Hospital Medicine

Even though I could not remember her name, I remembered her story, and I would bet that my colleagues did as well. She was someone that we had all cared for at one time or another. She frequently presented to the hospital with chest pain or shortness of breath attributable to a combination of longstanding congestive heart failure, chronic obstructive pulmonary disease, and cocaine abuse. But most tragic of all, she was homeless, which meant that she was frequently hospitalized not only for medical complaints but also for a night’s shelter and a bite of food. Even though she often refused medical treatment and social workers’ efforts to stabilize her housing situation, the staff in the emergency room and observation unit all knew her by name and greeted her like an old friend. And then one day she stopped showing up to the hospital. Sitting in the emergency department (ED), I overheard that she was found outside of a storefront and had passed away. Saddened by her death, which was not unexpected given her medical issues, I still wondered if we had done right by her during the hundreds of times that she had come to our hospital. Clinicians at busy safety-net hospitals face these questions every day, and it would seem beyond doubt that our duty is to address both medical and nonmedical determinants of health of everyone that walks through our door. But is this in fact the right thing to do? Is it possible that we unwittingly expose these vulnerable patients to risks from hospitalization alone?

In this month’s Journal of Hospital Medicine, Sekijima et al. sought to quantify precisely the risks of hospitalization, particularly among the subset of patients whose “severity” of medical problems alone might not have warranted hospital admission, a scenario known colloquially as a “social” admission.¹ In real time, an inhouse triage physician classified patients as being admitted with or without “definite medical acuity.” Investigators retrospectively identified adverse events and illness acuity using standardized instruments, the Institute for Healthcare Improvement Global Trigger Tool and Emergency Severity Index, respectively. Despite the acknowledged differences in the patient population and the inherent subjectivity within the designation process, Sekijima et al. found no statistically significant difference in the percentage of admissions with an adverse event nor in the rate of adverse events per 1,000 patient days. Falls, oversedation/hypotension and code/arrest/rapid response activation were the most frequently encountered adverse events.

Delving deeper into the origin of admissions without definite medical acuity, the authors identified homelessness, lack of outpatient social support, substance use disorder, and lack of outpatient medical support as the most common reasons for “nonmedical” admissions. As healthcare providers, we recognize that these factors are generally long-term, chronic socioeconomic determinants of health. Despite our objective knowledge that we are limited in our ability to fix these problems on a short-term basis, the authors’ observations reflect our compulsion to try and help in any way possible. Patients admitted without definite medical acuity were more vulnerable and had higher rates of public insurance and housing insecurity. However, they were less acutely ill, as indicated by lower Emergency Severity Index scores. These factors were not associated with statistically significant differences in either 48-hour ED readmission or 30-day hospital readmission rates.

The process of appropriately triaging patients to an inpatient setting is challenging because of wide variability in both patients and ED providers. Hospitalists are increasingly recognized as an additional resource to assist in the triage process, as we are uniquely in a position to view the patient’s clinical presentation within the context of their anticipated clinical trajectory, promote effective utilization of inpatient bed availability, and anticipate potential barriers to discharge. Graduate medical education now identifies the triage process as a specific milestone within the transitions of care competency, as it requires mastery of interpersonal communication, professionalism, systems-based thinking, and patient-centered care.² However, many institutions lack a dedicated faculty member to perform the triage role. Our institution recently examined the feasibility of instituting a daily “huddle” between the admitting hospitalist and the ED to facilitate interdepartmental communication to create care plans in patient triage and to promote patient throughput. Available admission beds are valuable commodities, and one challenge is that the ED makes disposition decisions without knowledge of the number of available beds in the hospital. The goal of the huddle was to quickly discuss all patients potentially requiring admission prior to the final disposition decision and to address any modifiable factors to potentially prevent a “social” admission with social work early in the day. Further work is in progress to determine if introducing flexibility within existing provider roles can improve the triage process in a measurable and efficient manner.

Many challenges remain as we balance the medical needs of patients with any potential social drivers that necessitate admission to the inpatient hospital setting. From an ED perspective, social support and community follow-up were “universally considered powerful influences on admission,” and other factors such as time of day, clinical volume, and the four-hour waiting time target also played a significant role in the decision to admit.³ Hunter et al. found that admissions with moderate to low acuity may be shorter or less costly,⁴ which presents an interesting question of cost-effectiveness as an avenue for further study. As clinicians, we are intuitively aware of the subjective risk of hospitalization itself, and this work provides new objective evidence that hospitalization confers specific and quantifiable risks. Though we can undoubtedly use this knowledge to guide internal decisions about admissions and discharges, do we also have an obligation to inform our patients about these risks in real time? Ultimately, hospitalization itself might be viewed as a “procedure” or intervention that has inherent risks for all who receive it, regardless of the individual patient or hospital characteristics. As hospitalists, we should continue to strive to reduce these risks, but we should also initiate a conversation about the risks and benefits of hospitalization similarly to how we discuss other procedures with patients and their families.

Even though I could not remember her name, I remembered her story, and I would bet that my colleagues did as well. She was someone that we had all cared for at one time or another. She frequently presented to the hospital with chest pain or shortness of breath attributable to a combination of longstanding congestive heart failure, chronic obstructive pulmonary disease, and cocaine abuse. But most tragic of all, she was homeless, which meant that she was frequently hospitalized not only for medical complaints but also for a night’s shelter and a bite of food. Even though she often refused medical treatment and social workers’ efforts to stabilize her housing situation, the staff in the emergency room and observation unit all knew her by name and greeted her like an old friend. And then one day she stopped showing up to the hospital. Sitting in the emergency department (ED), I overheard that she was found outside of a storefront and had passed away. Saddened by her death, which was not unexpected given her medical issues, I still wondered if we had done right by her during the hundreds of times that she had come to our hospital. Clinicians at busy safety-net hospitals face these questions every day, and it would seem beyond doubt that our duty is to address both medical and nonmedical determinants of health of everyone that walks through our door. But is this in fact the right thing to do? Is it possible that we unwittingly expose these vulnerable patients to risks from hospitalization alone?

In this month’s Journal of Hospital Medicine, Sekijima et al. sought to quantify precisely the risks of hospitalization, particularly among the subset of patients whose “severity” of medical problems alone might not have warranted hospital admission, a scenario known colloquially as a “social” admission.¹ In real time, an inhouse triage physician classified patients as being admitted with or without “definite medical acuity.” Investigators retrospectively identified adverse events and illness acuity using standardized instruments, the Institute for Healthcare Improvement Global Trigger Tool and Emergency Severity Index, respectively. Despite the acknowledged differences in the patient population and the inherent subjectivity within the designation process, Sekijima et al. found no statistically significant difference in the percentage of admissions with an adverse event nor in the rate of adverse events per 1,000 patient days. Falls, oversedation/hypotension and code/arrest/rapid response activation were the most frequently encountered adverse events.

Delving deeper into the origin of admissions without definite medical acuity, the authors identified homelessness, lack of outpatient social support, substance use disorder, and lack of outpatient medical support as the most common reasons for “nonmedical” admissions. As healthcare providers, we recognize that these factors are generally long-term, chronic socioeconomic determinants of health. Despite our objective knowledge that we are limited in our ability to fix these problems on a short-term basis, the authors’ observations reflect our compulsion to try and help in any way possible. Patients admitted without definite medical acuity were more vulnerable and had higher rates of public insurance and housing insecurity. However, they were less acutely ill, as indicated by lower Emergency Severity Index scores. These factors were not associated with statistically significant differences in either 48-hour ED readmission or 30-day hospital readmission rates.

The process of appropriately triaging patients to an inpatient setting is challenging because of wide variability in both patients and ED providers. Hospitalists are increasingly recognized as an additional resource to assist in the triage process, as we are uniquely in a position to view the patient’s clinical presentation within the context of their anticipated clinical trajectory, promote effective utilization of inpatient bed availability, and anticipate potential barriers to discharge. Graduate medical education now identifies the triage process as a specific milestone within the transitions of care competency, as it requires mastery of interpersonal communication, professionalism, systems-based thinking, and patient-centered care.² However, many institutions lack a dedicated faculty member to perform the triage role. Our institution recently examined the feasibility of instituting a daily “huddle” between the admitting hospitalist and the ED to facilitate interdepartmental communication to create care plans in patient triage and to promote patient throughput. Available admission beds are valuable commodities, and one challenge is that the ED makes disposition decisions without knowledge of the number of available beds in the hospital. The goal of the huddle was to quickly discuss all patients potentially requiring admission prior to the final disposition decision and to address any modifiable factors to potentially prevent a “social” admission with social work early in the day. Further work is in progress to determine if introducing flexibility within existing provider roles can improve the triage process in a measurable and efficient manner.

Many challenges remain as we balance the medical needs of patients with any potential social drivers that necessitate admission to the inpatient hospital setting. From an ED perspective, social support and community follow-up were “universally considered powerful influences on admission,” and other factors such as time of day, clinical volume, and the four-hour waiting time target also played a significant role in the decision to admit.³ Hunter et al. found that admissions with moderate to low acuity may be shorter or less costly,⁴ which presents an interesting question of cost-effectiveness as an avenue for further study. As clinicians, we are intuitively aware of the subjective risk of hospitalization itself, and this work provides new objective evidence that hospitalization confers specific and quantifiable risks. Though we can undoubtedly use this knowledge to guide internal decisions about admissions and discharges, do we also have an obligation to inform our patients about these risks in real time? Ultimately, hospitalization itself might be viewed as a “procedure” or intervention that has inherent risks for all who receive it, regardless of the individual patient or hospital characteristics. As hospitalists, we should continue to strive to reduce these risks, but we should also initiate a conversation about the risks and benefits of hospitalization similarly to how we discuss other procedures with patients and their families.

Even though I could not remember her name, I remembered her story, and I would bet that my colleagues did as well. She was someone that we had all cared for at one time or another. She frequently presented to the hospital with chest pain or shortness of breath attributable to a combination of longstanding congestive heart failure, chronic obstructive pulmonary disease, and cocaine abuse. But most tragic of all, she was homeless, which meant that she was frequently hospitalized not only for medical complaints but also for a night’s shelter and a bite of food. Even though she often refused medical treatment and social workers’ efforts to stabilize her housing situation, the staff in the emergency room and observation unit all knew her by name and greeted her like an old friend. And then one day she stopped showing up to the hospital. Sitting in the emergency department (ED), I overheard that she was found outside of a storefront and had passed away. Saddened by her death, which was not unexpected given her medical issues, I still wondered if we had done right by her during the hundreds of times that she had come to our hospital. Clinicians at busy safety-net hospitals face these questions every day, and it would seem beyond doubt that our duty is to address both medical and nonmedical determinants of health of everyone that walks through our door. But is this in fact the right thing to do? Is it possible that we unwittingly expose these vulnerable patients to risks from hospitalization alone?

In this month’s Journal of Hospital Medicine, Sekijima et al. sought to quantify precisely the risks of hospitalization, particularly among the subset of patients whose “severity” of medical problems alone might not have warranted hospital admission, a scenario known colloquially as a “social” admission.¹ In real time, an inhouse triage physician classified patients as being admitted with or without “definite medical acuity.” Investigators retrospectively identified adverse events and illness acuity using standardized instruments, the Institute for Healthcare Improvement Global Trigger Tool and Emergency Severity Index, respectively. Despite the acknowledged differences in the patient population and the inherent subjectivity within the designation process, Sekijima et al. found no statistically significant difference in the percentage of admissions with an adverse event nor in the rate of adverse events per 1,000 patient days. Falls, oversedation/hypotension and code/arrest/rapid response activation were the most frequently encountered adverse events.

Delving deeper into the origin of admissions without definite medical acuity, the authors identified homelessness, lack of outpatient social support, substance use disorder, and lack of outpatient medical support as the most common reasons for “nonmedical” admissions. As healthcare providers, we recognize that these factors are generally long-term, chronic socioeconomic determinants of health. Despite our objective knowledge that we are limited in our ability to fix these problems on a short-term basis, the authors’ observations reflect our compulsion to try and help in any way possible. Patients admitted without definite medical acuity were more vulnerable and had higher rates of public insurance and housing insecurity. However, they were less acutely ill, as indicated by lower Emergency Severity Index scores. These factors were not associated with statistically significant differences in either 48-hour ED readmission or 30-day hospital readmission rates.

The process of appropriately triaging patients to an inpatient setting is challenging because of wide variability in both patients and ED providers. Hospitalists are increasingly recognized as an additional resource to assist in the triage process, as we are uniquely in a position to view the patient’s clinical presentation within the context of their anticipated clinical trajectory, promote effective utilization of inpatient bed availability, and anticipate potential barriers to discharge. Graduate medical education now identifies the triage process as a specific milestone within the transitions of care competency, as it requires mastery of interpersonal communication, professionalism, systems-based thinking, and patient-centered care.² However, many institutions lack a dedicated faculty member to perform the triage role. Our institution recently examined the feasibility of instituting a daily “huddle” between the admitting hospitalist and the ED to facilitate interdepartmental communication to create care plans in patient triage and to promote patient throughput. Available admission beds are valuable commodities, and one challenge is that the ED makes disposition decisions without knowledge of the number of available beds in the hospital. The goal of the huddle was to quickly discuss all patients potentially requiring admission prior to the final disposition decision and to address any modifiable factors to potentially prevent a “social” admission with social work early in the day. Further work is in progress to determine if introducing flexibility within existing provider roles can improve the triage process in a measurable and efficient manner.

Many challenges remain as we balance the medical needs of patients with any potential social drivers that necessitate admission to the inpatient hospital setting. From an ED perspective, social support and community follow-up were “universally considered powerful influences on admission,” and other factors such as time of day, clinical volume, and the four-hour waiting time target also played a significant role in the decision to admit.³ Hunter et al. found that admissions with moderate to low acuity may be shorter or less costly,⁴ which presents an interesting question of cost-effectiveness as an avenue for further study. As clinicians, we are intuitively aware of the subjective risk of hospitalization itself, and this work provides new objective evidence that hospitalization confers specific and quantifiable risks. Though we can undoubtedly use this knowledge to guide internal decisions about admissions and discharges, do we also have an obligation to inform our patients about these risks in real time? Ultimately, hospitalization itself might be viewed as a “procedure” or intervention that has inherent risks for all who receive it, regardless of the individual patient or hospital characteristics. As hospitalists, we should continue to strive to reduce these risks, but we should also initiate a conversation about the risks and benefits of hospitalization similarly to how we discuss other procedures with patients and their families.

“If you define the problem correctly, you almost have the solution.”
—Steve Jobs

In the classic tale of a chaotic kitchen before an important dinner, two feuding chefs urgently need the only remaining orange in the pantry for their respective dishes. The first chef asserts its necessity for his prized sauce. The second chef retorts that her dessert will be ruined without it. After an emotion-laden battle, they finally agree to compromise, cutting the orange in half. The first chef squeezes the juice out of his half of the orange for his sauce, while the second grates half the zest she needs for her cake. Each chef had less of the orange than their recipe needed, but figured this was the best they could do given the dispute.¹

Conflict frequently occurs for hospitalists leading change efforts, managing service lines, and caring for patients. Often conflict can help clarify a decision or course of action. However, when navigated poorly, disputes can also consume precious energy and sap the goodwill and cooperation needed to effectively lead change and ensure excellent clinical care. Worse yet, ineffective conversations can result in begrudging and ultimately value-destroying agreements, as the chefs above demonstrate.

Instead of focusing on someone’s position (the need for the orange), successful leaders first seek to understand all discernible underlying interests (zest, juice) and motivations (creating a signature dish) of each party.¹ Essential to this process is swift recognition of the conflict and self-regulation. Rather than succumbing to strong fight-or-flight reactions, the wise hospitalist first takes inventory of their own interests and calmly applies a known schema, similar to their approach to common clinical scenarios.

So how can you get to the underlying interests effectively? We use a three-step process reminding us of the benefits of the orange’s ACID.²

Ask open-ended questions and closely listen to their responses. Listening more than talking is critical to this process. When facing conflict, it is common to listen only to refute the other’s position. Instead, actively suppress your instinct to “reload” and seek to genuinely understand the other’s perspective. Continue to ask clarifying questions until you feel you understand their interests.

A new hire requests a higher salary than offered. Ask with curiosity: “Can you tell me more about some of your financial priorities? Even if I can’t do much about the dollar figure, there may be benefits and other helpful tips I can suggest.”

Restate your understanding of their interests from listening. This critical step serves to confirm your good-faith effort to address a common problem and to demonstrate that you have heard their perspective accurately. Even if you ultimately cannot agree on a solution to the dispute at hand, demonstrating an understanding of their perspective helps to preserve the relationship, which can be useful for future conflicts.

“I am hearing that you are hoping to save money for the future, to pay down outstanding loans, and to expand your family. Is that right?”

Accurately defining interests and demonstrating your understanding will maximize the possibility of mutually acceptable solutions. Share your own perspective, being careful to describe your underlying interests, not positions. What mutual goals do you share? What potential solutions were not immediately evident based on positions alone? During this process, remain open to arriving at a solution that you had not anticipated.

“While I unfortunately have little wiggle room on annual salary, there are some options for loan repayment, housing down payment assistance, and low-cost childcare at the health system, which is where my kids went.”

Whether you are a chef or a hospitalist and whether you are dividing oranges or clinical shifts, understanding the interests buried within the conflict will help define and potentially solve the problem. When you encounter an orange, remember the value of its ACID.

Acknowledgement

The authors wish to thank Charlie Wray, DO, Division of Hospital Medicine, San Francisco VA, for assistance with revisions of early drafts.

“If you define the problem correctly, you almost have the solution.”
—Steve Jobs

In the classic tale of a chaotic kitchen before an important dinner, two feuding chefs urgently need the only remaining orange in the pantry for their respective dishes. The first chef asserts its necessity for his prized sauce. The second chef retorts that her dessert will be ruined without it. After an emotion-laden battle, they finally agree to compromise, cutting the orange in half. The first chef squeezes the juice out of his half of the orange for his sauce, while the second grates half the zest she needs for her cake. Each chef had less of the orange than their recipe needed, but figured this was the best they could do given the dispute.¹

Conflict frequently occurs for hospitalists leading change efforts, managing service lines, and caring for patients. Often conflict can help clarify a decision or course of action. However, when navigated poorly, disputes can also consume precious energy and sap the goodwill and cooperation needed to effectively lead change and ensure excellent clinical care. Worse yet, ineffective conversations can result in begrudging and ultimately value-destroying agreements, as the chefs above demonstrate.

Instead of focusing on someone’s position (the need for the orange), successful leaders first seek to understand all discernible underlying interests (zest, juice) and motivations (creating a signature dish) of each party.¹ Essential to this process is swift recognition of the conflict and self-regulation. Rather than succumbing to strong fight-or-flight reactions, the wise hospitalist first takes inventory of their own interests and calmly applies a known schema, similar to their approach to common clinical scenarios.

So how can you get to the underlying interests effectively? We use a three-step process reminding us of the benefits of the orange’s ACID.²

Ask open-ended questions and closely listen to their responses. Listening more than talking is critical to this process. When facing conflict, it is common to listen only to refute the other’s position. Instead, actively suppress your instinct to “reload” and seek to genuinely understand the other’s perspective. Continue to ask clarifying questions until you feel you understand their interests.

A new hire requests a higher salary than offered. Ask with curiosity: “Can you tell me more about some of your financial priorities? Even if I can’t do much about the dollar figure, there may be benefits and other helpful tips I can suggest.”

Restate your understanding of their interests from listening. This critical step serves to confirm your good-faith effort to address a common problem and to demonstrate that you have heard their perspective accurately. Even if you ultimately cannot agree on a solution to the dispute at hand, demonstrating an understanding of their perspective helps to preserve the relationship, which can be useful for future conflicts.

“I am hearing that you are hoping to save money for the future, to pay down outstanding loans, and to expand your family. Is that right?”

Accurately defining interests and demonstrating your understanding will maximize the possibility of mutually acceptable solutions. Share your own perspective, being careful to describe your underlying interests, not positions. What mutual goals do you share? What potential solutions were not immediately evident based on positions alone? During this process, remain open to arriving at a solution that you had not anticipated.

“While I unfortunately have little wiggle room on annual salary, there are some options for loan repayment, housing down payment assistance, and low-cost childcare at the health system, which is where my kids went.”

Whether you are a chef or a hospitalist and whether you are dividing oranges or clinical shifts, understanding the interests buried within the conflict will help define and potentially solve the problem. When you encounter an orange, remember the value of its ACID.

Acknowledgement

The authors wish to thank Charlie Wray, DO, Division of Hospital Medicine, San Francisco VA, for assistance with revisions of early drafts.

“If you define the problem correctly, you almost have the solution.”
—Steve Jobs

In the classic tale of a chaotic kitchen before an important dinner, two feuding chefs urgently need the only remaining orange in the pantry for their respective dishes. The first chef asserts its necessity for his prized sauce. The second chef retorts that her dessert will be ruined without it. After an emotion-laden battle, they finally agree to compromise, cutting the orange in half. The first chef squeezes the juice out of his half of the orange for his sauce, while the second grates half the zest she needs for her cake. Each chef had less of the orange than their recipe needed, but figured this was the best they could do given the dispute.¹

Conflict frequently occurs for hospitalists leading change efforts, managing service lines, and caring for patients. Often conflict can help clarify a decision or course of action. However, when navigated poorly, disputes can also consume precious energy and sap the goodwill and cooperation needed to effectively lead change and ensure excellent clinical care. Worse yet, ineffective conversations can result in begrudging and ultimately value-destroying agreements, as the chefs above demonstrate.

Instead of focusing on someone’s position (the need for the orange), successful leaders first seek to understand all discernible underlying interests (zest, juice) and motivations (creating a signature dish) of each party.¹ Essential to this process is swift recognition of the conflict and self-regulation. Rather than succumbing to strong fight-or-flight reactions, the wise hospitalist first takes inventory of their own interests and calmly applies a known schema, similar to their approach to common clinical scenarios.

So how can you get to the underlying interests effectively? We use a three-step process reminding us of the benefits of the orange’s ACID.²

Ask open-ended questions and closely listen to their responses. Listening more than talking is critical to this process. When facing conflict, it is common to listen only to refute the other’s position. Instead, actively suppress your instinct to “reload” and seek to genuinely understand the other’s perspective. Continue to ask clarifying questions until you feel you understand their interests.

A new hire requests a higher salary than offered. Ask with curiosity: “Can you tell me more about some of your financial priorities? Even if I can’t do much about the dollar figure, there may be benefits and other helpful tips I can suggest.”

Restate your understanding of their interests from listening. This critical step serves to confirm your good-faith effort to address a common problem and to demonstrate that you have heard their perspective accurately. Even if you ultimately cannot agree on a solution to the dispute at hand, demonstrating an understanding of their perspective helps to preserve the relationship, which can be useful for future conflicts.

“I am hearing that you are hoping to save money for the future, to pay down outstanding loans, and to expand your family. Is that right?”

Accurately defining interests and demonstrating your understanding will maximize the possibility of mutually acceptable solutions. Share your own perspective, being careful to describe your underlying interests, not positions. What mutual goals do you share? What potential solutions were not immediately evident based on positions alone? During this process, remain open to arriving at a solution that you had not anticipated.

“While I unfortunately have little wiggle room on annual salary, there are some options for loan repayment, housing down payment assistance, and low-cost childcare at the health system, which is where my kids went.”

Whether you are a chef or a hospitalist and whether you are dividing oranges or clinical shifts, understanding the interests buried within the conflict will help define and potentially solve the problem. When you encounter an orange, remember the value of its ACID.

Acknowledgement

The authors wish to thank Charlie Wray, DO, Division of Hospital Medicine, San Francisco VA, for assistance with revisions of early drafts.

I appreciate the input from Dr. Rauch regarding the terminology of “fellowship” in regards to APP postgraduate training programs.¹ When researching these programs, the overwhelming majority we surveyed described themselves as fellowships. Because of this, we chose to use the same nomenclature. The survey we used was meant to explore and quantify certain discreet components of program creation and execution, and further study would be needed to shed light on how they name themselves.

While it is not known if the term “fellowship” in this context would be confusing to patients, it does seem that the ideal terminology has not yet been clarified. In 2014, the American Association of Nurse Practitioners released a position statement that, for NP postgraduate training programs, the term “fellowship” should be used above other terms.² We were unable to find a similar position statement regarding postgraduate physician assistant training, but did note that the Association of Post-Graduate PA Programs website uses the terms “residency” and “fellowship” seemingly interchangeably.³ As most of the programs that we surveyed train mixed groups of nurse practitioners and physician assistants, developing unified language will be an important step in the future.

I appreciate the input from Dr. Rauch regarding the terminology of “fellowship” in regards to APP postgraduate training programs.¹ When researching these programs, the overwhelming majority we surveyed described themselves as fellowships. Because of this, we chose to use the same nomenclature. The survey we used was meant to explore and quantify certain discreet components of program creation and execution, and further study would be needed to shed light on how they name themselves.

While it is not known if the term “fellowship” in this context would be confusing to patients, it does seem that the ideal terminology has not yet been clarified. In 2014, the American Association of Nurse Practitioners released a position statement that, for NP postgraduate training programs, the term “fellowship” should be used above other terms.² We were unable to find a similar position statement regarding postgraduate physician assistant training, but did note that the Association of Post-Graduate PA Programs website uses the terms “residency” and “fellowship” seemingly interchangeably.³ As most of the programs that we surveyed train mixed groups of nurse practitioners and physician assistants, developing unified language will be an important step in the future.

I appreciate the input from Dr. Rauch regarding the terminology of “fellowship” in regards to APP postgraduate training programs.¹ When researching these programs, the overwhelming majority we surveyed described themselves as fellowships. Because of this, we chose to use the same nomenclature. The survey we used was meant to explore and quantify certain discreet components of program creation and execution, and further study would be needed to shed light on how they name themselves.

While it is not known if the term “fellowship” in this context would be confusing to patients, it does seem that the ideal terminology has not yet been clarified. In 2014, the American Association of Nurse Practitioners released a position statement that, for NP postgraduate training programs, the term “fellowship” should be used above other terms.² We were unable to find a similar position statement regarding postgraduate physician assistant training, but did note that the Association of Post-Graduate PA Programs website uses the terms “residency” and “fellowship” seemingly interchangeably.³ As most of the programs that we surveyed train mixed groups of nurse practitioners and physician assistants, developing unified language will be an important step in the future.

I read with interest the recent article by Klimpl et al. “The Current State of Advanced Practice provider Fellowships in Hospital Medicine: A Survey of Program Directors.”¹ I appreciate the description of the variation in training as well as the discussion points about the driving forces behind the training programs. However, I am concerned about the terminology used, specifically “fellowship,” and how it can create confusion for patients. Accredited medical/surgical fellowships have a precise meaning and convey an assurance of standardized additional training. Even many non-Accreditation Council for Graduate Medical Education fellowships within a single field have a shared curriculum. Using the same terminology for other medical providers may be seen as equating their post-training competency with physicians who have completed fellowship training. As the authors point out, there is a wide divergence in the clinical experience required to become a licensed practitioner among NPs, PAs, and physicians. As such, using the same terminology for their respective training programs makes it difficult for the public to differentiate between them.

I read with interest the recent article by Klimpl et al. “The Current State of Advanced Practice provider Fellowships in Hospital Medicine: A Survey of Program Directors.”¹ I appreciate the description of the variation in training as well as the discussion points about the driving forces behind the training programs. However, I am concerned about the terminology used, specifically “fellowship,” and how it can create confusion for patients. Accredited medical/surgical fellowships have a precise meaning and convey an assurance of standardized additional training. Even many non-Accreditation Council for Graduate Medical Education fellowships within a single field have a shared curriculum. Using the same terminology for other medical providers may be seen as equating their post-training competency with physicians who have completed fellowship training. As the authors point out, there is a wide divergence in the clinical experience required to become a licensed practitioner among NPs, PAs, and physicians. As such, using the same terminology for their respective training programs makes it difficult for the public to differentiate between them.

I read with interest the recent article by Klimpl et al. “The Current State of Advanced Practice provider Fellowships in Hospital Medicine: A Survey of Program Directors.”¹ I appreciate the description of the variation in training as well as the discussion points about the driving forces behind the training programs. However, I am concerned about the terminology used, specifically “fellowship,” and how it can create confusion for patients. Accredited medical/surgical fellowships have a precise meaning and convey an assurance of standardized additional training. Even many non-Accreditation Council for Graduate Medical Education fellowships within a single field have a shared curriculum. Using the same terminology for other medical providers may be seen as equating their post-training competency with physicians who have completed fellowship training. As the authors point out, there is a wide divergence in the clinical experience required to become a licensed practitioner among NPs, PAs, and physicians. As such, using the same terminology for their respective training programs makes it difficult for the public to differentiate between them.

A 73-year-old man presents to the emergency department with sepsis secondary to community-acquired pneumonia. The patient requires supplemental oxygen and is started on intravenous antibiotics. His admitting physician expects he will need more than two nights of hospital care and suggests that inpatient status, rather than outpatient (observation) status, would be appropriate under Medicare’s “Two-Midnight Rule.” The physician also suspects the patient may need a brief stay in a skilled nursing facility (SNF) following the mentioned hospitalization and notes that the patient has a Medicare Advantage plan (Table) and wonders if the Two-Midnight Rule applies. Further, she questions whether Medicare’s “Three-Midnight Rule” for SNF benefits will factor in the patient’s discharge planning.

Since the 1970s, the Centers for Medicare & Medicaid Services (CMS) has allowed enrollees to receive their Medicare benefits from privately managed health plans through the so-called Medicare Advantage programs. CMS contracts with commercial insurers who, in exchange for a set payment per Medicare enrollee, “accept full responsibility (ie, risk) for the costs of their enrollees’ care.”¹ Over the past 20 years the percent of Medicare Advantage enrollees has nearly doubled nationwide, from 18% to 34%, and is projected to grow even further to 42% by 2028.^2,3 The reasons beneficiaries choose to enroll in Medicare Advantage over Traditional Medicare have yet to be thoroughly studied; ease of enrollment and plan administration, as well as lower deductibles, copays, and out-of-pocket maximums for in-network services, are thought to be some of the driving factors.

The federal government has asserted two goals for the development of Medicare Advantage: beneficiary choice and economic efficiency.¹ Medicare Advantage plans must be actuarially equal to Traditional Medicare but do not have to cover services in precisely the same way. Medicare Advantage plans may achieve cost savings through narrower networks, strict control of access to SNF services and acute care inpatient rehabilitation, and prior authorization requirements, the latter of which has received recent congressional attention.^4,5 On the other hand, many Medicare Advantage plans offer dental, fitness, optical, and caregiver benefits that are not included under Traditional Medicare. Beneficiaries can theoretically compare the coverage and costs of Traditional Medicare to Medicare Advantage programs and make informed choices based on their individualized needs. The second stated goal for the Medicare Advantage option assumes that privately managed plans provide care at lower costs compared with CMS; this assumption has yet to be confirmed with solid data. Indeed, a recent analysis comparing the overall costs of Medicare Advantage to those of Traditional Medicare concluded that Medicare Advantage costs CMS more than Traditional Medicare,⁶ perhaps in part due to risk adjustment practices.⁷

There are a number of areas of uncertainty regarding the specifics of how Medicare Advantage plans work, including Medicare Advantage programs’ use of outpatient (observation) stays. CMS has tried to provide guidance to healthcare organizations and clinicians regarding the appropriate use of inpatient hospitalizations for patients with Traditional Medicare, including the implementation of the Two-Midnight Rule in 2013. According to the rule, clinicians should place inpatient admission orders when they reasonably expect a patient’s care to extend across two midnights.⁸ Such admission decisions are subject to review by Medicare contractors and Quality Improvement Organizations.

In contrast, Medicare Advantage plans which enter into contracts with specific healthcare systems are not required to abide by CMS’ guidelines for the Two-Midnight Rule.⁹ When Medicare Advantage firms negotiate contracts with individual hospitals and healthcare organizations, CMS has been clear that such contracts are not required to include the Two-Midnight Rule when it comes to making hospitalization status decisions.¹⁰ Instead, in these instances, Medicare Advantage plans often use proprietary decision tools containing clinical criteria, such as Milliman Care Guidelines or InterQual, and/or their own plan’s internal criteria as part of the decision-making process to grant inpatient or outpatient (observation) status. More importantly, CMS has stated that for hospitals and healthcare systems that do not contract with Medicare Advantage programs, the Two-Midnight Rule should apply when it comes to making hospitalization status decisions.¹⁰

Implications for Patients

Currently, there are no data available to compare between Medicare Advantage enrollees and traditional medicine beneficiaries in terms of the frequency of observation use and out-of-pocket cost for observation stays. As alluded to in the patient’s case, the use of outpatient (observation) status has implications for a patient’s posthospitalization SNF benefit. Under Traditional Medicare, patients must be hospitalized for three consecutive inpatient midnights in order to qualify for the SNF benefit. Time spent under outpatient (observation) status does not count toward this three-day requirement. Interestingly, some Medicare Advantage programs have demonstrated innovation in this area, waiving the three inpatient midnight requirement for their beneficiaries;¹¹ there is evidence, however, that compared with their Traditional Medicare counterparts, Medicare Advantage beneficiaries are admitted to lower quality SNFs.¹² The posthospitalization consequences of an inpatient versus outpatient (observation) status determination for a Medicare Advantage beneficiary is thus unclear, further complicating the decision-making process for patients when it comes to choosing a Medicare policy, and for providers when it comes to choosing an admission status.

Implications for Clinicians and Healthcare Systems

After performing an initial history and physical exam, if a healthcare provider determines that a patient requires hospitalization, an order is placed to classify the stay as inpatient or outpatient (observation). For beneficiaries with Traditional Medicare or a Medicare Advantage plan that has not contracted with the hospital, clinicians should follow the Two-Midnight Rule for making this determination. For contracted Medicare Advantage, the rules are variable. Under Medicare’s Conditions of Participation, hospitals and healthcare organizations are required to have utilization management (UM) programs to assist physicians in making appropriate admission decisions. UM reviews can happen at any point during or after a patient’s stay, however, and physicians may have to make decisions using their best judgment at the time of admission without real-time input from UM teams.

Outpatient (observation) care and the challenges surrounding appropriate status orders have complicated the admission decision. In one study of 2014 Traditional Medicare claims, almost half of outpatient (observation) stays contained a status change.¹³ Based on a recent survey of hospitalist physicians, about two-thirds of hospitalists report at least monthly requests from patients to change their status.¹⁴ Hospital medicine physicians report that these requests “can severely damage the therapeutic bond”¹⁴ between provider and patient because the provider must assign status based on CMS rules, not patient request.

CMS could improve the current system in one of two ways. First, CMS could require that all Medicare Advantage plans follow the same polices as Traditional Medicare policies regarding the Two- and Three-Midnight Rules. This would eliminate the need for both hospitals and healthcare organizations to dedicate time and resources to negotiating with each Medicare Advantage program and to managing each Medicare Advantage patient admission based on a specific contract. Ideally, CMS could completely eliminate its outpatient (observation) policy so that all hospitalizations are treated exactly the same, classified under the same billing status and with beneficiaries having the same postacute benefit. This would be consistent with the sentiment behind the recent Office of Inspector General’s (OIG) report suggesting that CMS consider counting outpatient midnights toward the three-midnight requirement for postacute SNF care “so that beneficiaries receiving similar hospital care have similar access to these services.”¹⁵

The physician in the example above should tell their patient that they will be admitted as an inpatient given her expectation that the patient will need hospitalization for oxygen support, parenteral antibiotics, and evaluation by physical therapy to determine a medically appropriate discharge plan. The physician should document the medical necessity for the admission, specifically her expectation that the patient will require at least two midnights of medically necessary hospital care. If the patient has Traditional Medicare, this documentation, along with the inpatient status order, will fulfill the requirements for an inpatient stay. If the patient has a Medicare Advantage plan, the physician can advise the patient that the plan administrators will ultimately determine if an inpatient stay will be covered or denied.

In the proposed clinical scenario, the rules determining the patient’s hospitalization status depend on whether the hospital contracts with the patient’s Medicare Advantage plan, and if so, what the contracted criteria are in determining inpatient and outpatient (observation) status. The physician could consider real-time input from the hospital’s UM team, if available. Regardless of UM input, if the physician hospitalizes the patient as an inpatient, the Medicare Advantage plan administrators will make a determination regarding the appropriateness of the admission status, as well as whether the patient qualifies for posthospitalization Medicare SNF benefits (if requested) and, additionally, which SNFs will be covered. If denied, the hospitalist will have the option of a peer-to-peer discussion with the insurance company to overturn the denial. Given the confusion, complexity, and implications presented by this admission status decision-making process, standardization across Traditional Medicare and Medicare Advantage plans, or a budget-neutral plan to eliminate status distinction altogether, is certainly warranted.

A 73-year-old man presents to the emergency department with sepsis secondary to community-acquired pneumonia. The patient requires supplemental oxygen and is started on intravenous antibiotics. His admitting physician expects he will need more than two nights of hospital care and suggests that inpatient status, rather than outpatient (observation) status, would be appropriate under Medicare’s “Two-Midnight Rule.” The physician also suspects the patient may need a brief stay in a skilled nursing facility (SNF) following the mentioned hospitalization and notes that the patient has a Medicare Advantage plan (Table) and wonders if the Two-Midnight Rule applies. Further, she questions whether Medicare’s “Three-Midnight Rule” for SNF benefits will factor in the patient’s discharge planning.

Since the 1970s, the Centers for Medicare & Medicaid Services (CMS) has allowed enrollees to receive their Medicare benefits from privately managed health plans through the so-called Medicare Advantage programs. CMS contracts with commercial insurers who, in exchange for a set payment per Medicare enrollee, “accept full responsibility (ie, risk) for the costs of their enrollees’ care.”¹ Over the past 20 years the percent of Medicare Advantage enrollees has nearly doubled nationwide, from 18% to 34%, and is projected to grow even further to 42% by 2028.^2,3 The reasons beneficiaries choose to enroll in Medicare Advantage over Traditional Medicare have yet to be thoroughly studied; ease of enrollment and plan administration, as well as lower deductibles, copays, and out-of-pocket maximums for in-network services, are thought to be some of the driving factors.

The federal government has asserted two goals for the development of Medicare Advantage: beneficiary choice and economic efficiency.¹ Medicare Advantage plans must be actuarially equal to Traditional Medicare but do not have to cover services in precisely the same way. Medicare Advantage plans may achieve cost savings through narrower networks, strict control of access to SNF services and acute care inpatient rehabilitation, and prior authorization requirements, the latter of which has received recent congressional attention.^4,5 On the other hand, many Medicare Advantage plans offer dental, fitness, optical, and caregiver benefits that are not included under Traditional Medicare. Beneficiaries can theoretically compare the coverage and costs of Traditional Medicare to Medicare Advantage programs and make informed choices based on their individualized needs. The second stated goal for the Medicare Advantage option assumes that privately managed plans provide care at lower costs compared with CMS; this assumption has yet to be confirmed with solid data. Indeed, a recent analysis comparing the overall costs of Medicare Advantage to those of Traditional Medicare concluded that Medicare Advantage costs CMS more than Traditional Medicare,⁶ perhaps in part due to risk adjustment practices.⁷

There are a number of areas of uncertainty regarding the specifics of how Medicare Advantage plans work, including Medicare Advantage programs’ use of outpatient (observation) stays. CMS has tried to provide guidance to healthcare organizations and clinicians regarding the appropriate use of inpatient hospitalizations for patients with Traditional Medicare, including the implementation of the Two-Midnight Rule in 2013. According to the rule, clinicians should place inpatient admission orders when they reasonably expect a patient’s care to extend across two midnights.⁸ Such admission decisions are subject to review by Medicare contractors and Quality Improvement Organizations.

In contrast, Medicare Advantage plans which enter into contracts with specific healthcare systems are not required to abide by CMS’ guidelines for the Two-Midnight Rule.⁹ When Medicare Advantage firms negotiate contracts with individual hospitals and healthcare organizations, CMS has been clear that such contracts are not required to include the Two-Midnight Rule when it comes to making hospitalization status decisions.¹⁰ Instead, in these instances, Medicare Advantage plans often use proprietary decision tools containing clinical criteria, such as Milliman Care Guidelines or InterQual, and/or their own plan’s internal criteria as part of the decision-making process to grant inpatient or outpatient (observation) status. More importantly, CMS has stated that for hospitals and healthcare systems that do not contract with Medicare Advantage programs, the Two-Midnight Rule should apply when it comes to making hospitalization status decisions.¹⁰

Implications for Patients

Currently, there are no data available to compare between Medicare Advantage enrollees and traditional medicine beneficiaries in terms of the frequency of observation use and out-of-pocket cost for observation stays. As alluded to in the patient’s case, the use of outpatient (observation) status has implications for a patient’s posthospitalization SNF benefit. Under Traditional Medicare, patients must be hospitalized for three consecutive inpatient midnights in order to qualify for the SNF benefit. Time spent under outpatient (observation) status does not count toward this three-day requirement. Interestingly, some Medicare Advantage programs have demonstrated innovation in this area, waiving the three inpatient midnight requirement for their beneficiaries;¹¹ there is evidence, however, that compared with their Traditional Medicare counterparts, Medicare Advantage beneficiaries are admitted to lower quality SNFs.¹² The posthospitalization consequences of an inpatient versus outpatient (observation) status determination for a Medicare Advantage beneficiary is thus unclear, further complicating the decision-making process for patients when it comes to choosing a Medicare policy, and for providers when it comes to choosing an admission status.

Implications for Clinicians and Healthcare Systems

After performing an initial history and physical exam, if a healthcare provider determines that a patient requires hospitalization, an order is placed to classify the stay as inpatient or outpatient (observation). For beneficiaries with Traditional Medicare or a Medicare Advantage plan that has not contracted with the hospital, clinicians should follow the Two-Midnight Rule for making this determination. For contracted Medicare Advantage, the rules are variable. Under Medicare’s Conditions of Participation, hospitals and healthcare organizations are required to have utilization management (UM) programs to assist physicians in making appropriate admission decisions. UM reviews can happen at any point during or after a patient’s stay, however, and physicians may have to make decisions using their best judgment at the time of admission without real-time input from UM teams.

Outpatient (observation) care and the challenges surrounding appropriate status orders have complicated the admission decision. In one study of 2014 Traditional Medicare claims, almost half of outpatient (observation) stays contained a status change.¹³ Based on a recent survey of hospitalist physicians, about two-thirds of hospitalists report at least monthly requests from patients to change their status.¹⁴ Hospital medicine physicians report that these requests “can severely damage the therapeutic bond”¹⁴ between provider and patient because the provider must assign status based on CMS rules, not patient request.

CMS could improve the current system in one of two ways. First, CMS could require that all Medicare Advantage plans follow the same polices as Traditional Medicare policies regarding the Two- and Three-Midnight Rules. This would eliminate the need for both hospitals and healthcare organizations to dedicate time and resources to negotiating with each Medicare Advantage program and to managing each Medicare Advantage patient admission based on a specific contract. Ideally, CMS could completely eliminate its outpatient (observation) policy so that all hospitalizations are treated exactly the same, classified under the same billing status and with beneficiaries having the same postacute benefit. This would be consistent with the sentiment behind the recent Office of Inspector General’s (OIG) report suggesting that CMS consider counting outpatient midnights toward the three-midnight requirement for postacute SNF care “so that beneficiaries receiving similar hospital care have similar access to these services.”¹⁵

The physician in the example above should tell their patient that they will be admitted as an inpatient given her expectation that the patient will need hospitalization for oxygen support, parenteral antibiotics, and evaluation by physical therapy to determine a medically appropriate discharge plan. The physician should document the medical necessity for the admission, specifically her expectation that the patient will require at least two midnights of medically necessary hospital care. If the patient has Traditional Medicare, this documentation, along with the inpatient status order, will fulfill the requirements for an inpatient stay. If the patient has a Medicare Advantage plan, the physician can advise the patient that the plan administrators will ultimately determine if an inpatient stay will be covered or denied.

In the proposed clinical scenario, the rules determining the patient’s hospitalization status depend on whether the hospital contracts with the patient’s Medicare Advantage plan, and if so, what the contracted criteria are in determining inpatient and outpatient (observation) status. The physician could consider real-time input from the hospital’s UM team, if available. Regardless of UM input, if the physician hospitalizes the patient as an inpatient, the Medicare Advantage plan administrators will make a determination regarding the appropriateness of the admission status, as well as whether the patient qualifies for posthospitalization Medicare SNF benefits (if requested) and, additionally, which SNFs will be covered. If denied, the hospitalist will have the option of a peer-to-peer discussion with the insurance company to overturn the denial. Given the confusion, complexity, and implications presented by this admission status decision-making process, standardization across Traditional Medicare and Medicare Advantage plans, or a budget-neutral plan to eliminate status distinction altogether, is certainly warranted.

A 73-year-old man presents to the emergency department with sepsis secondary to community-acquired pneumonia. The patient requires supplemental oxygen and is started on intravenous antibiotics. His admitting physician expects he will need more than two nights of hospital care and suggests that inpatient status, rather than outpatient (observation) status, would be appropriate under Medicare’s “Two-Midnight Rule.” The physician also suspects the patient may need a brief stay in a skilled nursing facility (SNF) following the mentioned hospitalization and notes that the patient has a Medicare Advantage plan (Table) and wonders if the Two-Midnight Rule applies. Further, she questions whether Medicare’s “Three-Midnight Rule” for SNF benefits will factor in the patient’s discharge planning.

Since the 1970s, the Centers for Medicare & Medicaid Services (CMS) has allowed enrollees to receive their Medicare benefits from privately managed health plans through the so-called Medicare Advantage programs. CMS contracts with commercial insurers who, in exchange for a set payment per Medicare enrollee, “accept full responsibility (ie, risk) for the costs of their enrollees’ care.”¹ Over the past 20 years the percent of Medicare Advantage enrollees has nearly doubled nationwide, from 18% to 34%, and is projected to grow even further to 42% by 2028.^2,3 The reasons beneficiaries choose to enroll in Medicare Advantage over Traditional Medicare have yet to be thoroughly studied; ease of enrollment and plan administration, as well as lower deductibles, copays, and out-of-pocket maximums for in-network services, are thought to be some of the driving factors.

The federal government has asserted two goals for the development of Medicare Advantage: beneficiary choice and economic efficiency.¹ Medicare Advantage plans must be actuarially equal to Traditional Medicare but do not have to cover services in precisely the same way. Medicare Advantage plans may achieve cost savings through narrower networks, strict control of access to SNF services and acute care inpatient rehabilitation, and prior authorization requirements, the latter of which has received recent congressional attention.^4,5 On the other hand, many Medicare Advantage plans offer dental, fitness, optical, and caregiver benefits that are not included under Traditional Medicare. Beneficiaries can theoretically compare the coverage and costs of Traditional Medicare to Medicare Advantage programs and make informed choices based on their individualized needs. The second stated goal for the Medicare Advantage option assumes that privately managed plans provide care at lower costs compared with CMS; this assumption has yet to be confirmed with solid data. Indeed, a recent analysis comparing the overall costs of Medicare Advantage to those of Traditional Medicare concluded that Medicare Advantage costs CMS more than Traditional Medicare,⁶ perhaps in part due to risk adjustment practices.⁷

There are a number of areas of uncertainty regarding the specifics of how Medicare Advantage plans work, including Medicare Advantage programs’ use of outpatient (observation) stays. CMS has tried to provide guidance to healthcare organizations and clinicians regarding the appropriate use of inpatient hospitalizations for patients with Traditional Medicare, including the implementation of the Two-Midnight Rule in 2013. According to the rule, clinicians should place inpatient admission orders when they reasonably expect a patient’s care to extend across two midnights.⁸ Such admission decisions are subject to review by Medicare contractors and Quality Improvement Organizations.

In contrast, Medicare Advantage plans which enter into contracts with specific healthcare systems are not required to abide by CMS’ guidelines for the Two-Midnight Rule.⁹ When Medicare Advantage firms negotiate contracts with individual hospitals and healthcare organizations, CMS has been clear that such contracts are not required to include the Two-Midnight Rule when it comes to making hospitalization status decisions.¹⁰ Instead, in these instances, Medicare Advantage plans often use proprietary decision tools containing clinical criteria, such as Milliman Care Guidelines or InterQual, and/or their own plan’s internal criteria as part of the decision-making process to grant inpatient or outpatient (observation) status. More importantly, CMS has stated that for hospitals and healthcare systems that do not contract with Medicare Advantage programs, the Two-Midnight Rule should apply when it comes to making hospitalization status decisions.¹⁰

Implications for Patients

Currently, there are no data available to compare between Medicare Advantage enrollees and traditional medicine beneficiaries in terms of the frequency of observation use and out-of-pocket cost for observation stays. As alluded to in the patient’s case, the use of outpatient (observation) status has implications for a patient’s posthospitalization SNF benefit. Under Traditional Medicare, patients must be hospitalized for three consecutive inpatient midnights in order to qualify for the SNF benefit. Time spent under outpatient (observation) status does not count toward this three-day requirement. Interestingly, some Medicare Advantage programs have demonstrated innovation in this area, waiving the three inpatient midnight requirement for their beneficiaries;¹¹ there is evidence, however, that compared with their Traditional Medicare counterparts, Medicare Advantage beneficiaries are admitted to lower quality SNFs.¹² The posthospitalization consequences of an inpatient versus outpatient (observation) status determination for a Medicare Advantage beneficiary is thus unclear, further complicating the decision-making process for patients when it comes to choosing a Medicare policy, and for providers when it comes to choosing an admission status.

Implications for Clinicians and Healthcare Systems

After performing an initial history and physical exam, if a healthcare provider determines that a patient requires hospitalization, an order is placed to classify the stay as inpatient or outpatient (observation). For beneficiaries with Traditional Medicare or a Medicare Advantage plan that has not contracted with the hospital, clinicians should follow the Two-Midnight Rule for making this determination. For contracted Medicare Advantage, the rules are variable. Under Medicare’s Conditions of Participation, hospitals and healthcare organizations are required to have utilization management (UM) programs to assist physicians in making appropriate admission decisions. UM reviews can happen at any point during or after a patient’s stay, however, and physicians may have to make decisions using their best judgment at the time of admission without real-time input from UM teams.

Outpatient (observation) care and the challenges surrounding appropriate status orders have complicated the admission decision. In one study of 2014 Traditional Medicare claims, almost half of outpatient (observation) stays contained a status change.¹³ Based on a recent survey of hospitalist physicians, about two-thirds of hospitalists report at least monthly requests from patients to change their status.¹⁴ Hospital medicine physicians report that these requests “can severely damage the therapeutic bond”¹⁴ between provider and patient because the provider must assign status based on CMS rules, not patient request.

CMS could improve the current system in one of two ways. First, CMS could require that all Medicare Advantage plans follow the same polices as Traditional Medicare policies regarding the Two- and Three-Midnight Rules. This would eliminate the need for both hospitals and healthcare organizations to dedicate time and resources to negotiating with each Medicare Advantage program and to managing each Medicare Advantage patient admission based on a specific contract. Ideally, CMS could completely eliminate its outpatient (observation) policy so that all hospitalizations are treated exactly the same, classified under the same billing status and with beneficiaries having the same postacute benefit. This would be consistent with the sentiment behind the recent Office of Inspector General’s (OIG) report suggesting that CMS consider counting outpatient midnights toward the three-midnight requirement for postacute SNF care “so that beneficiaries receiving similar hospital care have similar access to these services.”¹⁵

The physician in the example above should tell their patient that they will be admitted as an inpatient given her expectation that the patient will need hospitalization for oxygen support, parenteral antibiotics, and evaluation by physical therapy to determine a medically appropriate discharge plan. The physician should document the medical necessity for the admission, specifically her expectation that the patient will require at least two midnights of medically necessary hospital care. If the patient has Traditional Medicare, this documentation, along with the inpatient status order, will fulfill the requirements for an inpatient stay. If the patient has a Medicare Advantage plan, the physician can advise the patient that the plan administrators will ultimately determine if an inpatient stay will be covered or denied.

In the proposed clinical scenario, the rules determining the patient’s hospitalization status depend on whether the hospital contracts with the patient’s Medicare Advantage plan, and if so, what the contracted criteria are in determining inpatient and outpatient (observation) status. The physician could consider real-time input from the hospital’s UM team, if available. Regardless of UM input, if the physician hospitalizes the patient as an inpatient, the Medicare Advantage plan administrators will make a determination regarding the appropriateness of the admission status, as well as whether the patient qualifies for posthospitalization Medicare SNF benefits (if requested) and, additionally, which SNFs will be covered. If denied, the hospitalist will have the option of a peer-to-peer discussion with the insurance company to overturn the denial. Given the confusion, complexity, and implications presented by this admission status decision-making process, standardization across Traditional Medicare and Medicare Advantage plans, or a budget-neutral plan to eliminate status distinction altogether, is certainly warranted.

The Journal of Hospital Medicine introduced the Choosing Wisely^®: Next Steps in Improving Healthcare Value series in 2015¹ as a companion to the popular Choosing Wisely^®: Things We Do For No Reason^™ series² that was introduced in October in the same year. Both series were created in partnership with the American Board of Internal Medicine Foundation and were designed in the spirit of the Choosing Wisely^® campaign’s mission to “promote conversations between clinicians and patients” in choosing care supported by evidence that minimizes harm, including avoidance of unnecessary treatments and tests.³ The Choosing Wisely^®: Next Steps in Improving Healthcare Value series extends these principles as a forum for manuscripts that focus on translating value-based concepts into daily operations, including systems-level care delivery redesign initiatives, payment model innovations, and analyses of relevant policies or practice trends.

Since its inception, 16 Choosing Wisely^®: Next Steps in Improving Healthcare Value manuscripts have been published, encompassing a wide range of topics such as postacute care transitions,⁴ the role of hospital medicine practice within accountable care organizations (ACOs),⁵ and quality and value at end-of-life.⁶

Few physicians receive health policy training.^7,8 Hospital medicine practitioners are a core component of the workforce, driving change and value-based improvements at almost every inpatient facility across the country. Regardless of their background or experience, hospital medicine practitioners must interface with legislation, regulation, and other policies every day while providing patient care. Intentional, value-based improvements are more likely to succeed if those providing direct patient care understand health policies, particularly the effects of those policies on transactional, point-of-care decisions.

We are pleased to expand the Choosing Wisely^®: Next Steps in Improving Healthcare Value series to include articles exploring health policy implications at the bedside. These articles will use common clinical scenarios to illuminate health policies most germane to hospital medicine practitioners and present applications of the policies as they relate to value at the level of patient–provider interactions. Each article will present a clinical scenario, explain key policy terms, address implications of specific policies in clinical practice, and propose how those policies can be improved (Appendix). Going forward, Choosing Wisely^®: Next Steps in Improving Healthcare Value manuscript titles will include either “Policy in Clinical Practice” or “Improving Healthcare Value” to better establish a connection to the series and distinguish between the two article types.

The first Choosing Wisely^®: Next Steps in Improving Healthcare Value—Implications of Health Policy on Clinical Decision-Making manuscript appears in this issue of the Journal of Hospital Medicine.⁹ As is the current practice for Choosing Wisely^®: Next Steps in Improving Healthcare Value, authors are requested to send series editors a 500-word precis for review to ensure topic suitability before submission of a full manuscript. The precis, as well as any questions pertaining to the new series, can be directed to [email protected].

Acknowledgments

The authors thank the American Board of Internal Medicine Foundation for supporting this series.

The Journal of Hospital Medicine introduced the Choosing Wisely^®: Next Steps in Improving Healthcare Value series in 2015¹ as a companion to the popular Choosing Wisely^®: Things We Do For No Reason^™ series² that was introduced in October in the same year. Both series were created in partnership with the American Board of Internal Medicine Foundation and were designed in the spirit of the Choosing Wisely^® campaign’s mission to “promote conversations between clinicians and patients” in choosing care supported by evidence that minimizes harm, including avoidance of unnecessary treatments and tests.³ The Choosing Wisely^®: Next Steps in Improving Healthcare Value series extends these principles as a forum for manuscripts that focus on translating value-based concepts into daily operations, including systems-level care delivery redesign initiatives, payment model innovations, and analyses of relevant policies or practice trends.

Since its inception, 16 Choosing Wisely^®: Next Steps in Improving Healthcare Value manuscripts have been published, encompassing a wide range of topics such as postacute care transitions,⁴ the role of hospital medicine practice within accountable care organizations (ACOs),⁵ and quality and value at end-of-life.⁶

Few physicians receive health policy training.^7,8 Hospital medicine practitioners are a core component of the workforce, driving change and value-based improvements at almost every inpatient facility across the country. Regardless of their background or experience, hospital medicine practitioners must interface with legislation, regulation, and other policies every day while providing patient care. Intentional, value-based improvements are more likely to succeed if those providing direct patient care understand health policies, particularly the effects of those policies on transactional, point-of-care decisions.

We are pleased to expand the Choosing Wisely^®: Next Steps in Improving Healthcare Value series to include articles exploring health policy implications at the bedside. These articles will use common clinical scenarios to illuminate health policies most germane to hospital medicine practitioners and present applications of the policies as they relate to value at the level of patient–provider interactions. Each article will present a clinical scenario, explain key policy terms, address implications of specific policies in clinical practice, and propose how those policies can be improved (Appendix). Going forward, Choosing Wisely^®: Next Steps in Improving Healthcare Value manuscript titles will include either “Policy in Clinical Practice” or “Improving Healthcare Value” to better establish a connection to the series and distinguish between the two article types.

The first Choosing Wisely^®: Next Steps in Improving Healthcare Value—Implications of Health Policy on Clinical Decision-Making manuscript appears in this issue of the Journal of Hospital Medicine.⁹ As is the current practice for Choosing Wisely^®: Next Steps in Improving Healthcare Value, authors are requested to send series editors a 500-word precis for review to ensure topic suitability before submission of a full manuscript. The precis, as well as any questions pertaining to the new series, can be directed to [email protected].

Acknowledgments

The authors thank the American Board of Internal Medicine Foundation for supporting this series.

The Journal of Hospital Medicine introduced the Choosing Wisely^®: Next Steps in Improving Healthcare Value series in 2015¹ as a companion to the popular Choosing Wisely^®: Things We Do For No Reason^™ series² that was introduced in October in the same year. Both series were created in partnership with the American Board of Internal Medicine Foundation and were designed in the spirit of the Choosing Wisely^® campaign’s mission to “promote conversations between clinicians and patients” in choosing care supported by evidence that minimizes harm, including avoidance of unnecessary treatments and tests.³ The Choosing Wisely^®: Next Steps in Improving Healthcare Value series extends these principles as a forum for manuscripts that focus on translating value-based concepts into daily operations, including systems-level care delivery redesign initiatives, payment model innovations, and analyses of relevant policies or practice trends.

Since its inception, 16 Choosing Wisely^®: Next Steps in Improving Healthcare Value manuscripts have been published, encompassing a wide range of topics such as postacute care transitions,⁴ the role of hospital medicine practice within accountable care organizations (ACOs),⁵ and quality and value at end-of-life.⁶

Few physicians receive health policy training.^7,8 Hospital medicine practitioners are a core component of the workforce, driving change and value-based improvements at almost every inpatient facility across the country. Regardless of their background or experience, hospital medicine practitioners must interface with legislation, regulation, and other policies every day while providing patient care. Intentional, value-based improvements are more likely to succeed if those providing direct patient care understand health policies, particularly the effects of those policies on transactional, point-of-care decisions.

We are pleased to expand the Choosing Wisely^®: Next Steps in Improving Healthcare Value series to include articles exploring health policy implications at the bedside. These articles will use common clinical scenarios to illuminate health policies most germane to hospital medicine practitioners and present applications of the policies as they relate to value at the level of patient–provider interactions. Each article will present a clinical scenario, explain key policy terms, address implications of specific policies in clinical practice, and propose how those policies can be improved (Appendix). Going forward, Choosing Wisely^®: Next Steps in Improving Healthcare Value manuscript titles will include either “Policy in Clinical Practice” or “Improving Healthcare Value” to better establish a connection to the series and distinguish between the two article types.

The first Choosing Wisely^®: Next Steps in Improving Healthcare Value—Implications of Health Policy on Clinical Decision-Making manuscript appears in this issue of the Journal of Hospital Medicine.⁹ As is the current practice for Choosing Wisely^®: Next Steps in Improving Healthcare Value, authors are requested to send series editors a 500-word precis for review to ensure topic suitability before submission of a full manuscript. The precis, as well as any questions pertaining to the new series, can be directed to [email protected].

Acknowledgments

The authors thank the American Board of Internal Medicine Foundation for supporting this series.

“I don’t think she’ll ever make it home again.”

I stood at the nursing station with two staff nurses from our medical ward. The patient, a woman with metastatic cancer and acute respiratory failure, had just arrived by a medical helicopter from an out-of-state community hospital. At the previous hospital, days had stretched into weeks, and she was not getting better. Limited documentation told us that the patient’s family sought further options at our facility. Beyond that, we knew little about the conversations that had transpired. The transfer had been arranged and off she went, arriving on our helipad in worsening respiratory distress, now needing a higher level of supplemental oxygen and teetering on the edge of endotracheal intubation. Above all, she was extremely uncomfortable from shortness of breath, and an urgent palliative care consult was placed a few hours after she touched down.

I arrived at the bedside to meet the patient and family. In these circumstances, I often feel that a palliative care consult is not the miracle that patients seek, but the grim consolation prize behind door two of a tragic and exhausting game show of a hospital transfer. I read the family’s dismayed facial expressions as they gazed at my badge reading “Palliative Care” and imagined that they would have preferred a different answer to their question that led them here: “Is this all that can be done?”

The hope of patients and families is a precious thing. As a palliative care physician, I recognize that my role is never to take away hope but rather reframe the wish for recovery into the realm of the achievable. Some people can pivot when the hospital transfer happens. They feel that they have “done all they could” and searched the earth for the reversal of their medical circumstances. I empathize with the wish to try everything and respect the motivation that lies behind it. I also see the cost of chasing hope.

In 2017, 1.5 million patients were transferred, comprising 3.5% of all hospital admissions.¹ Although the majority of hospital transfers are medically appropriate and hold the possibility of treatment options unavailable at smaller facilities, there are also significant drawbacks. Transfers have been identified as risky times for adverse events, are often expensive, and are associated with higher mortality and longer length of stay.² There are often lapses in documentation and provider communication, and handoff practices vary widely between hospitals.³ Some transferred seriously ill patients become functionally trapped in the accepting hospital. Patients arrive too sick to undergo any meaningful disease-directed therapy and too medically tenuous to return to their home community.

When patients and families seem overly hopeful about what a transfer might provide, the request for transfer may indicate a deeper need for empathic understanding. Clinical conversations about “what can be done” typically focus on medical aspects and often miss a critical element—a complete exploration of a seriously ill patient’s prognostic awareness.

In palliative care, we use the term prognostic awareness to define patients’ dynamic understanding of their prognosis in terms of likely longevity and quality of life. Accurate prognostic awareness—where there is concordance between a patient’s worries and the medical facts as understood by their treatment team—has been associated with enhanced quality of life and mood when patients have enough emotional reserve to actively cope with the illness; for example, by reframing things in a positive light.^4,5 However, when patients are struggling to cope, talking about the prognosis is hard for patients and for their clinicians, who often accurately perceive their patient’s struggle and delay conversations, hoping that more time will help their patient better adapt and prepare to talk about it.^6,7 However, delaying conversations makes it even harder for patients and families to develop accurate prognostic awareness, leaving them unprepared when medical decisions arise.⁸ Such delays have a particularly strong impact in nononcology care, where a more unpredictable illness trajectory makes it even harder for patients to understand and prepare for what might happen.

When seriously ill patients and families consider transfer to a tertiary medical center in a situation of medical crisis, it can be a good time to pause. Palliative care specialists are trained to communicate around these difficult points of transition, but generalist clinicians already involved in the patient’s care can also sensitively explore patients’ prognostic awareness as it relates to the hospital transfer.⁹ In the Table, The phrases mentioned suggest language that is helpful in broaching such discussions, which assesses the patient’s illness understanding, hopes, and worries. Asking about patients’ hopes for their illness enables clinicians to quickly know some of their most important priorities. Giving patients the permission to be future-oriented and positive also supports them to cope in these challenging conversations. Asking patients to identify two or three hopes places their most optimistic hopes within a larger context and can lead to a discussion of the potential tradeoffs of the transfer.¹⁰ For example, the hope for a little more time from treatments available through transfer may be at odds with the hope to spend as much time as possible with family. Once the patient’s hopes are better understood, the clinician can then ask about worries. Most seriously ill patients are deeply (often silently) worried about the future, and when asked, can articulate worries about dying that can be the foundation for an honest conversation about the likely course of the hospital transfer.

With empathic assessment, several patients can speak honestly with their clinicians about their illness, including the pros and cons of hospital transfer. However, some continue to struggle, often asking clinicians to remain positive and not endorsing any worry. We describe these patients as having low prognostic awareness.¹¹ With such patients, palliative care expertise may be needed to ensure that patients and their families have the information they need to engage in informed medical decision-making. There are emerging models for distance palliative care integration, which may be helpful in these situations.¹² If these technologies became common in practice, frontline clinicians may increasingly find virtual consultation helpful in working with patients to develop more accurate prognostic awareness. There is also the possibility of clinician-to-clinician electronic consultation, or peer coaching, where the patient is not seen directly by the consultant, but expert advice is offered to the local provider.¹³ Although both these innovations offer service that currently may not be available in certain care settings, in-person consultation remains the gold standard. If a nuanced discussion cannot be had, palliative care expertise may be the reason for transfer.

Back at our hospital, I met with the patient and her partner. There were tradeoffs to be made and hard truths to be acknowledged. In this unfamiliar place, with caregivers she had met just hours before, the patient changed her resuscitation order to allow for a natural death. She passed away later that evening, surrounded by her immediate family but far away from the community that had held her throughout her illness. I reflect on the loss that can come with choosing “everything” when efforts are often better spent on ensuring comfort. Although hospital transfer is often the right answer for seriously ill patients seeking diagnostic and therapeutic options unavailable at their home medical centers, the question should also be an impetus for a nuanced assessment of patients’ prognostic awareness to prepare patients if things do not go as hoped or to enlist palliative care expertise for those struggling to cope. As there is a workforce shortage of palliative care providers, particularly in smaller and rural American hospitals, frontline hospitalist clinicians may find themselves increasingly playing a critical role in discussions where transfer is considered. By assessing patients’ prognostic awareness through thoughtful, compassionate inquiry in these moments of transition, we can support informed medical decision-making.

“I don’t think she’ll ever make it home again.”

I stood at the nursing station with two staff nurses from our medical ward. The patient, a woman with metastatic cancer and acute respiratory failure, had just arrived by a medical helicopter from an out-of-state community hospital. At the previous hospital, days had stretched into weeks, and she was not getting better. Limited documentation told us that the patient’s family sought further options at our facility. Beyond that, we knew little about the conversations that had transpired. The transfer had been arranged and off she went, arriving on our helipad in worsening respiratory distress, now needing a higher level of supplemental oxygen and teetering on the edge of endotracheal intubation. Above all, she was extremely uncomfortable from shortness of breath, and an urgent palliative care consult was placed a few hours after she touched down.

I arrived at the bedside to meet the patient and family. In these circumstances, I often feel that a palliative care consult is not the miracle that patients seek, but the grim consolation prize behind door two of a tragic and exhausting game show of a hospital transfer. I read the family’s dismayed facial expressions as they gazed at my badge reading “Palliative Care” and imagined that they would have preferred a different answer to their question that led them here: “Is this all that can be done?”

The hope of patients and families is a precious thing. As a palliative care physician, I recognize that my role is never to take away hope but rather reframe the wish for recovery into the realm of the achievable. Some people can pivot when the hospital transfer happens. They feel that they have “done all they could” and searched the earth for the reversal of their medical circumstances. I empathize with the wish to try everything and respect the motivation that lies behind it. I also see the cost of chasing hope.

In 2017, 1.5 million patients were transferred, comprising 3.5% of all hospital admissions.¹ Although the majority of hospital transfers are medically appropriate and hold the possibility of treatment options unavailable at smaller facilities, there are also significant drawbacks. Transfers have been identified as risky times for adverse events, are often expensive, and are associated with higher mortality and longer length of stay.² There are often lapses in documentation and provider communication, and handoff practices vary widely between hospitals.³ Some transferred seriously ill patients become functionally trapped in the accepting hospital. Patients arrive too sick to undergo any meaningful disease-directed therapy and too medically tenuous to return to their home community.

When patients and families seem overly hopeful about what a transfer might provide, the request for transfer may indicate a deeper need for empathic understanding. Clinical conversations about “what can be done” typically focus on medical aspects and often miss a critical element—a complete exploration of a seriously ill patient’s prognostic awareness.

In palliative care, we use the term prognostic awareness to define patients’ dynamic understanding of their prognosis in terms of likely longevity and quality of life. Accurate prognostic awareness—where there is concordance between a patient’s worries and the medical facts as understood by their treatment team—has been associated with enhanced quality of life and mood when patients have enough emotional reserve to actively cope with the illness; for example, by reframing things in a positive light.^4,5 However, when patients are struggling to cope, talking about the prognosis is hard for patients and for their clinicians, who often accurately perceive their patient’s struggle and delay conversations, hoping that more time will help their patient better adapt and prepare to talk about it.^6,7 However, delaying conversations makes it even harder for patients and families to develop accurate prognostic awareness, leaving them unprepared when medical decisions arise.⁸ Such delays have a particularly strong impact in nononcology care, where a more unpredictable illness trajectory makes it even harder for patients to understand and prepare for what might happen.

When seriously ill patients and families consider transfer to a tertiary medical center in a situation of medical crisis, it can be a good time to pause. Palliative care specialists are trained to communicate around these difficult points of transition, but generalist clinicians already involved in the patient’s care can also sensitively explore patients’ prognostic awareness as it relates to the hospital transfer.⁹ In the Table, The phrases mentioned suggest language that is helpful in broaching such discussions, which assesses the patient’s illness understanding, hopes, and worries. Asking about patients’ hopes for their illness enables clinicians to quickly know some of their most important priorities. Giving patients the permission to be future-oriented and positive also supports them to cope in these challenging conversations. Asking patients to identify two or three hopes places their most optimistic hopes within a larger context and can lead to a discussion of the potential tradeoffs of the transfer.¹⁰ For example, the hope for a little more time from treatments available through transfer may be at odds with the hope to spend as much time as possible with family. Once the patient’s hopes are better understood, the clinician can then ask about worries. Most seriously ill patients are deeply (often silently) worried about the future, and when asked, can articulate worries about dying that can be the foundation for an honest conversation about the likely course of the hospital transfer.

With empathic assessment, several patients can speak honestly with their clinicians about their illness, including the pros and cons of hospital transfer. However, some continue to struggle, often asking clinicians to remain positive and not endorsing any worry. We describe these patients as having low prognostic awareness.¹¹ With such patients, palliative care expertise may be needed to ensure that patients and their families have the information they need to engage in informed medical decision-making. There are emerging models for distance palliative care integration, which may be helpful in these situations.¹² If these technologies became common in practice, frontline clinicians may increasingly find virtual consultation helpful in working with patients to develop more accurate prognostic awareness. There is also the possibility of clinician-to-clinician electronic consultation, or peer coaching, where the patient is not seen directly by the consultant, but expert advice is offered to the local provider.¹³ Although both these innovations offer service that currently may not be available in certain care settings, in-person consultation remains the gold standard. If a nuanced discussion cannot be had, palliative care expertise may be the reason for transfer.

Back at our hospital, I met with the patient and her partner. There were tradeoffs to be made and hard truths to be acknowledged. In this unfamiliar place, with caregivers she had met just hours before, the patient changed her resuscitation order to allow for a natural death. She passed away later that evening, surrounded by her immediate family but far away from the community that had held her throughout her illness. I reflect on the loss that can come with choosing “everything” when efforts are often better spent on ensuring comfort. Although hospital transfer is often the right answer for seriously ill patients seeking diagnostic and therapeutic options unavailable at their home medical centers, the question should also be an impetus for a nuanced assessment of patients’ prognostic awareness to prepare patients if things do not go as hoped or to enlist palliative care expertise for those struggling to cope. As there is a workforce shortage of palliative care providers, particularly in smaller and rural American hospitals, frontline hospitalist clinicians may find themselves increasingly playing a critical role in discussions where transfer is considered. By assessing patients’ prognostic awareness through thoughtful, compassionate inquiry in these moments of transition, we can support informed medical decision-making.

“I don’t think she’ll ever make it home again.”

I stood at the nursing station with two staff nurses from our medical ward. The patient, a woman with metastatic cancer and acute respiratory failure, had just arrived by a medical helicopter from an out-of-state community hospital. At the previous hospital, days had stretched into weeks, and she was not getting better. Limited documentation told us that the patient’s family sought further options at our facility. Beyond that, we knew little about the conversations that had transpired. The transfer had been arranged and off she went, arriving on our helipad in worsening respiratory distress, now needing a higher level of supplemental oxygen and teetering on the edge of endotracheal intubation. Above all, she was extremely uncomfortable from shortness of breath, and an urgent palliative care consult was placed a few hours after she touched down.

I arrived at the bedside to meet the patient and family. In these circumstances, I often feel that a palliative care consult is not the miracle that patients seek, but the grim consolation prize behind door two of a tragic and exhausting game show of a hospital transfer. I read the family’s dismayed facial expressions as they gazed at my badge reading “Palliative Care” and imagined that they would have preferred a different answer to their question that led them here: “Is this all that can be done?”

The hope of patients and families is a precious thing. As a palliative care physician, I recognize that my role is never to take away hope but rather reframe the wish for recovery into the realm of the achievable. Some people can pivot when the hospital transfer happens. They feel that they have “done all they could” and searched the earth for the reversal of their medical circumstances. I empathize with the wish to try everything and respect the motivation that lies behind it. I also see the cost of chasing hope.

In 2017, 1.5 million patients were transferred, comprising 3.5% of all hospital admissions.¹ Although the majority of hospital transfers are medically appropriate and hold the possibility of treatment options unavailable at smaller facilities, there are also significant drawbacks. Transfers have been identified as risky times for adverse events, are often expensive, and are associated with higher mortality and longer length of stay.² There are often lapses in documentation and provider communication, and handoff practices vary widely between hospitals.³ Some transferred seriously ill patients become functionally trapped in the accepting hospital. Patients arrive too sick to undergo any meaningful disease-directed therapy and too medically tenuous to return to their home community.

When patients and families seem overly hopeful about what a transfer might provide, the request for transfer may indicate a deeper need for empathic understanding. Clinical conversations about “what can be done” typically focus on medical aspects and often miss a critical element—a complete exploration of a seriously ill patient’s prognostic awareness.

In palliative care, we use the term prognostic awareness to define patients’ dynamic understanding of their prognosis in terms of likely longevity and quality of life. Accurate prognostic awareness—where there is concordance between a patient’s worries and the medical facts as understood by their treatment team—has been associated with enhanced quality of life and mood when patients have enough emotional reserve to actively cope with the illness; for example, by reframing things in a positive light.^4,5 However, when patients are struggling to cope, talking about the prognosis is hard for patients and for their clinicians, who often accurately perceive their patient’s struggle and delay conversations, hoping that more time will help their patient better adapt and prepare to talk about it.^6,7 However, delaying conversations makes it even harder for patients and families to develop accurate prognostic awareness, leaving them unprepared when medical decisions arise.⁸ Such delays have a particularly strong impact in nononcology care, where a more unpredictable illness trajectory makes it even harder for patients to understand and prepare for what might happen.

When seriously ill patients and families consider transfer to a tertiary medical center in a situation of medical crisis, it can be a good time to pause. Palliative care specialists are trained to communicate around these difficult points of transition, but generalist clinicians already involved in the patient’s care can also sensitively explore patients’ prognostic awareness as it relates to the hospital transfer.⁹ In the Table, The phrases mentioned suggest language that is helpful in broaching such discussions, which assesses the patient’s illness understanding, hopes, and worries. Asking about patients’ hopes for their illness enables clinicians to quickly know some of their most important priorities. Giving patients the permission to be future-oriented and positive also supports them to cope in these challenging conversations. Asking patients to identify two or three hopes places their most optimistic hopes within a larger context and can lead to a discussion of the potential tradeoffs of the transfer.¹⁰ For example, the hope for a little more time from treatments available through transfer may be at odds with the hope to spend as much time as possible with family. Once the patient’s hopes are better understood, the clinician can then ask about worries. Most seriously ill patients are deeply (often silently) worried about the future, and when asked, can articulate worries about dying that can be the foundation for an honest conversation about the likely course of the hospital transfer.

With empathic assessment, several patients can speak honestly with their clinicians about their illness, including the pros and cons of hospital transfer. However, some continue to struggle, often asking clinicians to remain positive and not endorsing any worry. We describe these patients as having low prognostic awareness.¹¹ With such patients, palliative care expertise may be needed to ensure that patients and their families have the information they need to engage in informed medical decision-making. There are emerging models for distance palliative care integration, which may be helpful in these situations.¹² If these technologies became common in practice, frontline clinicians may increasingly find virtual consultation helpful in working with patients to develop more accurate prognostic awareness. There is also the possibility of clinician-to-clinician electronic consultation, or peer coaching, where the patient is not seen directly by the consultant, but expert advice is offered to the local provider.¹³ Although both these innovations offer service that currently may not be available in certain care settings, in-person consultation remains the gold standard. If a nuanced discussion cannot be had, palliative care expertise may be the reason for transfer.

Back at our hospital, I met with the patient and her partner. There were tradeoffs to be made and hard truths to be acknowledged. In this unfamiliar place, with caregivers she had met just hours before, the patient changed her resuscitation order to allow for a natural death. She passed away later that evening, surrounded by her immediate family but far away from the community that had held her throughout her illness. I reflect on the loss that can come with choosing “everything” when efforts are often better spent on ensuring comfort. Although hospital transfer is often the right answer for seriously ill patients seeking diagnostic and therapeutic options unavailable at their home medical centers, the question should also be an impetus for a nuanced assessment of patients’ prognostic awareness to prepare patients if things do not go as hoped or to enlist palliative care expertise for those struggling to cope. As there is a workforce shortage of palliative care providers, particularly in smaller and rural American hospitals, frontline hospitalist clinicians may find themselves increasingly playing a critical role in discussions where transfer is considered. By assessing patients’ prognostic awareness through thoughtful, compassionate inquiry in these moments of transition, we can support informed medical decision-making.

As a result of the epidemic of opioid use disorder (OUD), there has been a secondary surge in hospitalizations for infectious complications of injection drug use (IDU).^1,2 In the previous 10 years, there have been significant increases in IDU-associated human immunodeficiency virus (HIV)³ and hepatitis C virus (HCV)⁴ infection as well as increased hospitalizations from IDU-associated skin and soft tissue infections, osteomyelitis, septic arthritis, bacteremia, fungemia, and infective endocarditis in the United States.^2,5-7 Patients admitted with IDU-associated infections have long lengths of stay, high rates of leaving against medical advice (AMA), readmission, and mortality.^8-13 In a British cohort (median age 36 years), five-year mortality after an episode of IDU-associated endocarditis was 42%.¹⁴ Admissions for IDU-associated infections can be a troubling experience for both patients and providers alike.¹⁵ While management decisions of IDU-associated infectious syndromes have sometimes been based on emotion, dogma, and an often-stigmatizing approach toward people suffering from addiction,¹⁶ with a better understanding of addiction and effective treatments, as well as accumulating data in both addiction and infectious disease fields, it is an appropriate time to reevaluate the approach to treatment.

The goal of this review is to examine recent evidence and attempt to answer questions that frequently arise in the management of hospitalized patients with IDU-associated infections. The questions addressed in this review primarily stem from the discussion of Schranz and colleagues in their description of increasing hospitalizations for IDU-associated endocarditis.⁷ Additionally, questions were developed from discussions with practicing academic hospitalists. For each question, a review of the published literature was performed, with a focus on articles published between 2014 and 2019. Finally, a framework for how to approach patients with infectious complications of IDU is presented. As a comprehensive review of infectious complications of OUD would be difficult to cover in one review, this review will focus on eight questions that frequently arise in the care of inpatients.

How Should OUD Be Managed in the Hospital?

Management of an IDU-associated infection is incomplete without addressing the underlying addiction in some way. Addiction is highly undertreated among patients with IDU-associated infections, which may contribute to poor infection-related outcomes.^8,13,17 Opioid agonist therapy (buprenorphine and methadone) to prevent withdrawal should be routinely offered to all patients with OUD including those with infectious complications of OUD to facilitate appropriate medical treatment and engage patients in long-term addiction treatment. Referral to addiction treatment has been associated with improved IDU-associated endocarditis mortality,¹⁸ and initiation of medications for OUD (MOUD) can be achieved successfully in the emergency department, inpatient wards, and specifically in patients admitted with IDU-associated endocarditis.^19-21 Protocols and resources for inpatient management of withdrawal and initiation of MOUD are available along with telephone support services for providers seeking guidance on specific cases.^21,22 Inpatient addiction consult services are an important resource for the management of hospitalized patients with addiction and are associated with increased completion of antibiotics, decreased AMA discharge, and increased rates of MOUD provision among patients with IDU-associated infections.¹² However, when unavailable, initiation of opioid agonist therapy does not require an addiction specialist. Linkage to outpatient addiction care is ideal; however, opioid agonist therapy initiated in the hospital can be tapered prior to discharge if this is unavailable. Figure 1 outlines the initiation of methadone or buprenorphine for the treatment of both withdrawal and OUD in the inpatient setting.^20,21

Who Can Prescribe Medications for Treatment of OUD in Hospitalized Patients?

Although buprenorphine prescribing in the outpatient setting requires certification, inpatient physicians are exempt from these requirements and can prescribe buprenorphine or methadone in the hospital setting.²⁰ In the outpatient setting, buprenorphine prescription is restricted to providers with a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver, also known as an “X-waiver”. X-waiver training is eight hours, and free web-based training is available.²³ At the time of discharge, non-X-waivered physicians can prescribe up to 72 hours of buprenorphine as a bridge to follow-up with outpatient addiction services.²⁴ In the outpatient setting, methadone can only be obtained through approved methadone maintenance programs (MMP); however, many such programs are often willing to do intakes on the same day or next day following hospital discharge. For patients already taking methadone at the time of admission, their MMP should be contacted during business hours to confirm the patient-reported dose. If the MMP cannot be contacted on the day of admission, the starting dose of methadone indicated in Figure 1 is sufficient to prevent precipitation of acute withdrawal. The decision of whether to initiate buprenorphine, methadone, or extended-release naltrexone for the treatment of OUD is nuanced and includes consideration of local resources, patient preference, comorbidities, and hospital policy. Successful initiation of inpatient MOUD requires knowledge of local addiction treatment resources. Social workers and case managers can be used to identify outpatient providers willing to continue MOUD. If no plans or desire for outpatient addiction treatment exist, methadone and buprenorphine can be tapered during the last week of hospitalization.

Is It Safe to Place a Peripherally Inserted Central Catheter in a Patient Who Injects Drugs?

Many practitioners believe that IDU is an absolute contraindication to the use of peripherally inserted central catheters (PICC) for administration of antimicrobials; however, evidence of harm is lacking.^25,26 In a review of outpatient parenteral antimicrobial therapy (OPAT) in patients with IDU, there were low overall rates of line-related adverse events and no significant difference in complications between IDU and non-IDU patients receiving OPAT.²⁷ As with any medical intervention, risks and benefits must be balanced. Aside from patient comfort, a PICC allows patients to receive intravenous (IV) antimicrobials in a nonhospital setting, which may be more therapeutic for their addiction. Peripheral venous access can be difficult in patients with IDU who often have atrophic superficial veins. While often cited as a reason to avoid PICCs, there is no empirical evidence that PICC placement leads to increased drug use among people with OUD. Similarly, depriving a patient of a PICC does not prevent drug use, but it may prevent patients from completing infection treatment in a more acceptable setting. The most serious concern with a PICC is that if a patient injects drugs, transient bacteremia/fungemia could seed this prosthetic material and lead to worsening infection. Providers should employ a risk-based approach to the use of PICCs considering patient preferences, addiction disease activity, and stability of home environment weighed against the potential risks of prolonged hospitalization, clinic-based antibiotic infusions through a peripheral IV, or possibly suboptimal oral antimicrobial treatment.

What Is the Best Location for Patients to Receive Antibiotics for Their IDU-Associated Infection?

Antimicrobial treatment for severe IDU-associated infections such as endocarditis and osteomyelitis has traditionally included four- to six-week hospital admissions to complete the entirety of IV therapy. This practice has recently been called into question. Extended hospitalization for patients with IDU-associated infections—often not receiving evidence-based treatment for their addiction—can be a harrowing experience and may be antitherapeutic.^15,28 Disposition decisions for patients with IDU-associated infections should involve risk stratification to assess addiction disease activity and take into account inpatient addiction treatment resources and patient preference, culture/availability of skilled nursing facilities (SNFs), and safety of the home environment.²⁹ Some emerging models of care take advantage of long hospitalizations by engaging patients with comprehensive addiction services including substance use group meetings, counseling, and social resources. Another model using OPAT with intensive outpatient follow-up for both addiction and infection treatment showed similar infection outcomes, lower cost, and improved patient satisfaction compared with in-hospital treatment.³⁰ When available, medical respite programs and OPAT-friendly residential addiction programs have shown success and financial savings as well.^31,32 Still, many patients would prefer home OPAT, and there is evidence that home OPAT is no less successful than OPAT provided in an SNF.³³ Despite this mounting evidence, there remains systemic stigmatization of people with OUD and inequity as many SNFs, and home infusion companies will not provide either MOUD or services to patients with OUD.³⁴

Can Oral Antibiotics Be Used to Treat Severe Infections Due to IDU?

A general principle of infectious diseases is that oral antibiotics should be used whenever possible when presumed to be noninferior to IV alternatives. Accumulating evidence in the infectious disease literature suggests that there is a role for increasing the use of oral antibiotics for serious infections. Two recent pivotal randomized trials have questioned the dogma surrounding the use of IV antibiotics for the management of orthopedic infections and endocarditis. However, these studies included few patients with infections due to IDU.^35,36 One study of oral antibiotics specifically in patients with IDU-associated infection showed that an all-oral regimen for the management of IDU-associated right-sided endocarditis was effective and well-tolerated.³⁷ While oral antibiotics decrease the need for long-term hospitalization and OPAT, similar or even more intensive follow-up of these patients is required to ensure an appropriate response to treatment. Oral antibiotics should not be used to simply expedite discharge but instead should be done with careful planning and close follow-up.

When using oral antibiotics for severe infections, attempts should be made to use agents with the highest oral bioavailability, tolerability, and affordability. Antimicrobials with near-complete oral bioavailability include fluoroquinolones, triazoles, oxazolidinones (linezolid and tedizolid), clindamycin, trimethoprim-sulfamethoxazole, doxycycline, metronidazole, cefadroxil, and other select oral cephalosporins. One approach is to complete a short course of inpatient induction therapy with IV antimicrobials followed by consolidation therapy with oral antibiotics. In a study of uncomplicated Staphylococcus aureus bacteremia, a similar approach with initial IV therapy and oral linezolid follow-up treatment was noninferior to all-IV treatment.³⁸ Decisions about the early transition to oral antimicrobials should be made in conjunction with infectious disease specialists where available.

What Is the Role of Long Half-Life IV Antibiotics for Treating IDU-Associated Infections?

Dalbavancin and oritavancin are extremely long half-life IV glycopeptide antibiotics for gram-positive bacterial infections that require, at most, weekly administration. These agents allow IV-equivalent antibiotics to be delivered without the need for daily infusions or PICCs. Currently, both are approved by the United States Food and Drug Administration only for skin and skin structure infections, but there are increasing reports of successful use in more severe infections including osteomyelitis, bacteremia, and endocarditis.^39-42Two studies of dalbavancin in vulnerable populations, including primarily IDU-associated infections, found a somewhat unimpressive 56% and 71% clinical response and success rate, respectively. Without comparison groups, one cannot conclude that patients would have done any better with traditional OPAT or long-term hospitalization.^24,43 Overall, the role of these antimicrobials in IDU-associated infections remains unclear.

Is Surgical Placement of Prosthetic Material Safe in Patients With IDU-Associated Infections?

When surgery for an IDU-associated infection has the potential to be acutely lifesaving, it should be offered. There is a concern that surgical interventions that require placement of prosthetic material might serve as a nidus of future infection in the setting of ongoing IDU. Although treatments for many substance use disorders are effective—particularly medications to treat OUD—addiction is a relapsing chronic condition, and at least, some future drug use is an expected part of the course. Research comparing outcomes after valve surgery between IDU and non-IDU-associated endocarditis patients shows no difference in short-term outcomes,⁴⁴ but longer-term data show increased mortality between 60 and 180 days postoperatively, higher rates of valve-related complications, and up to 53% reinfection rates.^10,45,46 These studies are limited by the lack of a nonsurgically treated control group and little information on the rate of addiction treatment, which may be protective against these negative outcomes. In contrast, another study found that surgery was the strongest predictor of survival among patients with IDU-associated endocarditis after a median of 3.6 years follow-up.¹⁸ Another consideration is that patients with IDU-associated infection tend to be younger, and despite advancements, many modern prostheses have a finite lifespan. When multiple surgical options exist, a procedure that avoids prosthetic material is preferred. For example, in a meta-analysis of studies of tricuspid valve endocarditis (41% IDU-associated), there was no mortality difference between valve repair compared with valve replacement, but there was a significantly lower rate of recurrent endocarditis among those with a repair only.⁴⁷ Decisions about surgery must be individualized and consider a patient’s engagement in OUD treatment, social support, prior success with treatment, treatment and relapse prevention resources, and access to harm reduction interventions such as sterile syringes.

What Are Appropriate Harm Reduction Interventions for Patients Hospitalized With Infections Due to IDU?

A prolonged admission for IDU-associated infections is an opportunity to provide patients with education, health maintenance services, and secondary prevention interventions for both infection and overdose. Based on epidemiologic risk, patients should be screened for HIV, HCV, hepatitis B, syphilis, gonorrhea, and chlamydia. Patients should be vaccinated against hepatitis A, influenza, and tetanus (and pneumococcus if indicated), if unvaccinated or without vaccination records. Patients positive for HIV should be evaluated by an infectious disease specialist with consideration of the rapid initiation of antiretroviral therapy. Patients positive for HCV or hepatitis B should be referred for treatment in the outpatient setting. Patients without HIV should be educated about HIV preexposure prophylaxis and referred to outpatient services.

Harm reduction involves meeting patients where they are and providing services they are willing to accept to improve their health or prevent negative outcomes. One important strategy for reducing harm involves maintaining patients in care for their addiction and infection as much as possible, ideally avoiding AMA discharge. In one cohort of patients admitted with IDU-associated infections and OUD, 49% of those without an addiction medicine consult left AMA.¹² If a patient plans to leave AMA, all efforts should be made to provide them with oral antibiotics that might be effective, even if suboptimal, for their infection. Hospitalists should consider documenting an oral “antibiotic contingency plan” that can be rapidly enacted if a patient is imminently leaving the hospital. They should be provided with outpatient follow-up appointments with infectious disease or primary care. All patients with IDU-associated infections should be discharged with naloxone, overdose prevention education, and community resources for addiction treatment and syringe exchange programs.

Management of IDU-associated infection should be organized around a multidisciplinary framework with careful attention to infection treatment, OUD treatment, and harm reduction interventions (Figure 2). The first step in managing IDU-associated infections is recognizing addiction in the acute care setting. Substance use disorders, including OUD, are often unrecognized in patients presenting with IDU-associated infections.⁴⁸ The Rapid Opioid Dependence Screen, a validated screening tool for OUD, can be quickly administered for all patients who present with endocarditis, bacteremia, skin and soft tissue infections, vertebral and epidural infections, and HIV and HCV infections.⁴⁹ In addition to directly questioning patients about substance use, Figure 2 lists epidemiologic, physical exam, and laboratory findings that might suggest to the provider that OUD may be present.

The approach to infection management is similar to non-IDU-associated infections, including identifying a source, evaluating for complications and need for source control procedures, and administering antimicrobials. Management of the substance use disorder includes treatment of acute withdrawal, control of pain, initiation of MOUD when appropriate, and linkage to outpatient addiction treatment services in addition to harm reduction interventions.

Hospital admissions for infectious complications of IDU are increasingly common and are difficult experiences for both patients and providers. However, these hospitalizations serve as a “reachable moment” to engage patients with OUD into medical care and initiate holistic treatment of their infection and underlying substance use disorder.^28,50Significant systems-level barriers remain to comprehensive management of the overlapping infectious disease and opioid epidemics. Nevertheless, it is critical to acknowledge that the infections are a symptom of an underlying substance use disorder, a key first step in improving the care of patients hospitalized with infectious complications of OUD. Just like the many acute exacerbations of chronic illness managed by hospitalists, treatment of these episodes of “acute decompensated addiction” require evidence-based management of the underlying disease and its infectious consequences using a harm reduction approach.

Disclosures

The authors both report no conflict of interest.

As a result of the epidemic of opioid use disorder (OUD), there has been a secondary surge in hospitalizations for infectious complications of injection drug use (IDU).^1,2 In the previous 10 years, there have been significant increases in IDU-associated human immunodeficiency virus (HIV)³ and hepatitis C virus (HCV)⁴ infection as well as increased hospitalizations from IDU-associated skin and soft tissue infections, osteomyelitis, septic arthritis, bacteremia, fungemia, and infective endocarditis in the United States.^2,5-7 Patients admitted with IDU-associated infections have long lengths of stay, high rates of leaving against medical advice (AMA), readmission, and mortality.^8-13 In a British cohort (median age 36 years), five-year mortality after an episode of IDU-associated endocarditis was 42%.¹⁴ Admissions for IDU-associated infections can be a troubling experience for both patients and providers alike.¹⁵ While management decisions of IDU-associated infectious syndromes have sometimes been based on emotion, dogma, and an often-stigmatizing approach toward people suffering from addiction,¹⁶ with a better understanding of addiction and effective treatments, as well as accumulating data in both addiction and infectious disease fields, it is an appropriate time to reevaluate the approach to treatment.

The goal of this review is to examine recent evidence and attempt to answer questions that frequently arise in the management of hospitalized patients with IDU-associated infections. The questions addressed in this review primarily stem from the discussion of Schranz and colleagues in their description of increasing hospitalizations for IDU-associated endocarditis.⁷ Additionally, questions were developed from discussions with practicing academic hospitalists. For each question, a review of the published literature was performed, with a focus on articles published between 2014 and 2019. Finally, a framework for how to approach patients with infectious complications of IDU is presented. As a comprehensive review of infectious complications of OUD would be difficult to cover in one review, this review will focus on eight questions that frequently arise in the care of inpatients.

How Should OUD Be Managed in the Hospital?

Management of an IDU-associated infection is incomplete without addressing the underlying addiction in some way. Addiction is highly undertreated among patients with IDU-associated infections, which may contribute to poor infection-related outcomes.^8,13,17 Opioid agonist therapy (buprenorphine and methadone) to prevent withdrawal should be routinely offered to all patients with OUD including those with infectious complications of OUD to facilitate appropriate medical treatment and engage patients in long-term addiction treatment. Referral to addiction treatment has been associated with improved IDU-associated endocarditis mortality,¹⁸ and initiation of medications for OUD (MOUD) can be achieved successfully in the emergency department, inpatient wards, and specifically in patients admitted with IDU-associated endocarditis.^19-21 Protocols and resources for inpatient management of withdrawal and initiation of MOUD are available along with telephone support services for providers seeking guidance on specific cases.^21,22 Inpatient addiction consult services are an important resource for the management of hospitalized patients with addiction and are associated with increased completion of antibiotics, decreased AMA discharge, and increased rates of MOUD provision among patients with IDU-associated infections.¹² However, when unavailable, initiation of opioid agonist therapy does not require an addiction specialist. Linkage to outpatient addiction care is ideal; however, opioid agonist therapy initiated in the hospital can be tapered prior to discharge if this is unavailable. Figure 1 outlines the initiation of methadone or buprenorphine for the treatment of both withdrawal and OUD in the inpatient setting.^20,21

Who Can Prescribe Medications for Treatment of OUD in Hospitalized Patients?

Although buprenorphine prescribing in the outpatient setting requires certification, inpatient physicians are exempt from these requirements and can prescribe buprenorphine or methadone in the hospital setting.²⁰ In the outpatient setting, buprenorphine prescription is restricted to providers with a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver, also known as an “X-waiver”. X-waiver training is eight hours, and free web-based training is available.²³ At the time of discharge, non-X-waivered physicians can prescribe up to 72 hours of buprenorphine as a bridge to follow-up with outpatient addiction services.²⁴ In the outpatient setting, methadone can only be obtained through approved methadone maintenance programs (MMP); however, many such programs are often willing to do intakes on the same day or next day following hospital discharge. For patients already taking methadone at the time of admission, their MMP should be contacted during business hours to confirm the patient-reported dose. If the MMP cannot be contacted on the day of admission, the starting dose of methadone indicated in Figure 1 is sufficient to prevent precipitation of acute withdrawal. The decision of whether to initiate buprenorphine, methadone, or extended-release naltrexone for the treatment of OUD is nuanced and includes consideration of local resources, patient preference, comorbidities, and hospital policy. Successful initiation of inpatient MOUD requires knowledge of local addiction treatment resources. Social workers and case managers can be used to identify outpatient providers willing to continue MOUD. If no plans or desire for outpatient addiction treatment exist, methadone and buprenorphine can be tapered during the last week of hospitalization.

Is It Safe to Place a Peripherally Inserted Central Catheter in a Patient Who Injects Drugs?

Many practitioners believe that IDU is an absolute contraindication to the use of peripherally inserted central catheters (PICC) for administration of antimicrobials; however, evidence of harm is lacking.^25,26 In a review of outpatient parenteral antimicrobial therapy (OPAT) in patients with IDU, there were low overall rates of line-related adverse events and no significant difference in complications between IDU and non-IDU patients receiving OPAT.²⁷ As with any medical intervention, risks and benefits must be balanced. Aside from patient comfort, a PICC allows patients to receive intravenous (IV) antimicrobials in a nonhospital setting, which may be more therapeutic for their addiction. Peripheral venous access can be difficult in patients with IDU who often have atrophic superficial veins. While often cited as a reason to avoid PICCs, there is no empirical evidence that PICC placement leads to increased drug use among people with OUD. Similarly, depriving a patient of a PICC does not prevent drug use, but it may prevent patients from completing infection treatment in a more acceptable setting. The most serious concern with a PICC is that if a patient injects drugs, transient bacteremia/fungemia could seed this prosthetic material and lead to worsening infection. Providers should employ a risk-based approach to the use of PICCs considering patient preferences, addiction disease activity, and stability of home environment weighed against the potential risks of prolonged hospitalization, clinic-based antibiotic infusions through a peripheral IV, or possibly suboptimal oral antimicrobial treatment.

What Is the Best Location for Patients to Receive Antibiotics for Their IDU-Associated Infection?

Antimicrobial treatment for severe IDU-associated infections such as endocarditis and osteomyelitis has traditionally included four- to six-week hospital admissions to complete the entirety of IV therapy. This practice has recently been called into question. Extended hospitalization for patients with IDU-associated infections—often not receiving evidence-based treatment for their addiction—can be a harrowing experience and may be antitherapeutic.^15,28 Disposition decisions for patients with IDU-associated infections should involve risk stratification to assess addiction disease activity and take into account inpatient addiction treatment resources and patient preference, culture/availability of skilled nursing facilities (SNFs), and safety of the home environment.²⁹ Some emerging models of care take advantage of long hospitalizations by engaging patients with comprehensive addiction services including substance use group meetings, counseling, and social resources. Another model using OPAT with intensive outpatient follow-up for both addiction and infection treatment showed similar infection outcomes, lower cost, and improved patient satisfaction compared with in-hospital treatment.³⁰ When available, medical respite programs and OPAT-friendly residential addiction programs have shown success and financial savings as well.^31,32 Still, many patients would prefer home OPAT, and there is evidence that home OPAT is no less successful than OPAT provided in an SNF.³³ Despite this mounting evidence, there remains systemic stigmatization of people with OUD and inequity as many SNFs, and home infusion companies will not provide either MOUD or services to patients with OUD.³⁴

Can Oral Antibiotics Be Used to Treat Severe Infections Due to IDU?

A general principle of infectious diseases is that oral antibiotics should be used whenever possible when presumed to be noninferior to IV alternatives. Accumulating evidence in the infectious disease literature suggests that there is a role for increasing the use of oral antibiotics for serious infections. Two recent pivotal randomized trials have questioned the dogma surrounding the use of IV antibiotics for the management of orthopedic infections and endocarditis. However, these studies included few patients with infections due to IDU.^35,36 One study of oral antibiotics specifically in patients with IDU-associated infection showed that an all-oral regimen for the management of IDU-associated right-sided endocarditis was effective and well-tolerated.³⁷ While oral antibiotics decrease the need for long-term hospitalization and OPAT, similar or even more intensive follow-up of these patients is required to ensure an appropriate response to treatment. Oral antibiotics should not be used to simply expedite discharge but instead should be done with careful planning and close follow-up.

When using oral antibiotics for severe infections, attempts should be made to use agents with the highest oral bioavailability, tolerability, and affordability. Antimicrobials with near-complete oral bioavailability include fluoroquinolones, triazoles, oxazolidinones (linezolid and tedizolid), clindamycin, trimethoprim-sulfamethoxazole, doxycycline, metronidazole, cefadroxil, and other select oral cephalosporins. One approach is to complete a short course of inpatient induction therapy with IV antimicrobials followed by consolidation therapy with oral antibiotics. In a study of uncomplicated Staphylococcus aureus bacteremia, a similar approach with initial IV therapy and oral linezolid follow-up treatment was noninferior to all-IV treatment.³⁸ Decisions about the early transition to oral antimicrobials should be made in conjunction with infectious disease specialists where available.

What Is the Role of Long Half-Life IV Antibiotics for Treating IDU-Associated Infections?

Dalbavancin and oritavancin are extremely long half-life IV glycopeptide antibiotics for gram-positive bacterial infections that require, at most, weekly administration. These agents allow IV-equivalent antibiotics to be delivered without the need for daily infusions or PICCs. Currently, both are approved by the United States Food and Drug Administration only for skin and skin structure infections, but there are increasing reports of successful use in more severe infections including osteomyelitis, bacteremia, and endocarditis.^39-42Two studies of dalbavancin in vulnerable populations, including primarily IDU-associated infections, found a somewhat unimpressive 56% and 71% clinical response and success rate, respectively. Without comparison groups, one cannot conclude that patients would have done any better with traditional OPAT or long-term hospitalization.^24,43 Overall, the role of these antimicrobials in IDU-associated infections remains unclear.

Is Surgical Placement of Prosthetic Material Safe in Patients With IDU-Associated Infections?

When surgery for an IDU-associated infection has the potential to be acutely lifesaving, it should be offered. There is a concern that surgical interventions that require placement of prosthetic material might serve as a nidus of future infection in the setting of ongoing IDU. Although treatments for many substance use disorders are effective—particularly medications to treat OUD—addiction is a relapsing chronic condition, and at least, some future drug use is an expected part of the course. Research comparing outcomes after valve surgery between IDU and non-IDU-associated endocarditis patients shows no difference in short-term outcomes,⁴⁴ but longer-term data show increased mortality between 60 and 180 days postoperatively, higher rates of valve-related complications, and up to 53% reinfection rates.^10,45,46 These studies are limited by the lack of a nonsurgically treated control group and little information on the rate of addiction treatment, which may be protective against these negative outcomes. In contrast, another study found that surgery was the strongest predictor of survival among patients with IDU-associated endocarditis after a median of 3.6 years follow-up.¹⁸ Another consideration is that patients with IDU-associated infection tend to be younger, and despite advancements, many modern prostheses have a finite lifespan. When multiple surgical options exist, a procedure that avoids prosthetic material is preferred. For example, in a meta-analysis of studies of tricuspid valve endocarditis (41% IDU-associated), there was no mortality difference between valve repair compared with valve replacement, but there was a significantly lower rate of recurrent endocarditis among those with a repair only.⁴⁷ Decisions about surgery must be individualized and consider a patient’s engagement in OUD treatment, social support, prior success with treatment, treatment and relapse prevention resources, and access to harm reduction interventions such as sterile syringes.

What Are Appropriate Harm Reduction Interventions for Patients Hospitalized With Infections Due to IDU?

A prolonged admission for IDU-associated infections is an opportunity to provide patients with education, health maintenance services, and secondary prevention interventions for both infection and overdose. Based on epidemiologic risk, patients should be screened for HIV, HCV, hepatitis B, syphilis, gonorrhea, and chlamydia. Patients should be vaccinated against hepatitis A, influenza, and tetanus (and pneumococcus if indicated), if unvaccinated or without vaccination records. Patients positive for HIV should be evaluated by an infectious disease specialist with consideration of the rapid initiation of antiretroviral therapy. Patients positive for HCV or hepatitis B should be referred for treatment in the outpatient setting. Patients without HIV should be educated about HIV preexposure prophylaxis and referred to outpatient services.

Harm reduction involves meeting patients where they are and providing services they are willing to accept to improve their health or prevent negative outcomes. One important strategy for reducing harm involves maintaining patients in care for their addiction and infection as much as possible, ideally avoiding AMA discharge. In one cohort of patients admitted with IDU-associated infections and OUD, 49% of those without an addiction medicine consult left AMA.¹² If a patient plans to leave AMA, all efforts should be made to provide them with oral antibiotics that might be effective, even if suboptimal, for their infection. Hospitalists should consider documenting an oral “antibiotic contingency plan” that can be rapidly enacted if a patient is imminently leaving the hospital. They should be provided with outpatient follow-up appointments with infectious disease or primary care. All patients with IDU-associated infections should be discharged with naloxone, overdose prevention education, and community resources for addiction treatment and syringe exchange programs.

Management of IDU-associated infection should be organized around a multidisciplinary framework with careful attention to infection treatment, OUD treatment, and harm reduction interventions (Figure 2). The first step in managing IDU-associated infections is recognizing addiction in the acute care setting. Substance use disorders, including OUD, are often unrecognized in patients presenting with IDU-associated infections.⁴⁸ The Rapid Opioid Dependence Screen, a validated screening tool for OUD, can be quickly administered for all patients who present with endocarditis, bacteremia, skin and soft tissue infections, vertebral and epidural infections, and HIV and HCV infections.⁴⁹ In addition to directly questioning patients about substance use, Figure 2 lists epidemiologic, physical exam, and laboratory findings that might suggest to the provider that OUD may be present.

The approach to infection management is similar to non-IDU-associated infections, including identifying a source, evaluating for complications and need for source control procedures, and administering antimicrobials. Management of the substance use disorder includes treatment of acute withdrawal, control of pain, initiation of MOUD when appropriate, and linkage to outpatient addiction treatment services in addition to harm reduction interventions.

Hospital admissions for infectious complications of IDU are increasingly common and are difficult experiences for both patients and providers. However, these hospitalizations serve as a “reachable moment” to engage patients with OUD into medical care and initiate holistic treatment of their infection and underlying substance use disorder.^28,50Significant systems-level barriers remain to comprehensive management of the overlapping infectious disease and opioid epidemics. Nevertheless, it is critical to acknowledge that the infections are a symptom of an underlying substance use disorder, a key first step in improving the care of patients hospitalized with infectious complications of OUD. Just like the many acute exacerbations of chronic illness managed by hospitalists, treatment of these episodes of “acute decompensated addiction” require evidence-based management of the underlying disease and its infectious consequences using a harm reduction approach.

Disclosures

The authors both report no conflict of interest.

As a result of the epidemic of opioid use disorder (OUD), there has been a secondary surge in hospitalizations for infectious complications of injection drug use (IDU).^1,2 In the previous 10 years, there have been significant increases in IDU-associated human immunodeficiency virus (HIV)³ and hepatitis C virus (HCV)⁴ infection as well as increased hospitalizations from IDU-associated skin and soft tissue infections, osteomyelitis, septic arthritis, bacteremia, fungemia, and infective endocarditis in the United States.^2,5-7 Patients admitted with IDU-associated infections have long lengths of stay, high rates of leaving against medical advice (AMA), readmission, and mortality.^8-13 In a British cohort (median age 36 years), five-year mortality after an episode of IDU-associated endocarditis was 42%.¹⁴ Admissions for IDU-associated infections can be a troubling experience for both patients and providers alike.¹⁵ While management decisions of IDU-associated infectious syndromes have sometimes been based on emotion, dogma, and an often-stigmatizing approach toward people suffering from addiction,¹⁶ with a better understanding of addiction and effective treatments, as well as accumulating data in both addiction and infectious disease fields, it is an appropriate time to reevaluate the approach to treatment.

The goal of this review is to examine recent evidence and attempt to answer questions that frequently arise in the management of hospitalized patients with IDU-associated infections. The questions addressed in this review primarily stem from the discussion of Schranz and colleagues in their description of increasing hospitalizations for IDU-associated endocarditis.⁷ Additionally, questions were developed from discussions with practicing academic hospitalists. For each question, a review of the published literature was performed, with a focus on articles published between 2014 and 2019. Finally, a framework for how to approach patients with infectious complications of IDU is presented. As a comprehensive review of infectious complications of OUD would be difficult to cover in one review, this review will focus on eight questions that frequently arise in the care of inpatients.

How Should OUD Be Managed in the Hospital?

Management of an IDU-associated infection is incomplete without addressing the underlying addiction in some way. Addiction is highly undertreated among patients with IDU-associated infections, which may contribute to poor infection-related outcomes.^8,13,17 Opioid agonist therapy (buprenorphine and methadone) to prevent withdrawal should be routinely offered to all patients with OUD including those with infectious complications of OUD to facilitate appropriate medical treatment and engage patients in long-term addiction treatment. Referral to addiction treatment has been associated with improved IDU-associated endocarditis mortality,¹⁸ and initiation of medications for OUD (MOUD) can be achieved successfully in the emergency department, inpatient wards, and specifically in patients admitted with IDU-associated endocarditis.^19-21 Protocols and resources for inpatient management of withdrawal and initiation of MOUD are available along with telephone support services for providers seeking guidance on specific cases.^21,22 Inpatient addiction consult services are an important resource for the management of hospitalized patients with addiction and are associated with increased completion of antibiotics, decreased AMA discharge, and increased rates of MOUD provision among patients with IDU-associated infections.¹² However, when unavailable, initiation of opioid agonist therapy does not require an addiction specialist. Linkage to outpatient addiction care is ideal; however, opioid agonist therapy initiated in the hospital can be tapered prior to discharge if this is unavailable. Figure 1 outlines the initiation of methadone or buprenorphine for the treatment of both withdrawal and OUD in the inpatient setting.^20,21

Who Can Prescribe Medications for Treatment of OUD in Hospitalized Patients?

Although buprenorphine prescribing in the outpatient setting requires certification, inpatient physicians are exempt from these requirements and can prescribe buprenorphine or methadone in the hospital setting.²⁰ In the outpatient setting, buprenorphine prescription is restricted to providers with a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver, also known as an “X-waiver”. X-waiver training is eight hours, and free web-based training is available.²³ At the time of discharge, non-X-waivered physicians can prescribe up to 72 hours of buprenorphine as a bridge to follow-up with outpatient addiction services.²⁴ In the outpatient setting, methadone can only be obtained through approved methadone maintenance programs (MMP); however, many such programs are often willing to do intakes on the same day or next day following hospital discharge. For patients already taking methadone at the time of admission, their MMP should be contacted during business hours to confirm the patient-reported dose. If the MMP cannot be contacted on the day of admission, the starting dose of methadone indicated in Figure 1 is sufficient to prevent precipitation of acute withdrawal. The decision of whether to initiate buprenorphine, methadone, or extended-release naltrexone for the treatment of OUD is nuanced and includes consideration of local resources, patient preference, comorbidities, and hospital policy. Successful initiation of inpatient MOUD requires knowledge of local addiction treatment resources. Social workers and case managers can be used to identify outpatient providers willing to continue MOUD. If no plans or desire for outpatient addiction treatment exist, methadone and buprenorphine can be tapered during the last week of hospitalization.

Is It Safe to Place a Peripherally Inserted Central Catheter in a Patient Who Injects Drugs?

Many practitioners believe that IDU is an absolute contraindication to the use of peripherally inserted central catheters (PICC) for administration of antimicrobials; however, evidence of harm is lacking.^25,26 In a review of outpatient parenteral antimicrobial therapy (OPAT) in patients with IDU, there were low overall rates of line-related adverse events and no significant difference in complications between IDU and non-IDU patients receiving OPAT.²⁷ As with any medical intervention, risks and benefits must be balanced. Aside from patient comfort, a PICC allows patients to receive intravenous (IV) antimicrobials in a nonhospital setting, which may be more therapeutic for their addiction. Peripheral venous access can be difficult in patients with IDU who often have atrophic superficial veins. While often cited as a reason to avoid PICCs, there is no empirical evidence that PICC placement leads to increased drug use among people with OUD. Similarly, depriving a patient of a PICC does not prevent drug use, but it may prevent patients from completing infection treatment in a more acceptable setting. The most serious concern with a PICC is that if a patient injects drugs, transient bacteremia/fungemia could seed this prosthetic material and lead to worsening infection. Providers should employ a risk-based approach to the use of PICCs considering patient preferences, addiction disease activity, and stability of home environment weighed against the potential risks of prolonged hospitalization, clinic-based antibiotic infusions through a peripheral IV, or possibly suboptimal oral antimicrobial treatment.

What Is the Best Location for Patients to Receive Antibiotics for Their IDU-Associated Infection?

Antimicrobial treatment for severe IDU-associated infections such as endocarditis and osteomyelitis has traditionally included four- to six-week hospital admissions to complete the entirety of IV therapy. This practice has recently been called into question. Extended hospitalization for patients with IDU-associated infections—often not receiving evidence-based treatment for their addiction—can be a harrowing experience and may be antitherapeutic.^15,28 Disposition decisions for patients with IDU-associated infections should involve risk stratification to assess addiction disease activity and take into account inpatient addiction treatment resources and patient preference, culture/availability of skilled nursing facilities (SNFs), and safety of the home environment.²⁹ Some emerging models of care take advantage of long hospitalizations by engaging patients with comprehensive addiction services including substance use group meetings, counseling, and social resources. Another model using OPAT with intensive outpatient follow-up for both addiction and infection treatment showed similar infection outcomes, lower cost, and improved patient satisfaction compared with in-hospital treatment.³⁰ When available, medical respite programs and OPAT-friendly residential addiction programs have shown success and financial savings as well.^31,32 Still, many patients would prefer home OPAT, and there is evidence that home OPAT is no less successful than OPAT provided in an SNF.³³ Despite this mounting evidence, there remains systemic stigmatization of people with OUD and inequity as many SNFs, and home infusion companies will not provide either MOUD or services to patients with OUD.³⁴

Can Oral Antibiotics Be Used to Treat Severe Infections Due to IDU?

A general principle of infectious diseases is that oral antibiotics should be used whenever possible when presumed to be noninferior to IV alternatives. Accumulating evidence in the infectious disease literature suggests that there is a role for increasing the use of oral antibiotics for serious infections. Two recent pivotal randomized trials have questioned the dogma surrounding the use of IV antibiotics for the management of orthopedic infections and endocarditis. However, these studies included few patients with infections due to IDU.^35,36 One study of oral antibiotics specifically in patients with IDU-associated infection showed that an all-oral regimen for the management of IDU-associated right-sided endocarditis was effective and well-tolerated.³⁷ While oral antibiotics decrease the need for long-term hospitalization and OPAT, similar or even more intensive follow-up of these patients is required to ensure an appropriate response to treatment. Oral antibiotics should not be used to simply expedite discharge but instead should be done with careful planning and close follow-up.

When using oral antibiotics for severe infections, attempts should be made to use agents with the highest oral bioavailability, tolerability, and affordability. Antimicrobials with near-complete oral bioavailability include fluoroquinolones, triazoles, oxazolidinones (linezolid and tedizolid), clindamycin, trimethoprim-sulfamethoxazole, doxycycline, metronidazole, cefadroxil, and other select oral cephalosporins. One approach is to complete a short course of inpatient induction therapy with IV antimicrobials followed by consolidation therapy with oral antibiotics. In a study of uncomplicated Staphylococcus aureus bacteremia, a similar approach with initial IV therapy and oral linezolid follow-up treatment was noninferior to all-IV treatment.³⁸ Decisions about the early transition to oral antimicrobials should be made in conjunction with infectious disease specialists where available.

What Is the Role of Long Half-Life IV Antibiotics for Treating IDU-Associated Infections?

Dalbavancin and oritavancin are extremely long half-life IV glycopeptide antibiotics for gram-positive bacterial infections that require, at most, weekly administration. These agents allow IV-equivalent antibiotics to be delivered without the need for daily infusions or PICCs. Currently, both are approved by the United States Food and Drug Administration only for skin and skin structure infections, but there are increasing reports of successful use in more severe infections including osteomyelitis, bacteremia, and endocarditis.^39-42Two studies of dalbavancin in vulnerable populations, including primarily IDU-associated infections, found a somewhat unimpressive 56% and 71% clinical response and success rate, respectively. Without comparison groups, one cannot conclude that patients would have done any better with traditional OPAT or long-term hospitalization.^24,43 Overall, the role of these antimicrobials in IDU-associated infections remains unclear.

Is Surgical Placement of Prosthetic Material Safe in Patients With IDU-Associated Infections?

When surgery for an IDU-associated infection has the potential to be acutely lifesaving, it should be offered. There is a concern that surgical interventions that require placement of prosthetic material might serve as a nidus of future infection in the setting of ongoing IDU. Although treatments for many substance use disorders are effective—particularly medications to treat OUD—addiction is a relapsing chronic condition, and at least, some future drug use is an expected part of the course. Research comparing outcomes after valve surgery between IDU and non-IDU-associated endocarditis patients shows no difference in short-term outcomes,⁴⁴ but longer-term data show increased mortality between 60 and 180 days postoperatively, higher rates of valve-related complications, and up to 53% reinfection rates.^10,45,46 These studies are limited by the lack of a nonsurgically treated control group and little information on the rate of addiction treatment, which may be protective against these negative outcomes. In contrast, another study found that surgery was the strongest predictor of survival among patients with IDU-associated endocarditis after a median of 3.6 years follow-up.¹⁸ Another consideration is that patients with IDU-associated infection tend to be younger, and despite advancements, many modern prostheses have a finite lifespan. When multiple surgical options exist, a procedure that avoids prosthetic material is preferred. For example, in a meta-analysis of studies of tricuspid valve endocarditis (41% IDU-associated), there was no mortality difference between valve repair compared with valve replacement, but there was a significantly lower rate of recurrent endocarditis among those with a repair only.⁴⁷ Decisions about surgery must be individualized and consider a patient’s engagement in OUD treatment, social support, prior success with treatment, treatment and relapse prevention resources, and access to harm reduction interventions such as sterile syringes.

What Are Appropriate Harm Reduction Interventions for Patients Hospitalized With Infections Due to IDU?

A prolonged admission for IDU-associated infections is an opportunity to provide patients with education, health maintenance services, and secondary prevention interventions for both infection and overdose. Based on epidemiologic risk, patients should be screened for HIV, HCV, hepatitis B, syphilis, gonorrhea, and chlamydia. Patients should be vaccinated against hepatitis A, influenza, and tetanus (and pneumococcus if indicated), if unvaccinated or without vaccination records. Patients positive for HIV should be evaluated by an infectious disease specialist with consideration of the rapid initiation of antiretroviral therapy. Patients positive for HCV or hepatitis B should be referred for treatment in the outpatient setting. Patients without HIV should be educated about HIV preexposure prophylaxis and referred to outpatient services.

Harm reduction involves meeting patients where they are and providing services they are willing to accept to improve their health or prevent negative outcomes. One important strategy for reducing harm involves maintaining patients in care for their addiction and infection as much as possible, ideally avoiding AMA discharge. In one cohort of patients admitted with IDU-associated infections and OUD, 49% of those without an addiction medicine consult left AMA.¹² If a patient plans to leave AMA, all efforts should be made to provide them with oral antibiotics that might be effective, even if suboptimal, for their infection. Hospitalists should consider documenting an oral “antibiotic contingency plan” that can be rapidly enacted if a patient is imminently leaving the hospital. They should be provided with outpatient follow-up appointments with infectious disease or primary care. All patients with IDU-associated infections should be discharged with naloxone, overdose prevention education, and community resources for addiction treatment and syringe exchange programs.

Management of IDU-associated infection should be organized around a multidisciplinary framework with careful attention to infection treatment, OUD treatment, and harm reduction interventions (Figure 2). The first step in managing IDU-associated infections is recognizing addiction in the acute care setting. Substance use disorders, including OUD, are often unrecognized in patients presenting with IDU-associated infections.⁴⁸ The Rapid Opioid Dependence Screen, a validated screening tool for OUD, can be quickly administered for all patients who present with endocarditis, bacteremia, skin and soft tissue infections, vertebral and epidural infections, and HIV and HCV infections.⁴⁹ In addition to directly questioning patients about substance use, Figure 2 lists epidemiologic, physical exam, and laboratory findings that might suggest to the provider that OUD may be present.

The approach to infection management is similar to non-IDU-associated infections, including identifying a source, evaluating for complications and need for source control procedures, and administering antimicrobials. Management of the substance use disorder includes treatment of acute withdrawal, control of pain, initiation of MOUD when appropriate, and linkage to outpatient addiction treatment services in addition to harm reduction interventions.

Hospital admissions for infectious complications of IDU are increasingly common and are difficult experiences for both patients and providers. However, these hospitalizations serve as a “reachable moment” to engage patients with OUD into medical care and initiate holistic treatment of their infection and underlying substance use disorder.^28,50Significant systems-level barriers remain to comprehensive management of the overlapping infectious disease and opioid epidemics. Nevertheless, it is critical to acknowledge that the infections are a symptom of an underlying substance use disorder, a key first step in improving the care of patients hospitalized with infectious complications of OUD. Just like the many acute exacerbations of chronic illness managed by hospitalists, treatment of these episodes of “acute decompensated addiction” require evidence-based management of the underlying disease and its infectious consequences using a harm reduction approach.

Disclosures

The authors both report no conflict of interest.

Point-of-care ultrasound (POCUS) continues to gain traction in contemporary clinical practice both as a diagnostic tool and as an extension of the physical examination. Hospital Medicine (HM) lags behind Emergency Medicine (EM) and Critical Care (CC) in our uptake of such technology, although momentum is gaining. Leaders in HM have published frameworks for competency and credentialing, and the Society for Hospital Medicine has created a pathway for certification.¹ POCUS use is the standard of care for several bedside procedures, but evidence for diagnostic applications is changing rapidly as the literature expands. However, the applicability of this evidence to HM patients can be challenging as most published studies are still from EM and CC settings. This Progress Note focuses on how a hospitalist might incorporate POCUS in the evaluation of adult patients with dyspnea. This topic was chosen after reviewing several relevant studies published in the past five years and recognizing the importance of dyspnea in HM. The Progress Note begins with a review of POCUS for undifferentiated dyspnea before exploring studies of common diagnoses that present with dyspnea, including pneumonia, pleural effusion, and acute decompensated heart failure (ADHF), aiming to update the knowledge of HM providers regarding this technology as well as to stimulate further study in this field.

In collaboration with an academic librarian in March 2019, PubMed was searched for studies published within the past five years using several MESH search terms for POCUS. The search was originally focused to the field of HM using specific search terms, but this yielded a very limited number of studies. Therefore, the search strategy was expanded to include EM and CC studies. This final search generated 346 papers that were supplemented with additional literature searches using references from studies found in the initial search.

Dyspnea is common in HM, both as the reason for a patient’s admission and as a symptom that develops during hospitalization such as after intravenous fluid resuscitation, a possible aspiration event, or central line placement. The differential diagnosis is broad, and multiple studies suggest that POCUS can aid in the evaluation of undifferentiated dyspnea while also being cost effective and avoiding the potential radiation of other testing modalities. The pulmonary POCUS evaluation incorporates a combination of several findings, including “A-lines” or horizontal artifacts from normal aerated lung; “B-lines”, vertical artifacts generated by extra-alveolar fluid, consolidation or “tissue-like pattern”; air bronchograms, consolidated lung surrounding airways; anechoic or hypoechoic areas in dependent zones of the lung; and the presence or absence of pleural sliding.²

In one prospective observational study of five internal medicine residents with no prior POCUS experience and three hours of training, the addition of handheld POCUS devices to usual clinical information improved the diagnostic accuracy for pneumonia, pulmonary edema, pleural effusion, and obstructive lung disease when evaluating patients with a primary complaint of dyspnea (area under the curve [AUC] 0.81 vs 0.87, P < .01).² However, the largest improvements in the operating characteristics were observed with the two residents who received an extended two-week elective of training.

In another study of 383 consecutive patients presenting to the ED with dyspnea, physicians with basic and advanced POCUS training were blinded to all clinical information and recorded a diagnosis after performing a lung POCUS examination. The “ultrasound physician’s” diagnosis was then compared to the treating emergency department (ED) physician’s diagnosis using history, physical, and other diagnostic data. Lung POCUS had a sensitivity and a specificity of 87.6% and 96.2% for pulmonary edema, 85.7% and 99% for pneumonia, 98.2% and 67.3% for asthma/chronic obstructive pulmonary disease (COPD), 46.2% and 100% for pulmonary embolus (PE), and 71.4% and 100% for pneumothorax, respectively.³ The scanning protocol used, the BLUE (Bedside Lung Ultrasound Examination) protocol, was focused on ruling out significant pulmonary etiologies of dyspnea. The protocol classified the finding of normal lung ultrasound (A-line profile) as COPD or asthma since these conditions will have a normal sonographic appearance. This approach could lead to incorrect labeling of other extrapulmonary causes of dyspnea as COPD or asthma. The findings of this study suggest that POCUS is most effective at ruling in pulmonary edema and pneumonia while being most effective at ruling out asthma or COPD as causes of dyspnea. It is both sensitive and specific for pneumothorax. However, as other studies have found, the sensitivity of POCUS for COPD, asthma, and PE was inferior to traditional clinical evaluation.⁴ One of the few studies looking specifically at hospitalized ward patients compared a blinded lung POCUS diagnosis and a discharge clinical diagnosis classified as cardiac, pulmonary, or mixed dyspnea. The authors of that study found an “interstitial pattern” (two areas with more than two B-lines) in 94% of those classified as cardiac on discharge, but POCUS findings were less precise for those discharged with a pulmonary etiology of dyspnea.⁵ Identifying B-lines on lung POCUS appears to be helpful in rapidly differentiating cardiac from pulmonary etiologies of dyspnea.

An additional advantage of POCUS is that multiple organ systems can be evaluated in rapid succession when the etiology of dyspnea is unknown. In a smaller ED study of patients presenting with undifferentiated dyspnea, a diagnosis was recorded after history-taking and physical examination and then recorded again after lung, cardiac, and inferior vena cava POCUS. Clinician diagnostic accuracy improved from 53% to 77% with the use of POCUS (P = .003) compared with the final diagnosis.⁶ The treating physician’s primary impression changed in almost 50% of cases after using POCUS, most of which was driven by improved sensitivity and specificity of ADHF. In another study of 2,700 patients presenting to the ED with dyspnea, cardiopulmonary POCUS shortened the time to diagnosis (186 ± 72 minutes vs 24 ± 10 minutes, P = .025).⁴ These studies suggest that the use of POCUS in the initial evaluation of patients with undifferentiated dyspnea is a valuable tool with respect to diagnostic accuracy and timeliness.

There are several different sonographic findings that can indicate pneumonia, such as consolidation or “hepatization”, the “shred” sign of an irregular border between consolidated lung and aerated lung, unilateral B-lines, and dynamic air bronchograms. Several recent systematic reviews and meta-analyses have investigated the operating characteristics of POCUS for the diagnosis of pneumonia. These reviews are limited by heterogeneity with respect to different patient populations, sonographers, and reference standards, but all three reviews found similar results, with the pooled AUC values ranging from 95% to 98%.^7-9 This recent evidence along with other reviews suggests that lung ultrasound can serve as a primary diagnostic tool in pneumonia and is probably superior to chest radiography.

Pleural effusions are observed with POCUS as anechoic or hypoechoic areas, generally in dependent lung zones. POCUS may provide additional benefit by better characterizing the effusion as having septations or floating fibrin strands. One recent systematic review and meta-analysis including 1,554 patients found that POCUS had excellent sensitivity and specificity (94% and 98%, respectively) in detecting pleural effusion versus chest radiography (51% and 91%, respectively), both compared with reference standard imaging such as computed tomography. The subgroup analysis found that sensitivity was higher for scanners who were intensivists or radiologists than for other physicians (97% vs 90%; P ≤ .001) and also found a nonstatistically significant trend toward reduced sensitivity when pocket-sized devices were used (90% vs 95%, P = .09).¹⁰

It is extremely important to recognize that a POCUS finding of decreased left ventricular ejection fraction is not synonymous with a diagnosis of ADHF. Bedside providers can use POCUS to estimate cardiac function, but other clinical information is required to determine whether the syndrome of ADHF is present. In one study, examinations performed by 10 internists with approximately 18 hours of training in focused cardiac POCUS had a sensitivity and a specificity of 91% and 88%, respectively, for classifying left ventricular systolic function as normal or mildly, moderately, or severely depressed with “good/substantial” agreement (k = 0.77) compared with formal echocardiography.¹¹ The presence of bilateral B-lines as a sign of pulmonary edema suggests accompanying functional decompensation. A meta-analysis of seven articles including 1075 patients in various clinical settings (ED, ICU, and inpatient wards) found a sensitivity of 94.1% and a specificity of 92.4% for using B-lines to diagnose acute cardiogenic pulmonary edema compared with the final clinical diagnosis.¹² Al Deeb et al. examined 226 patients and found similar sensitivity (95.3%) and specificity (88.2%) for diagnosing acute cardiogenic pulmonary edema when nurses were trained to evaluate for bilateral B-lines in dyspneic patients admitted to the hospital, also compared with the adjudicated final diagnosis.¹³ Carlino et al. evaluated dyspneic patients using a three-minute pocket-sized device scan of the heart, lungs, and inferior vena cava and found that no single view offered a substantial improvement in diagnostic accuracy; however, the combination of bilateral B-lines and/or pleural effusion and either a dilated left atrium or left ventricular ejection fraction (LVEF) of <40% had a very high diagnostic accuracy (AUC 0.97).¹⁴ Russell et al. performed a secondary analysis of a prospective observational study of patients with dyspnea and found that a simple three-view scanning protocol looking for the presence of B-lines on the right and left anterior superior lung zones and an LVEF of <45% took an average of one minute and 32 seconds to perform and had 100% specificity for ADHF if all three were positive.¹⁵ Another recent systematic review and meta-analysis of six studies and 1,827 patients found a sensitivity of 88% (CI 75%-95%) for lung POCUS compared with a chest radiography at a sensitivity of 73% (70%-76%) for the diagnosis of ADHF.¹⁶ All these studies suggest that improving the diagnosis of ADHF does not require complex echocardiographic views and is probably more feasible and accessible than many expect.

POCUS continues to show promise for evaluating patients with dyspnea. It is clear that adding a few POCUS examination maneuvers to a provider’s toolbox, such as looking for B-lines and overall cardiac function, can improve the evaluation of dyspneic patients. However, POCUS enthusiasm should not outpace the evidence. The studies discussed in this update highlight an important need for additional research in HM settings and patient populations. Most of the studies were conducted in non-HM patients, with sonographers varying widely in experience, highlighting the importance of proper training. In addition, future studies should investigate outcome measures such as mortality, length of stay, and cost efficacy. Furthermore, those employing POCUS must remember that improved sensitivity for detecting certain conditions can come at the expense of adequate specificity. POCUS findings, although potentially powerful, must always be synthesized with other clinical findings and considered within the larger clinical context for individual patients.

Point-of-care ultrasound (POCUS) continues to gain traction in contemporary clinical practice both as a diagnostic tool and as an extension of the physical examination. Hospital Medicine (HM) lags behind Emergency Medicine (EM) and Critical Care (CC) in our uptake of such technology, although momentum is gaining. Leaders in HM have published frameworks for competency and credentialing, and the Society for Hospital Medicine has created a pathway for certification.¹ POCUS use is the standard of care for several bedside procedures, but evidence for diagnostic applications is changing rapidly as the literature expands. However, the applicability of this evidence to HM patients can be challenging as most published studies are still from EM and CC settings. This Progress Note focuses on how a hospitalist might incorporate POCUS in the evaluation of adult patients with dyspnea. This topic was chosen after reviewing several relevant studies published in the past five years and recognizing the importance of dyspnea in HM. The Progress Note begins with a review of POCUS for undifferentiated dyspnea before exploring studies of common diagnoses that present with dyspnea, including pneumonia, pleural effusion, and acute decompensated heart failure (ADHF), aiming to update the knowledge of HM providers regarding this technology as well as to stimulate further study in this field.

In collaboration with an academic librarian in March 2019, PubMed was searched for studies published within the past five years using several MESH search terms for POCUS. The search was originally focused to the field of HM using specific search terms, but this yielded a very limited number of studies. Therefore, the search strategy was expanded to include EM and CC studies. This final search generated 346 papers that were supplemented with additional literature searches using references from studies found in the initial search.

Dyspnea is common in HM, both as the reason for a patient’s admission and as a symptom that develops during hospitalization such as after intravenous fluid resuscitation, a possible aspiration event, or central line placement. The differential diagnosis is broad, and multiple studies suggest that POCUS can aid in the evaluation of undifferentiated dyspnea while also being cost effective and avoiding the potential radiation of other testing modalities. The pulmonary POCUS evaluation incorporates a combination of several findings, including “A-lines” or horizontal artifacts from normal aerated lung; “B-lines”, vertical artifacts generated by extra-alveolar fluid, consolidation or “tissue-like pattern”; air bronchograms, consolidated lung surrounding airways; anechoic or hypoechoic areas in dependent zones of the lung; and the presence or absence of pleural sliding.²

In one prospective observational study of five internal medicine residents with no prior POCUS experience and three hours of training, the addition of handheld POCUS devices to usual clinical information improved the diagnostic accuracy for pneumonia, pulmonary edema, pleural effusion, and obstructive lung disease when evaluating patients with a primary complaint of dyspnea (area under the curve [AUC] 0.81 vs 0.87, P < .01).² However, the largest improvements in the operating characteristics were observed with the two residents who received an extended two-week elective of training.

In another study of 383 consecutive patients presenting to the ED with dyspnea, physicians with basic and advanced POCUS training were blinded to all clinical information and recorded a diagnosis after performing a lung POCUS examination. The “ultrasound physician’s” diagnosis was then compared to the treating emergency department (ED) physician’s diagnosis using history, physical, and other diagnostic data. Lung POCUS had a sensitivity and a specificity of 87.6% and 96.2% for pulmonary edema, 85.7% and 99% for pneumonia, 98.2% and 67.3% for asthma/chronic obstructive pulmonary disease (COPD), 46.2% and 100% for pulmonary embolus (PE), and 71.4% and 100% for pneumothorax, respectively.³ The scanning protocol used, the BLUE (Bedside Lung Ultrasound Examination) protocol, was focused on ruling out significant pulmonary etiologies of dyspnea. The protocol classified the finding of normal lung ultrasound (A-line profile) as COPD or asthma since these conditions will have a normal sonographic appearance. This approach could lead to incorrect labeling of other extrapulmonary causes of dyspnea as COPD or asthma. The findings of this study suggest that POCUS is most effective at ruling in pulmonary edema and pneumonia while being most effective at ruling out asthma or COPD as causes of dyspnea. It is both sensitive and specific for pneumothorax. However, as other studies have found, the sensitivity of POCUS for COPD, asthma, and PE was inferior to traditional clinical evaluation.⁴ One of the few studies looking specifically at hospitalized ward patients compared a blinded lung POCUS diagnosis and a discharge clinical diagnosis classified as cardiac, pulmonary, or mixed dyspnea. The authors of that study found an “interstitial pattern” (two areas with more than two B-lines) in 94% of those classified as cardiac on discharge, but POCUS findings were less precise for those discharged with a pulmonary etiology of dyspnea.⁵ Identifying B-lines on lung POCUS appears to be helpful in rapidly differentiating cardiac from pulmonary etiologies of dyspnea.

An additional advantage of POCUS is that multiple organ systems can be evaluated in rapid succession when the etiology of dyspnea is unknown. In a smaller ED study of patients presenting with undifferentiated dyspnea, a diagnosis was recorded after history-taking and physical examination and then recorded again after lung, cardiac, and inferior vena cava POCUS. Clinician diagnostic accuracy improved from 53% to 77% with the use of POCUS (P = .003) compared with the final diagnosis.⁶ The treating physician’s primary impression changed in almost 50% of cases after using POCUS, most of which was driven by improved sensitivity and specificity of ADHF. In another study of 2,700 patients presenting to the ED with dyspnea, cardiopulmonary POCUS shortened the time to diagnosis (186 ± 72 minutes vs 24 ± 10 minutes, P = .025).⁴ These studies suggest that the use of POCUS in the initial evaluation of patients with undifferentiated dyspnea is a valuable tool with respect to diagnostic accuracy and timeliness.

There are several different sonographic findings that can indicate pneumonia, such as consolidation or “hepatization”, the “shred” sign of an irregular border between consolidated lung and aerated lung, unilateral B-lines, and dynamic air bronchograms. Several recent systematic reviews and meta-analyses have investigated the operating characteristics of POCUS for the diagnosis of pneumonia. These reviews are limited by heterogeneity with respect to different patient populations, sonographers, and reference standards, but all three reviews found similar results, with the pooled AUC values ranging from 95% to 98%.^7-9 This recent evidence along with other reviews suggests that lung ultrasound can serve as a primary diagnostic tool in pneumonia and is probably superior to chest radiography.

Pleural effusions are observed with POCUS as anechoic or hypoechoic areas, generally in dependent lung zones. POCUS may provide additional benefit by better characterizing the effusion as having septations or floating fibrin strands. One recent systematic review and meta-analysis including 1,554 patients found that POCUS had excellent sensitivity and specificity (94% and 98%, respectively) in detecting pleural effusion versus chest radiography (51% and 91%, respectively), both compared with reference standard imaging such as computed tomography. The subgroup analysis found that sensitivity was higher for scanners who were intensivists or radiologists than for other physicians (97% vs 90%; P ≤ .001) and also found a nonstatistically significant trend toward reduced sensitivity when pocket-sized devices were used (90% vs 95%, P = .09).¹⁰

It is extremely important to recognize that a POCUS finding of decreased left ventricular ejection fraction is not synonymous with a diagnosis of ADHF. Bedside providers can use POCUS to estimate cardiac function, but other clinical information is required to determine whether the syndrome of ADHF is present. In one study, examinations performed by 10 internists with approximately 18 hours of training in focused cardiac POCUS had a sensitivity and a specificity of 91% and 88%, respectively, for classifying left ventricular systolic function as normal or mildly, moderately, or severely depressed with “good/substantial” agreement (k = 0.77) compared with formal echocardiography.¹¹ The presence of bilateral B-lines as a sign of pulmonary edema suggests accompanying functional decompensation. A meta-analysis of seven articles including 1075 patients in various clinical settings (ED, ICU, and inpatient wards) found a sensitivity of 94.1% and a specificity of 92.4% for using B-lines to diagnose acute cardiogenic pulmonary edema compared with the final clinical diagnosis.¹² Al Deeb et al. examined 226 patients and found similar sensitivity (95.3%) and specificity (88.2%) for diagnosing acute cardiogenic pulmonary edema when nurses were trained to evaluate for bilateral B-lines in dyspneic patients admitted to the hospital, also compared with the adjudicated final diagnosis.¹³ Carlino et al. evaluated dyspneic patients using a three-minute pocket-sized device scan of the heart, lungs, and inferior vena cava and found that no single view offered a substantial improvement in diagnostic accuracy; however, the combination of bilateral B-lines and/or pleural effusion and either a dilated left atrium or left ventricular ejection fraction (LVEF) of <40% had a very high diagnostic accuracy (AUC 0.97).¹⁴ Russell et al. performed a secondary analysis of a prospective observational study of patients with dyspnea and found that a simple three-view scanning protocol looking for the presence of B-lines on the right and left anterior superior lung zones and an LVEF of <45% took an average of one minute and 32 seconds to perform and had 100% specificity for ADHF if all three were positive.¹⁵ Another recent systematic review and meta-analysis of six studies and 1,827 patients found a sensitivity of 88% (CI 75%-95%) for lung POCUS compared with a chest radiography at a sensitivity of 73% (70%-76%) for the diagnosis of ADHF.¹⁶ All these studies suggest that improving the diagnosis of ADHF does not require complex echocardiographic views and is probably more feasible and accessible than many expect.

POCUS continues to show promise for evaluating patients with dyspnea. It is clear that adding a few POCUS examination maneuvers to a provider’s toolbox, such as looking for B-lines and overall cardiac function, can improve the evaluation of dyspneic patients. However, POCUS enthusiasm should not outpace the evidence. The studies discussed in this update highlight an important need for additional research in HM settings and patient populations. Most of the studies were conducted in non-HM patients, with sonographers varying widely in experience, highlighting the importance of proper training. In addition, future studies should investigate outcome measures such as mortality, length of stay, and cost efficacy. Furthermore, those employing POCUS must remember that improved sensitivity for detecting certain conditions can come at the expense of adequate specificity. POCUS findings, although potentially powerful, must always be synthesized with other clinical findings and considered within the larger clinical context for individual patients.

Point-of-care ultrasound (POCUS) continues to gain traction in contemporary clinical practice both as a diagnostic tool and as an extension of the physical examination. Hospital Medicine (HM) lags behind Emergency Medicine (EM) and Critical Care (CC) in our uptake of such technology, although momentum is gaining. Leaders in HM have published frameworks for competency and credentialing, and the Society for Hospital Medicine has created a pathway for certification.¹ POCUS use is the standard of care for several bedside procedures, but evidence for diagnostic applications is changing rapidly as the literature expands. However, the applicability of this evidence to HM patients can be challenging as most published studies are still from EM and CC settings. This Progress Note focuses on how a hospitalist might incorporate POCUS in the evaluation of adult patients with dyspnea. This topic was chosen after reviewing several relevant studies published in the past five years and recognizing the importance of dyspnea in HM. The Progress Note begins with a review of POCUS for undifferentiated dyspnea before exploring studies of common diagnoses that present with dyspnea, including pneumonia, pleural effusion, and acute decompensated heart failure (ADHF), aiming to update the knowledge of HM providers regarding this technology as well as to stimulate further study in this field.

In collaboration with an academic librarian in March 2019, PubMed was searched for studies published within the past five years using several MESH search terms for POCUS. The search was originally focused to the field of HM using specific search terms, but this yielded a very limited number of studies. Therefore, the search strategy was expanded to include EM and CC studies. This final search generated 346 papers that were supplemented with additional literature searches using references from studies found in the initial search.

Dyspnea is common in HM, both as the reason for a patient’s admission and as a symptom that develops during hospitalization such as after intravenous fluid resuscitation, a possible aspiration event, or central line placement. The differential diagnosis is broad, and multiple studies suggest that POCUS can aid in the evaluation of undifferentiated dyspnea while also being cost effective and avoiding the potential radiation of other testing modalities. The pulmonary POCUS evaluation incorporates a combination of several findings, including “A-lines” or horizontal artifacts from normal aerated lung; “B-lines”, vertical artifacts generated by extra-alveolar fluid, consolidation or “tissue-like pattern”; air bronchograms, consolidated lung surrounding airways; anechoic or hypoechoic areas in dependent zones of the lung; and the presence or absence of pleural sliding.²

In one prospective observational study of five internal medicine residents with no prior POCUS experience and three hours of training, the addition of handheld POCUS devices to usual clinical information improved the diagnostic accuracy for pneumonia, pulmonary edema, pleural effusion, and obstructive lung disease when evaluating patients with a primary complaint of dyspnea (area under the curve [AUC] 0.81 vs 0.87, P < .01).² However, the largest improvements in the operating characteristics were observed with the two residents who received an extended two-week elective of training.

In another study of 383 consecutive patients presenting to the ED with dyspnea, physicians with basic and advanced POCUS training were blinded to all clinical information and recorded a diagnosis after performing a lung POCUS examination. The “ultrasound physician’s” diagnosis was then compared to the treating emergency department (ED) physician’s diagnosis using history, physical, and other diagnostic data. Lung POCUS had a sensitivity and a specificity of 87.6% and 96.2% for pulmonary edema, 85.7% and 99% for pneumonia, 98.2% and 67.3% for asthma/chronic obstructive pulmonary disease (COPD), 46.2% and 100% for pulmonary embolus (PE), and 71.4% and 100% for pneumothorax, respectively.³ The scanning protocol used, the BLUE (Bedside Lung Ultrasound Examination) protocol, was focused on ruling out significant pulmonary etiologies of dyspnea. The protocol classified the finding of normal lung ultrasound (A-line profile) as COPD or asthma since these conditions will have a normal sonographic appearance. This approach could lead to incorrect labeling of other extrapulmonary causes of dyspnea as COPD or asthma. The findings of this study suggest that POCUS is most effective at ruling in pulmonary edema and pneumonia while being most effective at ruling out asthma or COPD as causes of dyspnea. It is both sensitive and specific for pneumothorax. However, as other studies have found, the sensitivity of POCUS for COPD, asthma, and PE was inferior to traditional clinical evaluation.⁴ One of the few studies looking specifically at hospitalized ward patients compared a blinded lung POCUS diagnosis and a discharge clinical diagnosis classified as cardiac, pulmonary, or mixed dyspnea. The authors of that study found an “interstitial pattern” (two areas with more than two B-lines) in 94% of those classified as cardiac on discharge, but POCUS findings were less precise for those discharged with a pulmonary etiology of dyspnea.⁵ Identifying B-lines on lung POCUS appears to be helpful in rapidly differentiating cardiac from pulmonary etiologies of dyspnea.

An additional advantage of POCUS is that multiple organ systems can be evaluated in rapid succession when the etiology of dyspnea is unknown. In a smaller ED study of patients presenting with undifferentiated dyspnea, a diagnosis was recorded after history-taking and physical examination and then recorded again after lung, cardiac, and inferior vena cava POCUS. Clinician diagnostic accuracy improved from 53% to 77% with the use of POCUS (P = .003) compared with the final diagnosis.⁶ The treating physician’s primary impression changed in almost 50% of cases after using POCUS, most of which was driven by improved sensitivity and specificity of ADHF. In another study of 2,700 patients presenting to the ED with dyspnea, cardiopulmonary POCUS shortened the time to diagnosis (186 ± 72 minutes vs 24 ± 10 minutes, P = .025).⁴ These studies suggest that the use of POCUS in the initial evaluation of patients with undifferentiated dyspnea is a valuable tool with respect to diagnostic accuracy and timeliness.

There are several different sonographic findings that can indicate pneumonia, such as consolidation or “hepatization”, the “shred” sign of an irregular border between consolidated lung and aerated lung, unilateral B-lines, and dynamic air bronchograms. Several recent systematic reviews and meta-analyses have investigated the operating characteristics of POCUS for the diagnosis of pneumonia. These reviews are limited by heterogeneity with respect to different patient populations, sonographers, and reference standards, but all three reviews found similar results, with the pooled AUC values ranging from 95% to 98%.^7-9 This recent evidence along with other reviews suggests that lung ultrasound can serve as a primary diagnostic tool in pneumonia and is probably superior to chest radiography.

Pleural effusions are observed with POCUS as anechoic or hypoechoic areas, generally in dependent lung zones. POCUS may provide additional benefit by better characterizing the effusion as having septations or floating fibrin strands. One recent systematic review and meta-analysis including 1,554 patients found that POCUS had excellent sensitivity and specificity (94% and 98%, respectively) in detecting pleural effusion versus chest radiography (51% and 91%, respectively), both compared with reference standard imaging such as computed tomography. The subgroup analysis found that sensitivity was higher for scanners who were intensivists or radiologists than for other physicians (97% vs 90%; P ≤ .001) and also found a nonstatistically significant trend toward reduced sensitivity when pocket-sized devices were used (90% vs 95%, P = .09).¹⁰

It is extremely important to recognize that a POCUS finding of decreased left ventricular ejection fraction is not synonymous with a diagnosis of ADHF. Bedside providers can use POCUS to estimate cardiac function, but other clinical information is required to determine whether the syndrome of ADHF is present. In one study, examinations performed by 10 internists with approximately 18 hours of training in focused cardiac POCUS had a sensitivity and a specificity of 91% and 88%, respectively, for classifying left ventricular systolic function as normal or mildly, moderately, or severely depressed with “good/substantial” agreement (k = 0.77) compared with formal echocardiography.¹¹ The presence of bilateral B-lines as a sign of pulmonary edema suggests accompanying functional decompensation. A meta-analysis of seven articles including 1075 patients in various clinical settings (ED, ICU, and inpatient wards) found a sensitivity of 94.1% and a specificity of 92.4% for using B-lines to diagnose acute cardiogenic pulmonary edema compared with the final clinical diagnosis.¹² Al Deeb et al. examined 226 patients and found similar sensitivity (95.3%) and specificity (88.2%) for diagnosing acute cardiogenic pulmonary edema when nurses were trained to evaluate for bilateral B-lines in dyspneic patients admitted to the hospital, also compared with the adjudicated final diagnosis.¹³ Carlino et al. evaluated dyspneic patients using a three-minute pocket-sized device scan of the heart, lungs, and inferior vena cava and found that no single view offered a substantial improvement in diagnostic accuracy; however, the combination of bilateral B-lines and/or pleural effusion and either a dilated left atrium or left ventricular ejection fraction (LVEF) of <40% had a very high diagnostic accuracy (AUC 0.97).¹⁴ Russell et al. performed a secondary analysis of a prospective observational study of patients with dyspnea and found that a simple three-view scanning protocol looking for the presence of B-lines on the right and left anterior superior lung zones and an LVEF of <45% took an average of one minute and 32 seconds to perform and had 100% specificity for ADHF if all three were positive.¹⁵ Another recent systematic review and meta-analysis of six studies and 1,827 patients found a sensitivity of 88% (CI 75%-95%) for lung POCUS compared with a chest radiography at a sensitivity of 73% (70%-76%) for the diagnosis of ADHF.¹⁶ All these studies suggest that improving the diagnosis of ADHF does not require complex echocardiographic views and is probably more feasible and accessible than many expect.

POCUS continues to show promise for evaluating patients with dyspnea. It is clear that adding a few POCUS examination maneuvers to a provider’s toolbox, such as looking for B-lines and overall cardiac function, can improve the evaluation of dyspneic patients. However, POCUS enthusiasm should not outpace the evidence. The studies discussed in this update highlight an important need for additional research in HM settings and patient populations. Most of the studies were conducted in non-HM patients, with sonographers varying widely in experience, highlighting the importance of proper training. In addition, future studies should investigate outcome measures such as mortality, length of stay, and cost efficacy. Furthermore, those employing POCUS must remember that improved sensitivity for detecting certain conditions can come at the expense of adequate specificity. POCUS findings, although potentially powerful, must always be synthesized with other clinical findings and considered within the larger clinical context for individual patients.

Opioid use disorder (OUD) is a common, underrecognized, undertreated, and deadly medical condition. Although the focus of addressing the opioid epidemic has been centered in the outpatient setting, hospitalists play an important—and often underutilized—role in identifying OUD, initiating treatment, and assisting with linkage to longitudinal care after discharge.

Over the past 20 years, the annual rate of hospital discharges documenting OUD has quadrupled.¹ During 2010-2016, the annual discharge rate for heroin overdoses increased by 23%.¹ Although the total number of hospitalizations in the United States remained stable from 2002 to 2012, the number of admissions for opioid abuse or dependence increased from 301,707 to 520,275. More than 500,000 hospital admissions per year (1% of total nationwide hospitalizations) are now due primarily to OUD.²

Injection opioid use increases the risk of endocarditis, osteomyelitis, septic arthritis, and epidural abscesses, conditions that often prolong hospitalizations and frequently lead to readmissions. Admissions for OUD-related infections are rising at a startling rate. Between 2002 and 2012, the number of admissions for infections associated with OUDs had increased from 3,421 to 6,535.² In addition to providing the opportunity to diagnose OUD, hospitalizations offer an ideal time to engage patients in OUD treatment and linkage to outpatient care.

Although we uniformly offer patients antibiotic treatment for acute infection, hospitalists should consistently incorporate treatment of OUD to address the root cause of these admissions. As infection is but one sequelae of the underlying disease of addiction, treating without medications for OUD (MOUD) would be akin to treating a diabetic foot ulcer with antibiotics and not providing medications to improve glycemic control. Omitting such addiction treatment can contribute to treatment failure and worse health outcomes. Among patients with endocarditis and an associated valve repair, those who continue injection drug use have a 10 times higher risk of death or reoperation between 90 and 180 days after repair than those not engaged in drug use.³

Despite data demonstrating the significant benefit and the minimal harm of MOUD, significant gaps remain in providing MOUD and linking patients from the hospital to community care.^1,4 Hospital encounters are missed opportunities to provide life-saving MOUD treatment; the majority of patients with OUD do not receive evidence-based treatment while inpatient.⁵ Rosenthal et al. found that of 102 patients admitted with injection drug use-associated infective endocarditis from 2004 to 2014, only 8% received MOUD, and approximately half had a documentation of substance use treatment in their discharge worksheet.⁴ In Massachusetts, among individuals who experienced a nonfatal opioid overdose and had interaction with healthcare services, only 26% were on MOUD one year later.⁶ Based on our experience, a substantial proportion of patients with OUD do not seek or have access to medical care, acute care settings offer a critical opportunity to engage them in treatment for their addiction.

First, buprenorphine effectively treats withdrawal symptoms. Buprenorphine and methadone are superior to other medications in treating symptoms of withdrawal.⁷ If withdrawal symptoms are treated, patients are less likely to leave against medical advice⁸ and are more likely to complete treatment.

Second, MOUD is the standard of care for treating OUD.⁹ Medications include the full agonist methadone, the partial agonist buprenorphine, and the long-acting antagonist naltrexone. Although all these drugs are effective and legal to initiate for inpatients,⁶ this perspective focuses on buprenorphine in an effort to draw attention to associated policy barriers. Buprenorphine is the only MOUD that can be offered as office-based therapy by providers in the outpatient setting. Meta-analyses show that MOUD is associated with lower rates of mortality, illicit opioid use, HIV transmission, and violent crime and arrest.⁹

Third, MOUD treatment, rather than just referral, leads to higher long-term treatment success.¹⁰ When initiating buprenorphine in the hospital, treatment retention rates at one month were double that of referral alone. Six months after discharge, patients were five times more likely to remain engaged in treatment compared with those who received a detoxification protocol only.

Fourth, buprenorphine is not only effective, but it is also safe and has low risks of misuse. Because buprenorphine is a partial agonist, it has both a ceiling effect on respiratory depression (decreasing potential lethality) and on euphoria (decreasing the likelihood of misuse). Among individuals who took nonprescribed buprenorphine on the street, less than 7% reported taking it for any attempt at euphoria. Instead, people with OUD most often use nonprescribed or diverted buprenorphine to treat withdrawal symptoms.¹¹

Fifth, buprenorphine treatment is associated with fewer hospital readmissions.¹²

Finally, initiating OUD treatment is feasible in the hospital setting. Any hospitalist can legally prescribe buprenorphine to treat opioid withdrawal for hospitalized patients admitted for medical or surgical reasons. A waiver is necessary only for prescribing at the time of hospital discharge for use in non-inpatient settings of care.

The United States Congress passed the Drug Addiction Treatment Act (DATA) of 2000, which codified the X waiver, in response to the growing opioid crisis. Only those providers with the DATA X waiver can write buprenorphine prescriptions to be filled in an outpatient pharmacy. To obtain an X waiver, physicians must complete an 8-hour course, whereas physician assistants and nurse practitioners must complete a 24-hour course. This training far exceeds any required training to prescribe opioids for pain.

Unfortunately, the X waiver requirement obstructs hospitalists from initiating buprenorphine in the inpatient setting in the following ways: (1) hospitalists often choose not to initiate chronic buprenorphine treatment if they lack the X waiver that would allow them to write the discharge prescription and/or (2) they are unable to identify a waivered provider in the community to continue the prescription. Unfortunately, only 6% of all medical practitioners are waivered to prescribe buprenorphine; greater than 40% of US counties are “buprenorphine deserts,” with no providers waivered to prescribe buprenorphine.¹³

To address the opioid crisis, we must rethink our current policies. The Department of Health and Human Services should eliminate the X waiver and allow any licensed physician, nurse practitioner, or physician assistant to prescribe buprenorphine.¹⁴ Recent American Medical Association Opioid Task Force recommendations have called to “remove… inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment for OUD.”¹⁵ Legislation to remove the X wavier has been proposed in the United States.¹⁶

The removal of a buprenorphine waiver requirement has had success in other settings. The French deregulation of buprenorphine was associated with a reduction in opioid overdose deaths by 79%. Similar success in the United States would save an estimated 30,000 lives yearly.¹⁴ Removing the X waiver is an important step in empowering hospitalists to initiate MOUD for individuals in the hospital setting. Moreover, it opens the door to more outpatient primary care providers serving as community linkages for long-term addiction care.

Without the X waiver, the associated OUD training will no longer be required. This could have unintended consequences. For example, if hospitalists order buprenorphine while opioids remain active, precipitated withdrawal may ensue. Crucially, the current literature does not indicate that the required X waiver training improves knowledge, patient care, or outcomes.¹⁷ Nevertheless, MOUD and addiction training may help reduce knowledge gaps and empower providers to engage in productive conversations surrounding addiction. This highlights the crucial role of physician organizations, such as the Society of Hospital Medicine, in educating hospitalists about MOUD. (This organization, among others, has developed robust MOUD training.¹⁸)

It is also important to acknowledge that the waiver is only one obstacle. Other barriers have been identified in initiating buprenorphine, including access to treatment after discharge, access to social work support, and lack of EMR order sets, among others.¹⁹ Professional societies, hospitals, and hospitalists need to help address these barriers through ancillary support staff, quality improvement initiatives, and improved inpatient treatment of withdrawal with MOUD. This can be done successfully; one study found that 82% of hospitalized patients who engaged in a new transitional opioid program subsequently presented to outpatient opioid treatment.²⁰ Novel interventions must be part of a hospital-wide approach to optimizing improved longitudinal treatment for patients suffering from addiction.

Hospitalization is an ideal opportunity for clinicians to diagnose and treat OUD in a population that often has not sought, or has fallen out of, addiction treatment. Hospitalists can and should initiate buprenorphine in appropriate inpatients and plan for their transition to chronic care. Eliminating the waiver in combination with designing innovative educational opportunities and systems approaches to provide better linkages to outpatient OUD treatment is needed to combat the opioid crisis. To enable more hospitalists to successfully initiate long-term buprenorphine therapy—and to enable more outpatient providers to continue prescriptions—we must eliminate the X waiver.

Disclosures

Dr. Wilson received honorarium from the American Society of Addiction Medicine for teaching and creating CME outside the submitted work. All other authors have no conflicts of interest and have received no related funding to this topic.

Opioid use disorder (OUD) is a common, underrecognized, undertreated, and deadly medical condition. Although the focus of addressing the opioid epidemic has been centered in the outpatient setting, hospitalists play an important—and often underutilized—role in identifying OUD, initiating treatment, and assisting with linkage to longitudinal care after discharge.

Over the past 20 years, the annual rate of hospital discharges documenting OUD has quadrupled.¹ During 2010-2016, the annual discharge rate for heroin overdoses increased by 23%.¹ Although the total number of hospitalizations in the United States remained stable from 2002 to 2012, the number of admissions for opioid abuse or dependence increased from 301,707 to 520,275. More than 500,000 hospital admissions per year (1% of total nationwide hospitalizations) are now due primarily to OUD.²

Injection opioid use increases the risk of endocarditis, osteomyelitis, septic arthritis, and epidural abscesses, conditions that often prolong hospitalizations and frequently lead to readmissions. Admissions for OUD-related infections are rising at a startling rate. Between 2002 and 2012, the number of admissions for infections associated with OUDs had increased from 3,421 to 6,535.² In addition to providing the opportunity to diagnose OUD, hospitalizations offer an ideal time to engage patients in OUD treatment and linkage to outpatient care.

Although we uniformly offer patients antibiotic treatment for acute infection, hospitalists should consistently incorporate treatment of OUD to address the root cause of these admissions. As infection is but one sequelae of the underlying disease of addiction, treating without medications for OUD (MOUD) would be akin to treating a diabetic foot ulcer with antibiotics and not providing medications to improve glycemic control. Omitting such addiction treatment can contribute to treatment failure and worse health outcomes. Among patients with endocarditis and an associated valve repair, those who continue injection drug use have a 10 times higher risk of death or reoperation between 90 and 180 days after repair than those not engaged in drug use.³

Despite data demonstrating the significant benefit and the minimal harm of MOUD, significant gaps remain in providing MOUD and linking patients from the hospital to community care.^1,4 Hospital encounters are missed opportunities to provide life-saving MOUD treatment; the majority of patients with OUD do not receive evidence-based treatment while inpatient.⁵ Rosenthal et al. found that of 102 patients admitted with injection drug use-associated infective endocarditis from 2004 to 2014, only 8% received MOUD, and approximately half had a documentation of substance use treatment in their discharge worksheet.⁴ In Massachusetts, among individuals who experienced a nonfatal opioid overdose and had interaction with healthcare services, only 26% were on MOUD one year later.⁶ Based on our experience, a substantial proportion of patients with OUD do not seek or have access to medical care, acute care settings offer a critical opportunity to engage them in treatment for their addiction.

First, buprenorphine effectively treats withdrawal symptoms. Buprenorphine and methadone are superior to other medications in treating symptoms of withdrawal.⁷ If withdrawal symptoms are treated, patients are less likely to leave against medical advice⁸ and are more likely to complete treatment.

Second, MOUD is the standard of care for treating OUD.⁹ Medications include the full agonist methadone, the partial agonist buprenorphine, and the long-acting antagonist naltrexone. Although all these drugs are effective and legal to initiate for inpatients,⁶ this perspective focuses on buprenorphine in an effort to draw attention to associated policy barriers. Buprenorphine is the only MOUD that can be offered as office-based therapy by providers in the outpatient setting. Meta-analyses show that MOUD is associated with lower rates of mortality, illicit opioid use, HIV transmission, and violent crime and arrest.⁹

Third, MOUD treatment, rather than just referral, leads to higher long-term treatment success.¹⁰ When initiating buprenorphine in the hospital, treatment retention rates at one month were double that of referral alone. Six months after discharge, patients were five times more likely to remain engaged in treatment compared with those who received a detoxification protocol only.

Fourth, buprenorphine is not only effective, but it is also safe and has low risks of misuse. Because buprenorphine is a partial agonist, it has both a ceiling effect on respiratory depression (decreasing potential lethality) and on euphoria (decreasing the likelihood of misuse). Among individuals who took nonprescribed buprenorphine on the street, less than 7% reported taking it for any attempt at euphoria. Instead, people with OUD most often use nonprescribed or diverted buprenorphine to treat withdrawal symptoms.¹¹

Fifth, buprenorphine treatment is associated with fewer hospital readmissions.¹²

Finally, initiating OUD treatment is feasible in the hospital setting. Any hospitalist can legally prescribe buprenorphine to treat opioid withdrawal for hospitalized patients admitted for medical or surgical reasons. A waiver is necessary only for prescribing at the time of hospital discharge for use in non-inpatient settings of care.

The United States Congress passed the Drug Addiction Treatment Act (DATA) of 2000, which codified the X waiver, in response to the growing opioid crisis. Only those providers with the DATA X waiver can write buprenorphine prescriptions to be filled in an outpatient pharmacy. To obtain an X waiver, physicians must complete an 8-hour course, whereas physician assistants and nurse practitioners must complete a 24-hour course. This training far exceeds any required training to prescribe opioids for pain.

Unfortunately, the X waiver requirement obstructs hospitalists from initiating buprenorphine in the inpatient setting in the following ways: (1) hospitalists often choose not to initiate chronic buprenorphine treatment if they lack the X waiver that would allow them to write the discharge prescription and/or (2) they are unable to identify a waivered provider in the community to continue the prescription. Unfortunately, only 6% of all medical practitioners are waivered to prescribe buprenorphine; greater than 40% of US counties are “buprenorphine deserts,” with no providers waivered to prescribe buprenorphine.¹³

To address the opioid crisis, we must rethink our current policies. The Department of Health and Human Services should eliminate the X waiver and allow any licensed physician, nurse practitioner, or physician assistant to prescribe buprenorphine.¹⁴ Recent American Medical Association Opioid Task Force recommendations have called to “remove… inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment for OUD.”¹⁵ Legislation to remove the X wavier has been proposed in the United States.¹⁶

The removal of a buprenorphine waiver requirement has had success in other settings. The French deregulation of buprenorphine was associated with a reduction in opioid overdose deaths by 79%. Similar success in the United States would save an estimated 30,000 lives yearly.¹⁴ Removing the X waiver is an important step in empowering hospitalists to initiate MOUD for individuals in the hospital setting. Moreover, it opens the door to more outpatient primary care providers serving as community linkages for long-term addiction care.

Without the X waiver, the associated OUD training will no longer be required. This could have unintended consequences. For example, if hospitalists order buprenorphine while opioids remain active, precipitated withdrawal may ensue. Crucially, the current literature does not indicate that the required X waiver training improves knowledge, patient care, or outcomes.¹⁷ Nevertheless, MOUD and addiction training may help reduce knowledge gaps and empower providers to engage in productive conversations surrounding addiction. This highlights the crucial role of physician organizations, such as the Society of Hospital Medicine, in educating hospitalists about MOUD. (This organization, among others, has developed robust MOUD training.¹⁸)

It is also important to acknowledge that the waiver is only one obstacle. Other barriers have been identified in initiating buprenorphine, including access to treatment after discharge, access to social work support, and lack of EMR order sets, among others.¹⁹ Professional societies, hospitals, and hospitalists need to help address these barriers through ancillary support staff, quality improvement initiatives, and improved inpatient treatment of withdrawal with MOUD. This can be done successfully; one study found that 82% of hospitalized patients who engaged in a new transitional opioid program subsequently presented to outpatient opioid treatment.²⁰ Novel interventions must be part of a hospital-wide approach to optimizing improved longitudinal treatment for patients suffering from addiction.

Hospitalization is an ideal opportunity for clinicians to diagnose and treat OUD in a population that often has not sought, or has fallen out of, addiction treatment. Hospitalists can and should initiate buprenorphine in appropriate inpatients and plan for their transition to chronic care. Eliminating the waiver in combination with designing innovative educational opportunities and systems approaches to provide better linkages to outpatient OUD treatment is needed to combat the opioid crisis. To enable more hospitalists to successfully initiate long-term buprenorphine therapy—and to enable more outpatient providers to continue prescriptions—we must eliminate the X waiver.

Disclosures

Dr. Wilson received honorarium from the American Society of Addiction Medicine for teaching and creating CME outside the submitted work. All other authors have no conflicts of interest and have received no related funding to this topic.

Opioid use disorder (OUD) is a common, underrecognized, undertreated, and deadly medical condition. Although the focus of addressing the opioid epidemic has been centered in the outpatient setting, hospitalists play an important—and often underutilized—role in identifying OUD, initiating treatment, and assisting with linkage to longitudinal care after discharge.

Over the past 20 years, the annual rate of hospital discharges documenting OUD has quadrupled.¹ During 2010-2016, the annual discharge rate for heroin overdoses increased by 23%.¹ Although the total number of hospitalizations in the United States remained stable from 2002 to 2012, the number of admissions for opioid abuse or dependence increased from 301,707 to 520,275. More than 500,000 hospital admissions per year (1% of total nationwide hospitalizations) are now due primarily to OUD.²

Injection opioid use increases the risk of endocarditis, osteomyelitis, septic arthritis, and epidural abscesses, conditions that often prolong hospitalizations and frequently lead to readmissions. Admissions for OUD-related infections are rising at a startling rate. Between 2002 and 2012, the number of admissions for infections associated with OUDs had increased from 3,421 to 6,535.² In addition to providing the opportunity to diagnose OUD, hospitalizations offer an ideal time to engage patients in OUD treatment and linkage to outpatient care.

Although we uniformly offer patients antibiotic treatment for acute infection, hospitalists should consistently incorporate treatment of OUD to address the root cause of these admissions. As infection is but one sequelae of the underlying disease of addiction, treating without medications for OUD (MOUD) would be akin to treating a diabetic foot ulcer with antibiotics and not providing medications to improve glycemic control. Omitting such addiction treatment can contribute to treatment failure and worse health outcomes. Among patients with endocarditis and an associated valve repair, those who continue injection drug use have a 10 times higher risk of death or reoperation between 90 and 180 days after repair than those not engaged in drug use.³

Despite data demonstrating the significant benefit and the minimal harm of MOUD, significant gaps remain in providing MOUD and linking patients from the hospital to community care.^1,4 Hospital encounters are missed opportunities to provide life-saving MOUD treatment; the majority of patients with OUD do not receive evidence-based treatment while inpatient.⁵ Rosenthal et al. found that of 102 patients admitted with injection drug use-associated infective endocarditis from 2004 to 2014, only 8% received MOUD, and approximately half had a documentation of substance use treatment in their discharge worksheet.⁴ In Massachusetts, among individuals who experienced a nonfatal opioid overdose and had interaction with healthcare services, only 26% were on MOUD one year later.⁶ Based on our experience, a substantial proportion of patients with OUD do not seek or have access to medical care, acute care settings offer a critical opportunity to engage them in treatment for their addiction.

First, buprenorphine effectively treats withdrawal symptoms. Buprenorphine and methadone are superior to other medications in treating symptoms of withdrawal.⁷ If withdrawal symptoms are treated, patients are less likely to leave against medical advice⁸ and are more likely to complete treatment.

Second, MOUD is the standard of care for treating OUD.⁹ Medications include the full agonist methadone, the partial agonist buprenorphine, and the long-acting antagonist naltrexone. Although all these drugs are effective and legal to initiate for inpatients,⁶ this perspective focuses on buprenorphine in an effort to draw attention to associated policy barriers. Buprenorphine is the only MOUD that can be offered as office-based therapy by providers in the outpatient setting. Meta-analyses show that MOUD is associated with lower rates of mortality, illicit opioid use, HIV transmission, and violent crime and arrest.⁹

Third, MOUD treatment, rather than just referral, leads to higher long-term treatment success.¹⁰ When initiating buprenorphine in the hospital, treatment retention rates at one month were double that of referral alone. Six months after discharge, patients were five times more likely to remain engaged in treatment compared with those who received a detoxification protocol only.

Fourth, buprenorphine is not only effective, but it is also safe and has low risks of misuse. Because buprenorphine is a partial agonist, it has both a ceiling effect on respiratory depression (decreasing potential lethality) and on euphoria (decreasing the likelihood of misuse). Among individuals who took nonprescribed buprenorphine on the street, less than 7% reported taking it for any attempt at euphoria. Instead, people with OUD most often use nonprescribed or diverted buprenorphine to treat withdrawal symptoms.¹¹

Fifth, buprenorphine treatment is associated with fewer hospital readmissions.¹²

Finally, initiating OUD treatment is feasible in the hospital setting. Any hospitalist can legally prescribe buprenorphine to treat opioid withdrawal for hospitalized patients admitted for medical or surgical reasons. A waiver is necessary only for prescribing at the time of hospital discharge for use in non-inpatient settings of care.

The United States Congress passed the Drug Addiction Treatment Act (DATA) of 2000, which codified the X waiver, in response to the growing opioid crisis. Only those providers with the DATA X waiver can write buprenorphine prescriptions to be filled in an outpatient pharmacy. To obtain an X waiver, physicians must complete an 8-hour course, whereas physician assistants and nurse practitioners must complete a 24-hour course. This training far exceeds any required training to prescribe opioids for pain.

Unfortunately, the X waiver requirement obstructs hospitalists from initiating buprenorphine in the inpatient setting in the following ways: (1) hospitalists often choose not to initiate chronic buprenorphine treatment if they lack the X waiver that would allow them to write the discharge prescription and/or (2) they are unable to identify a waivered provider in the community to continue the prescription. Unfortunately, only 6% of all medical practitioners are waivered to prescribe buprenorphine; greater than 40% of US counties are “buprenorphine deserts,” with no providers waivered to prescribe buprenorphine.¹³

To address the opioid crisis, we must rethink our current policies. The Department of Health and Human Services should eliminate the X waiver and allow any licensed physician, nurse practitioner, or physician assistant to prescribe buprenorphine.¹⁴ Recent American Medical Association Opioid Task Force recommendations have called to “remove… inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment for OUD.”¹⁵ Legislation to remove the X wavier has been proposed in the United States.¹⁶

The removal of a buprenorphine waiver requirement has had success in other settings. The French deregulation of buprenorphine was associated with a reduction in opioid overdose deaths by 79%. Similar success in the United States would save an estimated 30,000 lives yearly.¹⁴ Removing the X waiver is an important step in empowering hospitalists to initiate MOUD for individuals in the hospital setting. Moreover, it opens the door to more outpatient primary care providers serving as community linkages for long-term addiction care.

Without the X waiver, the associated OUD training will no longer be required. This could have unintended consequences. For example, if hospitalists order buprenorphine while opioids remain active, precipitated withdrawal may ensue. Crucially, the current literature does not indicate that the required X waiver training improves knowledge, patient care, or outcomes.¹⁷ Nevertheless, MOUD and addiction training may help reduce knowledge gaps and empower providers to engage in productive conversations surrounding addiction. This highlights the crucial role of physician organizations, such as the Society of Hospital Medicine, in educating hospitalists about MOUD. (This organization, among others, has developed robust MOUD training.¹⁸)

It is also important to acknowledge that the waiver is only one obstacle. Other barriers have been identified in initiating buprenorphine, including access to treatment after discharge, access to social work support, and lack of EMR order sets, among others.¹⁹ Professional societies, hospitals, and hospitalists need to help address these barriers through ancillary support staff, quality improvement initiatives, and improved inpatient treatment of withdrawal with MOUD. This can be done successfully; one study found that 82% of hospitalized patients who engaged in a new transitional opioid program subsequently presented to outpatient opioid treatment.²⁰ Novel interventions must be part of a hospital-wide approach to optimizing improved longitudinal treatment for patients suffering from addiction.

Hospitalization is an ideal opportunity for clinicians to diagnose and treat OUD in a population that often has not sought, or has fallen out of, addiction treatment. Hospitalists can and should initiate buprenorphine in appropriate inpatients and plan for their transition to chronic care. Eliminating the waiver in combination with designing innovative educational opportunities and systems approaches to provide better linkages to outpatient OUD treatment is needed to combat the opioid crisis. To enable more hospitalists to successfully initiate long-term buprenorphine therapy—and to enable more outpatient providers to continue prescriptions—we must eliminate the X waiver.

Disclosures

Dr. Wilson received honorarium from the American Society of Addiction Medicine for teaching and creating CME outside the submitted work. All other authors have no conflicts of interest and have received no related funding to this topic.