Editorial

On March 21, 2010, the United States Congress passed the most comprehensive healthcare reform bill since the formation of Medicare. The legislation's greatest impact will be to improve access for nearly 50 million Americans who are presently uninsured. Yet the bill does little to tackle the fundamental problems of the payment and delivery systemsproblems that have resulted in major quality gaps, large numbers of medical errors, fragmented care, and backbreaking costs.

While these tough questions were mostly kicked down the road, the debate did bring many of the key questions and potential solutions into high relief. Our political leaders, pundits, and health policy scholars introduced or popularized a number of terms during the healthcare debates of 2009‐2010 (Table 1). I will attempt to place them in context and discuss their implications for future healthcare reform efforts.

Some Context for the Healthcare Reform Debate

In our capitalistic economy, we make most purchases based on considerations of value: quality divided by cost. There are few among us wealthy enough to always buy the best product, or cheap enough to always buy the least expensive. Instead, we try to determine value when we purchase a restaurant meal, a house, or a vacation.

Healthcare has traditionally been the major exception to this rule, both because healthcare insurance has partly insulated consumers (patients or their proxies) from the cost consequences of their decisions, and because it is so difficult to determine the quality of healthcare. But, over the past 10 to 15 years, problems with both the numerator and denominator of this equation have created widespread recognition of the need for change.

In the numerator, we now appreciate that there are nearly 100,000 deaths per year from medical mistakes;1 that we deliver evidence‐based care only about half the time,2 and that our healthcare system is extraordinarily fragmented and chaotic. We also know that there are more than 40 million people without healthcare insurance, a uniquely American problem, since other industrialized countries manage to guarantee coverage.

This is the fundamental conundrum that needs to be addressed by healthcare reform: we have a system that produces surprisingly low‐quality, unreliable care at an exorbitant and ever‐increasing cost, and does so while leaving more than 1 out of 8 citizens without coverage. Although government is a large payer (through Medicare, Medicaid, the Veterans Affairs [VA] programs and others), most Americans receive healthcare coverage as an employee benefit; a smaller number pay for health insurance themselves. The government has a key role even in these nongovernment‐sponsored payment systems, by providing tax breaks for healthcare coverage, creating a regulatory framework, and often defining the market through its actions in its public programs.

The end result is that all the involved partiesgovernments, businesses, providers, and patientsare crying out for change. An observer of this situation feels compelled to invoke the popular version of Stein's Law: if a trend can't continue, it won't.

Bending the Cost Curve

Everyone is now familiar with the scary trends (such as in Figure 1) demonstrating the unsustainable rate of healthcare inflation in the US, trends that are projected to lead to the insolvency of the Medicare Trust Fund within a decade. The term bending the cost curve implies that our solvency depends not on lowering total costs (a political impossibility), but rather on simply decreasing the rate of rise. There are only so many ways to do this.

Figure 1

The most attractive, of course, is to stop providing expensive care that adds no or little value in terms of patient outcomes. The term comparative effectiveness research (CER) emerged over the past few years to describe research that pits one approach against another (or, presumably, against no treatment) on both outcomes and cost.3 Obviously, one would favor the less expensive treatment if the efficacy were equal. However, the more common (and politically fraught) question is whether a more expensive but slightly better approach is worth its additional cost.

This, of course, makes complete sense in a world of limited resources, and some countries, mostly notably the United Kingdom, are using CER to inform healthcare coverage decisions. In the United Kingdom, the research is analyzed, and coverage recommendations made, by an organization called the National Institute for Health and Clinical Excellence (NICE).4 While NICE appears to be working well, all signs indicate that the US political system is not ready for such an approach. In fact, although Medicare generally supports CER, most of the healthcare reform proposals considered by Congress explicitly prohibited Medicare from using CER results to influence payment decisions.

If an overall CER approach is too politically difficult for the US, how about focusing on 1 small segment of healthcare: expensive care at the end of life? Over the past 30 years, a group of Dartmouth researchers has examined the costs and quality of care across the entire country, demonstrating a ubiquitous pattern of highly variable costs (varying up to 2‐fold) that is unassociated with quality and outcomes (and sometimes even inversely associated).5 The findings, well known among healthcare researchers but relatively unknown by the public until recently, were brought to public attention by a 2009 New Yorker article that made the border town of McAllen, Texas the poster child for a medical culture that produces high costs without comparable benefits.6 The Dartmouth researchers, who publish their data in a document known as The Dartmouth Atlas, have found striking variations in care at the end of life. For example, even among academic medical centers (which presumably have similarly sick patient populations), the number of hospital days in the last 6 months of life varies strikingly: patients at New York University average 27.1 days, whereas those in my hospital average 11.5 days.7

So promoting better end‐of‐life carebeing sure that patients are aware of their options and that high‐quality palliative care is availableseemed like an obvious solution to part of our cost‐quality conundrum. Some early drafts of reform bills in Congress contained provisions to pay for physicians' time to discuss end‐of‐life options. This, of course, was caricaturized into the now famous Death Panelsproving that American political discourse is not yet mature enough to support realistic discussions about difficult subjects.8

It seems like having payers (government, insurance companies) make formal decisions about which services to cover (ie, rationing) is too hard. Is there another way to force these tough choices but do so without creating a political piata?

Encircling a Population

Rather than explicitly rationing care (using CER results, for example), another way of constraining costs is to place a population of patients on a fixed budget. There is evidence that provider organizations, working within such a budget (structured in a way that permits the providers to pocket any savings), are able to reorganize and change their practice style in a way that can cut costs.9 In the 1990s, we conducted a national experiment by promoting managed care, working through integrated delivery systems called Health Maintenance Organizations (HMOs) that received fixed, capitated payments for every patient. And, in fact, these organizations did cut overall costs.

The problem was that patients neither liked HMOs nor trusted that they were acting in their best interests. Ultimately, managed care became a less important delivery mechanism, and even patients who remained in HMOs had fewer constraints on their choices. Of course, the softening of the managed care market resulted in an uptick in healthcare inflation, contributing to our present predicament.

The concept of fixed payments has resurfaced, but with some modern twists. It appears that organizations that perform best on the Dartmouth measures (namely, they provide high quality care at lower costs) are generally large delivery systems with advanced information technology, strong primary care infrastructures, andprobably most importantlytight integration between physicians and the rest of the organization. During the healthcare debate, the organizations that received the most attention were the Mayo and Cleveland Clinics and the Geisinger system in central Pennsylvania. The problem is that the defining characteristic of these organizations (and others like them) is that they have been at this business of integrated care for more than 50 years! Can the model be emulated?

Two main policy changes have been promoted to try to achieve this integration: one is a change in payment structure, the other a change in organization. The first is known as bundlingin which multiple providers are reimbursed a single sum for all the care related to an episode of illness (such as a hospitalization and a 60‐ or 90‐day period afterwards). You will recognize this as a new form of capitation, but, rather than covering all of a patient's care, a more circumscribed version, focusing on a single illness or procedure. There is some evidence that bundling does reduce costs and may improve quality, by forcing hospitals, post‐acute care facilities, and doctors into collaborative arrangements (both to deliver care and, just as complex, to split the single payment without undue acrimony).10 Fisher et al.11 have promoted a new structure to deliver this kind of bundled care more effectively: The Accountable Care Organization (ACO), which is best thought of as a less ambitious, and potentially more virtual, incarnation of the HMO.

Interestingly, while many healthcare organizations have struggled to remake themselves in Mayo's image in preparation for upcoming pressures to form ACOs, some organizations with hospitalist programs need look no further than these programs to chart a course toward more effective physician‐hospital integration.12 Why? The majority of US hospitals now have hospitalists, and virtually all hospitalist programs receive support payments from their hospital (a sizable minority are on salary from the hospital). Hospitalists recognize that part of their value equation (which justifies the hospital support dollars) is that they help the hospital deliver higher quality care more efficiently. Because of this relationship, a well‐functioning hospitalist program can assume many of the attributes of an ACO, even in organizations with otherwise challenging physician‐hospital relations. It may be that hospitals and doctors need not look to Rochester, Minnesota or Danville, Pennsylvania for positive examples of physician‐hospital integration, but simply to their own local hospitalist groups.

The Bottom Line

While proponents of the Obama reform plan celebrate its passage, virtually all experts agree that it left fundamental problems with the healthcare system unaddressed. Although the 20092010 debate did not solve these problems, the new vocabulary introduced during the debateboth reasonable policy ideas like bundling and ACOs and cynical caricatures like death panelsare here to stay. Understanding these terms and the context that shaped them will be critical for hospitalists and other stakeholders interested in the future of the American healthcare system.

On March 21, 2010, the United States Congress passed the most comprehensive healthcare reform bill since the formation of Medicare. The legislation's greatest impact will be to improve access for nearly 50 million Americans who are presently uninsured. Yet the bill does little to tackle the fundamental problems of the payment and delivery systemsproblems that have resulted in major quality gaps, large numbers of medical errors, fragmented care, and backbreaking costs.

While these tough questions were mostly kicked down the road, the debate did bring many of the key questions and potential solutions into high relief. Our political leaders, pundits, and health policy scholars introduced or popularized a number of terms during the healthcare debates of 2009‐2010 (Table 1). I will attempt to place them in context and discuss their implications for future healthcare reform efforts.

Some Context for the Healthcare Reform Debate

In our capitalistic economy, we make most purchases based on considerations of value: quality divided by cost. There are few among us wealthy enough to always buy the best product, or cheap enough to always buy the least expensive. Instead, we try to determine value when we purchase a restaurant meal, a house, or a vacation.

Healthcare has traditionally been the major exception to this rule, both because healthcare insurance has partly insulated consumers (patients or their proxies) from the cost consequences of their decisions, and because it is so difficult to determine the quality of healthcare. But, over the past 10 to 15 years, problems with both the numerator and denominator of this equation have created widespread recognition of the need for change.

In the numerator, we now appreciate that there are nearly 100,000 deaths per year from medical mistakes;1 that we deliver evidence‐based care only about half the time,2 and that our healthcare system is extraordinarily fragmented and chaotic. We also know that there are more than 40 million people without healthcare insurance, a uniquely American problem, since other industrialized countries manage to guarantee coverage.

This is the fundamental conundrum that needs to be addressed by healthcare reform: we have a system that produces surprisingly low‐quality, unreliable care at an exorbitant and ever‐increasing cost, and does so while leaving more than 1 out of 8 citizens without coverage. Although government is a large payer (through Medicare, Medicaid, the Veterans Affairs [VA] programs and others), most Americans receive healthcare coverage as an employee benefit; a smaller number pay for health insurance themselves. The government has a key role even in these nongovernment‐sponsored payment systems, by providing tax breaks for healthcare coverage, creating a regulatory framework, and often defining the market through its actions in its public programs.

The end result is that all the involved partiesgovernments, businesses, providers, and patientsare crying out for change. An observer of this situation feels compelled to invoke the popular version of Stein's Law: if a trend can't continue, it won't.

Bending the Cost Curve

Everyone is now familiar with the scary trends (such as in Figure 1) demonstrating the unsustainable rate of healthcare inflation in the US, trends that are projected to lead to the insolvency of the Medicare Trust Fund within a decade. The term bending the cost curve implies that our solvency depends not on lowering total costs (a political impossibility), but rather on simply decreasing the rate of rise. There are only so many ways to do this.

Figure 1

The most attractive, of course, is to stop providing expensive care that adds no or little value in terms of patient outcomes. The term comparative effectiveness research (CER) emerged over the past few years to describe research that pits one approach against another (or, presumably, against no treatment) on both outcomes and cost.3 Obviously, one would favor the less expensive treatment if the efficacy were equal. However, the more common (and politically fraught) question is whether a more expensive but slightly better approach is worth its additional cost.

This, of course, makes complete sense in a world of limited resources, and some countries, mostly notably the United Kingdom, are using CER to inform healthcare coverage decisions. In the United Kingdom, the research is analyzed, and coverage recommendations made, by an organization called the National Institute for Health and Clinical Excellence (NICE).4 While NICE appears to be working well, all signs indicate that the US political system is not ready for such an approach. In fact, although Medicare generally supports CER, most of the healthcare reform proposals considered by Congress explicitly prohibited Medicare from using CER results to influence payment decisions.

If an overall CER approach is too politically difficult for the US, how about focusing on 1 small segment of healthcare: expensive care at the end of life? Over the past 30 years, a group of Dartmouth researchers has examined the costs and quality of care across the entire country, demonstrating a ubiquitous pattern of highly variable costs (varying up to 2‐fold) that is unassociated with quality and outcomes (and sometimes even inversely associated).5 The findings, well known among healthcare researchers but relatively unknown by the public until recently, were brought to public attention by a 2009 New Yorker article that made the border town of McAllen, Texas the poster child for a medical culture that produces high costs without comparable benefits.6 The Dartmouth researchers, who publish their data in a document known as The Dartmouth Atlas, have found striking variations in care at the end of life. For example, even among academic medical centers (which presumably have similarly sick patient populations), the number of hospital days in the last 6 months of life varies strikingly: patients at New York University average 27.1 days, whereas those in my hospital average 11.5 days.7

So promoting better end‐of‐life carebeing sure that patients are aware of their options and that high‐quality palliative care is availableseemed like an obvious solution to part of our cost‐quality conundrum. Some early drafts of reform bills in Congress contained provisions to pay for physicians' time to discuss end‐of‐life options. This, of course, was caricaturized into the now famous Death Panelsproving that American political discourse is not yet mature enough to support realistic discussions about difficult subjects.8

It seems like having payers (government, insurance companies) make formal decisions about which services to cover (ie, rationing) is too hard. Is there another way to force these tough choices but do so without creating a political piata?

Encircling a Population

Rather than explicitly rationing care (using CER results, for example), another way of constraining costs is to place a population of patients on a fixed budget. There is evidence that provider organizations, working within such a budget (structured in a way that permits the providers to pocket any savings), are able to reorganize and change their practice style in a way that can cut costs.9 In the 1990s, we conducted a national experiment by promoting managed care, working through integrated delivery systems called Health Maintenance Organizations (HMOs) that received fixed, capitated payments for every patient. And, in fact, these organizations did cut overall costs.

The problem was that patients neither liked HMOs nor trusted that they were acting in their best interests. Ultimately, managed care became a less important delivery mechanism, and even patients who remained in HMOs had fewer constraints on their choices. Of course, the softening of the managed care market resulted in an uptick in healthcare inflation, contributing to our present predicament.

The concept of fixed payments has resurfaced, but with some modern twists. It appears that organizations that perform best on the Dartmouth measures (namely, they provide high quality care at lower costs) are generally large delivery systems with advanced information technology, strong primary care infrastructures, andprobably most importantlytight integration between physicians and the rest of the organization. During the healthcare debate, the organizations that received the most attention were the Mayo and Cleveland Clinics and the Geisinger system in central Pennsylvania. The problem is that the defining characteristic of these organizations (and others like them) is that they have been at this business of integrated care for more than 50 years! Can the model be emulated?

Two main policy changes have been promoted to try to achieve this integration: one is a change in payment structure, the other a change in organization. The first is known as bundlingin which multiple providers are reimbursed a single sum for all the care related to an episode of illness (such as a hospitalization and a 60‐ or 90‐day period afterwards). You will recognize this as a new form of capitation, but, rather than covering all of a patient's care, a more circumscribed version, focusing on a single illness or procedure. There is some evidence that bundling does reduce costs and may improve quality, by forcing hospitals, post‐acute care facilities, and doctors into collaborative arrangements (both to deliver care and, just as complex, to split the single payment without undue acrimony).10 Fisher et al.11 have promoted a new structure to deliver this kind of bundled care more effectively: The Accountable Care Organization (ACO), which is best thought of as a less ambitious, and potentially more virtual, incarnation of the HMO.

Interestingly, while many healthcare organizations have struggled to remake themselves in Mayo's image in preparation for upcoming pressures to form ACOs, some organizations with hospitalist programs need look no further than these programs to chart a course toward more effective physician‐hospital integration.12 Why? The majority of US hospitals now have hospitalists, and virtually all hospitalist programs receive support payments from their hospital (a sizable minority are on salary from the hospital). Hospitalists recognize that part of their value equation (which justifies the hospital support dollars) is that they help the hospital deliver higher quality care more efficiently. Because of this relationship, a well‐functioning hospitalist program can assume many of the attributes of an ACO, even in organizations with otherwise challenging physician‐hospital relations. It may be that hospitals and doctors need not look to Rochester, Minnesota or Danville, Pennsylvania for positive examples of physician‐hospital integration, but simply to their own local hospitalist groups.

The Bottom Line

While proponents of the Obama reform plan celebrate its passage, virtually all experts agree that it left fundamental problems with the healthcare system unaddressed. Although the 20092010 debate did not solve these problems, the new vocabulary introduced during the debateboth reasonable policy ideas like bundling and ACOs and cynical caricatures like death panelsare here to stay. Understanding these terms and the context that shaped them will be critical for hospitalists and other stakeholders interested in the future of the American healthcare system.

On March 21, 2010, the United States Congress passed the most comprehensive healthcare reform bill since the formation of Medicare. The legislation's greatest impact will be to improve access for nearly 50 million Americans who are presently uninsured. Yet the bill does little to tackle the fundamental problems of the payment and delivery systemsproblems that have resulted in major quality gaps, large numbers of medical errors, fragmented care, and backbreaking costs.

While these tough questions were mostly kicked down the road, the debate did bring many of the key questions and potential solutions into high relief. Our political leaders, pundits, and health policy scholars introduced or popularized a number of terms during the healthcare debates of 2009‐2010 (Table 1). I will attempt to place them in context and discuss their implications for future healthcare reform efforts.

Some Context for the Healthcare Reform Debate

In our capitalistic economy, we make most purchases based on considerations of value: quality divided by cost. There are few among us wealthy enough to always buy the best product, or cheap enough to always buy the least expensive. Instead, we try to determine value when we purchase a restaurant meal, a house, or a vacation.

Healthcare has traditionally been the major exception to this rule, both because healthcare insurance has partly insulated consumers (patients or their proxies) from the cost consequences of their decisions, and because it is so difficult to determine the quality of healthcare. But, over the past 10 to 15 years, problems with both the numerator and denominator of this equation have created widespread recognition of the need for change.

In the numerator, we now appreciate that there are nearly 100,000 deaths per year from medical mistakes;1 that we deliver evidence‐based care only about half the time,2 and that our healthcare system is extraordinarily fragmented and chaotic. We also know that there are more than 40 million people without healthcare insurance, a uniquely American problem, since other industrialized countries manage to guarantee coverage.

This is the fundamental conundrum that needs to be addressed by healthcare reform: we have a system that produces surprisingly low‐quality, unreliable care at an exorbitant and ever‐increasing cost, and does so while leaving more than 1 out of 8 citizens without coverage. Although government is a large payer (through Medicare, Medicaid, the Veterans Affairs [VA] programs and others), most Americans receive healthcare coverage as an employee benefit; a smaller number pay for health insurance themselves. The government has a key role even in these nongovernment‐sponsored payment systems, by providing tax breaks for healthcare coverage, creating a regulatory framework, and often defining the market through its actions in its public programs.

The end result is that all the involved partiesgovernments, businesses, providers, and patientsare crying out for change. An observer of this situation feels compelled to invoke the popular version of Stein's Law: if a trend can't continue, it won't.

Bending the Cost Curve

Everyone is now familiar with the scary trends (such as in Figure 1) demonstrating the unsustainable rate of healthcare inflation in the US, trends that are projected to lead to the insolvency of the Medicare Trust Fund within a decade. The term bending the cost curve implies that our solvency depends not on lowering total costs (a political impossibility), but rather on simply decreasing the rate of rise. There are only so many ways to do this.

Figure 1

The most attractive, of course, is to stop providing expensive care that adds no or little value in terms of patient outcomes. The term comparative effectiveness research (CER) emerged over the past few years to describe research that pits one approach against another (or, presumably, against no treatment) on both outcomes and cost.3 Obviously, one would favor the less expensive treatment if the efficacy were equal. However, the more common (and politically fraught) question is whether a more expensive but slightly better approach is worth its additional cost.

This, of course, makes complete sense in a world of limited resources, and some countries, mostly notably the United Kingdom, are using CER to inform healthcare coverage decisions. In the United Kingdom, the research is analyzed, and coverage recommendations made, by an organization called the National Institute for Health and Clinical Excellence (NICE).4 While NICE appears to be working well, all signs indicate that the US political system is not ready for such an approach. In fact, although Medicare generally supports CER, most of the healthcare reform proposals considered by Congress explicitly prohibited Medicare from using CER results to influence payment decisions.

If an overall CER approach is too politically difficult for the US, how about focusing on 1 small segment of healthcare: expensive care at the end of life? Over the past 30 years, a group of Dartmouth researchers has examined the costs and quality of care across the entire country, demonstrating a ubiquitous pattern of highly variable costs (varying up to 2‐fold) that is unassociated with quality and outcomes (and sometimes even inversely associated).5 The findings, well known among healthcare researchers but relatively unknown by the public until recently, were brought to public attention by a 2009 New Yorker article that made the border town of McAllen, Texas the poster child for a medical culture that produces high costs without comparable benefits.6 The Dartmouth researchers, who publish their data in a document known as The Dartmouth Atlas, have found striking variations in care at the end of life. For example, even among academic medical centers (which presumably have similarly sick patient populations), the number of hospital days in the last 6 months of life varies strikingly: patients at New York University average 27.1 days, whereas those in my hospital average 11.5 days.7

So promoting better end‐of‐life carebeing sure that patients are aware of their options and that high‐quality palliative care is availableseemed like an obvious solution to part of our cost‐quality conundrum. Some early drafts of reform bills in Congress contained provisions to pay for physicians' time to discuss end‐of‐life options. This, of course, was caricaturized into the now famous Death Panelsproving that American political discourse is not yet mature enough to support realistic discussions about difficult subjects.8

It seems like having payers (government, insurance companies) make formal decisions about which services to cover (ie, rationing) is too hard. Is there another way to force these tough choices but do so without creating a political piata?

Encircling a Population

Rather than explicitly rationing care (using CER results, for example), another way of constraining costs is to place a population of patients on a fixed budget. There is evidence that provider organizations, working within such a budget (structured in a way that permits the providers to pocket any savings), are able to reorganize and change their practice style in a way that can cut costs.9 In the 1990s, we conducted a national experiment by promoting managed care, working through integrated delivery systems called Health Maintenance Organizations (HMOs) that received fixed, capitated payments for every patient. And, in fact, these organizations did cut overall costs.

The problem was that patients neither liked HMOs nor trusted that they were acting in their best interests. Ultimately, managed care became a less important delivery mechanism, and even patients who remained in HMOs had fewer constraints on their choices. Of course, the softening of the managed care market resulted in an uptick in healthcare inflation, contributing to our present predicament.

The concept of fixed payments has resurfaced, but with some modern twists. It appears that organizations that perform best on the Dartmouth measures (namely, they provide high quality care at lower costs) are generally large delivery systems with advanced information technology, strong primary care infrastructures, andprobably most importantlytight integration between physicians and the rest of the organization. During the healthcare debate, the organizations that received the most attention were the Mayo and Cleveland Clinics and the Geisinger system in central Pennsylvania. The problem is that the defining characteristic of these organizations (and others like them) is that they have been at this business of integrated care for more than 50 years! Can the model be emulated?

Two main policy changes have been promoted to try to achieve this integration: one is a change in payment structure, the other a change in organization. The first is known as bundlingin which multiple providers are reimbursed a single sum for all the care related to an episode of illness (such as a hospitalization and a 60‐ or 90‐day period afterwards). You will recognize this as a new form of capitation, but, rather than covering all of a patient's care, a more circumscribed version, focusing on a single illness or procedure. There is some evidence that bundling does reduce costs and may improve quality, by forcing hospitals, post‐acute care facilities, and doctors into collaborative arrangements (both to deliver care and, just as complex, to split the single payment without undue acrimony).10 Fisher et al.11 have promoted a new structure to deliver this kind of bundled care more effectively: The Accountable Care Organization (ACO), which is best thought of as a less ambitious, and potentially more virtual, incarnation of the HMO.

Interestingly, while many healthcare organizations have struggled to remake themselves in Mayo's image in preparation for upcoming pressures to form ACOs, some organizations with hospitalist programs need look no further than these programs to chart a course toward more effective physician‐hospital integration.12 Why? The majority of US hospitals now have hospitalists, and virtually all hospitalist programs receive support payments from their hospital (a sizable minority are on salary from the hospital). Hospitalists recognize that part of their value equation (which justifies the hospital support dollars) is that they help the hospital deliver higher quality care more efficiently. Because of this relationship, a well‐functioning hospitalist program can assume many of the attributes of an ACO, even in organizations with otherwise challenging physician‐hospital relations. It may be that hospitals and doctors need not look to Rochester, Minnesota or Danville, Pennsylvania for positive examples of physician‐hospital integration, but simply to their own local hospitalist groups.

The Bottom Line

While proponents of the Obama reform plan celebrate its passage, virtually all experts agree that it left fundamental problems with the healthcare system unaddressed. Although the 20092010 debate did not solve these problems, the new vocabulary introduced during the debateboth reasonable policy ideas like bundling and ACOs and cynical caricatures like death panelsare here to stay. Understanding these terms and the context that shaped them will be critical for hospitalists and other stakeholders interested in the future of the American healthcare system.

Let's think about what we need to do ourselves. We have to acknowledge that orders we write drive up health care costs.1 AMA President, Nancy H. Nielsen, MD, PhD

As the most prominent providers of inpatient care, hospitalists should be aware that, of the total annual expenditures on US healthcare ($2.3 trillion in 2007),2 approximately one‐third goes to hospital‐based medical care, over one‐half of which (57%) is covered by public funds through Medicare and Medicaid3; this high cost of healthcare is increasingly being blamed for unnecessarily burdening our economy and preventing our industries from being globally competitive. I believe that the high proportion of spending on inpatient care places hospitalists firmly in the center of the debate on how to reduce healthcare costs. It is well known that the United States spends about twice as much per capita as other industrialized countries on healthcare,4 without evidence of superior health outcomes.5 However, it is also known that remarkable local and regional variations in healthcare spending also exist within the US, again, without evidence of superior health outcomes in the higher‐spending regions.6 Both of these observations suggest that we are spending many healthcare dollars on things that evidently do not improve the health of our patients. How much of this waste is administrative, operational, or clinical is debatable and remains the focus of growing national healthcare reform efforts.711 However, from the hospitalist perspective, we should be especially wary of providing so‐called flat‐of‐the‐curve medicine, that is, a level of intensity of care that provides no incremental health benefit.12 The purpose of this editorial is to challenge hospitalists to collectively examine how much of our inpatient spending is potentially unnecessary, and how we, as specialists in inpatient medicine, can assume a critical role in controlling healthcare costs.

To illustrate the issue, consider the following clinical scenario, managed in different ways by different hospitalists, with approximate costs itemized in Table 1. The patient is an elderly woman who presents to the emergency room with syncope occurring at church. The first hospitalist takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days. The second hospitalist receives the call from the emergency room and tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt‐table test scheduled.

Although the above scenarios purposely demonstrate 2 extremes of care, I suspect most readers would agree that each hospitalist has his or her own style of practice, and that these differences in style inevitably result in significant differences in the total cost of healthcare delivered. This variation in spending among individual physicians is perhaps more easily understood than the striking variations in healthcare spending seen when different states, regions, and hospitals are compared. For example, annual Medicare spending per beneficiary has varied widely from state to state, from $5436 in Iowa to $7995 in New York (in 2004), a 47% difference.13 Specific analysis of inpatient spending variations is presented in the Dartmouth Atlas of Health Care 2008, which reports healthcare spending in the last 2 years of life for patients with at least 1 chronic illness.14 While the average Medicare inpatient spending per capita for these patients was about $25,000, the state‐specific spending varied widely from $37,040 in New Jersey to $17,135 in Idaho. There was also significant variation in spending within individual states (ie, New York: Binghamton, $18,339; Manhattan, $57,000) and between similar types of hospitals (UCLA Medical Center, $63,900; Massachusetts General Hospital, $43,058). Yet there is no evidence that higher‐spending regions produce better health outcomes.6 Interestingly, the observed differences in spending within the US were primarily due to the volume and intensity of care, not the price of care, as has been seen in some comparisons of the US with other industrialized countries.8, 15 In overall Medicare expenditures, higher‐spending locations tended to have a more inpatient‐based and specialist‐oriented pattern of practice, with higher utilization of inpatient consultations, diagnostic testing, and minor procedures.6

Although the wide variation in spending observed is a bit baffling, the encouraging aspect of this data is that some places are apparently doing it right; that is, providing their patients with a much higher value per healthcare dollar. Ultimately, if the higher‐spending locations modeled the lower‐spending locations, we would have the potential to reduce overall healthcare costs by as much as 30% without harming health.9

What are the possible reasons that we are providing unnecessary care? There are both environment‐dependent and physician‐dependent reasons, which I will outline here. The first 3 reasons represent areas that would seem to require system‐wide change, whereas the remaining 7 reasons are perhaps more amenable to local and/or national hospitalist‐directed efforts.

• 1

  Working in a litigious environment promotes unnecessary testing and consultations with the intent of reducing our exposure to malpractice liability, so‐called defensive medicine.16

• 2

  A reimbursement system that is primarily fee‐for‐service encourages physicians to provide more care and involve more physicians in the care of each patient, with little or no incentive to spend less, a core problem that was recently highlighted in a public Society of Hospital Management (SHM) statement.17

• 3

  The lack of integrated medical record systems promotes waste by leading to duplicate testing, simply because we cannot easily obtain old records to confirm whether tests were previously done. Interestingly, data from the Commonwealth Fund conclude that US physicians order duplicate diagnostic tests (a test repeated within 2 years) at more than twice the rate of Canada and the United Kingdom, while the nation with the lowest rate of duplicate testing, The Netherlands, has the highest rate of electronic medical record use (98%).18

• 4

  Working with patients (or families) with high expectations who insist upon aggressive testing, treatment, and referral to specialists inflates spending, especially if associated with futile and expensive end‐of‐life care.

• 5

  The involvement of one or more specialists may subsequently lead to even more aggressive care ordered by each specialist.

• 6

  The availability and promotion of new technology (diagnostic testing, medical devices, etc.) may prompt us to make use of it simply because it is there, with or without evidence of a health benefit. Our natural curiosity or fascination with information, or our desire to do an overly complete evaluation, works against cost containment.

• 7

  Local trends or traditions within our specific work environment, as suggested by the variability data, may have a strong influence on our individual practice. In such a setting, inadequate knowledge of the cost‐effectiveness of various tests and treatment options likely leads to unnecessary health care spending.

• 8

  A hospitalist work environment in which a high patient load is carried will inevitably result in less time to gather a detailed history and obtain old records or other information that could help narrow a differential diagnosis and minimize unnecessary or duplicate testing.

• 9

  Preventable readmissions resulting from inadequate coordination of care add cost,19 a phenomenon highly dependent on efficient information systems and proper physician‐physician communication.20

• 10

  An overestimation of the need for inpatient evaluation and treatment (vs. outpatient) leads to unnecessary admissions and a longer average length‐of‐stay, each of which add dramatically to total healthcare costs. This is not only dependent on our individual threshold for admitting and discharging patients, but also on our efficiency in diagnosing and treating acute conditions. The fact that the average length‐of‐stay for congestive heart failure admissions, for example, ranges in different regions from 4.9 to 6.1 days (with costs of $9143 and $12,528, respectively)21 is enough to show that there is room for progress.

What joint efforts could be made to minimize unnecessary inpatient spending? The following are my personal opinions and suggestions (Table 2). Most importantly, I believe every physician deserves prompt and accurate feedback regarding their spending patterns, accompanied by valid comparisons to national and local standards, to demonstrate where they stand on the spectrum of healthcare spending. We are currently far behind other industries in our ability, as physicians, to evaluate what we are spending money on, how much, and why. If I knew, for example, that my spending was in the 95th percentile of all hospitalists in community hospitals similar to mine, I would be prompted to investigate where the differences were and why. In an informal survey of hospitalist colleagues, I found that the majority do not receive any data on the costs associated with their care, and are largely unaware of the actual cost of the inpatient tests they commonly order. Developing a secure, user‐friendly database of individual physician spending patterns relative to national and local standards could be a preliminary step, and would likely require a unified effort between government agencies, professional societies, hospitals, and the insurance industry. However, once available, the increased transparency and clarity of spending variations would hopefully prompt introspection and change. In the absence of hard data, however, individual self‐assessment on spending patterns could also be offered through the development of an online simulated case‐based examination in which a physician could gain a general idea of how his evaluation and treatment of a case scenario compares to his hospitalist colleagues, and to what degree each of his clinical decisions affects the overall cost of care. There are many excellent quality improvement tools offered through SHM but none that specifically address the cost of care.

Second, hospitalists need quick access to current evidence‐based guidelines regarding the true clinical value, or cost‐effectiveness, of testing and treatment for common inpatient conditions, including specific admission criteria. A single source or clearinghouse of guidelines, sponsored by SHM, may be particularly helpful, especially if it focuses on clarifying areas of highest variability in inpatient spending. In addition, I believe that, given the critically important interface between emergency medicine and hospital medicine, joint guidelines between the 2 groups would potentially be very helpful in controlling costs by limiting unnecessary admissions. Advocacy for comparative effectiveness research to establish validity in these guidelines will be fundamental22, 23; however, I suspect the common sense question: Will this added cost improve my patient's outcome? also needs to be applied more generously, since many individual clinical scenarios will not likely lend themselves to formal study. For discussion, some sample case scenarios are presented (Table 3).

Third, hospitalists could potentially benefit from the development of patient education materials, available through SHM, that address the cost‐effectiveness of common inpatient tests and treatments with the goal of decreasing patient demand for unnecessary testing. Education regarding advanced directives and end‐of‐life care decision‐making could be particularly valuable in minimizing futile care, as it is well‐documented that transitioning to palliative care as soon as it is appropriate reduces healthcare spending greatly during the end‐of‐life period.2427 At the same time, we need to be careful to reassure our patients that we are not trying to ration care, but are instead minimizing the risks and costs for them associated with unnecessary care. In my experience, most patients, if given appropriate time, attention, and education, are willing to accept the final recommendation of their physician.

Fourth, intensified federal and state advocacy in several areas could help reduce spending. For example, advocacy for medical liability reform may reduce the atmosphere of defensive medicine, although I suspect that because old habits die hard, it may take a full generation of decreased liability risk to actually change practice patterns. Advocacy for the development of a national, or at least more uniform, electronic medical record, may decrease duplicate testing and improve efficiency. Advocacy for value‐based reimbursement models may help dampen costs resulting from a predominantly fee‐for‐service environment.28

Fifth, and perhaps most fundamental to the future of our specialty, encouraging the broad professional development of hospitalists as a true specialists in inpatient medicine (based on the SHM Core Competencies,)29 could help minimize the unnecessary costs associated with specialist‐oriented care.6 With the desire to create, in the near future, a formal board‐certification in hospital medicine comes an obligation to develop broad knowledge and broad skill sets that are truly unique to our profession, whereas deferring to a specialist‐oriented pattern of care actually shrinks us down to something less than a traditional internist, rather than a unique entity.30 With our 24/7 focus on inpatient care, we should easily be able to demonstrate our superiority in safety, quality, and efficiency, all of which are closely linked to increased value per healthcare dollar. If, however, our focus is blurred by an overly productivity‐based practice, in which patient volume and procedures take precedence, we will not be able to claim any special value to the system.

Last, supporting efforts to improve coordination of care and transitions of care could reduce costs associated with unnecessary readmissions or posthospital complications. A recent policy statement from several professional societies, including SHM, highlights the importance of these transitions,20, 31 and within the past year, SHM has launched the successful Project BOOST (Better Outcomes for Older adults through Safe Transitions) to help in this effort.32

Unfortunately, there is an inherent problem with all of the above proposals: the assumption that physicians actually want to reduce healthcare spending. Since everyone who works in the medical industry benefits financially in some way from the current high levels of spending on healthcare, reducing spending is counterintuitive for many, and the incentives to spend more will likely persist until some form of spending targets or limits are set.33 Moreover, since physicians traditionally do not like to be told how to practice medicine, history would predict that, without attractive incentives, nothing will change. This is the fundamental and unfortunate dilemma that has apparently pushed us to the eleventh hour of a healthcare crisis.

Another concern with an extreme atmosphere of cost cutting is the risk of swinging too far in the opposite direction, focusing so intently on cost that we begin to compromise quality or access to care in order to achieve spending targets. Reassuringly, however, the data suggest that there is plenty of room for us to cut costs without harming health outcomes.

Despite these obstacles, during this historic time in US healthcare, I believe hospitalists have a unique and perhaps transient opportunity to demonstrate their singular commitment to rational healthcare spending and by doing so to gain significant influence in shaping the impending healthcare reforms. If we speak and act with one voice, with transparency, and with the proper data, we could be the first and only professional society to not only demonstrate our current pattern of spending, but also our potential for reducing spending and our plan on how to get there.

Let's think about what we need to do ourselves. We have to acknowledge that orders we write drive up health care costs.1 AMA President, Nancy H. Nielsen, MD, PhD

As the most prominent providers of inpatient care, hospitalists should be aware that, of the total annual expenditures on US healthcare ($2.3 trillion in 2007),2 approximately one‐third goes to hospital‐based medical care, over one‐half of which (57%) is covered by public funds through Medicare and Medicaid3; this high cost of healthcare is increasingly being blamed for unnecessarily burdening our economy and preventing our industries from being globally competitive. I believe that the high proportion of spending on inpatient care places hospitalists firmly in the center of the debate on how to reduce healthcare costs. It is well known that the United States spends about twice as much per capita as other industrialized countries on healthcare,4 without evidence of superior health outcomes.5 However, it is also known that remarkable local and regional variations in healthcare spending also exist within the US, again, without evidence of superior health outcomes in the higher‐spending regions.6 Both of these observations suggest that we are spending many healthcare dollars on things that evidently do not improve the health of our patients. How much of this waste is administrative, operational, or clinical is debatable and remains the focus of growing national healthcare reform efforts.711 However, from the hospitalist perspective, we should be especially wary of providing so‐called flat‐of‐the‐curve medicine, that is, a level of intensity of care that provides no incremental health benefit.12 The purpose of this editorial is to challenge hospitalists to collectively examine how much of our inpatient spending is potentially unnecessary, and how we, as specialists in inpatient medicine, can assume a critical role in controlling healthcare costs.

To illustrate the issue, consider the following clinical scenario, managed in different ways by different hospitalists, with approximate costs itemized in Table 1. The patient is an elderly woman who presents to the emergency room with syncope occurring at church. The first hospitalist takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days. The second hospitalist receives the call from the emergency room and tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt‐table test scheduled.

Although the above scenarios purposely demonstrate 2 extremes of care, I suspect most readers would agree that each hospitalist has his or her own style of practice, and that these differences in style inevitably result in significant differences in the total cost of healthcare delivered. This variation in spending among individual physicians is perhaps more easily understood than the striking variations in healthcare spending seen when different states, regions, and hospitals are compared. For example, annual Medicare spending per beneficiary has varied widely from state to state, from $5436 in Iowa to $7995 in New York (in 2004), a 47% difference.13 Specific analysis of inpatient spending variations is presented in the Dartmouth Atlas of Health Care 2008, which reports healthcare spending in the last 2 years of life for patients with at least 1 chronic illness.14 While the average Medicare inpatient spending per capita for these patients was about $25,000, the state‐specific spending varied widely from $37,040 in New Jersey to $17,135 in Idaho. There was also significant variation in spending within individual states (ie, New York: Binghamton, $18,339; Manhattan, $57,000) and between similar types of hospitals (UCLA Medical Center, $63,900; Massachusetts General Hospital, $43,058). Yet there is no evidence that higher‐spending regions produce better health outcomes.6 Interestingly, the observed differences in spending within the US were primarily due to the volume and intensity of care, not the price of care, as has been seen in some comparisons of the US with other industrialized countries.8, 15 In overall Medicare expenditures, higher‐spending locations tended to have a more inpatient‐based and specialist‐oriented pattern of practice, with higher utilization of inpatient consultations, diagnostic testing, and minor procedures.6

Although the wide variation in spending observed is a bit baffling, the encouraging aspect of this data is that some places are apparently doing it right; that is, providing their patients with a much higher value per healthcare dollar. Ultimately, if the higher‐spending locations modeled the lower‐spending locations, we would have the potential to reduce overall healthcare costs by as much as 30% without harming health.9

What are the possible reasons that we are providing unnecessary care? There are both environment‐dependent and physician‐dependent reasons, which I will outline here. The first 3 reasons represent areas that would seem to require system‐wide change, whereas the remaining 7 reasons are perhaps more amenable to local and/or national hospitalist‐directed efforts.

• 1

  Working in a litigious environment promotes unnecessary testing and consultations with the intent of reducing our exposure to malpractice liability, so‐called defensive medicine.16

• 2

  A reimbursement system that is primarily fee‐for‐service encourages physicians to provide more care and involve more physicians in the care of each patient, with little or no incentive to spend less, a core problem that was recently highlighted in a public Society of Hospital Management (SHM) statement.17

• 3

  The lack of integrated medical record systems promotes waste by leading to duplicate testing, simply because we cannot easily obtain old records to confirm whether tests were previously done. Interestingly, data from the Commonwealth Fund conclude that US physicians order duplicate diagnostic tests (a test repeated within 2 years) at more than twice the rate of Canada and the United Kingdom, while the nation with the lowest rate of duplicate testing, The Netherlands, has the highest rate of electronic medical record use (98%).18

• 4

  Working with patients (or families) with high expectations who insist upon aggressive testing, treatment, and referral to specialists inflates spending, especially if associated with futile and expensive end‐of‐life care.

• 5

  The involvement of one or more specialists may subsequently lead to even more aggressive care ordered by each specialist.

• 6

  The availability and promotion of new technology (diagnostic testing, medical devices, etc.) may prompt us to make use of it simply because it is there, with or without evidence of a health benefit. Our natural curiosity or fascination with information, or our desire to do an overly complete evaluation, works against cost containment.

• 7

  Local trends or traditions within our specific work environment, as suggested by the variability data, may have a strong influence on our individual practice. In such a setting, inadequate knowledge of the cost‐effectiveness of various tests and treatment options likely leads to unnecessary health care spending.

• 8

  A hospitalist work environment in which a high patient load is carried will inevitably result in less time to gather a detailed history and obtain old records or other information that could help narrow a differential diagnosis and minimize unnecessary or duplicate testing.

• 9

  Preventable readmissions resulting from inadequate coordination of care add cost,19 a phenomenon highly dependent on efficient information systems and proper physician‐physician communication.20

• 10

  An overestimation of the need for inpatient evaluation and treatment (vs. outpatient) leads to unnecessary admissions and a longer average length‐of‐stay, each of which add dramatically to total healthcare costs. This is not only dependent on our individual threshold for admitting and discharging patients, but also on our efficiency in diagnosing and treating acute conditions. The fact that the average length‐of‐stay for congestive heart failure admissions, for example, ranges in different regions from 4.9 to 6.1 days (with costs of $9143 and $12,528, respectively)21 is enough to show that there is room for progress.

What joint efforts could be made to minimize unnecessary inpatient spending? The following are my personal opinions and suggestions (Table 2). Most importantly, I believe every physician deserves prompt and accurate feedback regarding their spending patterns, accompanied by valid comparisons to national and local standards, to demonstrate where they stand on the spectrum of healthcare spending. We are currently far behind other industries in our ability, as physicians, to evaluate what we are spending money on, how much, and why. If I knew, for example, that my spending was in the 95th percentile of all hospitalists in community hospitals similar to mine, I would be prompted to investigate where the differences were and why. In an informal survey of hospitalist colleagues, I found that the majority do not receive any data on the costs associated with their care, and are largely unaware of the actual cost of the inpatient tests they commonly order. Developing a secure, user‐friendly database of individual physician spending patterns relative to national and local standards could be a preliminary step, and would likely require a unified effort between government agencies, professional societies, hospitals, and the insurance industry. However, once available, the increased transparency and clarity of spending variations would hopefully prompt introspection and change. In the absence of hard data, however, individual self‐assessment on spending patterns could also be offered through the development of an online simulated case‐based examination in which a physician could gain a general idea of how his evaluation and treatment of a case scenario compares to his hospitalist colleagues, and to what degree each of his clinical decisions affects the overall cost of care. There are many excellent quality improvement tools offered through SHM but none that specifically address the cost of care.

Second, hospitalists need quick access to current evidence‐based guidelines regarding the true clinical value, or cost‐effectiveness, of testing and treatment for common inpatient conditions, including specific admission criteria. A single source or clearinghouse of guidelines, sponsored by SHM, may be particularly helpful, especially if it focuses on clarifying areas of highest variability in inpatient spending. In addition, I believe that, given the critically important interface between emergency medicine and hospital medicine, joint guidelines between the 2 groups would potentially be very helpful in controlling costs by limiting unnecessary admissions. Advocacy for comparative effectiveness research to establish validity in these guidelines will be fundamental22, 23; however, I suspect the common sense question: Will this added cost improve my patient's outcome? also needs to be applied more generously, since many individual clinical scenarios will not likely lend themselves to formal study. For discussion, some sample case scenarios are presented (Table 3).

Third, hospitalists could potentially benefit from the development of patient education materials, available through SHM, that address the cost‐effectiveness of common inpatient tests and treatments with the goal of decreasing patient demand for unnecessary testing. Education regarding advanced directives and end‐of‐life care decision‐making could be particularly valuable in minimizing futile care, as it is well‐documented that transitioning to palliative care as soon as it is appropriate reduces healthcare spending greatly during the end‐of‐life period.2427 At the same time, we need to be careful to reassure our patients that we are not trying to ration care, but are instead minimizing the risks and costs for them associated with unnecessary care. In my experience, most patients, if given appropriate time, attention, and education, are willing to accept the final recommendation of their physician.

Fourth, intensified federal and state advocacy in several areas could help reduce spending. For example, advocacy for medical liability reform may reduce the atmosphere of defensive medicine, although I suspect that because old habits die hard, it may take a full generation of decreased liability risk to actually change practice patterns. Advocacy for the development of a national, or at least more uniform, electronic medical record, may decrease duplicate testing and improve efficiency. Advocacy for value‐based reimbursement models may help dampen costs resulting from a predominantly fee‐for‐service environment.28

Fifth, and perhaps most fundamental to the future of our specialty, encouraging the broad professional development of hospitalists as a true specialists in inpatient medicine (based on the SHM Core Competencies,)29 could help minimize the unnecessary costs associated with specialist‐oriented care.6 With the desire to create, in the near future, a formal board‐certification in hospital medicine comes an obligation to develop broad knowledge and broad skill sets that are truly unique to our profession, whereas deferring to a specialist‐oriented pattern of care actually shrinks us down to something less than a traditional internist, rather than a unique entity.30 With our 24/7 focus on inpatient care, we should easily be able to demonstrate our superiority in safety, quality, and efficiency, all of which are closely linked to increased value per healthcare dollar. If, however, our focus is blurred by an overly productivity‐based practice, in which patient volume and procedures take precedence, we will not be able to claim any special value to the system.

Last, supporting efforts to improve coordination of care and transitions of care could reduce costs associated with unnecessary readmissions or posthospital complications. A recent policy statement from several professional societies, including SHM, highlights the importance of these transitions,20, 31 and within the past year, SHM has launched the successful Project BOOST (Better Outcomes for Older adults through Safe Transitions) to help in this effort.32

Unfortunately, there is an inherent problem with all of the above proposals: the assumption that physicians actually want to reduce healthcare spending. Since everyone who works in the medical industry benefits financially in some way from the current high levels of spending on healthcare, reducing spending is counterintuitive for many, and the incentives to spend more will likely persist until some form of spending targets or limits are set.33 Moreover, since physicians traditionally do not like to be told how to practice medicine, history would predict that, without attractive incentives, nothing will change. This is the fundamental and unfortunate dilemma that has apparently pushed us to the eleventh hour of a healthcare crisis.

Another concern with an extreme atmosphere of cost cutting is the risk of swinging too far in the opposite direction, focusing so intently on cost that we begin to compromise quality or access to care in order to achieve spending targets. Reassuringly, however, the data suggest that there is plenty of room for us to cut costs without harming health outcomes.

Despite these obstacles, during this historic time in US healthcare, I believe hospitalists have a unique and perhaps transient opportunity to demonstrate their singular commitment to rational healthcare spending and by doing so to gain significant influence in shaping the impending healthcare reforms. If we speak and act with one voice, with transparency, and with the proper data, we could be the first and only professional society to not only demonstrate our current pattern of spending, but also our potential for reducing spending and our plan on how to get there.

Let's think about what we need to do ourselves. We have to acknowledge that orders we write drive up health care costs.1 AMA President, Nancy H. Nielsen, MD, PhD

As the most prominent providers of inpatient care, hospitalists should be aware that, of the total annual expenditures on US healthcare ($2.3 trillion in 2007),2 approximately one‐third goes to hospital‐based medical care, over one‐half of which (57%) is covered by public funds through Medicare and Medicaid3; this high cost of healthcare is increasingly being blamed for unnecessarily burdening our economy and preventing our industries from being globally competitive. I believe that the high proportion of spending on inpatient care places hospitalists firmly in the center of the debate on how to reduce healthcare costs. It is well known that the United States spends about twice as much per capita as other industrialized countries on healthcare,4 without evidence of superior health outcomes.5 However, it is also known that remarkable local and regional variations in healthcare spending also exist within the US, again, without evidence of superior health outcomes in the higher‐spending regions.6 Both of these observations suggest that we are spending many healthcare dollars on things that evidently do not improve the health of our patients. How much of this waste is administrative, operational, or clinical is debatable and remains the focus of growing national healthcare reform efforts.711 However, from the hospitalist perspective, we should be especially wary of providing so‐called flat‐of‐the‐curve medicine, that is, a level of intensity of care that provides no incremental health benefit.12 The purpose of this editorial is to challenge hospitalists to collectively examine how much of our inpatient spending is potentially unnecessary, and how we, as specialists in inpatient medicine, can assume a critical role in controlling healthcare costs.

To illustrate the issue, consider the following clinical scenario, managed in different ways by different hospitalists, with approximate costs itemized in Table 1. The patient is an elderly woman who presents to the emergency room with syncope occurring at church. The first hospitalist takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days. The second hospitalist receives the call from the emergency room and tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt‐table test scheduled.

Although the above scenarios purposely demonstrate 2 extremes of care, I suspect most readers would agree that each hospitalist has his or her own style of practice, and that these differences in style inevitably result in significant differences in the total cost of healthcare delivered. This variation in spending among individual physicians is perhaps more easily understood than the striking variations in healthcare spending seen when different states, regions, and hospitals are compared. For example, annual Medicare spending per beneficiary has varied widely from state to state, from $5436 in Iowa to $7995 in New York (in 2004), a 47% difference.13 Specific analysis of inpatient spending variations is presented in the Dartmouth Atlas of Health Care 2008, which reports healthcare spending in the last 2 years of life for patients with at least 1 chronic illness.14 While the average Medicare inpatient spending per capita for these patients was about $25,000, the state‐specific spending varied widely from $37,040 in New Jersey to $17,135 in Idaho. There was also significant variation in spending within individual states (ie, New York: Binghamton, $18,339; Manhattan, $57,000) and between similar types of hospitals (UCLA Medical Center, $63,900; Massachusetts General Hospital, $43,058). Yet there is no evidence that higher‐spending regions produce better health outcomes.6 Interestingly, the observed differences in spending within the US were primarily due to the volume and intensity of care, not the price of care, as has been seen in some comparisons of the US with other industrialized countries.8, 15 In overall Medicare expenditures, higher‐spending locations tended to have a more inpatient‐based and specialist‐oriented pattern of practice, with higher utilization of inpatient consultations, diagnostic testing, and minor procedures.6

Although the wide variation in spending observed is a bit baffling, the encouraging aspect of this data is that some places are apparently doing it right; that is, providing their patients with a much higher value per healthcare dollar. Ultimately, if the higher‐spending locations modeled the lower‐spending locations, we would have the potential to reduce overall healthcare costs by as much as 30% without harming health.9

What are the possible reasons that we are providing unnecessary care? There are both environment‐dependent and physician‐dependent reasons, which I will outline here. The first 3 reasons represent areas that would seem to require system‐wide change, whereas the remaining 7 reasons are perhaps more amenable to local and/or national hospitalist‐directed efforts.

• 1

  Working in a litigious environment promotes unnecessary testing and consultations with the intent of reducing our exposure to malpractice liability, so‐called defensive medicine.16

• 2

  A reimbursement system that is primarily fee‐for‐service encourages physicians to provide more care and involve more physicians in the care of each patient, with little or no incentive to spend less, a core problem that was recently highlighted in a public Society of Hospital Management (SHM) statement.17

• 3

  The lack of integrated medical record systems promotes waste by leading to duplicate testing, simply because we cannot easily obtain old records to confirm whether tests were previously done. Interestingly, data from the Commonwealth Fund conclude that US physicians order duplicate diagnostic tests (a test repeated within 2 years) at more than twice the rate of Canada and the United Kingdom, while the nation with the lowest rate of duplicate testing, The Netherlands, has the highest rate of electronic medical record use (98%).18

• 4

  Working with patients (or families) with high expectations who insist upon aggressive testing, treatment, and referral to specialists inflates spending, especially if associated with futile and expensive end‐of‐life care.

• 5

  The involvement of one or more specialists may subsequently lead to even more aggressive care ordered by each specialist.

• 6

  The availability and promotion of new technology (diagnostic testing, medical devices, etc.) may prompt us to make use of it simply because it is there, with or without evidence of a health benefit. Our natural curiosity or fascination with information, or our desire to do an overly complete evaluation, works against cost containment.

• 7

  Local trends or traditions within our specific work environment, as suggested by the variability data, may have a strong influence on our individual practice. In such a setting, inadequate knowledge of the cost‐effectiveness of various tests and treatment options likely leads to unnecessary health care spending.

• 8

  A hospitalist work environment in which a high patient load is carried will inevitably result in less time to gather a detailed history and obtain old records or other information that could help narrow a differential diagnosis and minimize unnecessary or duplicate testing.

• 9

  Preventable readmissions resulting from inadequate coordination of care add cost,19 a phenomenon highly dependent on efficient information systems and proper physician‐physician communication.20

• 10

  An overestimation of the need for inpatient evaluation and treatment (vs. outpatient) leads to unnecessary admissions and a longer average length‐of‐stay, each of which add dramatically to total healthcare costs. This is not only dependent on our individual threshold for admitting and discharging patients, but also on our efficiency in diagnosing and treating acute conditions. The fact that the average length‐of‐stay for congestive heart failure admissions, for example, ranges in different regions from 4.9 to 6.1 days (with costs of $9143 and $12,528, respectively)21 is enough to show that there is room for progress.

What joint efforts could be made to minimize unnecessary inpatient spending? The following are my personal opinions and suggestions (Table 2). Most importantly, I believe every physician deserves prompt and accurate feedback regarding their spending patterns, accompanied by valid comparisons to national and local standards, to demonstrate where they stand on the spectrum of healthcare spending. We are currently far behind other industries in our ability, as physicians, to evaluate what we are spending money on, how much, and why. If I knew, for example, that my spending was in the 95th percentile of all hospitalists in community hospitals similar to mine, I would be prompted to investigate where the differences were and why. In an informal survey of hospitalist colleagues, I found that the majority do not receive any data on the costs associated with their care, and are largely unaware of the actual cost of the inpatient tests they commonly order. Developing a secure, user‐friendly database of individual physician spending patterns relative to national and local standards could be a preliminary step, and would likely require a unified effort between government agencies, professional societies, hospitals, and the insurance industry. However, once available, the increased transparency and clarity of spending variations would hopefully prompt introspection and change. In the absence of hard data, however, individual self‐assessment on spending patterns could also be offered through the development of an online simulated case‐based examination in which a physician could gain a general idea of how his evaluation and treatment of a case scenario compares to his hospitalist colleagues, and to what degree each of his clinical decisions affects the overall cost of care. There are many excellent quality improvement tools offered through SHM but none that specifically address the cost of care.

Second, hospitalists need quick access to current evidence‐based guidelines regarding the true clinical value, or cost‐effectiveness, of testing and treatment for common inpatient conditions, including specific admission criteria. A single source or clearinghouse of guidelines, sponsored by SHM, may be particularly helpful, especially if it focuses on clarifying areas of highest variability in inpatient spending. In addition, I believe that, given the critically important interface between emergency medicine and hospital medicine, joint guidelines between the 2 groups would potentially be very helpful in controlling costs by limiting unnecessary admissions. Advocacy for comparative effectiveness research to establish validity in these guidelines will be fundamental22, 23; however, I suspect the common sense question: Will this added cost improve my patient's outcome? also needs to be applied more generously, since many individual clinical scenarios will not likely lend themselves to formal study. For discussion, some sample case scenarios are presented (Table 3).

Third, hospitalists could potentially benefit from the development of patient education materials, available through SHM, that address the cost‐effectiveness of common inpatient tests and treatments with the goal of decreasing patient demand for unnecessary testing. Education regarding advanced directives and end‐of‐life care decision‐making could be particularly valuable in minimizing futile care, as it is well‐documented that transitioning to palliative care as soon as it is appropriate reduces healthcare spending greatly during the end‐of‐life period.2427 At the same time, we need to be careful to reassure our patients that we are not trying to ration care, but are instead minimizing the risks and costs for them associated with unnecessary care. In my experience, most patients, if given appropriate time, attention, and education, are willing to accept the final recommendation of their physician.

Fourth, intensified federal and state advocacy in several areas could help reduce spending. For example, advocacy for medical liability reform may reduce the atmosphere of defensive medicine, although I suspect that because old habits die hard, it may take a full generation of decreased liability risk to actually change practice patterns. Advocacy for the development of a national, or at least more uniform, electronic medical record, may decrease duplicate testing and improve efficiency. Advocacy for value‐based reimbursement models may help dampen costs resulting from a predominantly fee‐for‐service environment.28

Fifth, and perhaps most fundamental to the future of our specialty, encouraging the broad professional development of hospitalists as a true specialists in inpatient medicine (based on the SHM Core Competencies,)29 could help minimize the unnecessary costs associated with specialist‐oriented care.6 With the desire to create, in the near future, a formal board‐certification in hospital medicine comes an obligation to develop broad knowledge and broad skill sets that are truly unique to our profession, whereas deferring to a specialist‐oriented pattern of care actually shrinks us down to something less than a traditional internist, rather than a unique entity.30 With our 24/7 focus on inpatient care, we should easily be able to demonstrate our superiority in safety, quality, and efficiency, all of which are closely linked to increased value per healthcare dollar. If, however, our focus is blurred by an overly productivity‐based practice, in which patient volume and procedures take precedence, we will not be able to claim any special value to the system.

Last, supporting efforts to improve coordination of care and transitions of care could reduce costs associated with unnecessary readmissions or posthospital complications. A recent policy statement from several professional societies, including SHM, highlights the importance of these transitions,20, 31 and within the past year, SHM has launched the successful Project BOOST (Better Outcomes for Older adults through Safe Transitions) to help in this effort.32

Unfortunately, there is an inherent problem with all of the above proposals: the assumption that physicians actually want to reduce healthcare spending. Since everyone who works in the medical industry benefits financially in some way from the current high levels of spending on healthcare, reducing spending is counterintuitive for many, and the incentives to spend more will likely persist until some form of spending targets or limits are set.33 Moreover, since physicians traditionally do not like to be told how to practice medicine, history would predict that, without attractive incentives, nothing will change. This is the fundamental and unfortunate dilemma that has apparently pushed us to the eleventh hour of a healthcare crisis.

Another concern with an extreme atmosphere of cost cutting is the risk of swinging too far in the opposite direction, focusing so intently on cost that we begin to compromise quality or access to care in order to achieve spending targets. Reassuringly, however, the data suggest that there is plenty of room for us to cut costs without harming health outcomes.

Despite these obstacles, during this historic time in US healthcare, I believe hospitalists have a unique and perhaps transient opportunity to demonstrate their singular commitment to rational healthcare spending and by doing so to gain significant influence in shaping the impending healthcare reforms. If we speak and act with one voice, with transparency, and with the proper data, we could be the first and only professional society to not only demonstrate our current pattern of spending, but also our potential for reducing spending and our plan on how to get there.

Ultrasound, one of the most reliable diagnostic technologies in medicine, has a unique long‐term safety profile across a wide spectrum of applications. In line with the trend toward the miniaturization of many other technologies, increasingly sophisticated hand‐held or hand‐carried ultrasound (HCU) devices have become widely available. To date, the U.S. Food and Drug Administration (FDA) has approved more than 10 new‐generation portable (1.0‐4.5 kg) ultrasound devices, and a recent industry report projected that the HCU market will see revenues in excess of $1 billion by 2011.1

Although cardiovascular assessment remains its primary use, hospitalist physicians are increasingly turning to this technology for the localization of fluid and other abnormalities prior to paracentesis and thoracentesis. While there are other potential uses (eg, managing acute scrotal pain, diagnosing meniscal tears, measuring carotid intimal thickness), the higher‐quality studies of hospitalist‐physicians' use of HCU have focused on cardiovascular assessment. HCU confers a number of potential workflow‐related advantages, including coordinated point‐of‐care evaluation at short notice when formal ultrasound may be unavailable, as well as circumvention of the need to call on radiology or cardiology specialists.2 Even for experienced cardiologists, heart failure can be difficult to identify using any modality, and the clinical diagnosis of cardiovascular disease by hospital physicians has been documented as poor.3, 4 Thus, the addition of HCU to the palette of diagnostic and teaching tools available to frontline physicians potentially offers improvements over stethoscope‐assisted physical examination alone (including visual inspection, palpation, and auscultation), which has remained essentially unaltered for 150 years.57

Evidence Base for HCU Use by Hospitalists

The few primary studies on HCU use by hospitalists have focused on the potential utility of this technology as a valuable adjunct to the physical exam for the detection of cardiovascular disease (eg, asymptomatic left ventricular [LV] dysfunction, cardiomegaly, pericardial effusion) in the ambulatory or acute care setting.8, 9 Operation of HCU by hospitalists is not clearly indicated for the evaluation of valvular disease (eg, aortic and mitral regurgitation), in part due to the limited Doppler capabilities of the smaller devices.911 The risk of a gradual erosion of physical exam skills accompanying expansion of HCU use by hospitalists could itself become a potential disadvantage of a premature replacement of the stethoscope, since the results obtained by hospitalists performing a standard physical exam have been shown to be better than those obtained with HCU.8, 9

The lack of large, multicenter studies of HCU use by hospitalists leaves many questions unanswered, including whether or not the relatively low initial cost of an HCU device ($9,000‐$50,000) vs. that of a full‐sized hospital ultrasound system ($250,000) will eventually translate into overall cost‐effectiveness or actual patient‐centered benefit.10 While cautious advocates have insisted that HCU provides additive information in conjunction with the physical exam, this approach is not meant to serve as a substitute for standard echocardiography in patients requiring full evaluation in inpatient settings relevant for hospitalists.1114 Referral for additional testing or specialist opinionsand the associated costs incurredcannot necessarily be circumvented by hospitalist‐operated HCU.

A major problem with the HCU literature in general is its lack of standardization betweenand withinstudies, which renders it nearly impossible to generalize findings about important clinical outcomes, patient satisfaction, quality‐of‐life, symptoms, physical functioning, and morbidity and mortality. There are a preponderance of underpowered, methodologically inconsistent, single‐center case series that do not evaluate diagnostic accuracy in terms of patient outcomes. For example, although one study did find a modest (22‐29%) reduction in department workload with HCU, the authors omitted important information regarding blinding, and no power calculations were reported; thus, it was not possible to ascertain whether or not the reported results were due to the intervention or to chance.15 There clearly remains a need to convincingly demonstrate that patient care, shortening of length of stay, long‐term prognosis, or potential financial savings could occur with use of these devices by hospitalists.5 The process of device acquisition and resource allocation is, at least in part, based on accumulated evidence from studies that have ill‐defined relevant outcomes (eg, left ventricular function). However, even if such outcomes were to be more closely examined, medical decision‐making would still suffer from discrepant findings due to numerous differences in study design, including parameters involving patient population and selection, setting (eg, echocardiography laboratory vs. critical care unit), provider background, and specific device(s) used.

Training Issues

Hospitalist proficiency across HCU imaging skills (ie, acquisition, measurement, interpretation) has been found to be inconsistent.9 Endorsement and expansion of hospitalist use of HCU may to some extent reflect an overgeneralization from disparate comparative studies showing moderate success obtained with HCU (vs. physical exam) by other practitioner groups such as medical students and fellows with limited experience.16, 17 Whereas in 2005, Hellmann et al.18 concluded that medical residents with minimal training can learn to perform some of the basic functions of HCU with reasonable accuracy, Martin et al.8, 9 (in 2007 and 2009) reported conflicting results from a study of hospitalists trained at the same institution.

Concern about switching from standard to nonstandard HCU operators is raised by studies in which specialized operators (eg, echocardiography technicians) obtained better results than hospitalists using these devices.8, 9 In 2004, Borges et al.19 reported the results of 315 patients referred to specialists at a cardiology clinic for preoperative assessment prior to noncardiac surgery; the results (94.8% and 96.7% agreement with standard echocardiography on the main echocardiographic finding and detection of valve disease, respectively) were attributed to the fact that experienced cardiologists were working under ideal conditions using only the most advanced HCU devices with Doppler as well as harmonic imaging capabilities. Likewise, in 2004, Tsutsui et al.20 studied 44 consecutive hospitalized patients who underwent comprehensive echocardiography and bedside HCU. They reported that hemodynamic assessment by HCU was poor, even when performed by practitioners with relatively high levels of training.20 In 2003, DeCara et al.12 performed standard echocardiography on 300 adult inpatients referred for imaging, and concluded that standardized training, competency testing, and quality assurance guidelines need to be established before these devices can be utilized for clinical decision‐making by physicians without formal training in echocardiography. Although there have been numerous calls for training guidelines, it has not yet been determined how much training would be optimalor even necessaryfor professionals of each subspecialty to achieve levels of accuracy that are acceptable. Furthermore, it is well known that skill level declines unless a technique is regularly reinforced with practice, and therefore, recertification or procedure volume standards should be established.

The issue of potential harm needs to be raised, if hospitalists with access to HCU are indeed less accurate in their diagnoses than trained cardiologists interpreting images acquired by an established alternative such as echocardiography. False negatives can lead to delayed treatment, and false positives to unwarranted treatment. Given that the treatment effects of HCU use by hospitalists have not been closely scrutinized, the expansion of such use appears unwarranted, at least until further randomized studies with well‐defined outcomes have been conducted. Although the HCU devices themselves have a good safety profile, their potential benefits and harms (eg, possibility of increased nosocomial infection) will ultimately reflect operator skill and their impact on patient management relative to the gold‐standard diagnostic modalities for which there is abundant evidence of safety and efficacy.21

Premarketing and Postmarketing Concerns

The controversy regarding hospitalist use of HCU exposes gaps in the FDA approval process for medical devices, which are subjected to much less rigorous scrutiny during the premarketing approval process than pharmaceuticals.22 Moreover, the aggressive marketing of newly approved devices (and drugs) can drive medically unwarranted overuse, or indication creep, which justifies calls for the establishment of rigorous standards of clinical relevance and practice.23, 24 While the available literature on HCU operation by hospitalists is focused on cardiovascular indications for the technology, hospital medicine physicians are increasingly using HCU to guide paracentesis and thoracentesis. Given how commonplace the expansion of such practices has become, it is noteworthy that HCU operation by hospitalists has not yet been evaluated and endorsed in larger, controlled trials demonstrating appropriate outcomes.25

Across all fields of medicine, the transition from traditional to newer modalities remains a slippery slope in terms of demonstration of persuasive evidence of patient‐centered benefit.26 Fascination with emerging technologies (so‐called gizmo idolatry) and increased reimbursement potential threaten to distract patients and their providers from legitimate concerns about how medical device manufacturers and for‐profit corporations increasingly influence device acquisition and clinical practice.2731 While we lack strong evidence demonstrating that diagnostic tests such as HCU are beneficial when performed by hospitalists, the expanded use of these handy new devices by hospitalists is simultaneously generating increased incidental and equivocal findings, which in turn render it necessary to go back and perform secondary verification studies by specialists using older, gold‐standard modalities. This vicious cycle, coupled with the current lack of evidence, will continue to degrade confidence in the initiation of either acute or chronic treatment on the basis of HCU results obtained by hospitalist physicians.

Eventually, the increased use of HCU by hospitalists might lead to demonstrations of improved hospital workflow management, but it may just as easily represent another new coupling of technology and practitioner that prematurely becomes the standard of care in the absence of any demonstration of added value. The initially enthusiastic application of pulmonary artery catheters (PACs) serves as a cautionary tale in which the acquisition of additional clinical data did not necessarily lead to improved clinical outcomes: whereas PACs did enhance the clinical understanding of hemodynamics, they were not associated with an overall advantage in terms of mortality, length of hospital stay, or cost.3235 Ultimately, more information is not necessarily better information. Although new medical technologies can produce extremely useful diagnostic results that aid in the management of critically ill patients, poor data interpretation resulting from lack of targeted training and experience can nullify point‐of‐care advantages, and perhaps lead to excess morbidity and mortality.14 In clinical practice, it is generally best to avoid reliance on assumptions of added value in lieu of demonstrations of the same.

Conclusions

Hospital practitioners should not yet put away their stethoscopes. New technologies such as HCU need to be embraced in parallel with accumulating evidence of benefit. In the hands of hospitalists, the smaller HCU devices may very well prove handy, but at present, the literature simply does not support the use of HCU by hospitalist physicians.

Ultrasound, one of the most reliable diagnostic technologies in medicine, has a unique long‐term safety profile across a wide spectrum of applications. In line with the trend toward the miniaturization of many other technologies, increasingly sophisticated hand‐held or hand‐carried ultrasound (HCU) devices have become widely available. To date, the U.S. Food and Drug Administration (FDA) has approved more than 10 new‐generation portable (1.0‐4.5 kg) ultrasound devices, and a recent industry report projected that the HCU market will see revenues in excess of $1 billion by 2011.1

Although cardiovascular assessment remains its primary use, hospitalist physicians are increasingly turning to this technology for the localization of fluid and other abnormalities prior to paracentesis and thoracentesis. While there are other potential uses (eg, managing acute scrotal pain, diagnosing meniscal tears, measuring carotid intimal thickness), the higher‐quality studies of hospitalist‐physicians' use of HCU have focused on cardiovascular assessment. HCU confers a number of potential workflow‐related advantages, including coordinated point‐of‐care evaluation at short notice when formal ultrasound may be unavailable, as well as circumvention of the need to call on radiology or cardiology specialists.2 Even for experienced cardiologists, heart failure can be difficult to identify using any modality, and the clinical diagnosis of cardiovascular disease by hospital physicians has been documented as poor.3, 4 Thus, the addition of HCU to the palette of diagnostic and teaching tools available to frontline physicians potentially offers improvements over stethoscope‐assisted physical examination alone (including visual inspection, palpation, and auscultation), which has remained essentially unaltered for 150 years.57

Evidence Base for HCU Use by Hospitalists

The few primary studies on HCU use by hospitalists have focused on the potential utility of this technology as a valuable adjunct to the physical exam for the detection of cardiovascular disease (eg, asymptomatic left ventricular [LV] dysfunction, cardiomegaly, pericardial effusion) in the ambulatory or acute care setting.8, 9 Operation of HCU by hospitalists is not clearly indicated for the evaluation of valvular disease (eg, aortic and mitral regurgitation), in part due to the limited Doppler capabilities of the smaller devices.911 The risk of a gradual erosion of physical exam skills accompanying expansion of HCU use by hospitalists could itself become a potential disadvantage of a premature replacement of the stethoscope, since the results obtained by hospitalists performing a standard physical exam have been shown to be better than those obtained with HCU.8, 9

The lack of large, multicenter studies of HCU use by hospitalists leaves many questions unanswered, including whether or not the relatively low initial cost of an HCU device ($9,000‐$50,000) vs. that of a full‐sized hospital ultrasound system ($250,000) will eventually translate into overall cost‐effectiveness or actual patient‐centered benefit.10 While cautious advocates have insisted that HCU provides additive information in conjunction with the physical exam, this approach is not meant to serve as a substitute for standard echocardiography in patients requiring full evaluation in inpatient settings relevant for hospitalists.1114 Referral for additional testing or specialist opinionsand the associated costs incurredcannot necessarily be circumvented by hospitalist‐operated HCU.

A major problem with the HCU literature in general is its lack of standardization betweenand withinstudies, which renders it nearly impossible to generalize findings about important clinical outcomes, patient satisfaction, quality‐of‐life, symptoms, physical functioning, and morbidity and mortality. There are a preponderance of underpowered, methodologically inconsistent, single‐center case series that do not evaluate diagnostic accuracy in terms of patient outcomes. For example, although one study did find a modest (22‐29%) reduction in department workload with HCU, the authors omitted important information regarding blinding, and no power calculations were reported; thus, it was not possible to ascertain whether or not the reported results were due to the intervention or to chance.15 There clearly remains a need to convincingly demonstrate that patient care, shortening of length of stay, long‐term prognosis, or potential financial savings could occur with use of these devices by hospitalists.5 The process of device acquisition and resource allocation is, at least in part, based on accumulated evidence from studies that have ill‐defined relevant outcomes (eg, left ventricular function). However, even if such outcomes were to be more closely examined, medical decision‐making would still suffer from discrepant findings due to numerous differences in study design, including parameters involving patient population and selection, setting (eg, echocardiography laboratory vs. critical care unit), provider background, and specific device(s) used.

Training Issues

Hospitalist proficiency across HCU imaging skills (ie, acquisition, measurement, interpretation) has been found to be inconsistent.9 Endorsement and expansion of hospitalist use of HCU may to some extent reflect an overgeneralization from disparate comparative studies showing moderate success obtained with HCU (vs. physical exam) by other practitioner groups such as medical students and fellows with limited experience.16, 17 Whereas in 2005, Hellmann et al.18 concluded that medical residents with minimal training can learn to perform some of the basic functions of HCU with reasonable accuracy, Martin et al.8, 9 (in 2007 and 2009) reported conflicting results from a study of hospitalists trained at the same institution.

Concern about switching from standard to nonstandard HCU operators is raised by studies in which specialized operators (eg, echocardiography technicians) obtained better results than hospitalists using these devices.8, 9 In 2004, Borges et al.19 reported the results of 315 patients referred to specialists at a cardiology clinic for preoperative assessment prior to noncardiac surgery; the results (94.8% and 96.7% agreement with standard echocardiography on the main echocardiographic finding and detection of valve disease, respectively) were attributed to the fact that experienced cardiologists were working under ideal conditions using only the most advanced HCU devices with Doppler as well as harmonic imaging capabilities. Likewise, in 2004, Tsutsui et al.20 studied 44 consecutive hospitalized patients who underwent comprehensive echocardiography and bedside HCU. They reported that hemodynamic assessment by HCU was poor, even when performed by practitioners with relatively high levels of training.20 In 2003, DeCara et al.12 performed standard echocardiography on 300 adult inpatients referred for imaging, and concluded that standardized training, competency testing, and quality assurance guidelines need to be established before these devices can be utilized for clinical decision‐making by physicians without formal training in echocardiography. Although there have been numerous calls for training guidelines, it has not yet been determined how much training would be optimalor even necessaryfor professionals of each subspecialty to achieve levels of accuracy that are acceptable. Furthermore, it is well known that skill level declines unless a technique is regularly reinforced with practice, and therefore, recertification or procedure volume standards should be established.

The issue of potential harm needs to be raised, if hospitalists with access to HCU are indeed less accurate in their diagnoses than trained cardiologists interpreting images acquired by an established alternative such as echocardiography. False negatives can lead to delayed treatment, and false positives to unwarranted treatment. Given that the treatment effects of HCU use by hospitalists have not been closely scrutinized, the expansion of such use appears unwarranted, at least until further randomized studies with well‐defined outcomes have been conducted. Although the HCU devices themselves have a good safety profile, their potential benefits and harms (eg, possibility of increased nosocomial infection) will ultimately reflect operator skill and their impact on patient management relative to the gold‐standard diagnostic modalities for which there is abundant evidence of safety and efficacy.21

Premarketing and Postmarketing Concerns

The controversy regarding hospitalist use of HCU exposes gaps in the FDA approval process for medical devices, which are subjected to much less rigorous scrutiny during the premarketing approval process than pharmaceuticals.22 Moreover, the aggressive marketing of newly approved devices (and drugs) can drive medically unwarranted overuse, or indication creep, which justifies calls for the establishment of rigorous standards of clinical relevance and practice.23, 24 While the available literature on HCU operation by hospitalists is focused on cardiovascular indications for the technology, hospital medicine physicians are increasingly using HCU to guide paracentesis and thoracentesis. Given how commonplace the expansion of such practices has become, it is noteworthy that HCU operation by hospitalists has not yet been evaluated and endorsed in larger, controlled trials demonstrating appropriate outcomes.25

Across all fields of medicine, the transition from traditional to newer modalities remains a slippery slope in terms of demonstration of persuasive evidence of patient‐centered benefit.26 Fascination with emerging technologies (so‐called gizmo idolatry) and increased reimbursement potential threaten to distract patients and their providers from legitimate concerns about how medical device manufacturers and for‐profit corporations increasingly influence device acquisition and clinical practice.2731 While we lack strong evidence demonstrating that diagnostic tests such as HCU are beneficial when performed by hospitalists, the expanded use of these handy new devices by hospitalists is simultaneously generating increased incidental and equivocal findings, which in turn render it necessary to go back and perform secondary verification studies by specialists using older, gold‐standard modalities. This vicious cycle, coupled with the current lack of evidence, will continue to degrade confidence in the initiation of either acute or chronic treatment on the basis of HCU results obtained by hospitalist physicians.

Eventually, the increased use of HCU by hospitalists might lead to demonstrations of improved hospital workflow management, but it may just as easily represent another new coupling of technology and practitioner that prematurely becomes the standard of care in the absence of any demonstration of added value. The initially enthusiastic application of pulmonary artery catheters (PACs) serves as a cautionary tale in which the acquisition of additional clinical data did not necessarily lead to improved clinical outcomes: whereas PACs did enhance the clinical understanding of hemodynamics, they were not associated with an overall advantage in terms of mortality, length of hospital stay, or cost.3235 Ultimately, more information is not necessarily better information. Although new medical technologies can produce extremely useful diagnostic results that aid in the management of critically ill patients, poor data interpretation resulting from lack of targeted training and experience can nullify point‐of‐care advantages, and perhaps lead to excess morbidity and mortality.14 In clinical practice, it is generally best to avoid reliance on assumptions of added value in lieu of demonstrations of the same.

Conclusions

Hospital practitioners should not yet put away their stethoscopes. New technologies such as HCU need to be embraced in parallel with accumulating evidence of benefit. In the hands of hospitalists, the smaller HCU devices may very well prove handy, but at present, the literature simply does not support the use of HCU by hospitalist physicians.

Ultrasound, one of the most reliable diagnostic technologies in medicine, has a unique long‐term safety profile across a wide spectrum of applications. In line with the trend toward the miniaturization of many other technologies, increasingly sophisticated hand‐held or hand‐carried ultrasound (HCU) devices have become widely available. To date, the U.S. Food and Drug Administration (FDA) has approved more than 10 new‐generation portable (1.0‐4.5 kg) ultrasound devices, and a recent industry report projected that the HCU market will see revenues in excess of $1 billion by 2011.1

Although cardiovascular assessment remains its primary use, hospitalist physicians are increasingly turning to this technology for the localization of fluid and other abnormalities prior to paracentesis and thoracentesis. While there are other potential uses (eg, managing acute scrotal pain, diagnosing meniscal tears, measuring carotid intimal thickness), the higher‐quality studies of hospitalist‐physicians' use of HCU have focused on cardiovascular assessment. HCU confers a number of potential workflow‐related advantages, including coordinated point‐of‐care evaluation at short notice when formal ultrasound may be unavailable, as well as circumvention of the need to call on radiology or cardiology specialists.2 Even for experienced cardiologists, heart failure can be difficult to identify using any modality, and the clinical diagnosis of cardiovascular disease by hospital physicians has been documented as poor.3, 4 Thus, the addition of HCU to the palette of diagnostic and teaching tools available to frontline physicians potentially offers improvements over stethoscope‐assisted physical examination alone (including visual inspection, palpation, and auscultation), which has remained essentially unaltered for 150 years.57

Evidence Base for HCU Use by Hospitalists

The few primary studies on HCU use by hospitalists have focused on the potential utility of this technology as a valuable adjunct to the physical exam for the detection of cardiovascular disease (eg, asymptomatic left ventricular [LV] dysfunction, cardiomegaly, pericardial effusion) in the ambulatory or acute care setting.8, 9 Operation of HCU by hospitalists is not clearly indicated for the evaluation of valvular disease (eg, aortic and mitral regurgitation), in part due to the limited Doppler capabilities of the smaller devices.911 The risk of a gradual erosion of physical exam skills accompanying expansion of HCU use by hospitalists could itself become a potential disadvantage of a premature replacement of the stethoscope, since the results obtained by hospitalists performing a standard physical exam have been shown to be better than those obtained with HCU.8, 9

The lack of large, multicenter studies of HCU use by hospitalists leaves many questions unanswered, including whether or not the relatively low initial cost of an HCU device ($9,000‐$50,000) vs. that of a full‐sized hospital ultrasound system ($250,000) will eventually translate into overall cost‐effectiveness or actual patient‐centered benefit.10 While cautious advocates have insisted that HCU provides additive information in conjunction with the physical exam, this approach is not meant to serve as a substitute for standard echocardiography in patients requiring full evaluation in inpatient settings relevant for hospitalists.1114 Referral for additional testing or specialist opinionsand the associated costs incurredcannot necessarily be circumvented by hospitalist‐operated HCU.

A major problem with the HCU literature in general is its lack of standardization betweenand withinstudies, which renders it nearly impossible to generalize findings about important clinical outcomes, patient satisfaction, quality‐of‐life, symptoms, physical functioning, and morbidity and mortality. There are a preponderance of underpowered, methodologically inconsistent, single‐center case series that do not evaluate diagnostic accuracy in terms of patient outcomes. For example, although one study did find a modest (22‐29%) reduction in department workload with HCU, the authors omitted important information regarding blinding, and no power calculations were reported; thus, it was not possible to ascertain whether or not the reported results were due to the intervention or to chance.15 There clearly remains a need to convincingly demonstrate that patient care, shortening of length of stay, long‐term prognosis, or potential financial savings could occur with use of these devices by hospitalists.5 The process of device acquisition and resource allocation is, at least in part, based on accumulated evidence from studies that have ill‐defined relevant outcomes (eg, left ventricular function). However, even if such outcomes were to be more closely examined, medical decision‐making would still suffer from discrepant findings due to numerous differences in study design, including parameters involving patient population and selection, setting (eg, echocardiography laboratory vs. critical care unit), provider background, and specific device(s) used.

Training Issues

Hospitalist proficiency across HCU imaging skills (ie, acquisition, measurement, interpretation) has been found to be inconsistent.9 Endorsement and expansion of hospitalist use of HCU may to some extent reflect an overgeneralization from disparate comparative studies showing moderate success obtained with HCU (vs. physical exam) by other practitioner groups such as medical students and fellows with limited experience.16, 17 Whereas in 2005, Hellmann et al.18 concluded that medical residents with minimal training can learn to perform some of the basic functions of HCU with reasonable accuracy, Martin et al.8, 9 (in 2007 and 2009) reported conflicting results from a study of hospitalists trained at the same institution.

Concern about switching from standard to nonstandard HCU operators is raised by studies in which specialized operators (eg, echocardiography technicians) obtained better results than hospitalists using these devices.8, 9 In 2004, Borges et al.19 reported the results of 315 patients referred to specialists at a cardiology clinic for preoperative assessment prior to noncardiac surgery; the results (94.8% and 96.7% agreement with standard echocardiography on the main echocardiographic finding and detection of valve disease, respectively) were attributed to the fact that experienced cardiologists were working under ideal conditions using only the most advanced HCU devices with Doppler as well as harmonic imaging capabilities. Likewise, in 2004, Tsutsui et al.20 studied 44 consecutive hospitalized patients who underwent comprehensive echocardiography and bedside HCU. They reported that hemodynamic assessment by HCU was poor, even when performed by practitioners with relatively high levels of training.20 In 2003, DeCara et al.12 performed standard echocardiography on 300 adult inpatients referred for imaging, and concluded that standardized training, competency testing, and quality assurance guidelines need to be established before these devices can be utilized for clinical decision‐making by physicians without formal training in echocardiography. Although there have been numerous calls for training guidelines, it has not yet been determined how much training would be optimalor even necessaryfor professionals of each subspecialty to achieve levels of accuracy that are acceptable. Furthermore, it is well known that skill level declines unless a technique is regularly reinforced with practice, and therefore, recertification or procedure volume standards should be established.

The issue of potential harm needs to be raised, if hospitalists with access to HCU are indeed less accurate in their diagnoses than trained cardiologists interpreting images acquired by an established alternative such as echocardiography. False negatives can lead to delayed treatment, and false positives to unwarranted treatment. Given that the treatment effects of HCU use by hospitalists have not been closely scrutinized, the expansion of such use appears unwarranted, at least until further randomized studies with well‐defined outcomes have been conducted. Although the HCU devices themselves have a good safety profile, their potential benefits and harms (eg, possibility of increased nosocomial infection) will ultimately reflect operator skill and their impact on patient management relative to the gold‐standard diagnostic modalities for which there is abundant evidence of safety and efficacy.21

Premarketing and Postmarketing Concerns

The controversy regarding hospitalist use of HCU exposes gaps in the FDA approval process for medical devices, which are subjected to much less rigorous scrutiny during the premarketing approval process than pharmaceuticals.22 Moreover, the aggressive marketing of newly approved devices (and drugs) can drive medically unwarranted overuse, or indication creep, which justifies calls for the establishment of rigorous standards of clinical relevance and practice.23, 24 While the available literature on HCU operation by hospitalists is focused on cardiovascular indications for the technology, hospital medicine physicians are increasingly using HCU to guide paracentesis and thoracentesis. Given how commonplace the expansion of such practices has become, it is noteworthy that HCU operation by hospitalists has not yet been evaluated and endorsed in larger, controlled trials demonstrating appropriate outcomes.25

Across all fields of medicine, the transition from traditional to newer modalities remains a slippery slope in terms of demonstration of persuasive evidence of patient‐centered benefit.26 Fascination with emerging technologies (so‐called gizmo idolatry) and increased reimbursement potential threaten to distract patients and their providers from legitimate concerns about how medical device manufacturers and for‐profit corporations increasingly influence device acquisition and clinical practice.2731 While we lack strong evidence demonstrating that diagnostic tests such as HCU are beneficial when performed by hospitalists, the expanded use of these handy new devices by hospitalists is simultaneously generating increased incidental and equivocal findings, which in turn render it necessary to go back and perform secondary verification studies by specialists using older, gold‐standard modalities. This vicious cycle, coupled with the current lack of evidence, will continue to degrade confidence in the initiation of either acute or chronic treatment on the basis of HCU results obtained by hospitalist physicians.

Eventually, the increased use of HCU by hospitalists might lead to demonstrations of improved hospital workflow management, but it may just as easily represent another new coupling of technology and practitioner that prematurely becomes the standard of care in the absence of any demonstration of added value. The initially enthusiastic application of pulmonary artery catheters (PACs) serves as a cautionary tale in which the acquisition of additional clinical data did not necessarily lead to improved clinical outcomes: whereas PACs did enhance the clinical understanding of hemodynamics, they were not associated with an overall advantage in terms of mortality, length of hospital stay, or cost.3235 Ultimately, more information is not necessarily better information. Although new medical technologies can produce extremely useful diagnostic results that aid in the management of critically ill patients, poor data interpretation resulting from lack of targeted training and experience can nullify point‐of‐care advantages, and perhaps lead to excess morbidity and mortality.14 In clinical practice, it is generally best to avoid reliance on assumptions of added value in lieu of demonstrations of the same.

Conclusions

Hospital practitioners should not yet put away their stethoscopes. New technologies such as HCU need to be embraced in parallel with accumulating evidence of benefit. In the hands of hospitalists, the smaller HCU devices may very well prove handy, but at present, the literature simply does not support the use of HCU by hospitalist physicians.

Hand‐carried ultrasound (HCU) is a field technique. Originally intended for military triage, the advent of small, portable, ultrasound devices has brought ultrasound imaging to the patient's bedside to guide procedures and evaluate life‐threatening conditions. Although many recently‐trained physicians in emergency or critical care medicine now routinely use HCU to place central lines1 and tap effusions,2, 3 the capability of this technique to augment physical examination by all physicians has far greater potential value in medicine. When applied in acute critical scenarios, HCU techniques can quickly demonstrate findings regarding abdominal aortic aneurysm,4 deep vein thrombosis,5 pericardial fluid, or hemoperitoneum6 in patients with unexplained hypotension, and examine inferior vena cava collapsibility7 or brachial artery velocity variation8 to help determine the need for volume resuscitation in sepsis. In patients with unexplained dyspnea, HCU can search for ultrasound lung comet‐tail artifacts as a sign of pulmonary edema,9 or use the presence of pleural sliding to exclude pneumothorax.10 In addition, numerous less urgent applications for HCU imaging are emerging such as cardiac, lung, vascular, musculoskeletal, nerve, thyroid, gallbladder, liver, spleen, renal, testicular, and bladder imaging.

Medical or surgical subspecialties familiar with ultrasound have developed limited HCU examinations that serve specific purposes within the relatively narrow clinical indications encountered by these specialties. As a consequence, overall expertise in bedside HCU currently requires the mastery of multiple unrelated ultrasound views and diagnostic criteria. Without central leadership within this burgeoning field, HCU has found no consensus on its use or development within general medical practice. No one has yet validated a single ultrasound imaging protocol for augmenting the physical examination on all patients akin to the use of the stethoscope. This review discusses the importance of the internisthospitalist at this critical point in the early development of bedside HCU examination, focusing on the cardiopulmonary component as a prototype that has universal application across medical practice. Involvement by hospitalists in pioneering the overall technique will direct research in clinical outcome, restructure internal medicine education, change perception of the physical examination, and spur industry in device development specific for general medicine.

The role of the hospitalist as the leading in‐house diagnostician is unique in medicine, requiring breadth in medical knowledge and unprecedented communication skills in the seamless care of the most medically ill patients in the community.11 Ideally, the hospitalist quickly recognizes disease, discriminately uses consultation or expensive diagnostic testing, chooses cost‐effective therapies, and shortens length of hospital stay. Early accurate diagnosis afforded by HCU imaging has the potential to improve efficiency of medical care across a wide spectrum of clinical presentations. Although to date there are no outcome studies using a mortality endpoint, small individual studies have demonstrated that specific HCU findings improve diagnostic accuracy and relate to hospital stay length12 and readmission.13 The hospitalist position is in theory well‐suited for learning and applying bedside ultrasound, having both expert resources in the hospital to guide training and a clinical objective to reduce unnecessary hospital costs.

Saving the Bedside Examination: The Laying‐on of Ultrasound

Bedside examination is a vital component of the initial hospitalist‐patient interaction, adding objective data to the patient's history. In this era of physician surrogates and telemedicine, physical examination remains a nonnegotiable reason why physicians must appear in person at the patient's bedside to lay on hands. However, bedside cardiovascular examination skills have greatly diminished over the past decade for a variety of reasons.14 In particular, physical examination is impaired in the environment in which the hospitalist must practice. The admitting physician must oftentimes hurriedly examine the patient on the gurney in the noisy emergency department or in bed in an alarm‐filled intensive care unit (ICU) or hospital room. Ambient noise levels often preclude auscultation of acute aortic and mitral valve regurgitation, splitting of valve sounds, low diastolic rumbles, soft gallops, and fine rales. Patient positioning is limited in ventilated patients or those in respiratory or circulatory distress. Although medical education still honors the value of teaching the traditional cardiac examination, no outcome data exist to justify the application of the various maneuvers and techniques learned in medical school to contemporary, commonly encountered inpatient care scenarios. For example, few physical examination data exist on how to evaluate central venous pressures of an obese patient on the ventilator or assess the severity of aortic stenosis in the elderly hypertensive patient. Furthermore, many important cardiopulmonary abnormalities that are easily detected by ultrasound, such as pericardial fluid, well‐compensated left ventricular systolic dysfunction, small pleural effusion, and left atrial enlargement, make no characteristic sound for auscultation. The effect of undiagnosed cardiac abnormalities on the patient's immediate hospital course is unknown, but is likely related to the clinical presentation and long‐term outcome. Today, the hospitalist's suspicion of cardiovascular abnormalities is more often generated from elements in the patient's initial history, serum biomarkers, chest radiography, or electrocardiogram, and less from auscultation. Accordingly, cardiac physical examination is only adjunctively used in determining the general direction of the ensuing evaluation and when abnormal, often generates additional diagnostic testing for confirmation.

The optimal role of HCU for the internist‐hospitalist is in augmentation of bedside physical diagnosis.15, 16 Unlike x‐ray or even rapid serum biomarkers, ultrasound is a safe, immediate, noninvasive modality and has been particularly effective in delineating cardiac structure and physiology. Accurate HCU estimation of a patient's central venous pressure,17 left atrial size,18 or left ventricular ejection fraction19, 20 is of particular value in those with unexplained respiratory distress or circulatory collapse, or in those in whom referral for echocardiography or cardiac consultation is not obvious. Asymptomatic left ventricular systolic dysfunction has an estimated prevalence of 5% in adult populations,21 and its detection would have immediate implications in regard to etiology, volume management, and drug therapy. Multiple studies have shown the prognostic importance of left atrial enlargement in ischemic cardiac disease, congestive heart failure, atrial arrhythmias, and stroke.22 The inferior vena cava diameter has been related to central venous pressure and prognosis in congestive heart failure. A recent study13 using medical residents employing HCU demonstrated that persistent dilatation of the inferior vena cava at discharge related to a higher readmission rate in patients with congestive heart failure. The potential exists to follow and guide a patient's response to therapy with HCU during daily rounds. Comparative studies2325 confirm that HCU examinations are better than expert auscultation and improve overall exam accuracy when added to traditional physical exam techniques. Entering into the modern‐day emergency room with a pocket‐sized ultrasound device that provides the immediate capability of detecting left ventricular dysfunction, left atrial enlargement, pericardial effusion, or abnormalities in volume status, provides an additional sense of being prepared for battle.

Deriving Limited Ultrasound Applications: Time Well Spent

However, in order for a hospitalist to use HCU, easily applied limited imaging protocols must be derived from standard ultrasound examination techniques for each organ. For the heart, studies from our laboratory have shown that it is feasible to distill the comprehensive echocardiogram down to simple cardiac screening examinations for rapid bedside HCU use.2628 We found that a limited cardiac ultrasound study consisting of a single parasternal long‐axis (PLAX) view (Figure 1) requires only seconds to perform and can identify those patients who have significant cardiac abnormalities. In an outpatient population (n = 196) followed in an internal medicine clinic, the PLAX component of an HCU cardiac screening protocol uncovered left atrial enlargement in 4 patients and left ventricular systolic dysfunction in 4 patients that had not been suspected by the patients' primary physicians.29 In a study of 124 patients in the emergency department with suspected cardiac disease,12 abnormal cardiac findings were noted 3 times more frequently by PLAX than by clinical evaluation, and an abnormal PLAX was significantly associated with a longer hospital length of stay. In other preliminary studies using cardiologists, limited imaging has been shown to reduce costs of unnecessary echo referral.28, 3032 Cost analysis has yet to be performed in nonexpert HCU users, but benefit is likely related to the difference between the user's own accuracy with the stethoscope and the HCU device.

Figure 1

Although experts in ultrasound exist in radiology and cardiology, it is unlikely these subspecialists will spontaneously create and optimize a full‐body HCU imaging protocol for hospitalists. Similar to the use of ultrasound in emergency medicine, anesthesiology, and critical care medicine, the derivation of a bedside ultrasound exam appropriate for the in‐hospital physical examination should be developed within the specialty itself, by those acquainted with the clinical scenarios in which HCU would be deployed. For example, the question of whether the gallbladder should be routinely imaged by a quick HCU exam in the evaluation of chest pain is similar to the question of whether the Valsalva maneuver should be performed in the evaluation of every murmurboth require Bayesian knowledge of disease prevalence, exam difficulty, and test accuracy. With the collaboration of experts in ultrasound, internists can derive brief, easily learned, limited ultrasound exams for left ventricular dysfunction, left atrial enlargement, carotid atherosclerosis, interstitial lung disease, hepatosplenomegaly, cholelithiasis, hydronephrosis, renal atrophy, pleural or pericardial effusion, ascites, deep vein thrombosis, and abdominal aortic aneurysm. The discovery of these disease states has clinical value for long‐term care, even if incidental to the patient's acute presentation. The lasting implications of a more comprehensive general examination will likely differentiate the use of HCU in internal medicine practice from that of emergency medicine.

Basic Training in HCU

A significant challenge to medical education will be in physician training in HCU. Over 15 studies12, 13, 15, 1720, 22, 23, 3343 have now shown the ability of briefly trained medical students, residents, and physicians in internal medicine to perform a limited cardiovascular ultrasound examination. Not surprisingly, these studies show variable degrees of training proficiency, apparently dependent upon the complexity of the imaging protocol. In a recent pair of studies from 1 institution,42, 43 10 hospitalists were trained to perform an extensive HCU echocardiogram including 4 views, color and spectral Doppler, and interpret severity of valvular disease, ventricular function, pericardial effusion. In 345 patients already referred for formal echocardiography, which later served as the gold standard, HCU improved the hospitalists' physical examination for left ventricular dysfunction, cardiomegaly, and pericardial effusion, but not for valvular disease. Notably, despite a focused training program including didactic teaching, self‐study cases, 5 training studies, and the imaging of 35 patients with assistance as needed, image acquisition was inferior to standard examination and image interpretation was inferior to that of cardiology fellows. Such data reemphasize the fact that the scope of each body‐system imaging protocol must be narrow in order to make the learning of a full‐body HCU exam feasible and to incorporate training into time already allocated to the bedside physical examination curriculum or continuing medical education activities.

At our institution, internal medical residents are trained in bedside cardiovascular ultrasound to blend results with their auscultative findings during bedside examination. We have developed 2 cardiovascular limited ultrasound examinations (CLUEs) that can be performed in 5 minutes and have evidence‐basis for their clinical use through pilot training studies.18, 19, 29, 35 Our basic CLUE, designed for general cardiovascular examination, includes screening the carotid bulb for subclinical atherosclerosis, PLAX imaging for left atrial enlargement and systolic dysfunction of the left ventricle, and abdominal scanning for abdominal aortic aneurysm. In this imaging protocol consisting of only 4 targets, atherosclerotic risk increases from top to bottom (cephalad to caudal), making the exam easy to remember. The CLUEparasternal, lung, and subcostal (CLUE‐PLUS), designed for the urgent evaluation of unexplained dyspnea or hypotension, uses a work backward imaging format (from left ventricle to right atrium) and a single cardiac transducer for simplicity. The PLAX view screens for left ventricular systolic dysfunction and then left atrial enlargement. Next, a brief 4‐point lung exam screens for ultrasonic lung comets and pleural effusion. A subcostal view of the heart is used to evaluate right ventricular size and pericardial effusion, and finally the inferior vena cava is evaluated for central venous pressures. CLUEs are taught in bedside and didactic formats over the 3 years of residency with formal competency testing after lecture attendance, practice imaging in our echo‐vascular laboratories, participation in rounds, and completion of at least 30 supervised examinations.

Reaffirming the Role of the Internist

Although emergency44 and critical care45 medical subspecialties have begun to train their constituencies in HCU, general diagnostic techniques that have wide‐ranging application in medical illness should be the evidence‐based tools of the internist. The rejuvenation of bedside examination using HCU on multiple organ systems should be orchestrated within internal medicine and not simply evolve as an unedited collection of all subspecialty organ ultrasound examinations. Device development can then be customized and made affordable for use in general internal medicine, perhaps limiting the unnecessary production costs and training requirements for advanced Doppler or multiple transducers.

Concern has been raised about the medical and economic impact of training internists in HCU. Although training costs can be incorporated in residency or hospital‐based continuing medical education, discussions regarding reimbursement for cardiac imaging require a distinction between the brief application of ultrasound using a small device by a nontraditional user and a limited echocardiogram as defined by payers and professional societies.46 To date, no procedural code or reimbursement has yet been approved for ultrasound‐assisted physical examination using HCU devices and likely awaits outcome data. There is also concern about the possibility of errors being made by HCU use by briefly trained physicians. Patient care and cost‐savings depend on HCU accuracy, being liable both for unnecessary referrals due to false‐positive screening HCU exams and delays in diagnosis due to false‐negative examinations. However, such errors are commonplace and accepted with standard physical examination techniques and the current use of the stethoscope, both of which lack sensitivity when compared to HCU.

HCU is a disruptive technology.47 However, unlike the successful disruption that small desktop computers had on their mainframe counterparts, HCU devices appeared before the operating system of their clinical application had been formulated, making dissemination to new users nearly impossible. Furthermore, placing ultrasound transducers into the hands of nontraditional users often alienates or displaces established users of ultrasound as well as established untrained members within the profession. Competency requirements will have to be derived, preferably from studies performed within the profession for specific uses in internal medicine. Perhaps championed by hospitalists and driven by hospital‐based outcome studies, the use of HCU by internists as a physical exam technique will require advocacy by internists themselves. The alternative, having the hospitalist ask the emergency department physician for help in examining the patient, is difficult to imagine. The answer to whether the hospitalist should use HCU should be a resounding yesbased upon the benefit of earlier, more accurate examination and the value of preserving the diagnostic role of the internist at the bedside. In regard to the latter, it is a concept worth fighting for.

Hand‐carried ultrasound (HCU) is a field technique. Originally intended for military triage, the advent of small, portable, ultrasound devices has brought ultrasound imaging to the patient's bedside to guide procedures and evaluate life‐threatening conditions. Although many recently‐trained physicians in emergency or critical care medicine now routinely use HCU to place central lines1 and tap effusions,2, 3 the capability of this technique to augment physical examination by all physicians has far greater potential value in medicine. When applied in acute critical scenarios, HCU techniques can quickly demonstrate findings regarding abdominal aortic aneurysm,4 deep vein thrombosis,5 pericardial fluid, or hemoperitoneum6 in patients with unexplained hypotension, and examine inferior vena cava collapsibility7 or brachial artery velocity variation8 to help determine the need for volume resuscitation in sepsis. In patients with unexplained dyspnea, HCU can search for ultrasound lung comet‐tail artifacts as a sign of pulmonary edema,9 or use the presence of pleural sliding to exclude pneumothorax.10 In addition, numerous less urgent applications for HCU imaging are emerging such as cardiac, lung, vascular, musculoskeletal, nerve, thyroid, gallbladder, liver, spleen, renal, testicular, and bladder imaging.

Medical or surgical subspecialties familiar with ultrasound have developed limited HCU examinations that serve specific purposes within the relatively narrow clinical indications encountered by these specialties. As a consequence, overall expertise in bedside HCU currently requires the mastery of multiple unrelated ultrasound views and diagnostic criteria. Without central leadership within this burgeoning field, HCU has found no consensus on its use or development within general medical practice. No one has yet validated a single ultrasound imaging protocol for augmenting the physical examination on all patients akin to the use of the stethoscope. This review discusses the importance of the internisthospitalist at this critical point in the early development of bedside HCU examination, focusing on the cardiopulmonary component as a prototype that has universal application across medical practice. Involvement by hospitalists in pioneering the overall technique will direct research in clinical outcome, restructure internal medicine education, change perception of the physical examination, and spur industry in device development specific for general medicine.

The role of the hospitalist as the leading in‐house diagnostician is unique in medicine, requiring breadth in medical knowledge and unprecedented communication skills in the seamless care of the most medically ill patients in the community.11 Ideally, the hospitalist quickly recognizes disease, discriminately uses consultation or expensive diagnostic testing, chooses cost‐effective therapies, and shortens length of hospital stay. Early accurate diagnosis afforded by HCU imaging has the potential to improve efficiency of medical care across a wide spectrum of clinical presentations. Although to date there are no outcome studies using a mortality endpoint, small individual studies have demonstrated that specific HCU findings improve diagnostic accuracy and relate to hospital stay length12 and readmission.13 The hospitalist position is in theory well‐suited for learning and applying bedside ultrasound, having both expert resources in the hospital to guide training and a clinical objective to reduce unnecessary hospital costs.

Saving the Bedside Examination: The Laying‐on of Ultrasound

Bedside examination is a vital component of the initial hospitalist‐patient interaction, adding objective data to the patient's history. In this era of physician surrogates and telemedicine, physical examination remains a nonnegotiable reason why physicians must appear in person at the patient's bedside to lay on hands. However, bedside cardiovascular examination skills have greatly diminished over the past decade for a variety of reasons.14 In particular, physical examination is impaired in the environment in which the hospitalist must practice. The admitting physician must oftentimes hurriedly examine the patient on the gurney in the noisy emergency department or in bed in an alarm‐filled intensive care unit (ICU) or hospital room. Ambient noise levels often preclude auscultation of acute aortic and mitral valve regurgitation, splitting of valve sounds, low diastolic rumbles, soft gallops, and fine rales. Patient positioning is limited in ventilated patients or those in respiratory or circulatory distress. Although medical education still honors the value of teaching the traditional cardiac examination, no outcome data exist to justify the application of the various maneuvers and techniques learned in medical school to contemporary, commonly encountered inpatient care scenarios. For example, few physical examination data exist on how to evaluate central venous pressures of an obese patient on the ventilator or assess the severity of aortic stenosis in the elderly hypertensive patient. Furthermore, many important cardiopulmonary abnormalities that are easily detected by ultrasound, such as pericardial fluid, well‐compensated left ventricular systolic dysfunction, small pleural effusion, and left atrial enlargement, make no characteristic sound for auscultation. The effect of undiagnosed cardiac abnormalities on the patient's immediate hospital course is unknown, but is likely related to the clinical presentation and long‐term outcome. Today, the hospitalist's suspicion of cardiovascular abnormalities is more often generated from elements in the patient's initial history, serum biomarkers, chest radiography, or electrocardiogram, and less from auscultation. Accordingly, cardiac physical examination is only adjunctively used in determining the general direction of the ensuing evaluation and when abnormal, often generates additional diagnostic testing for confirmation.

The optimal role of HCU for the internist‐hospitalist is in augmentation of bedside physical diagnosis.15, 16 Unlike x‐ray or even rapid serum biomarkers, ultrasound is a safe, immediate, noninvasive modality and has been particularly effective in delineating cardiac structure and physiology. Accurate HCU estimation of a patient's central venous pressure,17 left atrial size,18 or left ventricular ejection fraction19, 20 is of particular value in those with unexplained respiratory distress or circulatory collapse, or in those in whom referral for echocardiography or cardiac consultation is not obvious. Asymptomatic left ventricular systolic dysfunction has an estimated prevalence of 5% in adult populations,21 and its detection would have immediate implications in regard to etiology, volume management, and drug therapy. Multiple studies have shown the prognostic importance of left atrial enlargement in ischemic cardiac disease, congestive heart failure, atrial arrhythmias, and stroke.22 The inferior vena cava diameter has been related to central venous pressure and prognosis in congestive heart failure. A recent study13 using medical residents employing HCU demonstrated that persistent dilatation of the inferior vena cava at discharge related to a higher readmission rate in patients with congestive heart failure. The potential exists to follow and guide a patient's response to therapy with HCU during daily rounds. Comparative studies2325 confirm that HCU examinations are better than expert auscultation and improve overall exam accuracy when added to traditional physical exam techniques. Entering into the modern‐day emergency room with a pocket‐sized ultrasound device that provides the immediate capability of detecting left ventricular dysfunction, left atrial enlargement, pericardial effusion, or abnormalities in volume status, provides an additional sense of being prepared for battle.

Deriving Limited Ultrasound Applications: Time Well Spent

However, in order for a hospitalist to use HCU, easily applied limited imaging protocols must be derived from standard ultrasound examination techniques for each organ. For the heart, studies from our laboratory have shown that it is feasible to distill the comprehensive echocardiogram down to simple cardiac screening examinations for rapid bedside HCU use.2628 We found that a limited cardiac ultrasound study consisting of a single parasternal long‐axis (PLAX) view (Figure 1) requires only seconds to perform and can identify those patients who have significant cardiac abnormalities. In an outpatient population (n = 196) followed in an internal medicine clinic, the PLAX component of an HCU cardiac screening protocol uncovered left atrial enlargement in 4 patients and left ventricular systolic dysfunction in 4 patients that had not been suspected by the patients' primary physicians.29 In a study of 124 patients in the emergency department with suspected cardiac disease,12 abnormal cardiac findings were noted 3 times more frequently by PLAX than by clinical evaluation, and an abnormal PLAX was significantly associated with a longer hospital length of stay. In other preliminary studies using cardiologists, limited imaging has been shown to reduce costs of unnecessary echo referral.28, 3032 Cost analysis has yet to be performed in nonexpert HCU users, but benefit is likely related to the difference between the user's own accuracy with the stethoscope and the HCU device.

Figure 1

Although experts in ultrasound exist in radiology and cardiology, it is unlikely these subspecialists will spontaneously create and optimize a full‐body HCU imaging protocol for hospitalists. Similar to the use of ultrasound in emergency medicine, anesthesiology, and critical care medicine, the derivation of a bedside ultrasound exam appropriate for the in‐hospital physical examination should be developed within the specialty itself, by those acquainted with the clinical scenarios in which HCU would be deployed. For example, the question of whether the gallbladder should be routinely imaged by a quick HCU exam in the evaluation of chest pain is similar to the question of whether the Valsalva maneuver should be performed in the evaluation of every murmurboth require Bayesian knowledge of disease prevalence, exam difficulty, and test accuracy. With the collaboration of experts in ultrasound, internists can derive brief, easily learned, limited ultrasound exams for left ventricular dysfunction, left atrial enlargement, carotid atherosclerosis, interstitial lung disease, hepatosplenomegaly, cholelithiasis, hydronephrosis, renal atrophy, pleural or pericardial effusion, ascites, deep vein thrombosis, and abdominal aortic aneurysm. The discovery of these disease states has clinical value for long‐term care, even if incidental to the patient's acute presentation. The lasting implications of a more comprehensive general examination will likely differentiate the use of HCU in internal medicine practice from that of emergency medicine.

Basic Training in HCU

A significant challenge to medical education will be in physician training in HCU. Over 15 studies12, 13, 15, 1720, 22, 23, 3343 have now shown the ability of briefly trained medical students, residents, and physicians in internal medicine to perform a limited cardiovascular ultrasound examination. Not surprisingly, these studies show variable degrees of training proficiency, apparently dependent upon the complexity of the imaging protocol. In a recent pair of studies from 1 institution,42, 43 10 hospitalists were trained to perform an extensive HCU echocardiogram including 4 views, color and spectral Doppler, and interpret severity of valvular disease, ventricular function, pericardial effusion. In 345 patients already referred for formal echocardiography, which later served as the gold standard, HCU improved the hospitalists' physical examination for left ventricular dysfunction, cardiomegaly, and pericardial effusion, but not for valvular disease. Notably, despite a focused training program including didactic teaching, self‐study cases, 5 training studies, and the imaging of 35 patients with assistance as needed, image acquisition was inferior to standard examination and image interpretation was inferior to that of cardiology fellows. Such data reemphasize the fact that the scope of each body‐system imaging protocol must be narrow in order to make the learning of a full‐body HCU exam feasible and to incorporate training into time already allocated to the bedside physical examination curriculum or continuing medical education activities.

At our institution, internal medical residents are trained in bedside cardiovascular ultrasound to blend results with their auscultative findings during bedside examination. We have developed 2 cardiovascular limited ultrasound examinations (CLUEs) that can be performed in 5 minutes and have evidence‐basis for their clinical use through pilot training studies.18, 19, 29, 35 Our basic CLUE, designed for general cardiovascular examination, includes screening the carotid bulb for subclinical atherosclerosis, PLAX imaging for left atrial enlargement and systolic dysfunction of the left ventricle, and abdominal scanning for abdominal aortic aneurysm. In this imaging protocol consisting of only 4 targets, atherosclerotic risk increases from top to bottom (cephalad to caudal), making the exam easy to remember. The CLUEparasternal, lung, and subcostal (CLUE‐PLUS), designed for the urgent evaluation of unexplained dyspnea or hypotension, uses a work backward imaging format (from left ventricle to right atrium) and a single cardiac transducer for simplicity. The PLAX view screens for left ventricular systolic dysfunction and then left atrial enlargement. Next, a brief 4‐point lung exam screens for ultrasonic lung comets and pleural effusion. A subcostal view of the heart is used to evaluate right ventricular size and pericardial effusion, and finally the inferior vena cava is evaluated for central venous pressures. CLUEs are taught in bedside and didactic formats over the 3 years of residency with formal competency testing after lecture attendance, practice imaging in our echo‐vascular laboratories, participation in rounds, and completion of at least 30 supervised examinations.

Reaffirming the Role of the Internist

Although emergency44 and critical care45 medical subspecialties have begun to train their constituencies in HCU, general diagnostic techniques that have wide‐ranging application in medical illness should be the evidence‐based tools of the internist. The rejuvenation of bedside examination using HCU on multiple organ systems should be orchestrated within internal medicine and not simply evolve as an unedited collection of all subspecialty organ ultrasound examinations. Device development can then be customized and made affordable for use in general internal medicine, perhaps limiting the unnecessary production costs and training requirements for advanced Doppler or multiple transducers.

Concern has been raised about the medical and economic impact of training internists in HCU. Although training costs can be incorporated in residency or hospital‐based continuing medical education, discussions regarding reimbursement for cardiac imaging require a distinction between the brief application of ultrasound using a small device by a nontraditional user and a limited echocardiogram as defined by payers and professional societies.46 To date, no procedural code or reimbursement has yet been approved for ultrasound‐assisted physical examination using HCU devices and likely awaits outcome data. There is also concern about the possibility of errors being made by HCU use by briefly trained physicians. Patient care and cost‐savings depend on HCU accuracy, being liable both for unnecessary referrals due to false‐positive screening HCU exams and delays in diagnosis due to false‐negative examinations. However, such errors are commonplace and accepted with standard physical examination techniques and the current use of the stethoscope, both of which lack sensitivity when compared to HCU.

HCU is a disruptive technology.47 However, unlike the successful disruption that small desktop computers had on their mainframe counterparts, HCU devices appeared before the operating system of their clinical application had been formulated, making dissemination to new users nearly impossible. Furthermore, placing ultrasound transducers into the hands of nontraditional users often alienates or displaces established users of ultrasound as well as established untrained members within the profession. Competency requirements will have to be derived, preferably from studies performed within the profession for specific uses in internal medicine. Perhaps championed by hospitalists and driven by hospital‐based outcome studies, the use of HCU by internists as a physical exam technique will require advocacy by internists themselves. The alternative, having the hospitalist ask the emergency department physician for help in examining the patient, is difficult to imagine. The answer to whether the hospitalist should use HCU should be a resounding yesbased upon the benefit of earlier, more accurate examination and the value of preserving the diagnostic role of the internist at the bedside. In regard to the latter, it is a concept worth fighting for.

Hand‐carried ultrasound (HCU) is a field technique. Originally intended for military triage, the advent of small, portable, ultrasound devices has brought ultrasound imaging to the patient's bedside to guide procedures and evaluate life‐threatening conditions. Although many recently‐trained physicians in emergency or critical care medicine now routinely use HCU to place central lines1 and tap effusions,2, 3 the capability of this technique to augment physical examination by all physicians has far greater potential value in medicine. When applied in acute critical scenarios, HCU techniques can quickly demonstrate findings regarding abdominal aortic aneurysm,4 deep vein thrombosis,5 pericardial fluid, or hemoperitoneum6 in patients with unexplained hypotension, and examine inferior vena cava collapsibility7 or brachial artery velocity variation8 to help determine the need for volume resuscitation in sepsis. In patients with unexplained dyspnea, HCU can search for ultrasound lung comet‐tail artifacts as a sign of pulmonary edema,9 or use the presence of pleural sliding to exclude pneumothorax.10 In addition, numerous less urgent applications for HCU imaging are emerging such as cardiac, lung, vascular, musculoskeletal, nerve, thyroid, gallbladder, liver, spleen, renal, testicular, and bladder imaging.

Medical or surgical subspecialties familiar with ultrasound have developed limited HCU examinations that serve specific purposes within the relatively narrow clinical indications encountered by these specialties. As a consequence, overall expertise in bedside HCU currently requires the mastery of multiple unrelated ultrasound views and diagnostic criteria. Without central leadership within this burgeoning field, HCU has found no consensus on its use or development within general medical practice. No one has yet validated a single ultrasound imaging protocol for augmenting the physical examination on all patients akin to the use of the stethoscope. This review discusses the importance of the internisthospitalist at this critical point in the early development of bedside HCU examination, focusing on the cardiopulmonary component as a prototype that has universal application across medical practice. Involvement by hospitalists in pioneering the overall technique will direct research in clinical outcome, restructure internal medicine education, change perception of the physical examination, and spur industry in device development specific for general medicine.

The role of the hospitalist as the leading in‐house diagnostician is unique in medicine, requiring breadth in medical knowledge and unprecedented communication skills in the seamless care of the most medically ill patients in the community.11 Ideally, the hospitalist quickly recognizes disease, discriminately uses consultation or expensive diagnostic testing, chooses cost‐effective therapies, and shortens length of hospital stay. Early accurate diagnosis afforded by HCU imaging has the potential to improve efficiency of medical care across a wide spectrum of clinical presentations. Although to date there are no outcome studies using a mortality endpoint, small individual studies have demonstrated that specific HCU findings improve diagnostic accuracy and relate to hospital stay length12 and readmission.13 The hospitalist position is in theory well‐suited for learning and applying bedside ultrasound, having both expert resources in the hospital to guide training and a clinical objective to reduce unnecessary hospital costs.

Saving the Bedside Examination: The Laying‐on of Ultrasound

Bedside examination is a vital component of the initial hospitalist‐patient interaction, adding objective data to the patient's history. In this era of physician surrogates and telemedicine, physical examination remains a nonnegotiable reason why physicians must appear in person at the patient's bedside to lay on hands. However, bedside cardiovascular examination skills have greatly diminished over the past decade for a variety of reasons.14 In particular, physical examination is impaired in the environment in which the hospitalist must practice. The admitting physician must oftentimes hurriedly examine the patient on the gurney in the noisy emergency department or in bed in an alarm‐filled intensive care unit (ICU) or hospital room. Ambient noise levels often preclude auscultation of acute aortic and mitral valve regurgitation, splitting of valve sounds, low diastolic rumbles, soft gallops, and fine rales. Patient positioning is limited in ventilated patients or those in respiratory or circulatory distress. Although medical education still honors the value of teaching the traditional cardiac examination, no outcome data exist to justify the application of the various maneuvers and techniques learned in medical school to contemporary, commonly encountered inpatient care scenarios. For example, few physical examination data exist on how to evaluate central venous pressures of an obese patient on the ventilator or assess the severity of aortic stenosis in the elderly hypertensive patient. Furthermore, many important cardiopulmonary abnormalities that are easily detected by ultrasound, such as pericardial fluid, well‐compensated left ventricular systolic dysfunction, small pleural effusion, and left atrial enlargement, make no characteristic sound for auscultation. The effect of undiagnosed cardiac abnormalities on the patient's immediate hospital course is unknown, but is likely related to the clinical presentation and long‐term outcome. Today, the hospitalist's suspicion of cardiovascular abnormalities is more often generated from elements in the patient's initial history, serum biomarkers, chest radiography, or electrocardiogram, and less from auscultation. Accordingly, cardiac physical examination is only adjunctively used in determining the general direction of the ensuing evaluation and when abnormal, often generates additional diagnostic testing for confirmation.

The optimal role of HCU for the internist‐hospitalist is in augmentation of bedside physical diagnosis.15, 16 Unlike x‐ray or even rapid serum biomarkers, ultrasound is a safe, immediate, noninvasive modality and has been particularly effective in delineating cardiac structure and physiology. Accurate HCU estimation of a patient's central venous pressure,17 left atrial size,18 or left ventricular ejection fraction19, 20 is of particular value in those with unexplained respiratory distress or circulatory collapse, or in those in whom referral for echocardiography or cardiac consultation is not obvious. Asymptomatic left ventricular systolic dysfunction has an estimated prevalence of 5% in adult populations,21 and its detection would have immediate implications in regard to etiology, volume management, and drug therapy. Multiple studies have shown the prognostic importance of left atrial enlargement in ischemic cardiac disease, congestive heart failure, atrial arrhythmias, and stroke.22 The inferior vena cava diameter has been related to central venous pressure and prognosis in congestive heart failure. A recent study13 using medical residents employing HCU demonstrated that persistent dilatation of the inferior vena cava at discharge related to a higher readmission rate in patients with congestive heart failure. The potential exists to follow and guide a patient's response to therapy with HCU during daily rounds. Comparative studies2325 confirm that HCU examinations are better than expert auscultation and improve overall exam accuracy when added to traditional physical exam techniques. Entering into the modern‐day emergency room with a pocket‐sized ultrasound device that provides the immediate capability of detecting left ventricular dysfunction, left atrial enlargement, pericardial effusion, or abnormalities in volume status, provides an additional sense of being prepared for battle.

Deriving Limited Ultrasound Applications: Time Well Spent

However, in order for a hospitalist to use HCU, easily applied limited imaging protocols must be derived from standard ultrasound examination techniques for each organ. For the heart, studies from our laboratory have shown that it is feasible to distill the comprehensive echocardiogram down to simple cardiac screening examinations for rapid bedside HCU use.2628 We found that a limited cardiac ultrasound study consisting of a single parasternal long‐axis (PLAX) view (Figure 1) requires only seconds to perform and can identify those patients who have significant cardiac abnormalities. In an outpatient population (n = 196) followed in an internal medicine clinic, the PLAX component of an HCU cardiac screening protocol uncovered left atrial enlargement in 4 patients and left ventricular systolic dysfunction in 4 patients that had not been suspected by the patients' primary physicians.29 In a study of 124 patients in the emergency department with suspected cardiac disease,12 abnormal cardiac findings were noted 3 times more frequently by PLAX than by clinical evaluation, and an abnormal PLAX was significantly associated with a longer hospital length of stay. In other preliminary studies using cardiologists, limited imaging has been shown to reduce costs of unnecessary echo referral.28, 3032 Cost analysis has yet to be performed in nonexpert HCU users, but benefit is likely related to the difference between the user's own accuracy with the stethoscope and the HCU device.

Figure 1

Although experts in ultrasound exist in radiology and cardiology, it is unlikely these subspecialists will spontaneously create and optimize a full‐body HCU imaging protocol for hospitalists. Similar to the use of ultrasound in emergency medicine, anesthesiology, and critical care medicine, the derivation of a bedside ultrasound exam appropriate for the in‐hospital physical examination should be developed within the specialty itself, by those acquainted with the clinical scenarios in which HCU would be deployed. For example, the question of whether the gallbladder should be routinely imaged by a quick HCU exam in the evaluation of chest pain is similar to the question of whether the Valsalva maneuver should be performed in the evaluation of every murmurboth require Bayesian knowledge of disease prevalence, exam difficulty, and test accuracy. With the collaboration of experts in ultrasound, internists can derive brief, easily learned, limited ultrasound exams for left ventricular dysfunction, left atrial enlargement, carotid atherosclerosis, interstitial lung disease, hepatosplenomegaly, cholelithiasis, hydronephrosis, renal atrophy, pleural or pericardial effusion, ascites, deep vein thrombosis, and abdominal aortic aneurysm. The discovery of these disease states has clinical value for long‐term care, even if incidental to the patient's acute presentation. The lasting implications of a more comprehensive general examination will likely differentiate the use of HCU in internal medicine practice from that of emergency medicine.

Basic Training in HCU

A significant challenge to medical education will be in physician training in HCU. Over 15 studies12, 13, 15, 1720, 22, 23, 3343 have now shown the ability of briefly trained medical students, residents, and physicians in internal medicine to perform a limited cardiovascular ultrasound examination. Not surprisingly, these studies show variable degrees of training proficiency, apparently dependent upon the complexity of the imaging protocol. In a recent pair of studies from 1 institution,42, 43 10 hospitalists were trained to perform an extensive HCU echocardiogram including 4 views, color and spectral Doppler, and interpret severity of valvular disease, ventricular function, pericardial effusion. In 345 patients already referred for formal echocardiography, which later served as the gold standard, HCU improved the hospitalists' physical examination for left ventricular dysfunction, cardiomegaly, and pericardial effusion, but not for valvular disease. Notably, despite a focused training program including didactic teaching, self‐study cases, 5 training studies, and the imaging of 35 patients with assistance as needed, image acquisition was inferior to standard examination and image interpretation was inferior to that of cardiology fellows. Such data reemphasize the fact that the scope of each body‐system imaging protocol must be narrow in order to make the learning of a full‐body HCU exam feasible and to incorporate training into time already allocated to the bedside physical examination curriculum or continuing medical education activities.

At our institution, internal medical residents are trained in bedside cardiovascular ultrasound to blend results with their auscultative findings during bedside examination. We have developed 2 cardiovascular limited ultrasound examinations (CLUEs) that can be performed in 5 minutes and have evidence‐basis for their clinical use through pilot training studies.18, 19, 29, 35 Our basic CLUE, designed for general cardiovascular examination, includes screening the carotid bulb for subclinical atherosclerosis, PLAX imaging for left atrial enlargement and systolic dysfunction of the left ventricle, and abdominal scanning for abdominal aortic aneurysm. In this imaging protocol consisting of only 4 targets, atherosclerotic risk increases from top to bottom (cephalad to caudal), making the exam easy to remember. The CLUEparasternal, lung, and subcostal (CLUE‐PLUS), designed for the urgent evaluation of unexplained dyspnea or hypotension, uses a work backward imaging format (from left ventricle to right atrium) and a single cardiac transducer for simplicity. The PLAX view screens for left ventricular systolic dysfunction and then left atrial enlargement. Next, a brief 4‐point lung exam screens for ultrasonic lung comets and pleural effusion. A subcostal view of the heart is used to evaluate right ventricular size and pericardial effusion, and finally the inferior vena cava is evaluated for central venous pressures. CLUEs are taught in bedside and didactic formats over the 3 years of residency with formal competency testing after lecture attendance, practice imaging in our echo‐vascular laboratories, participation in rounds, and completion of at least 30 supervised examinations.

Reaffirming the Role of the Internist

Although emergency44 and critical care45 medical subspecialties have begun to train their constituencies in HCU, general diagnostic techniques that have wide‐ranging application in medical illness should be the evidence‐based tools of the internist. The rejuvenation of bedside examination using HCU on multiple organ systems should be orchestrated within internal medicine and not simply evolve as an unedited collection of all subspecialty organ ultrasound examinations. Device development can then be customized and made affordable for use in general internal medicine, perhaps limiting the unnecessary production costs and training requirements for advanced Doppler or multiple transducers.

Concern has been raised about the medical and economic impact of training internists in HCU. Although training costs can be incorporated in residency or hospital‐based continuing medical education, discussions regarding reimbursement for cardiac imaging require a distinction between the brief application of ultrasound using a small device by a nontraditional user and a limited echocardiogram as defined by payers and professional societies.46 To date, no procedural code or reimbursement has yet been approved for ultrasound‐assisted physical examination using HCU devices and likely awaits outcome data. There is also concern about the possibility of errors being made by HCU use by briefly trained physicians. Patient care and cost‐savings depend on HCU accuracy, being liable both for unnecessary referrals due to false‐positive screening HCU exams and delays in diagnosis due to false‐negative examinations. However, such errors are commonplace and accepted with standard physical examination techniques and the current use of the stethoscope, both of which lack sensitivity when compared to HCU.

HCU is a disruptive technology.47 However, unlike the successful disruption that small desktop computers had on their mainframe counterparts, HCU devices appeared before the operating system of their clinical application had been formulated, making dissemination to new users nearly impossible. Furthermore, placing ultrasound transducers into the hands of nontraditional users often alienates or displaces established users of ultrasound as well as established untrained members within the profession. Competency requirements will have to be derived, preferably from studies performed within the profession for specific uses in internal medicine. Perhaps championed by hospitalists and driven by hospital‐based outcome studies, the use of HCU by internists as a physical exam technique will require advocacy by internists themselves. The alternative, having the hospitalist ask the emergency department physician for help in examining the patient, is difficult to imagine. The answer to whether the hospitalist should use HCU should be a resounding yesbased upon the benefit of earlier, more accurate examination and the value of preserving the diagnostic role of the internist at the bedside. In regard to the latter, it is a concept worth fighting for.

The United States spends more on healthcare than any country in the world, and it is widely believed that the Nation could spend less while achieving comparable or better outcomes. The recent debate over healthcare reform in the United States, the large Federal budget deficit in the context of the current economic recession, and the prospect of widening gaps in Medicare funding with the increasing entry of baby boomers into old age suggest that the issue of healthcare cost will remain intense for many years to come. What roles hospitalists will play in the nation's struggle to control health care costs remain to be seen. Six papers in this issue of the Journal of Hospital Medicine discuss issues related to costs, and reflect several of the ways in which hospital medicine can contribute to understanding, and ultimately, controlling healthcare costs.

Two papers, one by Whelan et al.1 examining the costs associated with upper vs. lower GI bleeding and one by Lorch et al.2 examining the costs associated with herpex simplex virus (HSV) infections among neonates with and without congenital abnormalities, focus on epidemiologic determinants of healthcare costs. Such studies can identify subgroups of patients with high costs who may be logical targets for efforts to control costs. One tension in the use of such analyses to control cost is that total cost for any patient group is the product of both the cost per patient and the number of patients falling into each group. In the case of gastrointestinal (GI) bleeding, the surprise compared to past reports is that lower GI bleeding is about as common among hospitalized patients as upper GI bleeding. This may be because pharmacotherapy for conditions that cause upper GI bleeding is reducing the rate at which disease progresses to the point where hospitalization is required. The importance of prevalence is reinforced even in the findings about HSV infection, where despite 2‐ to 3‐fold higher average costs among babies with HSV who have congenital abnormalities, the fact that 90% of babies hospitalized with HSV lack congenital abnormalities implies that the clear majority of costs are due to babies without congenital abnormalities. In seeking strategies to control costs, it is important to pay attention to both the prevalence and cost per case of specific conditions. Because hospitalists are generalist physicians who typically care for few patients with any given diagnosis, the importance of prevalence implies that disease‐specific efforts to control costs may produce smaller total gains than those that cross diseases, such as efforts to improve communication between inpatient and outpatient physicians.

Moreover, the presence of high costs for some condition does not, of course, imply that effective interventions exist to reduce those costs. Two other papers, one by Mudge et al.3 examining a disease management program for heart failure, and one by Go et al.4 examining the effects of hospitalists on the costs of hospitalization for GI bleeding, reinforce the idea that interventions to reduce hospital costs are not always as effective as hoped. Even worse, efforts to control costs can have unintended effects, such as the delays in antimicrobial administration with antimicrobial approval policies that are reported by Winters et al.5 These studies also illustrate that analyses of the effectiveness of interventions can be performed using a variety of experimental designs (eg, the before/after comparison used by Mudge et al,3 and the natural experiments based on assignment of patients to physicians based on day of admission used by Go et al.4 or based on time of day used by Winters et al.)5 The role of hospitalists as clinical leaders in hospitals often places them in positions to design and execute experiments, but the role of hospitalists as astute clinicians who can recognize the presence of natural experiments in their clinical environment can be every bit as powerful in producing valid research designs.

As society seeks strategies to control healthcare costs in the years ahead, it will almost certainly turn to the same general strategies that have been used in the past: bundling services into fixed payments for a prospectively defined episode of care, asking patients to pay more of the costs of care, and simply not paying for, or paying less for, any given type of care. Hospitalists already have dealt with many of these approaches in one form or another. Medicare's prospective payment system and the payment of fixed annual fees for the care of patients in health maintenance organizations have given all hospitalists some exposure to the pressure for lower hospital resources use under prospective payment systems. Proposals for demonstration projects within healthcare reform to study the effects of bundling inpatient and outpatient care or even hospital and professional fees suggest that hospitalists may need to be open to new incentive structures in the years to come. For example, reduced incentives for rapid discharge if costs pushed into the outpatient setting are borne by the hospital, there may be co‐management models if professional and hospital fees are bundled. Increases in patient copayments may also play some role in healthcare reform, and the paper by Ross et al.6 should be a reminder to hospitalists that we may do our patients a great disservice if we fail to recognize the effects of our decisions on their out‐of‐pocket costs. Indeed, while doctors and patient both recognize the importance of discussing out‐of‐pocket costs, they both agree that these discussions rarely occur.7 That such discussions are not reimbursed explicitly suggests one of the many challenges of controlling healthcare costs; if physician payments are decreased to control costs and physicians respond by attempting to see even more patients in any given time period, discussions of important but less urgent issues such as out‐of‐pocket costs seem likely to be reduced. Such dilemmas arise frequently as the healthcare system devises increasingly complex approaches to the control of costs and suggest to many that fundamental reform of the payment and delivery system with greater reliance on integrated health systems paid through full capitation will eventually need to become the nation's approach to healthcare cost containment.8

The United States spends more on healthcare than any country in the world, and it is widely believed that the Nation could spend less while achieving comparable or better outcomes. The recent debate over healthcare reform in the United States, the large Federal budget deficit in the context of the current economic recession, and the prospect of widening gaps in Medicare funding with the increasing entry of baby boomers into old age suggest that the issue of healthcare cost will remain intense for many years to come. What roles hospitalists will play in the nation's struggle to control health care costs remain to be seen. Six papers in this issue of the Journal of Hospital Medicine discuss issues related to costs, and reflect several of the ways in which hospital medicine can contribute to understanding, and ultimately, controlling healthcare costs.

Two papers, one by Whelan et al.1 examining the costs associated with upper vs. lower GI bleeding and one by Lorch et al.2 examining the costs associated with herpex simplex virus (HSV) infections among neonates with and without congenital abnormalities, focus on epidemiologic determinants of healthcare costs. Such studies can identify subgroups of patients with high costs who may be logical targets for efforts to control costs. One tension in the use of such analyses to control cost is that total cost for any patient group is the product of both the cost per patient and the number of patients falling into each group. In the case of gastrointestinal (GI) bleeding, the surprise compared to past reports is that lower GI bleeding is about as common among hospitalized patients as upper GI bleeding. This may be because pharmacotherapy for conditions that cause upper GI bleeding is reducing the rate at which disease progresses to the point where hospitalization is required. The importance of prevalence is reinforced even in the findings about HSV infection, where despite 2‐ to 3‐fold higher average costs among babies with HSV who have congenital abnormalities, the fact that 90% of babies hospitalized with HSV lack congenital abnormalities implies that the clear majority of costs are due to babies without congenital abnormalities. In seeking strategies to control costs, it is important to pay attention to both the prevalence and cost per case of specific conditions. Because hospitalists are generalist physicians who typically care for few patients with any given diagnosis, the importance of prevalence implies that disease‐specific efforts to control costs may produce smaller total gains than those that cross diseases, such as efforts to improve communication between inpatient and outpatient physicians.

Moreover, the presence of high costs for some condition does not, of course, imply that effective interventions exist to reduce those costs. Two other papers, one by Mudge et al.3 examining a disease management program for heart failure, and one by Go et al.4 examining the effects of hospitalists on the costs of hospitalization for GI bleeding, reinforce the idea that interventions to reduce hospital costs are not always as effective as hoped. Even worse, efforts to control costs can have unintended effects, such as the delays in antimicrobial administration with antimicrobial approval policies that are reported by Winters et al.5 These studies also illustrate that analyses of the effectiveness of interventions can be performed using a variety of experimental designs (eg, the before/after comparison used by Mudge et al,3 and the natural experiments based on assignment of patients to physicians based on day of admission used by Go et al.4 or based on time of day used by Winters et al.)5 The role of hospitalists as clinical leaders in hospitals often places them in positions to design and execute experiments, but the role of hospitalists as astute clinicians who can recognize the presence of natural experiments in their clinical environment can be every bit as powerful in producing valid research designs.

As society seeks strategies to control healthcare costs in the years ahead, it will almost certainly turn to the same general strategies that have been used in the past: bundling services into fixed payments for a prospectively defined episode of care, asking patients to pay more of the costs of care, and simply not paying for, or paying less for, any given type of care. Hospitalists already have dealt with many of these approaches in one form or another. Medicare's prospective payment system and the payment of fixed annual fees for the care of patients in health maintenance organizations have given all hospitalists some exposure to the pressure for lower hospital resources use under prospective payment systems. Proposals for demonstration projects within healthcare reform to study the effects of bundling inpatient and outpatient care or even hospital and professional fees suggest that hospitalists may need to be open to new incentive structures in the years to come. For example, reduced incentives for rapid discharge if costs pushed into the outpatient setting are borne by the hospital, there may be co‐management models if professional and hospital fees are bundled. Increases in patient copayments may also play some role in healthcare reform, and the paper by Ross et al.6 should be a reminder to hospitalists that we may do our patients a great disservice if we fail to recognize the effects of our decisions on their out‐of‐pocket costs. Indeed, while doctors and patient both recognize the importance of discussing out‐of‐pocket costs, they both agree that these discussions rarely occur.7 That such discussions are not reimbursed explicitly suggests one of the many challenges of controlling healthcare costs; if physician payments are decreased to control costs and physicians respond by attempting to see even more patients in any given time period, discussions of important but less urgent issues such as out‐of‐pocket costs seem likely to be reduced. Such dilemmas arise frequently as the healthcare system devises increasingly complex approaches to the control of costs and suggest to many that fundamental reform of the payment and delivery system with greater reliance on integrated health systems paid through full capitation will eventually need to become the nation's approach to healthcare cost containment.8

The United States spends more on healthcare than any country in the world, and it is widely believed that the Nation could spend less while achieving comparable or better outcomes. The recent debate over healthcare reform in the United States, the large Federal budget deficit in the context of the current economic recession, and the prospect of widening gaps in Medicare funding with the increasing entry of baby boomers into old age suggest that the issue of healthcare cost will remain intense for many years to come. What roles hospitalists will play in the nation's struggle to control health care costs remain to be seen. Six papers in this issue of the Journal of Hospital Medicine discuss issues related to costs, and reflect several of the ways in which hospital medicine can contribute to understanding, and ultimately, controlling healthcare costs.

Two papers, one by Whelan et al.1 examining the costs associated with upper vs. lower GI bleeding and one by Lorch et al.2 examining the costs associated with herpex simplex virus (HSV) infections among neonates with and without congenital abnormalities, focus on epidemiologic determinants of healthcare costs. Such studies can identify subgroups of patients with high costs who may be logical targets for efforts to control costs. One tension in the use of such analyses to control cost is that total cost for any patient group is the product of both the cost per patient and the number of patients falling into each group. In the case of gastrointestinal (GI) bleeding, the surprise compared to past reports is that lower GI bleeding is about as common among hospitalized patients as upper GI bleeding. This may be because pharmacotherapy for conditions that cause upper GI bleeding is reducing the rate at which disease progresses to the point where hospitalization is required. The importance of prevalence is reinforced even in the findings about HSV infection, where despite 2‐ to 3‐fold higher average costs among babies with HSV who have congenital abnormalities, the fact that 90% of babies hospitalized with HSV lack congenital abnormalities implies that the clear majority of costs are due to babies without congenital abnormalities. In seeking strategies to control costs, it is important to pay attention to both the prevalence and cost per case of specific conditions. Because hospitalists are generalist physicians who typically care for few patients with any given diagnosis, the importance of prevalence implies that disease‐specific efforts to control costs may produce smaller total gains than those that cross diseases, such as efforts to improve communication between inpatient and outpatient physicians.

Moreover, the presence of high costs for some condition does not, of course, imply that effective interventions exist to reduce those costs. Two other papers, one by Mudge et al.3 examining a disease management program for heart failure, and one by Go et al.4 examining the effects of hospitalists on the costs of hospitalization for GI bleeding, reinforce the idea that interventions to reduce hospital costs are not always as effective as hoped. Even worse, efforts to control costs can have unintended effects, such as the delays in antimicrobial administration with antimicrobial approval policies that are reported by Winters et al.5 These studies also illustrate that analyses of the effectiveness of interventions can be performed using a variety of experimental designs (eg, the before/after comparison used by Mudge et al,3 and the natural experiments based on assignment of patients to physicians based on day of admission used by Go et al.4 or based on time of day used by Winters et al.)5 The role of hospitalists as clinical leaders in hospitals often places them in positions to design and execute experiments, but the role of hospitalists as astute clinicians who can recognize the presence of natural experiments in their clinical environment can be every bit as powerful in producing valid research designs.

As society seeks strategies to control healthcare costs in the years ahead, it will almost certainly turn to the same general strategies that have been used in the past: bundling services into fixed payments for a prospectively defined episode of care, asking patients to pay more of the costs of care, and simply not paying for, or paying less for, any given type of care. Hospitalists already have dealt with many of these approaches in one form or another. Medicare's prospective payment system and the payment of fixed annual fees for the care of patients in health maintenance organizations have given all hospitalists some exposure to the pressure for lower hospital resources use under prospective payment systems. Proposals for demonstration projects within healthcare reform to study the effects of bundling inpatient and outpatient care or even hospital and professional fees suggest that hospitalists may need to be open to new incentive structures in the years to come. For example, reduced incentives for rapid discharge if costs pushed into the outpatient setting are borne by the hospital, there may be co‐management models if professional and hospital fees are bundled. Increases in patient copayments may also play some role in healthcare reform, and the paper by Ross et al.6 should be a reminder to hospitalists that we may do our patients a great disservice if we fail to recognize the effects of our decisions on their out‐of‐pocket costs. Indeed, while doctors and patient both recognize the importance of discussing out‐of‐pocket costs, they both agree that these discussions rarely occur.7 That such discussions are not reimbursed explicitly suggests one of the many challenges of controlling healthcare costs; if physician payments are decreased to control costs and physicians respond by attempting to see even more patients in any given time period, discussions of important but less urgent issues such as out‐of‐pocket costs seem likely to be reduced. Such dilemmas arise frequently as the healthcare system devises increasingly complex approaches to the control of costs and suggest to many that fundamental reform of the payment and delivery system with greater reliance on integrated health systems paid through full capitation will eventually need to become the nation's approach to healthcare cost containment.8