confirmation.” Additionally, Mou et al. defined appropriateness more generously than current guidelines; for example, “recurrent provoked VTE” was listed as an appropriate indication for thrombophilia testing, although this is not supported by current guidelines for inherited thrombophilia evaluation. Similarly, Cox et al included cryptogenic stroke as an appropriate indication to perform thrombophilia testing; however, current American Heart Association and American Stroke Association guidelines state that usefulness of screening for hypercoagulable states in such patients is unknown.⁷ Furthermore, APS testing is not recommended in all cases of cryptogenic stroke in the absence of other clinical manifestations of APS.⁷

It remains puzzling why physicians continue to order inpatient thrombophilia testing despite their low clinical utility and inaccurate results. Cox and colleagues suggested that a lack of clinician and patient education may explain part of this reason. Likewise, easy access to “thrombophilia panels” make it easy for any clinician to order a number of tests that appear to be expert endorsed due to their inclusion in the panel. Cox et al. found that 79% of all thrombophilia tests were ordered as a part of a panel. Finally, patients and clinicians are continually searching for a reason why the thromboembolic event occurred. The thrombophilia test results (even if potentially inaccurate), may lead to a false sense of relief for both parties, no matter the results. If a thrombophilia is found, then patients and clinicians often have a sense for why the thrombotic event occurred. If the testing is negative, there may be a false sense of reassurance that “no genetic” cause for thrombosis exists.⁸

How can we improve care in this regard? Given the magnitude of financial and psychological cost of inappropriate inpatient thrombophilia testing,⁹ a robust deimplementation effort is needed.^10,11 Electronic-medical-record–based solutions may be the most effective tool to educate physicians at the point of care while simultaneously deterring inappropriate ordering. Examples include eliminating tests without evidence of clinical utility in the inpatient setting (ie, methylenetetrahydrofolate reductase); using hard stops to prevent unintentional duplicative tests¹²; and preventing providers from ordering tests that are not reliable in certain settings—such as protein S activity when patients are receiving warfarin. The latter intervention would have prevented 16% of tests (on 44% of the patients) performed in the Cox et al study. Other promising efforts include embedding guidelines into order sets and requiring the provider to choose a guideline-based reason before being allowed to order such a test. Finally, eliminating thrombophilia “panels” may reduce unnecessary duplicate testing and avoid giving a false sense of clinical validation to ordering providers who may not be familiar with the indications or nuances of each individual test.

In light of mounting evidence, including the 2 important studies discussed above, it is no longer appropriate or wise to allow unfettered access to thrombophilia testing in hospitalized patients. The evidence suggests that these tests are often ordered without regard to expense, utility, or accuracy in hospital-based settings. Deimplementation efforts that provide hard stops, education, and limited access to such testing in the electronic medical ordering system when ordering thrombophilia workups now appear necessary.

Disclosure

Lauren Heidemann and Christopher Petrilli have no conflicts of interest to report. Geoffrey Barnes reports the following conflicts of interest: Research funding from NIH/NHLBI (K01 HL135392), Blue Cross-Blue Shield of Michigan, and BMS/Pfizer. Consulting from BMS/Pfizer and Portola.

Any conversation about point-of-care ultrasound (POCUS) inevitably brings up discussion about credentialing, privileging, and certification. While credentialing and privileging are institution-specific processes, competency certification can be extramural through a national board or intramural through an institutional process.

Disclosure

Nilam Soni receives support from the U.S. Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). Brian P. Lucas receives support from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086). The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Any conversation about point-of-care ultrasound (POCUS) inevitably brings up discussion about credentialing, privileging, and certification. While credentialing and privileging are institution-specific processes, competency certification can be extramural through a national board or intramural through an institutional process.

Disclosure

Nilam Soni receives support from the U.S. Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). Brian P. Lucas receives support from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086). The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Any conversation about point-of-care ultrasound (POCUS) inevitably brings up discussion about credentialing, privileging, and certification. While credentialing and privileging are institution-specific processes, competency certification can be extramural through a national board or intramural through an institutional process.

Disclosure

Nilam Soni receives support from the U.S. Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). Brian P. Lucas receives support from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086). The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

There is no doubt about the importance of assessing, documenting, and honoring patient wishes regarding care. For hospitalized patients, code status is a critical treatment preference to document given that the need for cardiopulmonary resuscitation (CPR) arises suddenly, outcomes are often poor, and the default is for patients to receive the treatment unless they actively decline it. Hospitalists are expected to document code status for every hospitalized patient, but admission code status conversations are often brief—and that might be all right. A code status discussion for a 70-year-old man with no chronic medical problems and excellent functional status who has been admitted for pain after a motor vehicle accident may require only an introduction to the concept of advance care planning, the importance of having a surrogate, and confirmation of full code status. On the other hand, a 45-year-old woman with metastatic pancreatic cancer would likely benefit from a family meeting in which the hospitalist could review her disease course and prognosis, assess her values and priorities in the context of her advanced illness, make treatment recommendations—including code status—that are consistent with her values, and elicit questions.^1,2 We need to free up hospitalists from spending time discussing code status with every patient so that they can spend more time in quality goals of care discussions with seriously ill patients. The paradigm of the one doctor—one patient admission code status conversation for every patient is no longer realistic.

As reported by Merino and colleagues in this issue of JHM, video decision aids about CPR for hospitalized patients can offer an innovative solution to determining code status for hospitalized patients.³ The authors conducted a prospective, randomized controlled trial, which enrolled older adults admitted to the hospital medicine service at the Veteran’s Administration (VA) Hospital in Minneapolis. Participants (N = 119) were randomized to usual care or to watch a 6-minute video that explained code status options, used a mannequin to illustrate a mock code, and provided information about potential complications and survival rates. Patients who watched the video were more likely to choose do not resuscitate/do not intubate status, with a large effect size (56% in the intervention group vs. 17% in the control group, P < 0.00001).

This study adds to a growing body of literature about this powerful modality to assist with advanced care planning. Over the past 10 years, studies—conducted primarily by Volandes, El-Jawahri, and colleagues—have demonstrated how video decision aids impact the care that patients want in the setting of cancer, heart failure, serious illness with short prognosis, and future dementia.^4-9 This literature has also shown that video decision aids can increase patients’ knowledge about CPR and increase the stability of decisions over time. Further, video decision aids have been well accepted by patients, who report that they would recommended such videos to others. This body of evidence underscores the potential of video decision aids to improve concordance between patient preferences and care provided, which is key given the longstanding and widespread concern about patients receiving care that is inconsistent with their values at the end of life.¹⁰ In short, video decision aids work.

Merino and colleagues are the first to examine the use of a video decision aid about code status in a general population of older adults on a hospital medicine service and the second to integrate such a video into usual inpatient care, which are important advancements.^2,3 There are several issues that warrant further consideration prior to widely disseminating such a video, however. As the authors note, the participants in this VA study were overwhelmingly white men and their average age was 75. Further, the authors found a nonsignificant trend towards patients in the intervention group having less trust that “my doctors and healthcare team want what is best for me” (76% in the intervention group vs. 93% in the control group; P = 0.083). Decision making about life-sustaining therapies and reactions to communication about serious illness are heavily influenced by cultural and socioeconomic factors, including health literacy.¹¹ It will be important to seek feedback from a diverse group of patients and families to ensure that the video decision aid is interpreted accurately, renders decisions that are consistent with patients’ values, and does not negatively impact the clinician-patient relationship.¹² Additionally, as the above cases illustrate, code status discussions should be tailored to patient factors, including illness severity and point in the disease course. Hospitalists will ultimately benefit from having access to multiple different videos about a range of advance care planning topics that can be used when appropriate.

In addition to selecting the right video for the right patient, the next challenge for hospitalists and health systems will be how to implement them within real-world clinical care and a broader approach to advance care planning. There are technical and logistical challenges to displaying videos in hospital rooms, and more significant challenges in ensuring timely follow-up discussions, communication of patients’ dynamic care preferences to their surrogates, changes to inpatient orders, documentation in the electronic medical record where it can be easily found in the future, and completion of advance directives and Physician Orders for Life Sustaining Treatment forms to communicate patients’ goals of care beyond the hospital and health system. Each of these steps is critical and is supported through videos and activities in the free, patient-facing, PREPARE web-based tool (https://www.prepareforyourcare.org/).^2,13,14

The ubiquitous presence of videos in our lives speaks to their power to engage and affect us. Video decision aids provide detailed explanations and vivid images that convey more than words can alone. While there is more work to be done to ensure videos are appropriate for all hospitalized patients and support rather than detract from patient-doctor relationships, this study and others like it show that video decision aids are potent tools to promote better decision-making and higher value, more efficient care.

Disclosures

The authors have nothing to disclose.

There is no doubt about the importance of assessing, documenting, and honoring patient wishes regarding care. For hospitalized patients, code status is a critical treatment preference to document given that the need for cardiopulmonary resuscitation (CPR) arises suddenly, outcomes are often poor, and the default is for patients to receive the treatment unless they actively decline it. Hospitalists are expected to document code status for every hospitalized patient, but admission code status conversations are often brief—and that might be all right. A code status discussion for a 70-year-old man with no chronic medical problems and excellent functional status who has been admitted for pain after a motor vehicle accident may require only an introduction to the concept of advance care planning, the importance of having a surrogate, and confirmation of full code status. On the other hand, a 45-year-old woman with metastatic pancreatic cancer would likely benefit from a family meeting in which the hospitalist could review her disease course and prognosis, assess her values and priorities in the context of her advanced illness, make treatment recommendations—including code status—that are consistent with her values, and elicit questions.^1,2 We need to free up hospitalists from spending time discussing code status with every patient so that they can spend more time in quality goals of care discussions with seriously ill patients. The paradigm of the one doctor—one patient admission code status conversation for every patient is no longer realistic.

As reported by Merino and colleagues in this issue of JHM, video decision aids about CPR for hospitalized patients can offer an innovative solution to determining code status for hospitalized patients.³ The authors conducted a prospective, randomized controlled trial, which enrolled older adults admitted to the hospital medicine service at the Veteran’s Administration (VA) Hospital in Minneapolis. Participants (N = 119) were randomized to usual care or to watch a 6-minute video that explained code status options, used a mannequin to illustrate a mock code, and provided information about potential complications and survival rates. Patients who watched the video were more likely to choose do not resuscitate/do not intubate status, with a large effect size (56% in the intervention group vs. 17% in the control group, P < 0.00001).

This study adds to a growing body of literature about this powerful modality to assist with advanced care planning. Over the past 10 years, studies—conducted primarily by Volandes, El-Jawahri, and colleagues—have demonstrated how video decision aids impact the care that patients want in the setting of cancer, heart failure, serious illness with short prognosis, and future dementia.^4-9 This literature has also shown that video decision aids can increase patients’ knowledge about CPR and increase the stability of decisions over time. Further, video decision aids have been well accepted by patients, who report that they would recommended such videos to others. This body of evidence underscores the potential of video decision aids to improve concordance between patient preferences and care provided, which is key given the longstanding and widespread concern about patients receiving care that is inconsistent with their values at the end of life.¹⁰ In short, video decision aids work.

Merino and colleagues are the first to examine the use of a video decision aid about code status in a general population of older adults on a hospital medicine service and the second to integrate such a video into usual inpatient care, which are important advancements.^2,3 There are several issues that warrant further consideration prior to widely disseminating such a video, however. As the authors note, the participants in this VA study were overwhelmingly white men and their average age was 75. Further, the authors found a nonsignificant trend towards patients in the intervention group having less trust that “my doctors and healthcare team want what is best for me” (76% in the intervention group vs. 93% in the control group; P = 0.083). Decision making about life-sustaining therapies and reactions to communication about serious illness are heavily influenced by cultural and socioeconomic factors, including health literacy.¹¹ It will be important to seek feedback from a diverse group of patients and families to ensure that the video decision aid is interpreted accurately, renders decisions that are consistent with patients’ values, and does not negatively impact the clinician-patient relationship.¹² Additionally, as the above cases illustrate, code status discussions should be tailored to patient factors, including illness severity and point in the disease course. Hospitalists will ultimately benefit from having access to multiple different videos about a range of advance care planning topics that can be used when appropriate.

In addition to selecting the right video for the right patient, the next challenge for hospitalists and health systems will be how to implement them within real-world clinical care and a broader approach to advance care planning. There are technical and logistical challenges to displaying videos in hospital rooms, and more significant challenges in ensuring timely follow-up discussions, communication of patients’ dynamic care preferences to their surrogates, changes to inpatient orders, documentation in the electronic medical record where it can be easily found in the future, and completion of advance directives and Physician Orders for Life Sustaining Treatment forms to communicate patients’ goals of care beyond the hospital and health system. Each of these steps is critical and is supported through videos and activities in the free, patient-facing, PREPARE web-based tool (https://www.prepareforyourcare.org/).^2,13,14

The ubiquitous presence of videos in our lives speaks to their power to engage and affect us. Video decision aids provide detailed explanations and vivid images that convey more than words can alone. While there is more work to be done to ensure videos are appropriate for all hospitalized patients and support rather than detract from patient-doctor relationships, this study and others like it show that video decision aids are potent tools to promote better decision-making and higher value, more efficient care.

Disclosures

The authors have nothing to disclose.

There is no doubt about the importance of assessing, documenting, and honoring patient wishes regarding care. For hospitalized patients, code status is a critical treatment preference to document given that the need for cardiopulmonary resuscitation (CPR) arises suddenly, outcomes are often poor, and the default is for patients to receive the treatment unless they actively decline it. Hospitalists are expected to document code status for every hospitalized patient, but admission code status conversations are often brief—and that might be all right. A code status discussion for a 70-year-old man with no chronic medical problems and excellent functional status who has been admitted for pain after a motor vehicle accident may require only an introduction to the concept of advance care planning, the importance of having a surrogate, and confirmation of full code status. On the other hand, a 45-year-old woman with metastatic pancreatic cancer would likely benefit from a family meeting in which the hospitalist could review her disease course and prognosis, assess her values and priorities in the context of her advanced illness, make treatment recommendations—including code status—that are consistent with her values, and elicit questions.^1,2 We need to free up hospitalists from spending time discussing code status with every patient so that they can spend more time in quality goals of care discussions with seriously ill patients. The paradigm of the one doctor—one patient admission code status conversation for every patient is no longer realistic.

As reported by Merino and colleagues in this issue of JHM, video decision aids about CPR for hospitalized patients can offer an innovative solution to determining code status for hospitalized patients.³ The authors conducted a prospective, randomized controlled trial, which enrolled older adults admitted to the hospital medicine service at the Veteran’s Administration (VA) Hospital in Minneapolis. Participants (N = 119) were randomized to usual care or to watch a 6-minute video that explained code status options, used a mannequin to illustrate a mock code, and provided information about potential complications and survival rates. Patients who watched the video were more likely to choose do not resuscitate/do not intubate status, with a large effect size (56% in the intervention group vs. 17% in the control group, P < 0.00001).

This study adds to a growing body of literature about this powerful modality to assist with advanced care planning. Over the past 10 years, studies—conducted primarily by Volandes, El-Jawahri, and colleagues—have demonstrated how video decision aids impact the care that patients want in the setting of cancer, heart failure, serious illness with short prognosis, and future dementia.^4-9 This literature has also shown that video decision aids can increase patients’ knowledge about CPR and increase the stability of decisions over time. Further, video decision aids have been well accepted by patients, who report that they would recommended such videos to others. This body of evidence underscores the potential of video decision aids to improve concordance between patient preferences and care provided, which is key given the longstanding and widespread concern about patients receiving care that is inconsistent with their values at the end of life.¹⁰ In short, video decision aids work.

Merino and colleagues are the first to examine the use of a video decision aid about code status in a general population of older adults on a hospital medicine service and the second to integrate such a video into usual inpatient care, which are important advancements.^2,3 There are several issues that warrant further consideration prior to widely disseminating such a video, however. As the authors note, the participants in this VA study were overwhelmingly white men and their average age was 75. Further, the authors found a nonsignificant trend towards patients in the intervention group having less trust that “my doctors and healthcare team want what is best for me” (76% in the intervention group vs. 93% in the control group; P = 0.083). Decision making about life-sustaining therapies and reactions to communication about serious illness are heavily influenced by cultural and socioeconomic factors, including health literacy.¹¹ It will be important to seek feedback from a diverse group of patients and families to ensure that the video decision aid is interpreted accurately, renders decisions that are consistent with patients’ values, and does not negatively impact the clinician-patient relationship.¹² Additionally, as the above cases illustrate, code status discussions should be tailored to patient factors, including illness severity and point in the disease course. Hospitalists will ultimately benefit from having access to multiple different videos about a range of advance care planning topics that can be used when appropriate.

In addition to selecting the right video for the right patient, the next challenge for hospitalists and health systems will be how to implement them within real-world clinical care and a broader approach to advance care planning. There are technical and logistical challenges to displaying videos in hospital rooms, and more significant challenges in ensuring timely follow-up discussions, communication of patients’ dynamic care preferences to their surrogates, changes to inpatient orders, documentation in the electronic medical record where it can be easily found in the future, and completion of advance directives and Physician Orders for Life Sustaining Treatment forms to communicate patients’ goals of care beyond the hospital and health system. Each of these steps is critical and is supported through videos and activities in the free, patient-facing, PREPARE web-based tool (https://www.prepareforyourcare.org/).^2,13,14

The ubiquitous presence of videos in our lives speaks to their power to engage and affect us. Video decision aids provide detailed explanations and vivid images that convey more than words can alone. While there is more work to be done to ensure videos are appropriate for all hospitalized patients and support rather than detract from patient-doctor relationships, this study and others like it show that video decision aids are potent tools to promote better decision-making and higher value, more efficient care.

Disclosures

The authors have nothing to disclose.

Whether robbing banks or reducing healthcare spending, it makes sense to go where the money is. In the case of healthcare, 32% of spending goes to inpatient care, so hospitals represent a logical target for cost-reduction efforts. Because most hospital costs are fixed, there are basically 2 approaches to reducing spending—shorten length of stay or keep patients out of the hospital altogether. The government has tried both, using the power of financial incentives to spur adoption.

Faced with soaring hospital costs in the 1980s, Medicare introduced its prospective payment system, offering hospitals a fixed payment for each specific Diagnosis-Related Group. Hospitals responded by discharging patients sooner, with a resultant rise in admissions to skilled nursing facilities (SNFs) and rapid growth of the home care industry. Length of stay fell dramatically, dropping 9% in 1984 alone.¹ It continued to decline through the 1990s, falling by almost 20% between 1993 and 2000. In the following decade, despite the rise of hospital medicine, the rate of decrease slowed to 0.2% per year.²

Attention then turned to readmissions. In 2008, the Medicare Payment Advisory Committee proposed that hospitals with high risk-adjusted readmission rates receive lower payments, arguing that readmissions accounted for $15 billion in Medicare spending and that many were preventable. Thus the Hospital Readmissions Reduction Program was born, introducing readmission penalties in 2012.

Numerous interventions emerged from government and nongovernment parties to reduce readmissions. Many used intensive transitional care programs focusing on early follow-up or medication safety, and some even went as far as providing transitional housing.³ Shortly after passage of the Affordable Care Act, readmission rates fell rapidly. Within a few years, however, the rate of decline slowed dramatically and may have reached a plateau.⁴ Many have argued that only a small proportion of readmissions are preventable and that there are more direct ways to promote improved discharge planning without diverting resources from other areas.⁵ It seems that readmissions may not be feasibly reduced much further.

With the advent of accountable care organizations, health systems are now turning their focus to the small population of patients who consume a disproportionate share of healthcare dollars. Because the top 1% of patients—so-called super-utilizers—account for 21% of spending, efforts to reduce their utilization could produce outsized returns.⁶ Initial anecdotal reports described patients with complex physical, behavior, and social needs receiving fragmented care resulting in myriad expensive admissions. The response comprised teams of social workers and community health workers coupled with robust primary care, formulating individualized solutions. However, data supporting the effectiveness of this common-sense approach are lacking. In addition, our understanding of high-cost patients is evolving. For one thing, being a super-utilizer is often temporary, as just over one-quarter are still in that category a year later.⁷ Moreover, not all high-cost patients are frequently admitted.⁸

In this issue of The Journal of Hospital Medicine, Wick et al.⁹ provide additional insight into high utilizers of hospital services. The authors compare definitions of high utilizers based on cost, number of admissions, or cumulative length of stay over one year. Only 10 percent of high utilizers met all 3 definitions. The overlap between high utilizers by cost and length of stay was twice the overlap between high utilizers by number of admissions and either group. This finding is not surprising because hospitals have high fixed costs, so total cost tends to mirror length of stay.

The study was performed in Canada, and the overlap among these groups may be different in the US. The Canadian patients were hospitalized less frequently than their American counterparts, perhaps reflecting better access to primary care in the Canadian system. Regardless, Wick et al.⁹ add to the growing literature suggesting that the terms “high utilization” and “high cost” do not always describe the same population. This finding is important because strategies aimed at patients who are frequently admitted may not be effective for those who generate the highest costs. In trying to reduce overall costs, it may be time to revisit length of stay.

Given the long history of prospective payment in the US and the stagnation in length of stay over the past decade, it is reasonable to wonder whether further reductions are possible. In the study by Wick et al.,⁹ patients with longer lengths of stay were discharged to long-term care facilities. This observation is consistent with others’ reports. Studies of delays in care show that at least 10% of all hospital days can be attributed to delays in discharge, especially to SNFs. In the most recent study, 11% of hospital days were deemed unnecessary by hospitalists, with one-third of those delays due to lack of availability at an extended care facility.¹⁰ Six years earlier, Carey et al. found that 13.5% of inpatient days were unnecessary, with more than 60% of delays attributable to waiting for discharge to a SNF.¹¹

How, then, might we curtail unnecessary waiting, and whose job is it to solve the problem? The prospective payment system should reward hospitals for eliminating waiting—particularly those hospitals operating at capacity, for which the opportunity costs of occupied beds are most acute. Hospitalists, per se, have no incentive to discharge patients who are waiting; these patients are easy to round on, rarely have emergencies, and generate daily bills. Even when hospitalists are employed by the hospital and incentives for both are aligned, hospitalists may still be powerless to discharge waiting patients, summon busy consultants, or create extra slots in the endoscopy suite.

The move to value at the system level may offer hope. As health systems become responsible for the total cost of care, their focus must shift from the individual areas where care is provided to the transitions of care between treatment areas. It is in these transitions that US healthcare has failed most spectacularly, and consequently, it is where the greatest opportunity lies.

To date, most discharge interventions have focused on communication, with a goal of improving patient safety and, to a lesser extent, preventing readmissions. Partnering with SNFs can reduce the rate of readmissions,¹² but for the most part, the incentives for hospitals and post-acute care facilities remain misaligned. Because post-acute care facilities are paid per diem, they have little incentive to reduce patients’ stays or to admit new patients, who are more expensive to care for than existing ones. Physicians round on SNF patients infrequently and have no incentive to discharge patients, exacerbating the problem. Because post-acute care represents a growing proportion of costs for both medical and surgical patients, health systems will need to either have their own facilities or enter into contracts that align the incentives.

What can hospitalists do? As the predominant coordinators of hospitalized patients’ care both for medical and surgical teams, hospitalists meaningfully impact readmissions and lengths of stay through the care they provide.¹³ More important, as their roles in optimizing hospital throughput¹⁴ continue to expand, hospitalists are perhaps best positioned to observe a diverse range of inefficiencies and inadequacies in inpatient practice and translate those observations into new systems of care. Through thoughtful participation in hospital operations, administration, and health services research, hospitalists hold the key to improving the value of care we provide.

Disclosure 

Nothing to report.

Whether robbing banks or reducing healthcare spending, it makes sense to go where the money is. In the case of healthcare, 32% of spending goes to inpatient care, so hospitals represent a logical target for cost-reduction efforts. Because most hospital costs are fixed, there are basically 2 approaches to reducing spending—shorten length of stay or keep patients out of the hospital altogether. The government has tried both, using the power of financial incentives to spur adoption.

Faced with soaring hospital costs in the 1980s, Medicare introduced its prospective payment system, offering hospitals a fixed payment for each specific Diagnosis-Related Group. Hospitals responded by discharging patients sooner, with a resultant rise in admissions to skilled nursing facilities (SNFs) and rapid growth of the home care industry. Length of stay fell dramatically, dropping 9% in 1984 alone.¹ It continued to decline through the 1990s, falling by almost 20% between 1993 and 2000. In the following decade, despite the rise of hospital medicine, the rate of decrease slowed to 0.2% per year.²

Attention then turned to readmissions. In 2008, the Medicare Payment Advisory Committee proposed that hospitals with high risk-adjusted readmission rates receive lower payments, arguing that readmissions accounted for $15 billion in Medicare spending and that many were preventable. Thus the Hospital Readmissions Reduction Program was born, introducing readmission penalties in 2012.

Numerous interventions emerged from government and nongovernment parties to reduce readmissions. Many used intensive transitional care programs focusing on early follow-up or medication safety, and some even went as far as providing transitional housing.³ Shortly after passage of the Affordable Care Act, readmission rates fell rapidly. Within a few years, however, the rate of decline slowed dramatically and may have reached a plateau.⁴ Many have argued that only a small proportion of readmissions are preventable and that there are more direct ways to promote improved discharge planning without diverting resources from other areas.⁵ It seems that readmissions may not be feasibly reduced much further.

With the advent of accountable care organizations, health systems are now turning their focus to the small population of patients who consume a disproportionate share of healthcare dollars. Because the top 1% of patients—so-called super-utilizers—account for 21% of spending, efforts to reduce their utilization could produce outsized returns.⁶ Initial anecdotal reports described patients with complex physical, behavior, and social needs receiving fragmented care resulting in myriad expensive admissions. The response comprised teams of social workers and community health workers coupled with robust primary care, formulating individualized solutions. However, data supporting the effectiveness of this common-sense approach are lacking. In addition, our understanding of high-cost patients is evolving. For one thing, being a super-utilizer is often temporary, as just over one-quarter are still in that category a year later.⁷ Moreover, not all high-cost patients are frequently admitted.⁸

In this issue of The Journal of Hospital Medicine, Wick et al.⁹ provide additional insight into high utilizers of hospital services. The authors compare definitions of high utilizers based on cost, number of admissions, or cumulative length of stay over one year. Only 10 percent of high utilizers met all 3 definitions. The overlap between high utilizers by cost and length of stay was twice the overlap between high utilizers by number of admissions and either group. This finding is not surprising because hospitals have high fixed costs, so total cost tends to mirror length of stay.

The study was performed in Canada, and the overlap among these groups may be different in the US. The Canadian patients were hospitalized less frequently than their American counterparts, perhaps reflecting better access to primary care in the Canadian system. Regardless, Wick et al.⁹ add to the growing literature suggesting that the terms “high utilization” and “high cost” do not always describe the same population. This finding is important because strategies aimed at patients who are frequently admitted may not be effective for those who generate the highest costs. In trying to reduce overall costs, it may be time to revisit length of stay.

Given the long history of prospective payment in the US and the stagnation in length of stay over the past decade, it is reasonable to wonder whether further reductions are possible. In the study by Wick et al.,⁹ patients with longer lengths of stay were discharged to long-term care facilities. This observation is consistent with others’ reports. Studies of delays in care show that at least 10% of all hospital days can be attributed to delays in discharge, especially to SNFs. In the most recent study, 11% of hospital days were deemed unnecessary by hospitalists, with one-third of those delays due to lack of availability at an extended care facility.¹⁰ Six years earlier, Carey et al. found that 13.5% of inpatient days were unnecessary, with more than 60% of delays attributable to waiting for discharge to a SNF.¹¹

How, then, might we curtail unnecessary waiting, and whose job is it to solve the problem? The prospective payment system should reward hospitals for eliminating waiting—particularly those hospitals operating at capacity, for which the opportunity costs of occupied beds are most acute. Hospitalists, per se, have no incentive to discharge patients who are waiting; these patients are easy to round on, rarely have emergencies, and generate daily bills. Even when hospitalists are employed by the hospital and incentives for both are aligned, hospitalists may still be powerless to discharge waiting patients, summon busy consultants, or create extra slots in the endoscopy suite.

The move to value at the system level may offer hope. As health systems become responsible for the total cost of care, their focus must shift from the individual areas where care is provided to the transitions of care between treatment areas. It is in these transitions that US healthcare has failed most spectacularly, and consequently, it is where the greatest opportunity lies.

To date, most discharge interventions have focused on communication, with a goal of improving patient safety and, to a lesser extent, preventing readmissions. Partnering with SNFs can reduce the rate of readmissions,¹² but for the most part, the incentives for hospitals and post-acute care facilities remain misaligned. Because post-acute care facilities are paid per diem, they have little incentive to reduce patients’ stays or to admit new patients, who are more expensive to care for than existing ones. Physicians round on SNF patients infrequently and have no incentive to discharge patients, exacerbating the problem. Because post-acute care represents a growing proportion of costs for both medical and surgical patients, health systems will need to either have their own facilities or enter into contracts that align the incentives.

What can hospitalists do? As the predominant coordinators of hospitalized patients’ care both for medical and surgical teams, hospitalists meaningfully impact readmissions and lengths of stay through the care they provide.¹³ More important, as their roles in optimizing hospital throughput¹⁴ continue to expand, hospitalists are perhaps best positioned to observe a diverse range of inefficiencies and inadequacies in inpatient practice and translate those observations into new systems of care. Through thoughtful participation in hospital operations, administration, and health services research, hospitalists hold the key to improving the value of care we provide.

Disclosure 

Nothing to report.

Whether robbing banks or reducing healthcare spending, it makes sense to go where the money is. In the case of healthcare, 32% of spending goes to inpatient care, so hospitals represent a logical target for cost-reduction efforts. Because most hospital costs are fixed, there are basically 2 approaches to reducing spending—shorten length of stay or keep patients out of the hospital altogether. The government has tried both, using the power of financial incentives to spur adoption.

Faced with soaring hospital costs in the 1980s, Medicare introduced its prospective payment system, offering hospitals a fixed payment for each specific Diagnosis-Related Group. Hospitals responded by discharging patients sooner, with a resultant rise in admissions to skilled nursing facilities (SNFs) and rapid growth of the home care industry. Length of stay fell dramatically, dropping 9% in 1984 alone.¹ It continued to decline through the 1990s, falling by almost 20% between 1993 and 2000. In the following decade, despite the rise of hospital medicine, the rate of decrease slowed to 0.2% per year.²

Attention then turned to readmissions. In 2008, the Medicare Payment Advisory Committee proposed that hospitals with high risk-adjusted readmission rates receive lower payments, arguing that readmissions accounted for $15 billion in Medicare spending and that many were preventable. Thus the Hospital Readmissions Reduction Program was born, introducing readmission penalties in 2012.

Numerous interventions emerged from government and nongovernment parties to reduce readmissions. Many used intensive transitional care programs focusing on early follow-up or medication safety, and some even went as far as providing transitional housing.³ Shortly after passage of the Affordable Care Act, readmission rates fell rapidly. Within a few years, however, the rate of decline slowed dramatically and may have reached a plateau.⁴ Many have argued that only a small proportion of readmissions are preventable and that there are more direct ways to promote improved discharge planning without diverting resources from other areas.⁵ It seems that readmissions may not be feasibly reduced much further.

With the advent of accountable care organizations, health systems are now turning their focus to the small population of patients who consume a disproportionate share of healthcare dollars. Because the top 1% of patients—so-called super-utilizers—account for 21% of spending, efforts to reduce their utilization could produce outsized returns.⁶ Initial anecdotal reports described patients with complex physical, behavior, and social needs receiving fragmented care resulting in myriad expensive admissions. The response comprised teams of social workers and community health workers coupled with robust primary care, formulating individualized solutions. However, data supporting the effectiveness of this common-sense approach are lacking. In addition, our understanding of high-cost patients is evolving. For one thing, being a super-utilizer is often temporary, as just over one-quarter are still in that category a year later.⁷ Moreover, not all high-cost patients are frequently admitted.⁸

In this issue of The Journal of Hospital Medicine, Wick et al.⁹ provide additional insight into high utilizers of hospital services. The authors compare definitions of high utilizers based on cost, number of admissions, or cumulative length of stay over one year. Only 10 percent of high utilizers met all 3 definitions. The overlap between high utilizers by cost and length of stay was twice the overlap between high utilizers by number of admissions and either group. This finding is not surprising because hospitals have high fixed costs, so total cost tends to mirror length of stay.

The study was performed in Canada, and the overlap among these groups may be different in the US. The Canadian patients were hospitalized less frequently than their American counterparts, perhaps reflecting better access to primary care in the Canadian system. Regardless, Wick et al.⁹ add to the growing literature suggesting that the terms “high utilization” and “high cost” do not always describe the same population. This finding is important because strategies aimed at patients who are frequently admitted may not be effective for those who generate the highest costs. In trying to reduce overall costs, it may be time to revisit length of stay.

Given the long history of prospective payment in the US and the stagnation in length of stay over the past decade, it is reasonable to wonder whether further reductions are possible. In the study by Wick et al.,⁹ patients with longer lengths of stay were discharged to long-term care facilities. This observation is consistent with others’ reports. Studies of delays in care show that at least 10% of all hospital days can be attributed to delays in discharge, especially to SNFs. In the most recent study, 11% of hospital days were deemed unnecessary by hospitalists, with one-third of those delays due to lack of availability at an extended care facility.¹⁰ Six years earlier, Carey et al. found that 13.5% of inpatient days were unnecessary, with more than 60% of delays attributable to waiting for discharge to a SNF.¹¹

How, then, might we curtail unnecessary waiting, and whose job is it to solve the problem? The prospective payment system should reward hospitals for eliminating waiting—particularly those hospitals operating at capacity, for which the opportunity costs of occupied beds are most acute. Hospitalists, per se, have no incentive to discharge patients who are waiting; these patients are easy to round on, rarely have emergencies, and generate daily bills. Even when hospitalists are employed by the hospital and incentives for both are aligned, hospitalists may still be powerless to discharge waiting patients, summon busy consultants, or create extra slots in the endoscopy suite.

The move to value at the system level may offer hope. As health systems become responsible for the total cost of care, their focus must shift from the individual areas where care is provided to the transitions of care between treatment areas. It is in these transitions that US healthcare has failed most spectacularly, and consequently, it is where the greatest opportunity lies.

To date, most discharge interventions have focused on communication, with a goal of improving patient safety and, to a lesser extent, preventing readmissions. Partnering with SNFs can reduce the rate of readmissions,¹² but for the most part, the incentives for hospitals and post-acute care facilities remain misaligned. Because post-acute care facilities are paid per diem, they have little incentive to reduce patients’ stays or to admit new patients, who are more expensive to care for than existing ones. Physicians round on SNF patients infrequently and have no incentive to discharge patients, exacerbating the problem. Because post-acute care represents a growing proportion of costs for both medical and surgical patients, health systems will need to either have their own facilities or enter into contracts that align the incentives.

What can hospitalists do? As the predominant coordinators of hospitalized patients’ care both for medical and surgical teams, hospitalists meaningfully impact readmissions and lengths of stay through the care they provide.¹³ More important, as their roles in optimizing hospital throughput¹⁴ continue to expand, hospitalists are perhaps best positioned to observe a diverse range of inefficiencies and inadequacies in inpatient practice and translate those observations into new systems of care. Through thoughtful participation in hospital operations, administration, and health services research, hospitalists hold the key to improving the value of care we provide.

Disclosure 

Nothing to report.

Physicians, researchers, and policymakers aspire to improve the value of healthcare, with reduced overall costs of care and improved outcomes. An important component of increasing healthcare costs in the United States is the rising cost of prescription medications, accounting for an estimated 17% of all spending in healthcare services.¹ One potentially modifiable driver of low-value prescribing is poor awareness of medication cost.² While displaying price to the ordering physician has reduced laboratory order volume and associated testing costs,^3,4 applying cost transparency to medication ordering has produced variable results, perhaps reflecting conceptual differences in decision making regarding diagnosis and treatment.^4-6

In this issue of the Journal of Hospital Medicine, Conway et al.⁷ performed a retrospective analysis applying interrupted times series models to measure the impact of passive cost display on the ordering frequency of 9 high-cost intravenous (IV) or inhaled medications that were identified as likely overused. For 7 of the IV medications, lower-cost oral alternatives were available; 2 study medications had no clear therapeutic alternatives. It was expected that lower-cost oral alternatives would have a concomitant increase in ordering rate as the order rate of the study medications decreased (eg, oral linezolid use would increase as IV linezolid use decreased). Order rate was the primary outcome, reported each week as treatment orders per 10,000 patient days, and was compared for both the pre- and postimplementation time periods. The particular methodology of segmented regressions allowed the research team to control for preintervention trends in medication ordering, as well as to analyze both immediate and delayed effects of the cost-display intervention. The research team framed the cost display as a passive approach. The intervention displayed average wholesale cost data and lower-cost oral alternatives on the ordering screen, which did not significantly reduce the ordering rate. Over the course of the study, outside influences led to 2 more active approaches to higher-cost medications, and Conway et al. wisely measured their effect as well. Specifically, the IV pantoprazole ordering rate decreased after restrictions secondary to a national medication shortage, and the oral voriconazole ordering rate decreased following an oncology order set change from oral voriconazole to oral posaconazole. These ordering-rate decreases were not temporally related to the implementation of the cost display intervention.

It is important to note several limitations of this study, some of which the authors discuss in the manuscript. Because 2 of the medications studied (eculizumab and calcitonin) do not have direct therapeutic alternatives, it is not surprising that price display alone would have no effect. The ordering providers who received this cost information had a more complex decision to make than they would in a scenario with a lower-cost alternative, essentially requiring them to ask “Does this patient need this class of medications at all?” rather than simply, “Is a lower-cost alternative appropriate?” Similarly, choosing medication alternatives that would require different routes of administration (ie, IV and oral) may have limited the effectiveness of a price intervention, given that factors such as illness severity also may influence the decision between IV and oral agents. Thus, the lack of an effect for the price display intervention for these specific medications may not be generalizable to all other medication decisions. Additionally, this manuscript offers limited data on the context in which the intervention was implemented and what adaptations, if any, were made based on early findings. The results may have varied greatly based on the visual design and how the cost display was presented within the electronic medical record. The wider organizational context may also have affected the intervention’s impact. A cost-display intervention appearing in isolation could understandably have a different impact, compared with an intervention within the context of a broader cost/value curriculum directed at house staff and faculty.

In summary, Conway et al. found that just displaying cost data did little to change prescribing patterns, but that more active approaches were quite efficacious. So where does this leave value-minded hospitalists looking to reduce overuse? Relatedly, what are the next steps for research and improvement science? We think there are 3 key strategic areas on which to focus. First, behavioral economics offers a critically important middle ground between the passive approaches studied here and more heavy-handed approaches that may limit provider autonomy, such as restricting drug use at the formulary.⁸ An improved choice architecture that presents the preferred higher-value option as the default selection may result in improved adoption of the high-value choice while also preserving provider autonomy and expertise required when clinical circumstances make the higher-cost drug the better choice.^9,10 The second consideration is to minimize ethical tensions between cost displays that discourage use and a provider’s belief that a treatment is beneficial. Using available ethical frameworks for high-value care that engage both patient and societal concerns may help us choose and design interventions with more successful outcomes.¹¹ Finally, research has shown that providers have poor knowledge of both cost and the relative benefits and harms of treatments and testing.¹² Thus, the third opportunity for improvement is to provide appropriate clinical information (ie, relative therapeutic equivalency or adverse effects in alternative therapies) to support decision making at the point of order entry. Encouraging data already exists regarding how drug facts boxes can help patients understand benefits and side effects.¹³ A similar approach may aid physicians and may prove an easier task than improving patient understanding, given physicians’ substantial existing knowledge. These strategies may help guide providers to make a more informed value determination and obviate some ethical concerns related to clinical decisions based on cost alone. Despite their negative results, Conway et al.⁷ provided additional evidence that influencing complex decision making is not easy. However, we believe that continuing research into the factors that lead to successful value interventions has incredible potential for supporting high-value decision making in the future.

Disclosure 

Nothing to report.

Physicians, researchers, and policymakers aspire to improve the value of healthcare, with reduced overall costs of care and improved outcomes. An important component of increasing healthcare costs in the United States is the rising cost of prescription medications, accounting for an estimated 17% of all spending in healthcare services.¹ One potentially modifiable driver of low-value prescribing is poor awareness of medication cost.² While displaying price to the ordering physician has reduced laboratory order volume and associated testing costs,^3,4 applying cost transparency to medication ordering has produced variable results, perhaps reflecting conceptual differences in decision making regarding diagnosis and treatment.^4-6

In this issue of the Journal of Hospital Medicine, Conway et al.⁷ performed a retrospective analysis applying interrupted times series models to measure the impact of passive cost display on the ordering frequency of 9 high-cost intravenous (IV) or inhaled medications that were identified as likely overused. For 7 of the IV medications, lower-cost oral alternatives were available; 2 study medications had no clear therapeutic alternatives. It was expected that lower-cost oral alternatives would have a concomitant increase in ordering rate as the order rate of the study medications decreased (eg, oral linezolid use would increase as IV linezolid use decreased). Order rate was the primary outcome, reported each week as treatment orders per 10,000 patient days, and was compared for both the pre- and postimplementation time periods. The particular methodology of segmented regressions allowed the research team to control for preintervention trends in medication ordering, as well as to analyze both immediate and delayed effects of the cost-display intervention. The research team framed the cost display as a passive approach. The intervention displayed average wholesale cost data and lower-cost oral alternatives on the ordering screen, which did not significantly reduce the ordering rate. Over the course of the study, outside influences led to 2 more active approaches to higher-cost medications, and Conway et al. wisely measured their effect as well. Specifically, the IV pantoprazole ordering rate decreased after restrictions secondary to a national medication shortage, and the oral voriconazole ordering rate decreased following an oncology order set change from oral voriconazole to oral posaconazole. These ordering-rate decreases were not temporally related to the implementation of the cost display intervention.

It is important to note several limitations of this study, some of which the authors discuss in the manuscript. Because 2 of the medications studied (eculizumab and calcitonin) do not have direct therapeutic alternatives, it is not surprising that price display alone would have no effect. The ordering providers who received this cost information had a more complex decision to make than they would in a scenario with a lower-cost alternative, essentially requiring them to ask “Does this patient need this class of medications at all?” rather than simply, “Is a lower-cost alternative appropriate?” Similarly, choosing medication alternatives that would require different routes of administration (ie, IV and oral) may have limited the effectiveness of a price intervention, given that factors such as illness severity also may influence the decision between IV and oral agents. Thus, the lack of an effect for the price display intervention for these specific medications may not be generalizable to all other medication decisions. Additionally, this manuscript offers limited data on the context in which the intervention was implemented and what adaptations, if any, were made based on early findings. The results may have varied greatly based on the visual design and how the cost display was presented within the electronic medical record. The wider organizational context may also have affected the intervention’s impact. A cost-display intervention appearing in isolation could understandably have a different impact, compared with an intervention within the context of a broader cost/value curriculum directed at house staff and faculty.

In summary, Conway et al. found that just displaying cost data did little to change prescribing patterns, but that more active approaches were quite efficacious. So where does this leave value-minded hospitalists looking to reduce overuse? Relatedly, what are the next steps for research and improvement science? We think there are 3 key strategic areas on which to focus. First, behavioral economics offers a critically important middle ground between the passive approaches studied here and more heavy-handed approaches that may limit provider autonomy, such as restricting drug use at the formulary.⁸ An improved choice architecture that presents the preferred higher-value option as the default selection may result in improved adoption of the high-value choice while also preserving provider autonomy and expertise required when clinical circumstances make the higher-cost drug the better choice.^9,10 The second consideration is to minimize ethical tensions between cost displays that discourage use and a provider’s belief that a treatment is beneficial. Using available ethical frameworks for high-value care that engage both patient and societal concerns may help us choose and design interventions with more successful outcomes.¹¹ Finally, research has shown that providers have poor knowledge of both cost and the relative benefits and harms of treatments and testing.¹² Thus, the third opportunity for improvement is to provide appropriate clinical information (ie, relative therapeutic equivalency or adverse effects in alternative therapies) to support decision making at the point of order entry. Encouraging data already exists regarding how drug facts boxes can help patients understand benefits and side effects.¹³ A similar approach may aid physicians and may prove an easier task than improving patient understanding, given physicians’ substantial existing knowledge. These strategies may help guide providers to make a more informed value determination and obviate some ethical concerns related to clinical decisions based on cost alone. Despite their negative results, Conway et al.⁷ provided additional evidence that influencing complex decision making is not easy. However, we believe that continuing research into the factors that lead to successful value interventions has incredible potential for supporting high-value decision making in the future.

Disclosure 

Nothing to report.

Physicians, researchers, and policymakers aspire to improve the value of healthcare, with reduced overall costs of care and improved outcomes. An important component of increasing healthcare costs in the United States is the rising cost of prescription medications, accounting for an estimated 17% of all spending in healthcare services.¹ One potentially modifiable driver of low-value prescribing is poor awareness of medication cost.² While displaying price to the ordering physician has reduced laboratory order volume and associated testing costs,^3,4 applying cost transparency to medication ordering has produced variable results, perhaps reflecting conceptual differences in decision making regarding diagnosis and treatment.^4-6

In this issue of the Journal of Hospital Medicine, Conway et al.⁷ performed a retrospective analysis applying interrupted times series models to measure the impact of passive cost display on the ordering frequency of 9 high-cost intravenous (IV) or inhaled medications that were identified as likely overused. For 7 of the IV medications, lower-cost oral alternatives were available; 2 study medications had no clear therapeutic alternatives. It was expected that lower-cost oral alternatives would have a concomitant increase in ordering rate as the order rate of the study medications decreased (eg, oral linezolid use would increase as IV linezolid use decreased). Order rate was the primary outcome, reported each week as treatment orders per 10,000 patient days, and was compared for both the pre- and postimplementation time periods. The particular methodology of segmented regressions allowed the research team to control for preintervention trends in medication ordering, as well as to analyze both immediate and delayed effects of the cost-display intervention. The research team framed the cost display as a passive approach. The intervention displayed average wholesale cost data and lower-cost oral alternatives on the ordering screen, which did not significantly reduce the ordering rate. Over the course of the study, outside influences led to 2 more active approaches to higher-cost medications, and Conway et al. wisely measured their effect as well. Specifically, the IV pantoprazole ordering rate decreased after restrictions secondary to a national medication shortage, and the oral voriconazole ordering rate decreased following an oncology order set change from oral voriconazole to oral posaconazole. These ordering-rate decreases were not temporally related to the implementation of the cost display intervention.

It is important to note several limitations of this study, some of which the authors discuss in the manuscript. Because 2 of the medications studied (eculizumab and calcitonin) do not have direct therapeutic alternatives, it is not surprising that price display alone would have no effect. The ordering providers who received this cost information had a more complex decision to make than they would in a scenario with a lower-cost alternative, essentially requiring them to ask “Does this patient need this class of medications at all?” rather than simply, “Is a lower-cost alternative appropriate?” Similarly, choosing medication alternatives that would require different routes of administration (ie, IV and oral) may have limited the effectiveness of a price intervention, given that factors such as illness severity also may influence the decision between IV and oral agents. Thus, the lack of an effect for the price display intervention for these specific medications may not be generalizable to all other medication decisions. Additionally, this manuscript offers limited data on the context in which the intervention was implemented and what adaptations, if any, were made based on early findings. The results may have varied greatly based on the visual design and how the cost display was presented within the electronic medical record. The wider organizational context may also have affected the intervention’s impact. A cost-display intervention appearing in isolation could understandably have a different impact, compared with an intervention within the context of a broader cost/value curriculum directed at house staff and faculty.

In summary, Conway et al. found that just displaying cost data did little to change prescribing patterns, but that more active approaches were quite efficacious. So where does this leave value-minded hospitalists looking to reduce overuse? Relatedly, what are the next steps for research and improvement science? We think there are 3 key strategic areas on which to focus. First, behavioral economics offers a critically important middle ground between the passive approaches studied here and more heavy-handed approaches that may limit provider autonomy, such as restricting drug use at the formulary.⁸ An improved choice architecture that presents the preferred higher-value option as the default selection may result in improved adoption of the high-value choice while also preserving provider autonomy and expertise required when clinical circumstances make the higher-cost drug the better choice.^9,10 The second consideration is to minimize ethical tensions between cost displays that discourage use and a provider’s belief that a treatment is beneficial. Using available ethical frameworks for high-value care that engage both patient and societal concerns may help us choose and design interventions with more successful outcomes.¹¹ Finally, research has shown that providers have poor knowledge of both cost and the relative benefits and harms of treatments and testing.¹² Thus, the third opportunity for improvement is to provide appropriate clinical information (ie, relative therapeutic equivalency or adverse effects in alternative therapies) to support decision making at the point of order entry. Encouraging data already exists regarding how drug facts boxes can help patients understand benefits and side effects.¹³ A similar approach may aid physicians and may prove an easier task than improving patient understanding, given physicians’ substantial existing knowledge. These strategies may help guide providers to make a more informed value determination and obviate some ethical concerns related to clinical decisions based on cost alone. Despite their negative results, Conway et al.⁷ provided additional evidence that influencing complex decision making is not easy. However, we believe that continuing research into the factors that lead to successful value interventions has incredible potential for supporting high-value decision making in the future.

Disclosure 

Nothing to report.

According to a report from the US Centers for Disease Control and Prevention (CDC) on the incidence of sexually transmitted diseases (STDs), “Total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever”¹ since the CDC was founded in July 1946.

See related article

Nearly 24,000 cases of primary and secondary syphilis were reported in 2015, a 19% increase from the previous year. And Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, reported, “We have reached a decisive moment for the nation. STD rates are rising, and many of the country’s systems for preventing STDs have eroded. We must mobilize, rebuild, and expand services—or the human and economic burden will continue to grow.”¹

Dr. Mermin stressed the need to rebuild services because, “In recent years more than half of state and local STD programs have experienced budget cuts, resulting in more than 20 health department STD clinic closures in one year alone. Fewer clinics mean reduced access to STD testing and treatment for those who need these services.”¹

The CDC also reports that STD treatment costs the US healthcare system nearly $16 billion each year.

The CDC has identified several players whose engagement is necessary to stem the tide of this epidemic:

• Providers must make STD screening a standard part of medical care, especially in pregnant women, and integrate STD prevention and treatment into prenatal care and other routine visits.
• People need to talk openly about STDs, get tested regularly, and reduce risk by using condoms or practicing mutual monogamy if sexually active.
• Parents and providers need to offer young people safe, effective ways to get information and services.
• State and local health departments should continue to direct resources to people hardest hit by the STD epidemic and work with community partners to maximize their impact.¹

STD CAMPAIGNS 100 YEARS AGO

This message sounds familiar. Let’s go back 100 years to World War I. The book No Magic Bullet by Allan M. Brandt² provides fascinating details about this period in America’s battle against venereal diseases. While the book is well worth reading in its entirety, I will attempt here to summarize the pertinent facts.

In the late 1910s, antivenereal campaigns were in full swing, with publicly shown movies such as “Fit to Fight” to train soldiers about STD symptoms and prevention to keep them physically healthy for fighting in the war. Similar information was widely available stateside for both men and women in open, matter-of-fact formats to encourage STD prevention.

After the war ended, the national sentiment became split between sexual revolution and social moralism. “Social hygienists” blamed the widespread increase in promiscuity on the newly introduced sexually explicit philosophy of Sigmund Freud, the widespread availability of automobiles (ie, a mobile, private, backseat location for sex), popular “vulgar” dances, and social feminism, among many others. The sexual revolution clearly led to an increased risk of STDs. But the antivenereal campaigns that had been appropriate in wartime came to be considered amoral and unfit for public consumption, and a period of silence about venereal diseases ensued.

By the 1930s, the situation had worsened:

• Approximately 1 out of every 10 Americans suffered from syphilis.
• Each year, Americans contracted almost half a million new syphilis infections (twice as many cases as tuberculosis, and 100 times as many cases as polio).
• 18% of all deaths from organic heart disease could be attributed to syphilis.
• Up to 20% of all mental institution inmates suffered from tertiary syphilis.
• 60,000 children were born each year with congenital syphilis.²

Although penicillin was still a decade or more away from discovery, syphilis could be treated, though likely not cured, with arsenic compounds. A course of treatment from a private physician, however, could cost from $300 to $1,000. Many patients who could not pay these exorbitant prices turned to public clinics for help. However, funding for the Venereal Disease Division of the Public Health Service, originally $4 million in 1920, was cut to less than $60,000 by 1926.² Some hospitals refused to admit patients with syphilis and other venereal diseases, deeming them “morally tainted and less deserving of care.”²

Things couldn’t get much worse.

Dr. Thomas Parran was the New York State health commissioner in 1930, at the start of the Great Depression. Realizing that arguments for moral responsibility to prevent and treat venereal diseases were not effective, Dr. Parran and other public health officials turned to financial arguments. Among the most persuasive arguments, “More than $15 million was spent annually for the ambulatory care of venereal patients…Experts argued that syphilis costs taxpayers between $40 and $50 million each year for the institutional care of the insane, paralyzed, and blind.”² The American Medical Association calculated that “8 to 10 million workers lost 21 million working days each year at an average of $4 a day as a result of infection with these conditions.”² The cost was estimated at more than $100,000,000 annually.²

But the general public was not a part of the larger conversation regarding treatment and prevention of syphilis, thanks to the social hygienists. In November 1934, Dr. Parran was scheduled to give a radio broadcast on future goals for public health in New York. Notified that he would not be able to mention syphilis or gonorrhea by name, he refused to give the speech. Dr. Parran went on to lead the charge to reduce the moral cloud that blocked the ability to address syphilis openly and scientifically. With his extensive experience in public health, he proposed plans that had been effective in controlling other infectious diseases as measures to control the spread of syphilis. He outlined the following:

• Identify cases of syphilis. Offer free diagnostic centers where individuals could obtain confidential blood tests.
• Offer prompt therapy for identified cases.
• Identify, locate, and test all contacts of infected patients, and treat them if they are infected too.
• Make blood testing mandatory before marriage and early in all pregnancies.
• Educate the public concerning syphilis.²

Do these approaches sound familiar?

Appointed US Surgeon General in 1936 by President Franklin Delano Roosevelt, Dr. Parran published “The next great plague to go,”³ an article focusing on the medical approach to treating syphilis and other venereal diseases, while refusing to address the moral and social issues.³ This was widely acclaimed by the public and the press. Two years after he was blocked from mentioning syphilis and gonorrhea on the radio, he was pictured on the cover of Time magazine for his groundbreaking work.

With the advent of penicillin, syphilis became not only treatable but curable. Over the next decades, the number of patients infected with syphilis and the morbidity it caused continually declined until the 1990s, when there were even whispers of eradication in the United States. This likely came in part due to the AIDS epidemic and the increased public discourse on safe sex.

However, the 1990s saw a new rise in cases of syphilis. This clearly could not be blamed on the social hygienists; rather, it was likely due to apathy and a decline in public health spending. We are now in a period of rapid rise in STDs.

We have the benefit of antibiotics. We have the benefit of hindsight. What we need is to heed the call to arms of Dr. Mermin, to be inspired by the wisdom of Dr. Parran, and to act. Identify the case of syphilis, offer treatment, educate the public. Drs. Coleman, Fiahlo, and Brateanu have accomplished all of these in their article in this issue of the Journal.⁴

According to a report from the US Centers for Disease Control and Prevention (CDC) on the incidence of sexually transmitted diseases (STDs), “Total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever”¹ since the CDC was founded in July 1946.

See related article

Nearly 24,000 cases of primary and secondary syphilis were reported in 2015, a 19% increase from the previous year. And Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, reported, “We have reached a decisive moment for the nation. STD rates are rising, and many of the country’s systems for preventing STDs have eroded. We must mobilize, rebuild, and expand services—or the human and economic burden will continue to grow.”¹

Dr. Mermin stressed the need to rebuild services because, “In recent years more than half of state and local STD programs have experienced budget cuts, resulting in more than 20 health department STD clinic closures in one year alone. Fewer clinics mean reduced access to STD testing and treatment for those who need these services.”¹

The CDC also reports that STD treatment costs the US healthcare system nearly $16 billion each year.

The CDC has identified several players whose engagement is necessary to stem the tide of this epidemic:

• Providers must make STD screening a standard part of medical care, especially in pregnant women, and integrate STD prevention and treatment into prenatal care and other routine visits.
• People need to talk openly about STDs, get tested regularly, and reduce risk by using condoms or practicing mutual monogamy if sexually active.
• Parents and providers need to offer young people safe, effective ways to get information and services.
• State and local health departments should continue to direct resources to people hardest hit by the STD epidemic and work with community partners to maximize their impact.¹

STD CAMPAIGNS 100 YEARS AGO

This message sounds familiar. Let’s go back 100 years to World War I. The book No Magic Bullet by Allan M. Brandt² provides fascinating details about this period in America’s battle against venereal diseases. While the book is well worth reading in its entirety, I will attempt here to summarize the pertinent facts.

In the late 1910s, antivenereal campaigns were in full swing, with publicly shown movies such as “Fit to Fight” to train soldiers about STD symptoms and prevention to keep them physically healthy for fighting in the war. Similar information was widely available stateside for both men and women in open, matter-of-fact formats to encourage STD prevention.

After the war ended, the national sentiment became split between sexual revolution and social moralism. “Social hygienists” blamed the widespread increase in promiscuity on the newly introduced sexually explicit philosophy of Sigmund Freud, the widespread availability of automobiles (ie, a mobile, private, backseat location for sex), popular “vulgar” dances, and social feminism, among many others. The sexual revolution clearly led to an increased risk of STDs. But the antivenereal campaigns that had been appropriate in wartime came to be considered amoral and unfit for public consumption, and a period of silence about venereal diseases ensued.

By the 1930s, the situation had worsened:

• Approximately 1 out of every 10 Americans suffered from syphilis.
• Each year, Americans contracted almost half a million new syphilis infections (twice as many cases as tuberculosis, and 100 times as many cases as polio).
• 18% of all deaths from organic heart disease could be attributed to syphilis.
• Up to 20% of all mental institution inmates suffered from tertiary syphilis.
• 60,000 children were born each year with congenital syphilis.²

Although penicillin was still a decade or more away from discovery, syphilis could be treated, though likely not cured, with arsenic compounds. A course of treatment from a private physician, however, could cost from $300 to $1,000. Many patients who could not pay these exorbitant prices turned to public clinics for help. However, funding for the Venereal Disease Division of the Public Health Service, originally $4 million in 1920, was cut to less than $60,000 by 1926.² Some hospitals refused to admit patients with syphilis and other venereal diseases, deeming them “morally tainted and less deserving of care.”²

Things couldn’t get much worse.

Dr. Thomas Parran was the New York State health commissioner in 1930, at the start of the Great Depression. Realizing that arguments for moral responsibility to prevent and treat venereal diseases were not effective, Dr. Parran and other public health officials turned to financial arguments. Among the most persuasive arguments, “More than $15 million was spent annually for the ambulatory care of venereal patients…Experts argued that syphilis costs taxpayers between $40 and $50 million each year for the institutional care of the insane, paralyzed, and blind.”² The American Medical Association calculated that “8 to 10 million workers lost 21 million working days each year at an average of $4 a day as a result of infection with these conditions.”² The cost was estimated at more than $100,000,000 annually.²

But the general public was not a part of the larger conversation regarding treatment and prevention of syphilis, thanks to the social hygienists. In November 1934, Dr. Parran was scheduled to give a radio broadcast on future goals for public health in New York. Notified that he would not be able to mention syphilis or gonorrhea by name, he refused to give the speech. Dr. Parran went on to lead the charge to reduce the moral cloud that blocked the ability to address syphilis openly and scientifically. With his extensive experience in public health, he proposed plans that had been effective in controlling other infectious diseases as measures to control the spread of syphilis. He outlined the following:

• Identify cases of syphilis. Offer free diagnostic centers where individuals could obtain confidential blood tests.
• Offer prompt therapy for identified cases.
• Identify, locate, and test all contacts of infected patients, and treat them if they are infected too.
• Make blood testing mandatory before marriage and early in all pregnancies.
• Educate the public concerning syphilis.²

Do these approaches sound familiar?

Appointed US Surgeon General in 1936 by President Franklin Delano Roosevelt, Dr. Parran published “The next great plague to go,”³ an article focusing on the medical approach to treating syphilis and other venereal diseases, while refusing to address the moral and social issues.³ This was widely acclaimed by the public and the press. Two years after he was blocked from mentioning syphilis and gonorrhea on the radio, he was pictured on the cover of Time magazine for his groundbreaking work.

With the advent of penicillin, syphilis became not only treatable but curable. Over the next decades, the number of patients infected with syphilis and the morbidity it caused continually declined until the 1990s, when there were even whispers of eradication in the United States. This likely came in part due to the AIDS epidemic and the increased public discourse on safe sex.

However, the 1990s saw a new rise in cases of syphilis. This clearly could not be blamed on the social hygienists; rather, it was likely due to apathy and a decline in public health spending. We are now in a period of rapid rise in STDs.

We have the benefit of antibiotics. We have the benefit of hindsight. What we need is to heed the call to arms of Dr. Mermin, to be inspired by the wisdom of Dr. Parran, and to act. Identify the case of syphilis, offer treatment, educate the public. Drs. Coleman, Fiahlo, and Brateanu have accomplished all of these in their article in this issue of the Journal.⁴

According to a report from the US Centers for Disease Control and Prevention (CDC) on the incidence of sexually transmitted diseases (STDs), “Total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever”¹ since the CDC was founded in July 1946.

See related article

Nearly 24,000 cases of primary and secondary syphilis were reported in 2015, a 19% increase from the previous year. And Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, reported, “We have reached a decisive moment for the nation. STD rates are rising, and many of the country’s systems for preventing STDs have eroded. We must mobilize, rebuild, and expand services—or the human and economic burden will continue to grow.”¹

Dr. Mermin stressed the need to rebuild services because, “In recent years more than half of state and local STD programs have experienced budget cuts, resulting in more than 20 health department STD clinic closures in one year alone. Fewer clinics mean reduced access to STD testing and treatment for those who need these services.”¹

The CDC also reports that STD treatment costs the US healthcare system nearly $16 billion each year.

The CDC has identified several players whose engagement is necessary to stem the tide of this epidemic:

• Providers must make STD screening a standard part of medical care, especially in pregnant women, and integrate STD prevention and treatment into prenatal care and other routine visits.
• People need to talk openly about STDs, get tested regularly, and reduce risk by using condoms or practicing mutual monogamy if sexually active.
• Parents and providers need to offer young people safe, effective ways to get information and services.
• State and local health departments should continue to direct resources to people hardest hit by the STD epidemic and work with community partners to maximize their impact.¹

STD CAMPAIGNS 100 YEARS AGO

This message sounds familiar. Let’s go back 100 years to World War I. The book No Magic Bullet by Allan M. Brandt² provides fascinating details about this period in America’s battle against venereal diseases. While the book is well worth reading in its entirety, I will attempt here to summarize the pertinent facts.

In the late 1910s, antivenereal campaigns were in full swing, with publicly shown movies such as “Fit to Fight” to train soldiers about STD symptoms and prevention to keep them physically healthy for fighting in the war. Similar information was widely available stateside for both men and women in open, matter-of-fact formats to encourage STD prevention.

After the war ended, the national sentiment became split between sexual revolution and social moralism. “Social hygienists” blamed the widespread increase in promiscuity on the newly introduced sexually explicit philosophy of Sigmund Freud, the widespread availability of automobiles (ie, a mobile, private, backseat location for sex), popular “vulgar” dances, and social feminism, among many others. The sexual revolution clearly led to an increased risk of STDs. But the antivenereal campaigns that had been appropriate in wartime came to be considered amoral and unfit for public consumption, and a period of silence about venereal diseases ensued.

By the 1930s, the situation had worsened:

• Approximately 1 out of every 10 Americans suffered from syphilis.
• Each year, Americans contracted almost half a million new syphilis infections (twice as many cases as tuberculosis, and 100 times as many cases as polio).
• 18% of all deaths from organic heart disease could be attributed to syphilis.
• Up to 20% of all mental institution inmates suffered from tertiary syphilis.
• 60,000 children were born each year with congenital syphilis.²

Although penicillin was still a decade or more away from discovery, syphilis could be treated, though likely not cured, with arsenic compounds. A course of treatment from a private physician, however, could cost from $300 to $1,000. Many patients who could not pay these exorbitant prices turned to public clinics for help. However, funding for the Venereal Disease Division of the Public Health Service, originally $4 million in 1920, was cut to less than $60,000 by 1926.² Some hospitals refused to admit patients with syphilis and other venereal diseases, deeming them “morally tainted and less deserving of care.”²

Things couldn’t get much worse.

Dr. Thomas Parran was the New York State health commissioner in 1930, at the start of the Great Depression. Realizing that arguments for moral responsibility to prevent and treat venereal diseases were not effective, Dr. Parran and other public health officials turned to financial arguments. Among the most persuasive arguments, “More than $15 million was spent annually for the ambulatory care of venereal patients…Experts argued that syphilis costs taxpayers between $40 and $50 million each year for the institutional care of the insane, paralyzed, and blind.”² The American Medical Association calculated that “8 to 10 million workers lost 21 million working days each year at an average of $4 a day as a result of infection with these conditions.”² The cost was estimated at more than $100,000,000 annually.²

But the general public was not a part of the larger conversation regarding treatment and prevention of syphilis, thanks to the social hygienists. In November 1934, Dr. Parran was scheduled to give a radio broadcast on future goals for public health in New York. Notified that he would not be able to mention syphilis or gonorrhea by name, he refused to give the speech. Dr. Parran went on to lead the charge to reduce the moral cloud that blocked the ability to address syphilis openly and scientifically. With his extensive experience in public health, he proposed plans that had been effective in controlling other infectious diseases as measures to control the spread of syphilis. He outlined the following:

• Identify cases of syphilis. Offer free diagnostic centers where individuals could obtain confidential blood tests.
• Offer prompt therapy for identified cases.
• Identify, locate, and test all contacts of infected patients, and treat them if they are infected too.
• Make blood testing mandatory before marriage and early in all pregnancies.
• Educate the public concerning syphilis.²

Do these approaches sound familiar?

Appointed US Surgeon General in 1936 by President Franklin Delano Roosevelt, Dr. Parran published “The next great plague to go,”³ an article focusing on the medical approach to treating syphilis and other venereal diseases, while refusing to address the moral and social issues.³ This was widely acclaimed by the public and the press. Two years after he was blocked from mentioning syphilis and gonorrhea on the radio, he was pictured on the cover of Time magazine for his groundbreaking work.

With the advent of penicillin, syphilis became not only treatable but curable. Over the next decades, the number of patients infected with syphilis and the morbidity it caused continually declined until the 1990s, when there were even whispers of eradication in the United States. This likely came in part due to the AIDS epidemic and the increased public discourse on safe sex.

However, the 1990s saw a new rise in cases of syphilis. This clearly could not be blamed on the social hygienists; rather, it was likely due to apathy and a decline in public health spending. We are now in a period of rapid rise in STDs.

We have the benefit of antibiotics. We have the benefit of hindsight. What we need is to heed the call to arms of Dr. Mermin, to be inspired by the wisdom of Dr. Parran, and to act. Identify the case of syphilis, offer treatment, educate the public. Drs. Coleman, Fiahlo, and Brateanu have accomplished all of these in their article in this issue of the Journal.⁴

Anyone who has tried to appreciate the challenges we face in medicine has probably read the 1978 article by Groves, “Taking care of the hateful patient.”¹ This and a later article by Strous et al² label and group patients according to specific behaviors and, perhaps more importantly, how they make the clinician on the other end of the conversation feel.

See related article

How patients make us feel should not be underappreciated. Taking care of other human beings is a complex, intricate, intimate privilege. To characterize it as anything else—to simply consumerize it—is to not fully understand it.

Yet, now more than ever, the impact of challenges—not just with patients but in healthcare today—is staggering: 54% of US physicians report burnout,³ and significant numbers would not choose medicine again as a career. Too much time spent charting (up to 2 hours in a recent study⁴) and less time spent connecting as human beings are driving the meaning out of medicine. Calls are growing for more empathy in medicine and better services to meet the needs of patients and caregivers alike.

WORDS CAN STIGMATIZE, VALIDATE, DAMAGE, OR HEAL

As we read in the article by Schuermeyer et al in this issue of the Journal,⁵ there are steps forward and also continued opportunities. The article begins to shift us from labeling patients as “dependent clingers” and “entitled demanders” to a much needed and more meaningful discussion about difficult patient behaviors and how we might more effectively respond to them.

Even if we need to apply them in medicine at times, our labeling the type of person a patient is or how the patient behaves carries tremendous significance to our patients and should not be applied lightly. Depending on the words or labels we choose, our words can stigmatize, validate, damage, or heal. Have no doubt, however, that our words will be remembered.

PATIENTS LABEL US, TOO

As a chief experience officer, I review thousands of patient comments every month. And what patients say is that although their medical care may be spectacular, their emotional needs and expectations are not always met. Despite both valid and less-valid criticisms of patient satisfaction surveys, we have an obligation to listen and learn. We too are fallible.

We too could be—and most certainly are—labeled by patients. “Insensitive,” “uncaring,” and “rude” are words I too often hear from patients as they comment on the care they received from their physicians. These labels certainly do not embody the profound caring at the core of the healthcare profession, just as they do not embody our patients.

An additional and unforeseen risk to labeling is the end of meaningful reflection. When we label, we stop asking who this person is. What trauma did the person suffer that makes trust so difficult? What is he or she most afraid of? What am I contributing to this ineffective dialogue, and how can I adapt my own language and behavior? We have a professional responsibility to respond to frustration or challenges with patients, not with labeling in return, but with humility, listening, and reflection.

BEYOND LABELS

To truly enhance communication and the experience of our patients, we must model empathic curiosity. People are not the label we give them. They are not the disease they have. The richness of their lives, experiences, and emotions cannot possibly be embodied in a single word that we have assigned. Our role as healers requires not judgment but the willingness to know more about who they are and the skill to more effectively express our intention and meaning. Only then will our patients feel truly “seen” and known by us.

To that end, there are a few models of effective communication. One of them, the Relationship: Establishment, Development, and Engagement (REDE) model, was developed at Cleveland Clinic,⁶ and a recent study found that when physicians were trained in it, patient satisfaction, physician empathy, and burnout improved.⁷ Another, the Four Habit model, has been effectively used by Kaiser Permanente for decades.⁸ These models provide a framework and detailed skills that can be used with any patient, loved one, or colleague, especially those we find “challenging.”

In addition, Groves and Schuermeyer et al highlight the impact these difficult conversations have on the clinician. Because most clinicians care deeply about the patients they serve, they are haunted by conversations that don’t go well. When patients are unhappy or angry with our care, we often feel that it is our fault or that we have failed in some way. Alternatively, we seek to distance ourselves from the patient we find challenging.

EMPATHY IS HARD WORK

The most difficult work actually goes on in the space between withdrawing from our patients in anger and continuing to enable inappropriate behavior at an emotional cost to ourselves and our colleagues. That in-between space is an opportunity for the clinician to set boundaries and be consistent, while also seeking to build relationships based on empathy and trust. Otherwise, both parties walk away labeling each other, which prevents us from building relationships with the patients whom we find difficult. Relationships still matter in healthcare and have therapeutic benefits for our patients and ourselves.

Empathy is hard work. When we connect with the patient in front of us, empathy may be easy. Yet the real need for empathy is when we don’t connect with the person in front of us—when we feel frustrated, tired, and angry. And I believe as healers—not just doctors—we are absolutely up for the challenge.

Anyone who has tried to appreciate the challenges we face in medicine has probably read the 1978 article by Groves, “Taking care of the hateful patient.”¹ This and a later article by Strous et al² label and group patients according to specific behaviors and, perhaps more importantly, how they make the clinician on the other end of the conversation feel.

See related article

How patients make us feel should not be underappreciated. Taking care of other human beings is a complex, intricate, intimate privilege. To characterize it as anything else—to simply consumerize it—is to not fully understand it.

Yet, now more than ever, the impact of challenges—not just with patients but in healthcare today—is staggering: 54% of US physicians report burnout,³ and significant numbers would not choose medicine again as a career. Too much time spent charting (up to 2 hours in a recent study⁴) and less time spent connecting as human beings are driving the meaning out of medicine. Calls are growing for more empathy in medicine and better services to meet the needs of patients and caregivers alike.

WORDS CAN STIGMATIZE, VALIDATE, DAMAGE, OR HEAL

As we read in the article by Schuermeyer et al in this issue of the Journal,⁵ there are steps forward and also continued opportunities. The article begins to shift us from labeling patients as “dependent clingers” and “entitled demanders” to a much needed and more meaningful discussion about difficult patient behaviors and how we might more effectively respond to them.

Even if we need to apply them in medicine at times, our labeling the type of person a patient is or how the patient behaves carries tremendous significance to our patients and should not be applied lightly. Depending on the words or labels we choose, our words can stigmatize, validate, damage, or heal. Have no doubt, however, that our words will be remembered.

PATIENTS LABEL US, TOO

As a chief experience officer, I review thousands of patient comments every month. And what patients say is that although their medical care may be spectacular, their emotional needs and expectations are not always met. Despite both valid and less-valid criticisms of patient satisfaction surveys, we have an obligation to listen and learn. We too are fallible.

We too could be—and most certainly are—labeled by patients. “Insensitive,” “uncaring,” and “rude” are words I too often hear from patients as they comment on the care they received from their physicians. These labels certainly do not embody the profound caring at the core of the healthcare profession, just as they do not embody our patients.

An additional and unforeseen risk to labeling is the end of meaningful reflection. When we label, we stop asking who this person is. What trauma did the person suffer that makes trust so difficult? What is he or she most afraid of? What am I contributing to this ineffective dialogue, and how can I adapt my own language and behavior? We have a professional responsibility to respond to frustration or challenges with patients, not with labeling in return, but with humility, listening, and reflection.

BEYOND LABELS

To truly enhance communication and the experience of our patients, we must model empathic curiosity. People are not the label we give them. They are not the disease they have. The richness of their lives, experiences, and emotions cannot possibly be embodied in a single word that we have assigned. Our role as healers requires not judgment but the willingness to know more about who they are and the skill to more effectively express our intention and meaning. Only then will our patients feel truly “seen” and known by us.

To that end, there are a few models of effective communication. One of them, the Relationship: Establishment, Development, and Engagement (REDE) model, was developed at Cleveland Clinic,⁶ and a recent study found that when physicians were trained in it, patient satisfaction, physician empathy, and burnout improved.⁷ Another, the Four Habit model, has been effectively used by Kaiser Permanente for decades.⁸ These models provide a framework and detailed skills that can be used with any patient, loved one, or colleague, especially those we find “challenging.”

In addition, Groves and Schuermeyer et al highlight the impact these difficult conversations have on the clinician. Because most clinicians care deeply about the patients they serve, they are haunted by conversations that don’t go well. When patients are unhappy or angry with our care, we often feel that it is our fault or that we have failed in some way. Alternatively, we seek to distance ourselves from the patient we find challenging.

EMPATHY IS HARD WORK

The most difficult work actually goes on in the space between withdrawing from our patients in anger and continuing to enable inappropriate behavior at an emotional cost to ourselves and our colleagues. That in-between space is an opportunity for the clinician to set boundaries and be consistent, while also seeking to build relationships based on empathy and trust. Otherwise, both parties walk away labeling each other, which prevents us from building relationships with the patients whom we find difficult. Relationships still matter in healthcare and have therapeutic benefits for our patients and ourselves.

Empathy is hard work. When we connect with the patient in front of us, empathy may be easy. Yet the real need for empathy is when we don’t connect with the person in front of us—when we feel frustrated, tired, and angry. And I believe as healers—not just doctors—we are absolutely up for the challenge.

Anyone who has tried to appreciate the challenges we face in medicine has probably read the 1978 article by Groves, “Taking care of the hateful patient.”¹ This and a later article by Strous et al² label and group patients according to specific behaviors and, perhaps more importantly, how they make the clinician on the other end of the conversation feel.

See related article

How patients make us feel should not be underappreciated. Taking care of other human beings is a complex, intricate, intimate privilege. To characterize it as anything else—to simply consumerize it—is to not fully understand it.

Yet, now more than ever, the impact of challenges—not just with patients but in healthcare today—is staggering: 54% of US physicians report burnout,³ and significant numbers would not choose medicine again as a career. Too much time spent charting (up to 2 hours in a recent study⁴) and less time spent connecting as human beings are driving the meaning out of medicine. Calls are growing for more empathy in medicine and better services to meet the needs of patients and caregivers alike.

WORDS CAN STIGMATIZE, VALIDATE, DAMAGE, OR HEAL

As we read in the article by Schuermeyer et al in this issue of the Journal,⁵ there are steps forward and also continued opportunities. The article begins to shift us from labeling patients as “dependent clingers” and “entitled demanders” to a much needed and more meaningful discussion about difficult patient behaviors and how we might more effectively respond to them.

Even if we need to apply them in medicine at times, our labeling the type of person a patient is or how the patient behaves carries tremendous significance to our patients and should not be applied lightly. Depending on the words or labels we choose, our words can stigmatize, validate, damage, or heal. Have no doubt, however, that our words will be remembered.

PATIENTS LABEL US, TOO

As a chief experience officer, I review thousands of patient comments every month. And what patients say is that although their medical care may be spectacular, their emotional needs and expectations are not always met. Despite both valid and less-valid criticisms of patient satisfaction surveys, we have an obligation to listen and learn. We too are fallible.

We too could be—and most certainly are—labeled by patients. “Insensitive,” “uncaring,” and “rude” are words I too often hear from patients as they comment on the care they received from their physicians. These labels certainly do not embody the profound caring at the core of the healthcare profession, just as they do not embody our patients.

An additional and unforeseen risk to labeling is the end of meaningful reflection. When we label, we stop asking who this person is. What trauma did the person suffer that makes trust so difficult? What is he or she most afraid of? What am I contributing to this ineffective dialogue, and how can I adapt my own language and behavior? We have a professional responsibility to respond to frustration or challenges with patients, not with labeling in return, but with humility, listening, and reflection.

BEYOND LABELS

To truly enhance communication and the experience of our patients, we must model empathic curiosity. People are not the label we give them. They are not the disease they have. The richness of their lives, experiences, and emotions cannot possibly be embodied in a single word that we have assigned. Our role as healers requires not judgment but the willingness to know more about who they are and the skill to more effectively express our intention and meaning. Only then will our patients feel truly “seen” and known by us.

To that end, there are a few models of effective communication. One of them, the Relationship: Establishment, Development, and Engagement (REDE) model, was developed at Cleveland Clinic,⁶ and a recent study found that when physicians were trained in it, patient satisfaction, physician empathy, and burnout improved.⁷ Another, the Four Habit model, has been effectively used by Kaiser Permanente for decades.⁸ These models provide a framework and detailed skills that can be used with any patient, loved one, or colleague, especially those we find “challenging.”

In addition, Groves and Schuermeyer et al highlight the impact these difficult conversations have on the clinician. Because most clinicians care deeply about the patients they serve, they are haunted by conversations that don’t go well. When patients are unhappy or angry with our care, we often feel that it is our fault or that we have failed in some way. Alternatively, we seek to distance ourselves from the patient we find challenging.

EMPATHY IS HARD WORK

The most difficult work actually goes on in the space between withdrawing from our patients in anger and continuing to enable inappropriate behavior at an emotional cost to ourselves and our colleagues. That in-between space is an opportunity for the clinician to set boundaries and be consistent, while also seeking to build relationships based on empathy and trust. Otherwise, both parties walk away labeling each other, which prevents us from building relationships with the patients whom we find difficult. Relationships still matter in healthcare and have therapeutic benefits for our patients and ourselves.

Empathy is hard work. When we connect with the patient in front of us, empathy may be easy. Yet the real need for empathy is when we don’t connect with the person in front of us—when we feel frustrated, tired, and angry. And I believe as healers—not just doctors—we are absolutely up for the challenge.

Mobility impairment (reduced ability to change body position or ambulate) is common among older adults during hospitalization¹ and is correlated with higher rates of readmission,² long-term care placement,³ and even death.⁴ Although some may perceive mobility impairment during hospitalization as a temporary inconvenience, recent research suggests disruptions of basic activities of daily life such as mobility may be “traumatic” ⁵ or “toxic”⁶ to older adults with long-term post-hospital effects.⁷ While these studies highlight the underestimated effects of low mobility during hospitalization, they are based on data collected for research purposes using mobility measurement tools not typically utilized in routine hospital care.

The absence of a standardized mobility measurement tool used as part of routine hospital care poses a barrier to estimating the effects of low hospital mobility and programs seeking to improve mobility levels in hospitalized patients. In this issue of the Journal of Hospital Medicine, Valiani et al.⁸ found a novel approach to measure mobility using a universally disseminated clinical scale (Braden). Using the activity subscale of the Braden scale, the authors found that mobility level changes during hospitalization can have a striking impact on post-discharge mortality. Their results indicate that older adults who develop mobility impairment during hospitalization had higher odds of death, specifically 1.23 times greater risk, within 6 months after discharge (23% decreased chance of survival). Most of the risk applies in the first 30 days and remains to a lesser extent for up to 5 years post-hospitalization. An equally interesting finding was that those who enter the hospital with low mobility but improve have a 46% higher survival rate. Again, most of the benefit is seen during hospitalization or immediately afterward, but the benefit persists for up to 5 years. A schematic of the results are presented in the Figure. Notably, Valiani et al.⁸ did not find regression to the mean Braden score of 3.

Disclosure

Nothing to report.

Mobility impairment (reduced ability to change body position or ambulate) is common among older adults during hospitalization¹ and is correlated with higher rates of readmission,² long-term care placement,³ and even death.⁴ Although some may perceive mobility impairment during hospitalization as a temporary inconvenience, recent research suggests disruptions of basic activities of daily life such as mobility may be “traumatic” ⁵ or “toxic”⁶ to older adults with long-term post-hospital effects.⁷ While these studies highlight the underestimated effects of low mobility during hospitalization, they are based on data collected for research purposes using mobility measurement tools not typically utilized in routine hospital care.

The absence of a standardized mobility measurement tool used as part of routine hospital care poses a barrier to estimating the effects of low hospital mobility and programs seeking to improve mobility levels in hospitalized patients. In this issue of the Journal of Hospital Medicine, Valiani et al.⁸ found a novel approach to measure mobility using a universally disseminated clinical scale (Braden). Using the activity subscale of the Braden scale, the authors found that mobility level changes during hospitalization can have a striking impact on post-discharge mortality. Their results indicate that older adults who develop mobility impairment during hospitalization had higher odds of death, specifically 1.23 times greater risk, within 6 months after discharge (23% decreased chance of survival). Most of the risk applies in the first 30 days and remains to a lesser extent for up to 5 years post-hospitalization. An equally interesting finding was that those who enter the hospital with low mobility but improve have a 46% higher survival rate. Again, most of the benefit is seen during hospitalization or immediately afterward, but the benefit persists for up to 5 years. A schematic of the results are presented in the Figure. Notably, Valiani et al.⁸ did not find regression to the mean Braden score of 3.

Disclosure

Nothing to report.

Mobility impairment (reduced ability to change body position or ambulate) is common among older adults during hospitalization¹ and is correlated with higher rates of readmission,² long-term care placement,³ and even death.⁴ Although some may perceive mobility impairment during hospitalization as a temporary inconvenience, recent research suggests disruptions of basic activities of daily life such as mobility may be “traumatic” ⁵ or “toxic”⁶ to older adults with long-term post-hospital effects.⁷ While these studies highlight the underestimated effects of low mobility during hospitalization, they are based on data collected for research purposes using mobility measurement tools not typically utilized in routine hospital care.

The absence of a standardized mobility measurement tool used as part of routine hospital care poses a barrier to estimating the effects of low hospital mobility and programs seeking to improve mobility levels in hospitalized patients. In this issue of the Journal of Hospital Medicine, Valiani et al.⁸ found a novel approach to measure mobility using a universally disseminated clinical scale (Braden). Using the activity subscale of the Braden scale, the authors found that mobility level changes during hospitalization can have a striking impact on post-discharge mortality. Their results indicate that older adults who develop mobility impairment during hospitalization had higher odds of death, specifically 1.23 times greater risk, within 6 months after discharge (23% decreased chance of survival). Most of the risk applies in the first 30 days and remains to a lesser extent for up to 5 years post-hospitalization. An equally interesting finding was that those who enter the hospital with low mobility but improve have a 46% higher survival rate. Again, most of the benefit is seen during hospitalization or immediately afterward, but the benefit persists for up to 5 years. A schematic of the results are presented in the Figure. Notably, Valiani et al.⁸ did not find regression to the mean Braden score of 3.

Disclosure

Nothing to report.