Editorial

Acute atherothrombotic events associated with ischemic heart disease and stroke are the first and third most common causes of death in the United States, respectively.1 Despite an overall decrease in age‐adjusted mortality since 1970 in the United States, the worldwide prevalence of these diseases is anticipated to sharply increase by 2020.1, 2 Caring for patients with atherothrombosis is now within the purview of hospitalists to a larger extent than ever before. In recognition of the expanding role of these health care professionals and to reduce the risk of adverse cardiovascular events in the outpatient setting, the Society of Hospital Medicine held a symposium during its 10th Annual Meeting.

Rules of Engagement: The Hospitalist and Atherothrombosis took place on May 24, 2007, in Dallas, Texas. This supplement summarizes the highlights from this symposium and reviews the causes and polyvascular nature of atherothrombosis. The role of the hospitalist in managing atherothrombotic disease and evidence‐based practices for the evaluation and treatment of patients with various manifestations of atherothrombotic disease are also discussed.

ARTERIAL THROMBOSIS AND ITS POLYVASCULAR NATURE

Atherothrombosis refers to the formation of large and occlusive mural thrombi that arise from the rupture of an atherosclerotic plaque. Myocardial infarction (MI), ischemic stroke, and acute limb ischemia are the most severe manifestations of this disease.3, 4 This process begins when denuded or inflamed endothelial cells develop properties that permit platelet adhesion. At the site of endothelial dysfunction, activation of adherent platelet results in the release of inflammatory and mitogenic factors. After a series of dynamic and repetitive processes including amplified platelet activation, monocyte chemotaxis, adhesion, transmigration, and lipoprotein retention, plaque formation occurs.5 Consequently, the rupture or erosion of an atherosclerotic plaque produces a higher degree of platelet adhesion, activation, and aggregation, causing the fibrotic organization of a mural thrombus.3

The number of persons with multiple, concomitant cardiovascular disease (CAD), cerebrovascular disease (CVD), and peripheral arterial disease (PAD) accentuates the polyvascular nature of atherothrombosis (Fig. 1). The international Reduction of Atherothrombosis for Continued Health (REACH) Registry demonstrated that 1‐year incidence rates of major cardiovascular events (eg, MI, stroke, death) were high in patients with an established atherothrombotic disease and increased with the number of concomitant vascular diseases.6 These data infer that the burden on the vascular system is considered extensive on diagnosis of a single atherothrombotic disease. Thus, aggressive therapies are needed to reduce the risk of recurrent or other cardiovascular events. The management of risk factors for atherothrombosis such as hypercholesterolemia, dyslipidemia, hypertension, and diabetes mellitus fall under specific disease‐specific guidelines for patients presenting with atherothrombotic diseases.712

Figure 1

ANTIPLATELET THERAPIES

Antiplatelet therapies are used for the acute and long‐term treatment of patients after a thrombic event. Antiplatelet agents target the molecular mechanisms responsible for platelet activation and aggregation, such as the synthesis of thromboxane A₂. On platelet activation, free arachidonic acid is converted to prostaglandin H₂ (PGH₂) by cyclooxygenase‐1 (COX‐1; Fig. 2). Further metabolism of PGH₂ by thromboxane synthase produces thromboxane A₂, which induces vasoconstriction (Fig. 2). Fortunately, the ability of platelets to produce COX‐1 is limited, and irreversible inhibition of this enzyme can impair thromboxane A₂ synthesis for approximately 10 days.

Figure 2

Aspirin is a potent COX‐1 inhibitor, whose effects are evident 1 hour after dosing (Fig. 2).4, 13 Aspirin effectively prevents fatal and nonfatal vascular events in healthy individuals and in patients who present with acute MI or ischemic stroke.13 Unfortunately, a proportion of patients are aspirin resistant. Recent studies have indicated that interactions with the nonsteroidal anti‐inflammatory drug (NSAID) ibuprofen may diminish the primary and secondary protective effects of aspirin and may contribute to aspirin resistance, although the origin of this remains unclear.

The results of a post hoc subgroup analysis of 22,071 apparently healthy male physicians randomized to take aspirin or placebo for 5 years indicated that individuals who used NSAIDs for at least 60 days/year increased their risk of MI by more than 2‐fold compared with those who did not use NSAIDs.14 A second study conducted in patients following a major adverse cardiovascular event showed that the combination of aspirin plus ibuprofen increased the adjusted relative risk of cardiovascular mortality over an 8‐year period compared with aspirin alone.15 However, the effects of NSAIDS on aspirin's ability to inhibit COX‐1 are reversible and only last for the dosing interval and body clearance time of the drug.16

Adeonsine diphosphate (ADP)dependent stimulation of the P2Y₁₂ receptor is another target for antiplatelet therapy. On its release, ADP binds to the P2Y₁₂ receptor on platelets, resulting in activation and aggregation (Fig. 2). Ticlopidine and clopidogrel are thienopyridines that may irreversibly modify the P2Y₁₂ receptor (Fig. 2).13 Safety concerns associated with ticlopidine use, including severe neutropenia, have limited its administration. Conversely, clopidogrel is relatively well‐tolerated and can prevent cardiovascular events in patients with CAD, ischemic stroke, and PAD. This agent is an orally administered prodrug requiring activation by hepatic cytochrome P450 enzymes.13

Aspirin and thienopyridines do not inhibit platelet aggregation induced by the binding of fibrinogen to the platelet glycoprotein (GP) IIb/IIIa receptor (Fig. 2).4, 13 However, there are 3 commonly administered GP IIb/IIIa inhibitors: abciximab, eptifibatide, and tirofiban (Fig. 2).4 Abciximab is the fab fragment of the chimeric monoclonal antibody 7E3 and irreversibly inhibits the GP IIb/IIIa receptor. By contrast, eptifibatide is a cyclic heptapeptide, tirofiban is a nonpeptide, and both agents are reversible inhibitors. These agents are administered intravenously, and boluses are reserved for the short‐term treatment of atherothrombosis in patients undergoing percutaneous coronary intervention.13

CONCLUSIONS

Atherothrombosis is a systemic disease that often affects coronary, intracranial, and peripheral arterial beds concomitantly, which increases the probability of a thrombotic event. Aggressive treatments, including acute and long‐term antiplatelet therapies, are required to reduce the risks associated with atherothrombosis. This supplement reviews the evidence‐based approaches for managing atherothrombosis. It will provide hospitalists with the knowledge needed to treat patients with PAD, stroke, and acute coronary syndrome. First, the administration of antiplatelet therapies to patients with acute coronary syndrome will be described. Then, guidelines for the management of patients with acute ischemic stroke and the use of antiplatelet therapies to reduce mortality due to primary and secondary ischemic events will be reviewed. Finally, the role of the hospitalist in the diagnosis of PAD in asymptomatic patients and in those with confirmed atherothrombosis will be discussed.

Acute atherothrombotic events associated with ischemic heart disease and stroke are the first and third most common causes of death in the United States, respectively.1 Despite an overall decrease in age‐adjusted mortality since 1970 in the United States, the worldwide prevalence of these diseases is anticipated to sharply increase by 2020.1, 2 Caring for patients with atherothrombosis is now within the purview of hospitalists to a larger extent than ever before. In recognition of the expanding role of these health care professionals and to reduce the risk of adverse cardiovascular events in the outpatient setting, the Society of Hospital Medicine held a symposium during its 10th Annual Meeting.

Rules of Engagement: The Hospitalist and Atherothrombosis took place on May 24, 2007, in Dallas, Texas. This supplement summarizes the highlights from this symposium and reviews the causes and polyvascular nature of atherothrombosis. The role of the hospitalist in managing atherothrombotic disease and evidence‐based practices for the evaluation and treatment of patients with various manifestations of atherothrombotic disease are also discussed.

ARTERIAL THROMBOSIS AND ITS POLYVASCULAR NATURE

Atherothrombosis refers to the formation of large and occlusive mural thrombi that arise from the rupture of an atherosclerotic plaque. Myocardial infarction (MI), ischemic stroke, and acute limb ischemia are the most severe manifestations of this disease.3, 4 This process begins when denuded or inflamed endothelial cells develop properties that permit platelet adhesion. At the site of endothelial dysfunction, activation of adherent platelet results in the release of inflammatory and mitogenic factors. After a series of dynamic and repetitive processes including amplified platelet activation, monocyte chemotaxis, adhesion, transmigration, and lipoprotein retention, plaque formation occurs.5 Consequently, the rupture or erosion of an atherosclerotic plaque produces a higher degree of platelet adhesion, activation, and aggregation, causing the fibrotic organization of a mural thrombus.3

The number of persons with multiple, concomitant cardiovascular disease (CAD), cerebrovascular disease (CVD), and peripheral arterial disease (PAD) accentuates the polyvascular nature of atherothrombosis (Fig. 1). The international Reduction of Atherothrombosis for Continued Health (REACH) Registry demonstrated that 1‐year incidence rates of major cardiovascular events (eg, MI, stroke, death) were high in patients with an established atherothrombotic disease and increased with the number of concomitant vascular diseases.6 These data infer that the burden on the vascular system is considered extensive on diagnosis of a single atherothrombotic disease. Thus, aggressive therapies are needed to reduce the risk of recurrent or other cardiovascular events. The management of risk factors for atherothrombosis such as hypercholesterolemia, dyslipidemia, hypertension, and diabetes mellitus fall under specific disease‐specific guidelines for patients presenting with atherothrombotic diseases.712

Figure 1

ANTIPLATELET THERAPIES

Antiplatelet therapies are used for the acute and long‐term treatment of patients after a thrombic event. Antiplatelet agents target the molecular mechanisms responsible for platelet activation and aggregation, such as the synthesis of thromboxane A₂. On platelet activation, free arachidonic acid is converted to prostaglandin H₂ (PGH₂) by cyclooxygenase‐1 (COX‐1; Fig. 2). Further metabolism of PGH₂ by thromboxane synthase produces thromboxane A₂, which induces vasoconstriction (Fig. 2). Fortunately, the ability of platelets to produce COX‐1 is limited, and irreversible inhibition of this enzyme can impair thromboxane A₂ synthesis for approximately 10 days.

Figure 2

Aspirin is a potent COX‐1 inhibitor, whose effects are evident 1 hour after dosing (Fig. 2).4, 13 Aspirin effectively prevents fatal and nonfatal vascular events in healthy individuals and in patients who present with acute MI or ischemic stroke.13 Unfortunately, a proportion of patients are aspirin resistant. Recent studies have indicated that interactions with the nonsteroidal anti‐inflammatory drug (NSAID) ibuprofen may diminish the primary and secondary protective effects of aspirin and may contribute to aspirin resistance, although the origin of this remains unclear.

The results of a post hoc subgroup analysis of 22,071 apparently healthy male physicians randomized to take aspirin or placebo for 5 years indicated that individuals who used NSAIDs for at least 60 days/year increased their risk of MI by more than 2‐fold compared with those who did not use NSAIDs.14 A second study conducted in patients following a major adverse cardiovascular event showed that the combination of aspirin plus ibuprofen increased the adjusted relative risk of cardiovascular mortality over an 8‐year period compared with aspirin alone.15 However, the effects of NSAIDS on aspirin's ability to inhibit COX‐1 are reversible and only last for the dosing interval and body clearance time of the drug.16

Adeonsine diphosphate (ADP)dependent stimulation of the P2Y₁₂ receptor is another target for antiplatelet therapy. On its release, ADP binds to the P2Y₁₂ receptor on platelets, resulting in activation and aggregation (Fig. 2). Ticlopidine and clopidogrel are thienopyridines that may irreversibly modify the P2Y₁₂ receptor (Fig. 2).13 Safety concerns associated with ticlopidine use, including severe neutropenia, have limited its administration. Conversely, clopidogrel is relatively well‐tolerated and can prevent cardiovascular events in patients with CAD, ischemic stroke, and PAD. This agent is an orally administered prodrug requiring activation by hepatic cytochrome P450 enzymes.13

Aspirin and thienopyridines do not inhibit platelet aggregation induced by the binding of fibrinogen to the platelet glycoprotein (GP) IIb/IIIa receptor (Fig. 2).4, 13 However, there are 3 commonly administered GP IIb/IIIa inhibitors: abciximab, eptifibatide, and tirofiban (Fig. 2).4 Abciximab is the fab fragment of the chimeric monoclonal antibody 7E3 and irreversibly inhibits the GP IIb/IIIa receptor. By contrast, eptifibatide is a cyclic heptapeptide, tirofiban is a nonpeptide, and both agents are reversible inhibitors. These agents are administered intravenously, and boluses are reserved for the short‐term treatment of atherothrombosis in patients undergoing percutaneous coronary intervention.13

CONCLUSIONS

Atherothrombosis is a systemic disease that often affects coronary, intracranial, and peripheral arterial beds concomitantly, which increases the probability of a thrombotic event. Aggressive treatments, including acute and long‐term antiplatelet therapies, are required to reduce the risks associated with atherothrombosis. This supplement reviews the evidence‐based approaches for managing atherothrombosis. It will provide hospitalists with the knowledge needed to treat patients with PAD, stroke, and acute coronary syndrome. First, the administration of antiplatelet therapies to patients with acute coronary syndrome will be described. Then, guidelines for the management of patients with acute ischemic stroke and the use of antiplatelet therapies to reduce mortality due to primary and secondary ischemic events will be reviewed. Finally, the role of the hospitalist in the diagnosis of PAD in asymptomatic patients and in those with confirmed atherothrombosis will be discussed.

Acute atherothrombotic events associated with ischemic heart disease and stroke are the first and third most common causes of death in the United States, respectively.1 Despite an overall decrease in age‐adjusted mortality since 1970 in the United States, the worldwide prevalence of these diseases is anticipated to sharply increase by 2020.1, 2 Caring for patients with atherothrombosis is now within the purview of hospitalists to a larger extent than ever before. In recognition of the expanding role of these health care professionals and to reduce the risk of adverse cardiovascular events in the outpatient setting, the Society of Hospital Medicine held a symposium during its 10th Annual Meeting.

Rules of Engagement: The Hospitalist and Atherothrombosis took place on May 24, 2007, in Dallas, Texas. This supplement summarizes the highlights from this symposium and reviews the causes and polyvascular nature of atherothrombosis. The role of the hospitalist in managing atherothrombotic disease and evidence‐based practices for the evaluation and treatment of patients with various manifestations of atherothrombotic disease are also discussed.

ARTERIAL THROMBOSIS AND ITS POLYVASCULAR NATURE

Atherothrombosis refers to the formation of large and occlusive mural thrombi that arise from the rupture of an atherosclerotic plaque. Myocardial infarction (MI), ischemic stroke, and acute limb ischemia are the most severe manifestations of this disease.3, 4 This process begins when denuded or inflamed endothelial cells develop properties that permit platelet adhesion. At the site of endothelial dysfunction, activation of adherent platelet results in the release of inflammatory and mitogenic factors. After a series of dynamic and repetitive processes including amplified platelet activation, monocyte chemotaxis, adhesion, transmigration, and lipoprotein retention, plaque formation occurs.5 Consequently, the rupture or erosion of an atherosclerotic plaque produces a higher degree of platelet adhesion, activation, and aggregation, causing the fibrotic organization of a mural thrombus.3

The number of persons with multiple, concomitant cardiovascular disease (CAD), cerebrovascular disease (CVD), and peripheral arterial disease (PAD) accentuates the polyvascular nature of atherothrombosis (Fig. 1). The international Reduction of Atherothrombosis for Continued Health (REACH) Registry demonstrated that 1‐year incidence rates of major cardiovascular events (eg, MI, stroke, death) were high in patients with an established atherothrombotic disease and increased with the number of concomitant vascular diseases.6 These data infer that the burden on the vascular system is considered extensive on diagnosis of a single atherothrombotic disease. Thus, aggressive therapies are needed to reduce the risk of recurrent or other cardiovascular events. The management of risk factors for atherothrombosis such as hypercholesterolemia, dyslipidemia, hypertension, and diabetes mellitus fall under specific disease‐specific guidelines for patients presenting with atherothrombotic diseases.712

Figure 1

ANTIPLATELET THERAPIES

Antiplatelet therapies are used for the acute and long‐term treatment of patients after a thrombic event. Antiplatelet agents target the molecular mechanisms responsible for platelet activation and aggregation, such as the synthesis of thromboxane A₂. On platelet activation, free arachidonic acid is converted to prostaglandin H₂ (PGH₂) by cyclooxygenase‐1 (COX‐1; Fig. 2). Further metabolism of PGH₂ by thromboxane synthase produces thromboxane A₂, which induces vasoconstriction (Fig. 2). Fortunately, the ability of platelets to produce COX‐1 is limited, and irreversible inhibition of this enzyme can impair thromboxane A₂ synthesis for approximately 10 days.

Figure 2

Aspirin is a potent COX‐1 inhibitor, whose effects are evident 1 hour after dosing (Fig. 2).4, 13 Aspirin effectively prevents fatal and nonfatal vascular events in healthy individuals and in patients who present with acute MI or ischemic stroke.13 Unfortunately, a proportion of patients are aspirin resistant. Recent studies have indicated that interactions with the nonsteroidal anti‐inflammatory drug (NSAID) ibuprofen may diminish the primary and secondary protective effects of aspirin and may contribute to aspirin resistance, although the origin of this remains unclear.

The results of a post hoc subgroup analysis of 22,071 apparently healthy male physicians randomized to take aspirin or placebo for 5 years indicated that individuals who used NSAIDs for at least 60 days/year increased their risk of MI by more than 2‐fold compared with those who did not use NSAIDs.14 A second study conducted in patients following a major adverse cardiovascular event showed that the combination of aspirin plus ibuprofen increased the adjusted relative risk of cardiovascular mortality over an 8‐year period compared with aspirin alone.15 However, the effects of NSAIDS on aspirin's ability to inhibit COX‐1 are reversible and only last for the dosing interval and body clearance time of the drug.16

Adeonsine diphosphate (ADP)dependent stimulation of the P2Y₁₂ receptor is another target for antiplatelet therapy. On its release, ADP binds to the P2Y₁₂ receptor on platelets, resulting in activation and aggregation (Fig. 2). Ticlopidine and clopidogrel are thienopyridines that may irreversibly modify the P2Y₁₂ receptor (Fig. 2).13 Safety concerns associated with ticlopidine use, including severe neutropenia, have limited its administration. Conversely, clopidogrel is relatively well‐tolerated and can prevent cardiovascular events in patients with CAD, ischemic stroke, and PAD. This agent is an orally administered prodrug requiring activation by hepatic cytochrome P450 enzymes.13

Aspirin and thienopyridines do not inhibit platelet aggregation induced by the binding of fibrinogen to the platelet glycoprotein (GP) IIb/IIIa receptor (Fig. 2).4, 13 However, there are 3 commonly administered GP IIb/IIIa inhibitors: abciximab, eptifibatide, and tirofiban (Fig. 2).4 Abciximab is the fab fragment of the chimeric monoclonal antibody 7E3 and irreversibly inhibits the GP IIb/IIIa receptor. By contrast, eptifibatide is a cyclic heptapeptide, tirofiban is a nonpeptide, and both agents are reversible inhibitors. These agents are administered intravenously, and boluses are reserved for the short‐term treatment of atherothrombosis in patients undergoing percutaneous coronary intervention.13

CONCLUSIONS

Atherothrombosis is a systemic disease that often affects coronary, intracranial, and peripheral arterial beds concomitantly, which increases the probability of a thrombotic event. Aggressive treatments, including acute and long‐term antiplatelet therapies, are required to reduce the risks associated with atherothrombosis. This supplement reviews the evidence‐based approaches for managing atherothrombosis. It will provide hospitalists with the knowledge needed to treat patients with PAD, stroke, and acute coronary syndrome. First, the administration of antiplatelet therapies to patients with acute coronary syndrome will be described. Then, guidelines for the management of patients with acute ischemic stroke and the use of antiplatelet therapies to reduce mortality due to primary and secondary ischemic events will be reviewed. Finally, the role of the hospitalist in the diagnosis of PAD in asymptomatic patients and in those with confirmed atherothrombosis will be discussed.

Two years ago we published the first issue of the Journal of Hospital Medicine and declared, Our goal is that JHM become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.1 That first issue was just one of many steps toward this ambition. At the completion of its first year, JHM was selected for indexing and inclusion in the National Library of Medicine's Medical Literature Analysis and Retrieval System Online (MEDLINE), the primary component of PubMed. Following this huge step, we welcomed a remarkable increase in submissions and will have exceeded 300 in our second year, an approximately 50% increase from our first year!

As important, JHM quickly became a valuable benefit of membership in the Society of Hospital Medicine, and the innumerable compliments received by the staff reflect the diligent efforts of a remarkable editorial staff and work by our reviewers. With profound gratitude we list on page 86 these 325 reviewers who donated their priceless time and expertise to enhancing the quality of the manuscripts. To handle the marked increase in submissions, we are expanding and modifying our editorial staff. Please welcome Sunil Kripalani (Vanderbilt) and Daniel Brotman (Johns Hopkins), who join our previous six associate editors and all eight will now serve as JHM's deputy editors. Seven new associate editors also join our team. Among them, Tom Baudendistel (California Pacific Medical Center, San Francisco), Eric Alper (UMass Memorial Health Care, Worcester), Brian Harte (Cleveland Clinic), and Rehan Qayyum (Johns Hopkins) will all focus on optimizing content for practicing hospitalists. Paul Aronowitz will continue to develop our Images section as an associate editor. Recognizing the growing number of pediatric hospitalists, Lisa Zauotis (Childrens Hospital of Philadelphia) and Erin Stucky (Children's Hospital San Diego) join JHM as the other 2 new associate editors. Finally, we welcome new Editorial Board members Mary C. Ottolini (Children's National Medical Center), Douglas Carlson (St. Louis Children's Hospital), and Daniel Rauch (NYU Children's Hospital). The welcome addition of these nationally recognized academicians prepares us for continued growth in manuscript submissions to JHM.

Although we could not excel without the editors, reviewers and our terrific new managing editor, Phaedra McGuinness, we would not survive without the authors who submit their manuscripts to JHMthey are responsible for the caliber of the journal, and we are immensely indebted to them. Originally, we hoped to include individuals involved in all aspects of hospital care,1 and fortunately this is now happening. Complementing hospitalists are nurses and pharmacists2 who recognize the importance of teamwork in the care of hospitalized patients. I encourage all members of the hospital care team to send us the results of their research, teaching, and quality improvement efforts.

As the specialty of hospital medicine continues to evolve, now with more than 20,000 hospitalists, JHM will develop with it. I am honored and grateful to collaborate with such a remarkable group of colleagues as we build the premier journal for the fastest growing specialty in the history of medicine in the United States. On to year 3!

Two years ago we published the first issue of the Journal of Hospital Medicine and declared, Our goal is that JHM become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.1 That first issue was just one of many steps toward this ambition. At the completion of its first year, JHM was selected for indexing and inclusion in the National Library of Medicine's Medical Literature Analysis and Retrieval System Online (MEDLINE), the primary component of PubMed. Following this huge step, we welcomed a remarkable increase in submissions and will have exceeded 300 in our second year, an approximately 50% increase from our first year!

As important, JHM quickly became a valuable benefit of membership in the Society of Hospital Medicine, and the innumerable compliments received by the staff reflect the diligent efforts of a remarkable editorial staff and work by our reviewers. With profound gratitude we list on page 86 these 325 reviewers who donated their priceless time and expertise to enhancing the quality of the manuscripts. To handle the marked increase in submissions, we are expanding and modifying our editorial staff. Please welcome Sunil Kripalani (Vanderbilt) and Daniel Brotman (Johns Hopkins), who join our previous six associate editors and all eight will now serve as JHM's deputy editors. Seven new associate editors also join our team. Among them, Tom Baudendistel (California Pacific Medical Center, San Francisco), Eric Alper (UMass Memorial Health Care, Worcester), Brian Harte (Cleveland Clinic), and Rehan Qayyum (Johns Hopkins) will all focus on optimizing content for practicing hospitalists. Paul Aronowitz will continue to develop our Images section as an associate editor. Recognizing the growing number of pediatric hospitalists, Lisa Zauotis (Childrens Hospital of Philadelphia) and Erin Stucky (Children's Hospital San Diego) join JHM as the other 2 new associate editors. Finally, we welcome new Editorial Board members Mary C. Ottolini (Children's National Medical Center), Douglas Carlson (St. Louis Children's Hospital), and Daniel Rauch (NYU Children's Hospital). The welcome addition of these nationally recognized academicians prepares us for continued growth in manuscript submissions to JHM.

Although we could not excel without the editors, reviewers and our terrific new managing editor, Phaedra McGuinness, we would not survive without the authors who submit their manuscripts to JHMthey are responsible for the caliber of the journal, and we are immensely indebted to them. Originally, we hoped to include individuals involved in all aspects of hospital care,1 and fortunately this is now happening. Complementing hospitalists are nurses and pharmacists2 who recognize the importance of teamwork in the care of hospitalized patients. I encourage all members of the hospital care team to send us the results of their research, teaching, and quality improvement efforts.

As the specialty of hospital medicine continues to evolve, now with more than 20,000 hospitalists, JHM will develop with it. I am honored and grateful to collaborate with such a remarkable group of colleagues as we build the premier journal for the fastest growing specialty in the history of medicine in the United States. On to year 3!

Two years ago we published the first issue of the Journal of Hospital Medicine and declared, Our goal is that JHM become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.1 That first issue was just one of many steps toward this ambition. At the completion of its first year, JHM was selected for indexing and inclusion in the National Library of Medicine's Medical Literature Analysis and Retrieval System Online (MEDLINE), the primary component of PubMed. Following this huge step, we welcomed a remarkable increase in submissions and will have exceeded 300 in our second year, an approximately 50% increase from our first year!

As important, JHM quickly became a valuable benefit of membership in the Society of Hospital Medicine, and the innumerable compliments received by the staff reflect the diligent efforts of a remarkable editorial staff and work by our reviewers. With profound gratitude we list on page 86 these 325 reviewers who donated their priceless time and expertise to enhancing the quality of the manuscripts. To handle the marked increase in submissions, we are expanding and modifying our editorial staff. Please welcome Sunil Kripalani (Vanderbilt) and Daniel Brotman (Johns Hopkins), who join our previous six associate editors and all eight will now serve as JHM's deputy editors. Seven new associate editors also join our team. Among them, Tom Baudendistel (California Pacific Medical Center, San Francisco), Eric Alper (UMass Memorial Health Care, Worcester), Brian Harte (Cleveland Clinic), and Rehan Qayyum (Johns Hopkins) will all focus on optimizing content for practicing hospitalists. Paul Aronowitz will continue to develop our Images section as an associate editor. Recognizing the growing number of pediatric hospitalists, Lisa Zauotis (Childrens Hospital of Philadelphia) and Erin Stucky (Children's Hospital San Diego) join JHM as the other 2 new associate editors. Finally, we welcome new Editorial Board members Mary C. Ottolini (Children's National Medical Center), Douglas Carlson (St. Louis Children's Hospital), and Daniel Rauch (NYU Children's Hospital). The welcome addition of these nationally recognized academicians prepares us for continued growth in manuscript submissions to JHM.

Although we could not excel without the editors, reviewers and our terrific new managing editor, Phaedra McGuinness, we would not survive without the authors who submit their manuscripts to JHMthey are responsible for the caliber of the journal, and we are immensely indebted to them. Originally, we hoped to include individuals involved in all aspects of hospital care,1 and fortunately this is now happening. Complementing hospitalists are nurses and pharmacists2 who recognize the importance of teamwork in the care of hospitalized patients. I encourage all members of the hospital care team to send us the results of their research, teaching, and quality improvement efforts.

As the specialty of hospital medicine continues to evolve, now with more than 20,000 hospitalists, JHM will develop with it. I am honored and grateful to collaborate with such a remarkable group of colleagues as we build the premier journal for the fastest growing specialty in the history of medicine in the United States. On to year 3!

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

Communication, palliative care, and patient safety have been identified by the Society of Hospital Medicine as core competencies in hospital medicine. Effective communication is recognized as being central to the role of the hospitalist to promote efficient, safe, and high quality care.1 Hospitalists are increasingly recognized as having a central role in initiatives to improve palliative care for hospitalized patients and their families24 and have a vital role in leading and participating in interventions to mitigate system and process failures that affect patient safety.1 The obligation of the hospitalist to assure safe, quality care for hospitalized people with advanced illness extends from direct patient care to advocacy for systems that facilitate the provision of such care.

Four articles in this issue of the Journal of Hospital Medicine provide complementary perspectives on these crucial roles of the hospitalist. Cherlin and colleagues describe findings from a survey of hospitalists and medical residents regarding their knowledge, attitudes, and practices relative to caring for patients with terminal illness. The article identifies misperceptions related to core components of quality palliative care: pain and symptom control, hospice eligibility, and communication about prognosis and hospice and palliative care.5 Although this study was conducted at only a single academic medical center and certainly deserves to be repeated in an expanded and more representative sample, it clearly identifies deficits in core components of quality care for persons with advanced illness. The article by Minichiello and colleagues provides practical guidance and resources for addressing one of the deficits identified: communicating a poor prognosis, or bad news.6

Pain and symptom management and communication are commonly recognized aspects of quality care for persons with advanced illness. Less often appreciated are the significant threats to patient safety and medical errors that occur in the care of this vulnerable population.79 Potential errors include failure of a planned action to be completed as intended (ie, not following advance directives) and failure to treat symptoms adequately. The original research article and accompanying images discussion by Sehgal and colleagues serve as a call to action to both recognize and address the potentially significant patient safety issue related to the use of color‐coded wristbands, particularly variation in color used by different hospitals to designate do not resuscitate status.10, 11 What is exciting about this sequence of articles is that they describe opportunities for improvement and provide potential solutions. We have to be aware that there is a problem in order to initiate change. Hospitalists are in an a prime position to both identify these potential critical issues and effect the necessary changes to facilitate our ability to provide safe, effective care to our patients with advanced illness.

Palliative care is increasingly being accepted as a means for improving care for persons with advanced illness. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, released in 2004, was endorsed by the National Quality Forum and incorporated into its Framework for Hospice and Palliative Care in 2007.12, 13 The Joint Commission (TJC; previously known as JCAHO) is developing a Health Care Services Certification Program for palliative care services modeled on existing programs for diabetes and stroke care, to take effect in 2008.14 Newsweek featured palliative care in its August 2006 issue focused on Fixing America's Hospitals.15 US News and World Report has included hospice and palliative care indicators in its ranking of America's Best Hospitals since 2002.16 There has been significant recent growth in hospital‐based palliative care programs, with 1250 hospitals reporting palliative care programs in 2005, an increase of almost 100% over 2000. Seventy percent of U.S. hospitals with more than 250 beds report having a palliative care program.17

Although hospital‐based palliative care programs are increasing, it is the obligation of all hospitalists who care for an ill, often elderly population to assure that all hospitalized patients with advanced illness receive safe, quality care while hospitalized. This includes avoiding medical errors such as inappropriate resuscitation attempts because of miscommunication of do‐not‐resuscitate orders or advance directives, as well as minimizing distress, maximizing comfort, and addressing informational and psychosocial support needs. As evidenced by the 4 articles in this issue of the Journal of Hospital Medicine, we need to make safe, effective care for people with advanced illness a priority, then implement appropriate training and education and create systems that assure delivery of quality care.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.