Most vaccinations are given during childhood, but some require boosting during adulthood or are indicated for specific patient populations such as international travelers or those with certain medical conditions. Although generally safe, some vaccines contain live, attenuated organisms that can cause disease in immunocompromised patients. Thus, knowledge of the indications for and contraindications to specific vaccinations is critical to protect adults in special circumstances who are at risk.

See related commentary

Vaccines have helped eliminate or significantly reduce the burden of more than a dozen illnesses.^1–3 The Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention  (CDC) makes recommendations about vaccinations for normal adults and children as well as for certain groups at high risk of vaccine-preventable infections.⁴ Tables 1 and 2 summarize the recommendations for vaccination by medical condition.⁴  In addition, several applications are available online, including downloadable apps from the (www.cdc.gov/vaccines/schedules/Schedulers/adult-scheduler.html) and the American College of Physicians (http://immunization.acponline.org/app/).

HUMANITY’S GREATEST ADVANCES IN PREVENTING INFECTIOUS DISEASE

Immunization and improved sanitation are humanity’s greatest advances in preventing sickness and death from infectious diseases. Since Jenner’s discovery in 1796 that milkmaids who had contracted cowpox (vaccinia) were immune to smallpox, vaccination has eliminated smallpox, markedly decreased the incidence of many infectious diseases, and, most recently, shown efficacy in preventing cervical cancer (with the human papillomavirus vaccine) and hepatocellular cancer (with the hepatitis B vaccine).^1–3

Unfortunately, vaccination rates remain low for most routine vaccinations indicated for adults. For example, about 60% of adults over age 65 receive pneumococcal vaccination, and fewer than 10% of black patients over age 60 receive zoster vaccination.⁵ Various factors may account for these low rates, including financial disincentives.⁶

Nevertheless, vaccination remains one of medicine’s most effective defenses against infectious diseases and is especially important in the special populations discussed below. By being steadfast proponents of vaccination, especially for the most vulnerable patients, physicians can help ensure the optimum protection for their patients.

VACCINATING PREGNANT PATIENTS

When considering vaccination during pregnancy, one must consider the risk and benefit of the vaccine and the risk of the disease in both the mother and the child.

In general, if a pregnant woman is at high risk of exposure to a particular infection, the benefits of vaccinating her against it outweigh the risks. Vaccinating the mother can also protect against certain infections in early infancy through transfer of vaccine-induced immunoglobin G (IgG) across the placenta.⁷ In general, inactivated vaccines are considered safe in pregnancy, while live-attenuated vaccines are contraindicated.⁴ Special considerations for pregnant women include:

Tetanus, diphtheria, and acellular pertussis (Tdap). One dose of Tdap vaccine should be given during each pregnancy, preferably at 27 to 36 weeks of gestation, regardless of when the patient received a previous dose.⁸

Inactivated influenza vaccine should be given as early as possible during the influenza season (October to March) to all pregnant women, regardless of trimester.

Inactivated polio vaccine may be considered for pregnant women with known exposure to polio or travel to endemic areas.

Hepatitis A, hepatitis B, pneumococcal polysaccharide, meningococcal conjugate, and meningococcal polysaccharide vaccines can be given to women at risk of these infections. If a pregnant patient requires pneumococcal polysaccharide vaccine, it should be given during the second or third trimester, as the safety of this vaccine during the first trimester has not been established.⁹

Smallpox, measles-mumps-rubella, and varicella-containing vaccines are contraindicated in pregnancy. Household contacts of a pregnant woman should not receive smallpox vaccine, as it is the only vaccine known to cause harm to the fetus.¹⁰

Human papillomavirus vaccination is not recommended during pregnancy.

Yellow fever live-attenuated vaccine. The safety of this vaccine during pregnancy has not been established, and it is in the US Food and Drug Administration (FDA) pregnancy category C. However, this vaccine is required for entry into certain countries, and it may be offered if the patient is truly at risk of contracting yellow fever. Because pregnancy may affect immunologic response, serologic testing is recommended to document an immune response. If the patient’s itinerary puts her at low risk of yellow fever, then writing her a vaccine waiver letter can be considered.¹¹

VACCINATING IMMUNOCOMPROMISED PATIENTS (NON-HIV)

People who do not have human immunodeficiency virus (HIV) but have a condition such as functional asplenia (sickle cell disease), anatomic asplenia, or complement component deficiency are at higher risk of infection with the encapsulated bacteria Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b.

Corticosteroids, chemotherapy, radiation for hematologic or solid-organ malignancies, and immune modulators can alter the immune system and pose a risk with the use of live-attenuated vaccines. A corticosteroid dosage equivalent to 2 mg/kg of body weight per day or higher or 20 mg/day of prednisone or higher is generally considered immunosuppressive.

Candidates for organ transplantation should receive vaccinations as early as possible during the disease course leading to transplantation. Vaccinations should be given as soon as the decision is made that the patient is a candidate for transplantation, which could be years or months before the patient actually receives the transplant. In addition to reviewing previously administered vaccinations, pretransplant serologic testing for hepatitis B, varicella, measles, mumps, and rubella antibodies helps to evaluate the need for vaccination.¹²

Recipients of hematopoietic stem cell transplantation are at risk of infections with encapsulated bacteria and certain other vaccine-preventable infections. Antibody titers are significantly reduced after stem cell transplantation because of ablation of bone marrow, and thus certain vaccines should be readministered 3 to 6 months after transplantation (eg, influenza, pneumococcal, and H influenzae vaccines). If the recipient is presumed to be immunocompetent, then varicella or measles-mumps-rubella vaccine can be given 24 months after transplantation.¹³

Apart from adhering to the routine vaccination schedule and avoiding live-attenuated vaccines, specific recommendations apply to persons with immunocompromising conditions¹⁴:

Quadrivalent meningococcal conjugate vaccine should be given to adults of all ages with asplenia or complement component deficiency. The schedule includes two doses at least 2 months apart initially and then revaccination every 5 years.

H influenzae type b vaccine should be given to people with asplenia and recipients of hematopoietic stem cells. One dose is recommended for those with asplenia (functional, anatomic, or elective splenectomy) or sickle cell disease if they have not already received it. A three-dose schedule is considered for hematopoietic stem cell transplant recipients 6 to 12 months after successful transplantation.

Pneumococcal conjugate (PCV13) and pneumococcal polysaccharide (PPSV23) vaccinations are recommended for people who have immunocompromising conditions. PCV13, the newer pneumococcal vaccine, was approved by the FDA in 2010 for use in children and was recommended by the ACIP in 2012 for adults age 19 and older with immunocompromising conditions.

People who have not previously received either of these vaccines and are age 19 or older with immunocompromising conditions including asplenia, chronic renal failure, nephrotic syndrome, cerebrospinal fluid leakage, or cochlear implant should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later. One-time revaccination 5 years after the first dose of PPSV23 is recommended for patients with immunocompromising conditions.

For those who have previously been vaccinated with PPSV23, a dose of PCV13 can be given 1 or more years after the last dose of PPSV23. These dosing intervals are important, as lower opsonophagocytic antibody responses have been noted if repeat doses of either pneumococcal vaccine are given sooner than the recommended interval.¹⁵

Inactivated influenza vaccine is recommended annually, except for patients who are unlikely to respond or those who have received anti-B-cell antibodies within 6 months. Live-attenuated influenza vaccine should not be given to immunocompromised patients.

VACCINATING PATIENTS WHO HAVE HIV

People with HIV should be routinely screened for immunity against certain infections and should be offered vaccination if not immune. The response to vaccines may vary depending on the CD4 count, with a good response in patients whose infection is well controlled with antiretroviral agents and with a preserved CD4 count.¹⁶ Special considerations for HIV patients include the following:

Hepatitis A vaccine may be offered to all HIV patients who have no evidence of immunity against hepatitis A, with negative antihepatitis A total and IgG antibodies.

Human papillomavirus vaccine is recommended for men and women with HIV through age 26.

Varicella and measles-mumps-rubella are live-attenuated vaccines and may be considered in patients who are nonimmune and with CD4 counts of 200 cells/µL or higher. However, the ACIP does not make a recommendation regarding the zoster vaccine in HIV patients with CD4 cell counts of 200 cells/µL or higher. In general, live-attenuated vaccines should be avoided in patients with CD4 counts less than 200 or with severe immunocompromised status because of risk of acquiring severe, life-threatening infections.

Pneumococcal vaccine should be given to HIV patients if they have not received it before. The schedule is one dose of PCV13, followed by a dose of PPSV23 at least 8 weeks later. If a patient has been previously vaccinated with PPSV23, then PCV13 is recommended at least 1 year after PPSV23.

Inactivated influenza vaccine is recommended annually. Live-attenuated influenza vaccine should not be given.

Hepatitis B vaccine should be given to nonimmune patients without past or present hepatitis B infection. These patients require higher doses of hepatitis B vaccine (40 μg/mL) than immunocompetent patients, who receive 20 μg/mL. The options include Recombivax HB 40 μg/mL given on a three-dose schedule at 0, 1, and 6 months, and Engerix B, two 20-μg/mL injections given simultaneously on a four-dose schedule at 0, 1, 2, and 6 months.

Meningococcal vaccine. HIV infection is not an indication for meningococcal vaccine unless the patient has other risk factors, such as anatomic or functional asplenia, persistent complement component deficiency, occupational exposure, and travel to endemic areas.

VACCINATING PATIENTS WHO ARE OLDER THAN 60

The immune system deteriorates with age, as does immunity gained from previous vaccinations. Vaccination in this age group reduces the risk of illness and death.¹⁷

Zoster vaccine should be offered to people age 60 and older regardless of previous episodes of herpes zoster unless there is a contraindication such as severe immunodeficiency. The zoster vaccine can reduce the incidence of postherpetic neuralgia by 66.5% and herpes zoster by 51% in patients over age 60.¹⁸

Pneumococcal conjugate vaccine. PCV13 should be offered to all adults age 65 or older. If a person age 65 or older has not received any pneumococcal vaccine before then, PCV13 should be given first, followed by a dose of PPSV23 at least 6 to 12 months after PCV13.

Pneumococcal polysaccharide vaccine. If PPSV23 was given before age 65 for another indication, a dose of PCV 13 should be given at age 65 or later, as long as 6 to 12 months have passed since the previous dose of PPSV 23. The patient should receive the last dose of PPSV23 vaccine 5 years after the first dose of PPSV23.⁴

Influenza vaccine. People 65 or older are at higher risk of complications from influenza, and vaccine should be offered annually. High-dose inactivated influenza vaccine can be used in this age group.⁴

Tdap. If never given before, Tdap is recommended regardless of the interval since the most recent Td vaccination, followed by a Td booster every 10 years.

VACCINATING PATIENTS WHO HAVE CHRONIC KIDNEY DISEASE

Patients with chronic kidney disease are at risk of certain infections, so vaccination is an important preventive measure.¹⁹ Immunizations should be offered to all patients with chronic kidney disease regardless of the disease stage, but they are recommended during the early stages of progressive renal disease to increase the likelihood of vaccine-induced immunity.²⁰

Pneumococcal conjugate vaccine. PCV13 is recommended for adults 19 or older with chronic renal disease or nephrotic syndrome. One dose of PCV13 should be given, followed by a dose of PPSV23 at least 8 weeks later. If the patient has been previously vaccinated with PPSV23, then PCV13 at least 1 year after PPSV23 is recommended.

Hepatitis B vaccine should be given to nonimmune patients without past or present hepatitis B infection. Adult patients on hemodialysis require higher doses of hepatitis B vaccine. The options include Recombivax HB 40 μg/mL given on a three-dose schedule at 0, 1, and 6 months, and Engerix B, two 20-μg/mL injections given simultaneously on a four-dose schedule at 0, 1, 2, and 6 months.

Influenza vaccine should be offered annually to patients with chronic kidney disease.

VACCINATING IMMUNOCOMPROMISED INTERNATIONAL TRAVELERS

International travel for business or pleasure is increasingly common, and immunocompromised patients require specific attention as they may face unanticipated pathogens or have special requirements. Transplant recipients should ideally receive routine and travel-related vaccines as early as possible before transplantation. Vaccination is generally avoided in the first 6 months after organ transplantation to avoid confusion with early graft dysfunction or rejection.²¹ However, it should be considered as soon as a patient develops an illness that might lead to transplantation.

Evaluation of patients for vaccination should include an assessment of the travel-specific epidemiologic risk, the nature of the vaccine (live-attenuated or other), and the immune status. As discussed above, live-attenuated vaccines should be avoided in immunocompromised patients, and thus the injectable typhoid vaccine should be given in lieu of the attenuated oral vaccine.

Yellow fever vaccine is required before entrance to certain countries but should not be given to immunocompromised patients, although it can probably be given to asymptomatic HIV-infected adults with a CD4 count higher than 200 cells/μL who are exposed to substantial risk.²² For patients who cannot receive the vaccine, some governments will accept a physician’s letter stating the patient has a contraindication to vaccination.

VACCINATING HOUSEHOLD MEMBERS OF IMMUNOCOMPROMISED PATIENTS

Protecting immunocompromised patients from infectious diseases involves vaccinating not only the patient but also household members so that they do not acquire infections and then bring them into the household. Immunocompetent members of a household can receive inactivated vaccines based on the recommended ACIP schedule.

Annual inactivated influenza vaccination is recommended, although the live-attenuated influenza virus vaccine can be substituted if the immunocompromised patient is not within 2 months of hematopoietic stem cell transplantation, does not have graft-vs-host disease, and does not have severe combined immune deficiency.

Other live-attenuated vaccines can usually be given if indicated, including measles-mumps-rubella vaccine, rotavirus vaccine in infants, varicella vaccine, and zoster vaccine.¹⁴

Most vaccinations are given during childhood, but some require boosting during adulthood or are indicated for specific patient populations such as international travelers or those with certain medical conditions. Although generally safe, some vaccines contain live, attenuated organisms that can cause disease in immunocompromised patients. Thus, knowledge of the indications for and contraindications to specific vaccinations is critical to protect adults in special circumstances who are at risk.

See related commentary

Vaccines have helped eliminate or significantly reduce the burden of more than a dozen illnesses.^1–3 The Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention  (CDC) makes recommendations about vaccinations for normal adults and children as well as for certain groups at high risk of vaccine-preventable infections.⁴ Tables 1 and 2 summarize the recommendations for vaccination by medical condition.⁴  In addition, several applications are available online, including downloadable apps from the (www.cdc.gov/vaccines/schedules/Schedulers/adult-scheduler.html) and the American College of Physicians (http://immunization.acponline.org/app/).

HUMANITY’S GREATEST ADVANCES IN PREVENTING INFECTIOUS DISEASE

Immunization and improved sanitation are humanity’s greatest advances in preventing sickness and death from infectious diseases. Since Jenner’s discovery in 1796 that milkmaids who had contracted cowpox (vaccinia) were immune to smallpox, vaccination has eliminated smallpox, markedly decreased the incidence of many infectious diseases, and, most recently, shown efficacy in preventing cervical cancer (with the human papillomavirus vaccine) and hepatocellular cancer (with the hepatitis B vaccine).^1–3

Unfortunately, vaccination rates remain low for most routine vaccinations indicated for adults. For example, about 60% of adults over age 65 receive pneumococcal vaccination, and fewer than 10% of black patients over age 60 receive zoster vaccination.⁵ Various factors may account for these low rates, including financial disincentives.⁶

Nevertheless, vaccination remains one of medicine’s most effective defenses against infectious diseases and is especially important in the special populations discussed below. By being steadfast proponents of vaccination, especially for the most vulnerable patients, physicians can help ensure the optimum protection for their patients.

VACCINATING PREGNANT PATIENTS

When considering vaccination during pregnancy, one must consider the risk and benefit of the vaccine and the risk of the disease in both the mother and the child.

In general, if a pregnant woman is at high risk of exposure to a particular infection, the benefits of vaccinating her against it outweigh the risks. Vaccinating the mother can also protect against certain infections in early infancy through transfer of vaccine-induced immunoglobin G (IgG) across the placenta.⁷ In general, inactivated vaccines are considered safe in pregnancy, while live-attenuated vaccines are contraindicated.⁴ Special considerations for pregnant women include:

Tetanus, diphtheria, and acellular pertussis (Tdap). One dose of Tdap vaccine should be given during each pregnancy, preferably at 27 to 36 weeks of gestation, regardless of when the patient received a previous dose.⁸

Inactivated influenza vaccine should be given as early as possible during the influenza season (October to March) to all pregnant women, regardless of trimester.

Inactivated polio vaccine may be considered for pregnant women with known exposure to polio or travel to endemic areas.

Hepatitis A, hepatitis B, pneumococcal polysaccharide, meningococcal conjugate, and meningococcal polysaccharide vaccines can be given to women at risk of these infections. If a pregnant patient requires pneumococcal polysaccharide vaccine, it should be given during the second or third trimester, as the safety of this vaccine during the first trimester has not been established.⁹

Smallpox, measles-mumps-rubella, and varicella-containing vaccines are contraindicated in pregnancy. Household contacts of a pregnant woman should not receive smallpox vaccine, as it is the only vaccine known to cause harm to the fetus.¹⁰

Human papillomavirus vaccination is not recommended during pregnancy.

Yellow fever live-attenuated vaccine. The safety of this vaccine during pregnancy has not been established, and it is in the US Food and Drug Administration (FDA) pregnancy category C. However, this vaccine is required for entry into certain countries, and it may be offered if the patient is truly at risk of contracting yellow fever. Because pregnancy may affect immunologic response, serologic testing is recommended to document an immune response. If the patient’s itinerary puts her at low risk of yellow fever, then writing her a vaccine waiver letter can be considered.¹¹

VACCINATING IMMUNOCOMPROMISED PATIENTS (NON-HIV)

People who do not have human immunodeficiency virus (HIV) but have a condition such as functional asplenia (sickle cell disease), anatomic asplenia, or complement component deficiency are at higher risk of infection with the encapsulated bacteria Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b.

Corticosteroids, chemotherapy, radiation for hematologic or solid-organ malignancies, and immune modulators can alter the immune system and pose a risk with the use of live-attenuated vaccines. A corticosteroid dosage equivalent to 2 mg/kg of body weight per day or higher or 20 mg/day of prednisone or higher is generally considered immunosuppressive.

Candidates for organ transplantation should receive vaccinations as early as possible during the disease course leading to transplantation. Vaccinations should be given as soon as the decision is made that the patient is a candidate for transplantation, which could be years or months before the patient actually receives the transplant. In addition to reviewing previously administered vaccinations, pretransplant serologic testing for hepatitis B, varicella, measles, mumps, and rubella antibodies helps to evaluate the need for vaccination.¹²

Recipients of hematopoietic stem cell transplantation are at risk of infections with encapsulated bacteria and certain other vaccine-preventable infections. Antibody titers are significantly reduced after stem cell transplantation because of ablation of bone marrow, and thus certain vaccines should be readministered 3 to 6 months after transplantation (eg, influenza, pneumococcal, and H influenzae vaccines). If the recipient is presumed to be immunocompetent, then varicella or measles-mumps-rubella vaccine can be given 24 months after transplantation.¹³

Apart from adhering to the routine vaccination schedule and avoiding live-attenuated vaccines, specific recommendations apply to persons with immunocompromising conditions¹⁴:

Quadrivalent meningococcal conjugate vaccine should be given to adults of all ages with asplenia or complement component deficiency. The schedule includes two doses at least 2 months apart initially and then revaccination every 5 years.

H influenzae type b vaccine should be given to people with asplenia and recipients of hematopoietic stem cells. One dose is recommended for those with asplenia (functional, anatomic, or elective splenectomy) or sickle cell disease if they have not already received it. A three-dose schedule is considered for hematopoietic stem cell transplant recipients 6 to 12 months after successful transplantation.

Pneumococcal conjugate (PCV13) and pneumococcal polysaccharide (PPSV23) vaccinations are recommended for people who have immunocompromising conditions. PCV13, the newer pneumococcal vaccine, was approved by the FDA in 2010 for use in children and was recommended by the ACIP in 2012 for adults age 19 and older with immunocompromising conditions.

People who have not previously received either of these vaccines and are age 19 or older with immunocompromising conditions including asplenia, chronic renal failure, nephrotic syndrome, cerebrospinal fluid leakage, or cochlear implant should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later. One-time revaccination 5 years after the first dose of PPSV23 is recommended for patients with immunocompromising conditions.

For those who have previously been vaccinated with PPSV23, a dose of PCV13 can be given 1 or more years after the last dose of PPSV23. These dosing intervals are important, as lower opsonophagocytic antibody responses have been noted if repeat doses of either pneumococcal vaccine are given sooner than the recommended interval.¹⁵

Inactivated influenza vaccine is recommended annually, except for patients who are unlikely to respond or those who have received anti-B-cell antibodies within 6 months. Live-attenuated influenza vaccine should not be given to immunocompromised patients.

VACCINATING PATIENTS WHO HAVE HIV

People with HIV should be routinely screened for immunity against certain infections and should be offered vaccination if not immune. The response to vaccines may vary depending on the CD4 count, with a good response in patients whose infection is well controlled with antiretroviral agents and with a preserved CD4 count.¹⁶ Special considerations for HIV patients include the following:

Hepatitis A vaccine may be offered to all HIV patients who have no evidence of immunity against hepatitis A, with negative antihepatitis A total and IgG antibodies.

Human papillomavirus vaccine is recommended for men and women with HIV through age 26.

Varicella and measles-mumps-rubella are live-attenuated vaccines and may be considered in patients who are nonimmune and with CD4 counts of 200 cells/µL or higher. However, the ACIP does not make a recommendation regarding the zoster vaccine in HIV patients with CD4 cell counts of 200 cells/µL or higher. In general, live-attenuated vaccines should be avoided in patients with CD4 counts less than 200 or with severe immunocompromised status because of risk of acquiring severe, life-threatening infections.

Pneumococcal vaccine should be given to HIV patients if they have not received it before. The schedule is one dose of PCV13, followed by a dose of PPSV23 at least 8 weeks later. If a patient has been previously vaccinated with PPSV23, then PCV13 is recommended at least 1 year after PPSV23.

Inactivated influenza vaccine is recommended annually. Live-attenuated influenza vaccine should not be given.

Hepatitis B vaccine should be given to nonimmune patients without past or present hepatitis B infection. These patients require higher doses of hepatitis B vaccine (40 μg/mL) than immunocompetent patients, who receive 20 μg/mL. The options include Recombivax HB 40 μg/mL given on a three-dose schedule at 0, 1, and 6 months, and Engerix B, two 20-μg/mL injections given simultaneously on a four-dose schedule at 0, 1, 2, and 6 months.

Meningococcal vaccine. HIV infection is not an indication for meningococcal vaccine unless the patient has other risk factors, such as anatomic or functional asplenia, persistent complement component deficiency, occupational exposure, and travel to endemic areas.

VACCINATING PATIENTS WHO ARE OLDER THAN 60

The immune system deteriorates with age, as does immunity gained from previous vaccinations. Vaccination in this age group reduces the risk of illness and death.¹⁷

Zoster vaccine should be offered to people age 60 and older regardless of previous episodes of herpes zoster unless there is a contraindication such as severe immunodeficiency. The zoster vaccine can reduce the incidence of postherpetic neuralgia by 66.5% and herpes zoster by 51% in patients over age 60.¹⁸

Pneumococcal conjugate vaccine. PCV13 should be offered to all adults age 65 or older. If a person age 65 or older has not received any pneumococcal vaccine before then, PCV13 should be given first, followed by a dose of PPSV23 at least 6 to 12 months after PCV13.

Pneumococcal polysaccharide vaccine. If PPSV23 was given before age 65 for another indication, a dose of PCV 13 should be given at age 65 or later, as long as 6 to 12 months have passed since the previous dose of PPSV 23. The patient should receive the last dose of PPSV23 vaccine 5 years after the first dose of PPSV23.⁴

Influenza vaccine. People 65 or older are at higher risk of complications from influenza, and vaccine should be offered annually. High-dose inactivated influenza vaccine can be used in this age group.⁴

Tdap. If never given before, Tdap is recommended regardless of the interval since the most recent Td vaccination, followed by a Td booster every 10 years.

VACCINATING PATIENTS WHO HAVE CHRONIC KIDNEY DISEASE

Patients with chronic kidney disease are at risk of certain infections, so vaccination is an important preventive measure.¹⁹ Immunizations should be offered to all patients with chronic kidney disease regardless of the disease stage, but they are recommended during the early stages of progressive renal disease to increase the likelihood of vaccine-induced immunity.²⁰

Pneumococcal conjugate vaccine. PCV13 is recommended for adults 19 or older with chronic renal disease or nephrotic syndrome. One dose of PCV13 should be given, followed by a dose of PPSV23 at least 8 weeks later. If the patient has been previously vaccinated with PPSV23, then PCV13 at least 1 year after PPSV23 is recommended.

Hepatitis B vaccine should be given to nonimmune patients without past or present hepatitis B infection. Adult patients on hemodialysis require higher doses of hepatitis B vaccine. The options include Recombivax HB 40 μg/mL given on a three-dose schedule at 0, 1, and 6 months, and Engerix B, two 20-μg/mL injections given simultaneously on a four-dose schedule at 0, 1, 2, and 6 months.

Influenza vaccine should be offered annually to patients with chronic kidney disease.

VACCINATING IMMUNOCOMPROMISED INTERNATIONAL TRAVELERS

International travel for business or pleasure is increasingly common, and immunocompromised patients require specific attention as they may face unanticipated pathogens or have special requirements. Transplant recipients should ideally receive routine and travel-related vaccines as early as possible before transplantation. Vaccination is generally avoided in the first 6 months after organ transplantation to avoid confusion with early graft dysfunction or rejection.²¹ However, it should be considered as soon as a patient develops an illness that might lead to transplantation.

Evaluation of patients for vaccination should include an assessment of the travel-specific epidemiologic risk, the nature of the vaccine (live-attenuated or other), and the immune status. As discussed above, live-attenuated vaccines should be avoided in immunocompromised patients, and thus the injectable typhoid vaccine should be given in lieu of the attenuated oral vaccine.

Yellow fever vaccine is required before entrance to certain countries but should not be given to immunocompromised patients, although it can probably be given to asymptomatic HIV-infected adults with a CD4 count higher than 200 cells/μL who are exposed to substantial risk.²² For patients who cannot receive the vaccine, some governments will accept a physician’s letter stating the patient has a contraindication to vaccination.

VACCINATING HOUSEHOLD MEMBERS OF IMMUNOCOMPROMISED PATIENTS

Protecting immunocompromised patients from infectious diseases involves vaccinating not only the patient but also household members so that they do not acquire infections and then bring them into the household. Immunocompetent members of a household can receive inactivated vaccines based on the recommended ACIP schedule.

Annual inactivated influenza vaccination is recommended, although the live-attenuated influenza virus vaccine can be substituted if the immunocompromised patient is not within 2 months of hematopoietic stem cell transplantation, does not have graft-vs-host disease, and does not have severe combined immune deficiency.

Other live-attenuated vaccines can usually be given if indicated, including measles-mumps-rubella vaccine, rotavirus vaccine in infants, varicella vaccine, and zoster vaccine.¹⁴

Most vaccinations are given during childhood, but some require boosting during adulthood or are indicated for specific patient populations such as international travelers or those with certain medical conditions. Although generally safe, some vaccines contain live, attenuated organisms that can cause disease in immunocompromised patients. Thus, knowledge of the indications for and contraindications to specific vaccinations is critical to protect adults in special circumstances who are at risk.

See related commentary

Vaccines have helped eliminate or significantly reduce the burden of more than a dozen illnesses.^1–3 The Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention  (CDC) makes recommendations about vaccinations for normal adults and children as well as for certain groups at high risk of vaccine-preventable infections.⁴ Tables 1 and 2 summarize the recommendations for vaccination by medical condition.⁴  In addition, several applications are available online, including downloadable apps from the (www.cdc.gov/vaccines/schedules/Schedulers/adult-scheduler.html) and the American College of Physicians (http://immunization.acponline.org/app/).

HUMANITY’S GREATEST ADVANCES IN PREVENTING INFECTIOUS DISEASE

Immunization and improved sanitation are humanity’s greatest advances in preventing sickness and death from infectious diseases. Since Jenner’s discovery in 1796 that milkmaids who had contracted cowpox (vaccinia) were immune to smallpox, vaccination has eliminated smallpox, markedly decreased the incidence of many infectious diseases, and, most recently, shown efficacy in preventing cervical cancer (with the human papillomavirus vaccine) and hepatocellular cancer (with the hepatitis B vaccine).^1–3

Unfortunately, vaccination rates remain low for most routine vaccinations indicated for adults. For example, about 60% of adults over age 65 receive pneumococcal vaccination, and fewer than 10% of black patients over age 60 receive zoster vaccination.⁵ Various factors may account for these low rates, including financial disincentives.⁶

Nevertheless, vaccination remains one of medicine’s most effective defenses against infectious diseases and is especially important in the special populations discussed below. By being steadfast proponents of vaccination, especially for the most vulnerable patients, physicians can help ensure the optimum protection for their patients.

VACCINATING PREGNANT PATIENTS

When considering vaccination during pregnancy, one must consider the risk and benefit of the vaccine and the risk of the disease in both the mother and the child.

In general, if a pregnant woman is at high risk of exposure to a particular infection, the benefits of vaccinating her against it outweigh the risks. Vaccinating the mother can also protect against certain infections in early infancy through transfer of vaccine-induced immunoglobin G (IgG) across the placenta.⁷ In general, inactivated vaccines are considered safe in pregnancy, while live-attenuated vaccines are contraindicated.⁴ Special considerations for pregnant women include:

Tetanus, diphtheria, and acellular pertussis (Tdap). One dose of Tdap vaccine should be given during each pregnancy, preferably at 27 to 36 weeks of gestation, regardless of when the patient received a previous dose.⁸

Inactivated influenza vaccine should be given as early as possible during the influenza season (October to March) to all pregnant women, regardless of trimester.

Inactivated polio vaccine may be considered for pregnant women with known exposure to polio or travel to endemic areas.

Hepatitis A, hepatitis B, pneumococcal polysaccharide, meningococcal conjugate, and meningococcal polysaccharide vaccines can be given to women at risk of these infections. If a pregnant patient requires pneumococcal polysaccharide vaccine, it should be given during the second or third trimester, as the safety of this vaccine during the first trimester has not been established.⁹

Smallpox, measles-mumps-rubella, and varicella-containing vaccines are contraindicated in pregnancy. Household contacts of a pregnant woman should not receive smallpox vaccine, as it is the only vaccine known to cause harm to the fetus.¹⁰

Human papillomavirus vaccination is not recommended during pregnancy.

Yellow fever live-attenuated vaccine. The safety of this vaccine during pregnancy has not been established, and it is in the US Food and Drug Administration (FDA) pregnancy category C. However, this vaccine is required for entry into certain countries, and it may be offered if the patient is truly at risk of contracting yellow fever. Because pregnancy may affect immunologic response, serologic testing is recommended to document an immune response. If the patient’s itinerary puts her at low risk of yellow fever, then writing her a vaccine waiver letter can be considered.¹¹

VACCINATING IMMUNOCOMPROMISED PATIENTS (NON-HIV)

People who do not have human immunodeficiency virus (HIV) but have a condition such as functional asplenia (sickle cell disease), anatomic asplenia, or complement component deficiency are at higher risk of infection with the encapsulated bacteria Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b.

Corticosteroids, chemotherapy, radiation for hematologic or solid-organ malignancies, and immune modulators can alter the immune system and pose a risk with the use of live-attenuated vaccines. A corticosteroid dosage equivalent to 2 mg/kg of body weight per day or higher or 20 mg/day of prednisone or higher is generally considered immunosuppressive.

Candidates for organ transplantation should receive vaccinations as early as possible during the disease course leading to transplantation. Vaccinations should be given as soon as the decision is made that the patient is a candidate for transplantation, which could be years or months before the patient actually receives the transplant. In addition to reviewing previously administered vaccinations, pretransplant serologic testing for hepatitis B, varicella, measles, mumps, and rubella antibodies helps to evaluate the need for vaccination.¹²

Recipients of hematopoietic stem cell transplantation are at risk of infections with encapsulated bacteria and certain other vaccine-preventable infections. Antibody titers are significantly reduced after stem cell transplantation because of ablation of bone marrow, and thus certain vaccines should be readministered 3 to 6 months after transplantation (eg, influenza, pneumococcal, and H influenzae vaccines). If the recipient is presumed to be immunocompetent, then varicella or measles-mumps-rubella vaccine can be given 24 months after transplantation.¹³

Apart from adhering to the routine vaccination schedule and avoiding live-attenuated vaccines, specific recommendations apply to persons with immunocompromising conditions¹⁴:

Quadrivalent meningococcal conjugate vaccine should be given to adults of all ages with asplenia or complement component deficiency. The schedule includes two doses at least 2 months apart initially and then revaccination every 5 years.

H influenzae type b vaccine should be given to people with asplenia and recipients of hematopoietic stem cells. One dose is recommended for those with asplenia (functional, anatomic, or elective splenectomy) or sickle cell disease if they have not already received it. A three-dose schedule is considered for hematopoietic stem cell transplant recipients 6 to 12 months after successful transplantation.

Pneumococcal conjugate (PCV13) and pneumococcal polysaccharide (PPSV23) vaccinations are recommended for people who have immunocompromising conditions. PCV13, the newer pneumococcal vaccine, was approved by the FDA in 2010 for use in children and was recommended by the ACIP in 2012 for adults age 19 and older with immunocompromising conditions.

People who have not previously received either of these vaccines and are age 19 or older with immunocompromising conditions including asplenia, chronic renal failure, nephrotic syndrome, cerebrospinal fluid leakage, or cochlear implant should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later. One-time revaccination 5 years after the first dose of PPSV23 is recommended for patients with immunocompromising conditions.

For those who have previously been vaccinated with PPSV23, a dose of PCV13 can be given 1 or more years after the last dose of PPSV23. These dosing intervals are important, as lower opsonophagocytic antibody responses have been noted if repeat doses of either pneumococcal vaccine are given sooner than the recommended interval.¹⁵

Inactivated influenza vaccine is recommended annually, except for patients who are unlikely to respond or those who have received anti-B-cell antibodies within 6 months. Live-attenuated influenza vaccine should not be given to immunocompromised patients.

VACCINATING PATIENTS WHO HAVE HIV

People with HIV should be routinely screened for immunity against certain infections and should be offered vaccination if not immune. The response to vaccines may vary depending on the CD4 count, with a good response in patients whose infection is well controlled with antiretroviral agents and with a preserved CD4 count.¹⁶ Special considerations for HIV patients include the following:

Hepatitis A vaccine may be offered to all HIV patients who have no evidence of immunity against hepatitis A, with negative antihepatitis A total and IgG antibodies.

Human papillomavirus vaccine is recommended for men and women with HIV through age 26.

Varicella and measles-mumps-rubella are live-attenuated vaccines and may be considered in patients who are nonimmune and with CD4 counts of 200 cells/µL or higher. However, the ACIP does not make a recommendation regarding the zoster vaccine in HIV patients with CD4 cell counts of 200 cells/µL or higher. In general, live-attenuated vaccines should be avoided in patients with CD4 counts less than 200 or with severe immunocompromised status because of risk of acquiring severe, life-threatening infections.

Pneumococcal vaccine should be given to HIV patients if they have not received it before. The schedule is one dose of PCV13, followed by a dose of PPSV23 at least 8 weeks later. If a patient has been previously vaccinated with PPSV23, then PCV13 is recommended at least 1 year after PPSV23.

Inactivated influenza vaccine is recommended annually. Live-attenuated influenza vaccine should not be given.

Hepatitis B vaccine should be given to nonimmune patients without past or present hepatitis B infection. These patients require higher doses of hepatitis B vaccine (40 μg/mL) than immunocompetent patients, who receive 20 μg/mL. The options include Recombivax HB 40 μg/mL given on a three-dose schedule at 0, 1, and 6 months, and Engerix B, two 20-μg/mL injections given simultaneously on a four-dose schedule at 0, 1, 2, and 6 months.

Meningococcal vaccine. HIV infection is not an indication for meningococcal vaccine unless the patient has other risk factors, such as anatomic or functional asplenia, persistent complement component deficiency, occupational exposure, and travel to endemic areas.

VACCINATING PATIENTS WHO ARE OLDER THAN 60

The immune system deteriorates with age, as does immunity gained from previous vaccinations. Vaccination in this age group reduces the risk of illness and death.¹⁷

Zoster vaccine should be offered to people age 60 and older regardless of previous episodes of herpes zoster unless there is a contraindication such as severe immunodeficiency. The zoster vaccine can reduce the incidence of postherpetic neuralgia by 66.5% and herpes zoster by 51% in patients over age 60.¹⁸

Pneumococcal conjugate vaccine. PCV13 should be offered to all adults age 65 or older. If a person age 65 or older has not received any pneumococcal vaccine before then, PCV13 should be given first, followed by a dose of PPSV23 at least 6 to 12 months after PCV13.

Pneumococcal polysaccharide vaccine. If PPSV23 was given before age 65 for another indication, a dose of PCV 13 should be given at age 65 or later, as long as 6 to 12 months have passed since the previous dose of PPSV 23. The patient should receive the last dose of PPSV23 vaccine 5 years after the first dose of PPSV23.⁴

Influenza vaccine. People 65 or older are at higher risk of complications from influenza, and vaccine should be offered annually. High-dose inactivated influenza vaccine can be used in this age group.⁴

Tdap. If never given before, Tdap is recommended regardless of the interval since the most recent Td vaccination, followed by a Td booster every 10 years.

VACCINATING PATIENTS WHO HAVE CHRONIC KIDNEY DISEASE

Patients with chronic kidney disease are at risk of certain infections, so vaccination is an important preventive measure.¹⁹ Immunizations should be offered to all patients with chronic kidney disease regardless of the disease stage, but they are recommended during the early stages of progressive renal disease to increase the likelihood of vaccine-induced immunity.²⁰

Pneumococcal conjugate vaccine. PCV13 is recommended for adults 19 or older with chronic renal disease or nephrotic syndrome. One dose of PCV13 should be given, followed by a dose of PPSV23 at least 8 weeks later. If the patient has been previously vaccinated with PPSV23, then PCV13 at least 1 year after PPSV23 is recommended.

Hepatitis B vaccine should be given to nonimmune patients without past or present hepatitis B infection. Adult patients on hemodialysis require higher doses of hepatitis B vaccine. The options include Recombivax HB 40 μg/mL given on a three-dose schedule at 0, 1, and 6 months, and Engerix B, two 20-μg/mL injections given simultaneously on a four-dose schedule at 0, 1, 2, and 6 months.

Influenza vaccine should be offered annually to patients with chronic kidney disease.

VACCINATING IMMUNOCOMPROMISED INTERNATIONAL TRAVELERS

International travel for business or pleasure is increasingly common, and immunocompromised patients require specific attention as they may face unanticipated pathogens or have special requirements. Transplant recipients should ideally receive routine and travel-related vaccines as early as possible before transplantation. Vaccination is generally avoided in the first 6 months after organ transplantation to avoid confusion with early graft dysfunction or rejection.²¹ However, it should be considered as soon as a patient develops an illness that might lead to transplantation.

Evaluation of patients for vaccination should include an assessment of the travel-specific epidemiologic risk, the nature of the vaccine (live-attenuated or other), and the immune status. As discussed above, live-attenuated vaccines should be avoided in immunocompromised patients, and thus the injectable typhoid vaccine should be given in lieu of the attenuated oral vaccine.

Yellow fever vaccine is required before entrance to certain countries but should not be given to immunocompromised patients, although it can probably be given to asymptomatic HIV-infected adults with a CD4 count higher than 200 cells/μL who are exposed to substantial risk.²² For patients who cannot receive the vaccine, some governments will accept a physician’s letter stating the patient has a contraindication to vaccination.

VACCINATING HOUSEHOLD MEMBERS OF IMMUNOCOMPROMISED PATIENTS

Protecting immunocompromised patients from infectious diseases involves vaccinating not only the patient but also household members so that they do not acquire infections and then bring them into the household. Immunocompetent members of a household can receive inactivated vaccines based on the recommended ACIP schedule.

Annual inactivated influenza vaccination is recommended, although the live-attenuated influenza virus vaccine can be substituted if the immunocompromised patient is not within 2 months of hematopoietic stem cell transplantation, does not have graft-vs-host disease, and does not have severe combined immune deficiency.

Other live-attenuated vaccines can usually be given if indicated, including measles-mumps-rubella vaccine, rotavirus vaccine in infants, varicella vaccine, and zoster vaccine.¹⁴

In the April 2015 issue, on page 214 in the article by Jin XW, McKenzie ML, Yen-Lieberman B, “Can the test for human papillomavirus DNA be used as a stand-alone, first-line screening test for cervical cancer?”, the source for the information on predictive values was not cited. The final bulleted item should have read as follows:

• HPV testing by itself performed better than Pap-HPV cotesting, with positive predictive values of 12.25% vs 11.04% and negative predictive values of 99.58% vs 99.52% (data presented to the FDA Medical Devices Advisory Committee, Microbiology Panel. March 12, 2014. FDA Executive Summary).

This oversight has been corrected in the online version of the article.

In the April 2015 issue, on page 214 in the article by Jin XW, McKenzie ML, Yen-Lieberman B, “Can the test for human papillomavirus DNA be used as a stand-alone, first-line screening test for cervical cancer?”, the source for the information on predictive values was not cited. The final bulleted item should have read as follows:

• HPV testing by itself performed better than Pap-HPV cotesting, with positive predictive values of 12.25% vs 11.04% and negative predictive values of 99.58% vs 99.52% (data presented to the FDA Medical Devices Advisory Committee, Microbiology Panel. March 12, 2014. FDA Executive Summary).

This oversight has been corrected in the online version of the article.

In the April 2015 issue, on page 214 in the article by Jin XW, McKenzie ML, Yen-Lieberman B, “Can the test for human papillomavirus DNA be used as a stand-alone, first-line screening test for cervical cancer?”, the source for the information on predictive values was not cited. The final bulleted item should have read as follows:

• HPV testing by itself performed better than Pap-HPV cotesting, with positive predictive values of 12.25% vs 11.04% and negative predictive values of 99.58% vs 99.52% (data presented to the FDA Medical Devices Advisory Committee, Microbiology Panel. March 12, 2014. FDA Executive Summary).

This oversight has been corrected in the online version of the article.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

In April 2013, The Joint Commission issued a Sentinel Event Alert that provided hospitals with recommendations for assessing their individual circumstances and developing a systematic, coordinated approach regarding medical device alarms.

The recommendations correspond with those of the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute. Most of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.

The recommendations include the following:

1. Create a process for safe alarm management and response in high-risk areas;
2. Inventory alarm-equipped medical devices used for high-risk areas and conditions, and identify default alarm settings;
3. Have guidelines for tailoring alarm settings and limits for individual patients; and
4. Inspect, check, and maintain alarm-equipped devices.

The Joint Commission alert also recommended training and education for all clinical care team members on safe alarm management and response in high-risk areas. Organizations should also consider ways to reduce nuisance alarm signals.

“Patient harm and death that is caused by factors related to alarm management has persisted as the top patient safety issue,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill.

In addition to the alert and existing accreditation standards regarding alarm safety, The Joint Commission issued 2014 National Patient Safety Goals to help healthcare organizations address this issue.

Beginning in January 2014, hospitals were required to identify the most important alarms to manage based on their own internal situations. In phase 2, beginning in January 2016, hospitals will be expected to develop and implement specific components of alarm policies and procedures that address such items as clinically appropriate settings, when settings can be changed, and who is allowed to make such changes. Requirements only apply to organizations accredited by The Joint Commission.

In April 2013, The Joint Commission issued a Sentinel Event Alert that provided hospitals with recommendations for assessing their individual circumstances and developing a systematic, coordinated approach regarding medical device alarms.

The recommendations correspond with those of the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute. Most of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.

The recommendations include the following:

1. Create a process for safe alarm management and response in high-risk areas;
2. Inventory alarm-equipped medical devices used for high-risk areas and conditions, and identify default alarm settings;
3. Have guidelines for tailoring alarm settings and limits for individual patients; and
4. Inspect, check, and maintain alarm-equipped devices.

The Joint Commission alert also recommended training and education for all clinical care team members on safe alarm management and response in high-risk areas. Organizations should also consider ways to reduce nuisance alarm signals.

“Patient harm and death that is caused by factors related to alarm management has persisted as the top patient safety issue,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill.

In addition to the alert and existing accreditation standards regarding alarm safety, The Joint Commission issued 2014 National Patient Safety Goals to help healthcare organizations address this issue.

Beginning in January 2014, hospitals were required to identify the most important alarms to manage based on their own internal situations. In phase 2, beginning in January 2016, hospitals will be expected to develop and implement specific components of alarm policies and procedures that address such items as clinically appropriate settings, when settings can be changed, and who is allowed to make such changes. Requirements only apply to organizations accredited by The Joint Commission.

In April 2013, The Joint Commission issued a Sentinel Event Alert that provided hospitals with recommendations for assessing their individual circumstances and developing a systematic, coordinated approach regarding medical device alarms.

The recommendations correspond with those of the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute. Most of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.

The recommendations include the following:

1. Create a process for safe alarm management and response in high-risk areas;
2. Inventory alarm-equipped medical devices used for high-risk areas and conditions, and identify default alarm settings;
3. Have guidelines for tailoring alarm settings and limits for individual patients; and
4. Inspect, check, and maintain alarm-equipped devices.

The Joint Commission alert also recommended training and education for all clinical care team members on safe alarm management and response in high-risk areas. Organizations should also consider ways to reduce nuisance alarm signals.

“Patient harm and death that is caused by factors related to alarm management has persisted as the top patient safety issue,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill.

In addition to the alert and existing accreditation standards regarding alarm safety, The Joint Commission issued 2014 National Patient Safety Goals to help healthcare organizations address this issue.

Beginning in January 2014, hospitals were required to identify the most important alarms to manage based on their own internal situations. In phase 2, beginning in January 2016, hospitals will be expected to develop and implement specific components of alarm policies and procedures that address such items as clinically appropriate settings, when settings can be changed, and who is allowed to make such changes. Requirements only apply to organizations accredited by The Joint Commission.

As you may have heard, H.R. 876, a bill unanimously passed in the House recently, requires a hospital to give adequate oral and written notification of a patient’s observation status. The bill has now moved to the Senate.

“Notice of Observation Treatment and Implication for Care Eligibility Act,” known as the NOTICE Act, was sponsored by Rep. Lloyd Doggett (D-Texas) and co-sponsored by Rep. Earl Blumenauer (D-Ore.), Rep. Charles Rangel (D-N.Y.), and Rep. Todd Young (R-Ind.), all known to be admirable patient care advocates.

The bill proposes requiring that any patient who has been classified as observation status for more than 24 hours be given oral and written notice within 36 hours of that classification. That notice must include the reason for and implications of that status, including lack of coverage for services and cost sharing under Medicare Part B, as well as the name and title of the hospital staff who gave the oral notification. Written notification must be signed by the patient or, if the patient refuses, by the staff who presented it.

Although it is essential that patients are aware of observation status and its implications, this bill would not solve the underlying problem and would only create divisions between patients and the staff caring for them. Two issues stand out:

1. Observation status is not currently a medical determination; and
2. Hospitalized medical patients should not be considered outpatients.

When a patient is admitted to the hospital, acute inpatient versus observation status is often assigned by a non-clinician in the form of a “verbal” order before the attending hospitalist meets or even hears of the patient. This order must be signed promptly by that hospitalist to prevent penalization for lack of medical record compliance. Increasingly, more of these orders are for observation status, as hospitals fear bounty-hunting recovery audit contractors (RACs) in pursuit of “Medicare fraud.”

Under H.R. 876, the situation is further intensified for both clinicians and patients. Picture yourself in the middle of a busy day at your hospital, admitting and discharging patients, stabilizing critically ill patients, and discussing goals of care with patients given life-altering diagnoses. Your pager goes off.

“Mrs. H. on 6th Floor East wants to talk to you right away,” the conversation starts. Mrs. H is in tears, and her family is angry. “We were just told that Grandma is observation status, not admitted to the hospital! This makes no sense!”

Forty-five minutes later, you have agreed, commiserated, and let them know you have absolutely no control over the designation. To you, Mrs. H. is medically ill enough to require hospitalization, and she and her family agree, but Medicare regulations and fear of RAC audits keep her on observation status. What have you accomplished during that time?

H.R. 876 is not the problem, and it is clearly well intentioned. I regularly inform patients when I’m aware of their observation status, because it’s a lousy situation for the patient. We should all be doing as much.

But H.R. 876 is not the solution, either, because it does not address the core problems with observation policy. Now is the time for us all to step forward, voicing our support of SHM as it works to change observation status as we now know it. It is not an easy task. The ultimate goal is to be able to consider all hospitalized medical patients what they really are: inpatients.

Dr. Johnson is clinical associate professor in the department of internal medicine at the University of Iowa Carver College of Medicine. She is a member of the SHM Public Policy Committee and was one of the authors of the SHM PPC white paper on observation status released in July 2014.

As you may have heard, H.R. 876, a bill unanimously passed in the House recently, requires a hospital to give adequate oral and written notification of a patient’s observation status. The bill has now moved to the Senate.

“Notice of Observation Treatment and Implication for Care Eligibility Act,” known as the NOTICE Act, was sponsored by Rep. Lloyd Doggett (D-Texas) and co-sponsored by Rep. Earl Blumenauer (D-Ore.), Rep. Charles Rangel (D-N.Y.), and Rep. Todd Young (R-Ind.), all known to be admirable patient care advocates.

The bill proposes requiring that any patient who has been classified as observation status for more than 24 hours be given oral and written notice within 36 hours of that classification. That notice must include the reason for and implications of that status, including lack of coverage for services and cost sharing under Medicare Part B, as well as the name and title of the hospital staff who gave the oral notification. Written notification must be signed by the patient or, if the patient refuses, by the staff who presented it.

Although it is essential that patients are aware of observation status and its implications, this bill would not solve the underlying problem and would only create divisions between patients and the staff caring for them. Two issues stand out:

1. Observation status is not currently a medical determination; and
2. Hospitalized medical patients should not be considered outpatients.

When a patient is admitted to the hospital, acute inpatient versus observation status is often assigned by a non-clinician in the form of a “verbal” order before the attending hospitalist meets or even hears of the patient. This order must be signed promptly by that hospitalist to prevent penalization for lack of medical record compliance. Increasingly, more of these orders are for observation status, as hospitals fear bounty-hunting recovery audit contractors (RACs) in pursuit of “Medicare fraud.”

Under H.R. 876, the situation is further intensified for both clinicians and patients. Picture yourself in the middle of a busy day at your hospital, admitting and discharging patients, stabilizing critically ill patients, and discussing goals of care with patients given life-altering diagnoses. Your pager goes off.

“Mrs. H. on 6th Floor East wants to talk to you right away,” the conversation starts. Mrs. H is in tears, and her family is angry. “We were just told that Grandma is observation status, not admitted to the hospital! This makes no sense!”

Forty-five minutes later, you have agreed, commiserated, and let them know you have absolutely no control over the designation. To you, Mrs. H. is medically ill enough to require hospitalization, and she and her family agree, but Medicare regulations and fear of RAC audits keep her on observation status. What have you accomplished during that time?

H.R. 876 is not the problem, and it is clearly well intentioned. I regularly inform patients when I’m aware of their observation status, because it’s a lousy situation for the patient. We should all be doing as much.

But H.R. 876 is not the solution, either, because it does not address the core problems with observation policy. Now is the time for us all to step forward, voicing our support of SHM as it works to change observation status as we now know it. It is not an easy task. The ultimate goal is to be able to consider all hospitalized medical patients what they really are: inpatients.

Dr. Johnson is clinical associate professor in the department of internal medicine at the University of Iowa Carver College of Medicine. She is a member of the SHM Public Policy Committee and was one of the authors of the SHM PPC white paper on observation status released in July 2014.

As you may have heard, H.R. 876, a bill unanimously passed in the House recently, requires a hospital to give adequate oral and written notification of a patient’s observation status. The bill has now moved to the Senate.

“Notice of Observation Treatment and Implication for Care Eligibility Act,” known as the NOTICE Act, was sponsored by Rep. Lloyd Doggett (D-Texas) and co-sponsored by Rep. Earl Blumenauer (D-Ore.), Rep. Charles Rangel (D-N.Y.), and Rep. Todd Young (R-Ind.), all known to be admirable patient care advocates.

The bill proposes requiring that any patient who has been classified as observation status for more than 24 hours be given oral and written notice within 36 hours of that classification. That notice must include the reason for and implications of that status, including lack of coverage for services and cost sharing under Medicare Part B, as well as the name and title of the hospital staff who gave the oral notification. Written notification must be signed by the patient or, if the patient refuses, by the staff who presented it.

Although it is essential that patients are aware of observation status and its implications, this bill would not solve the underlying problem and would only create divisions between patients and the staff caring for them. Two issues stand out:

1. Observation status is not currently a medical determination; and
2. Hospitalized medical patients should not be considered outpatients.

When a patient is admitted to the hospital, acute inpatient versus observation status is often assigned by a non-clinician in the form of a “verbal” order before the attending hospitalist meets or even hears of the patient. This order must be signed promptly by that hospitalist to prevent penalization for lack of medical record compliance. Increasingly, more of these orders are for observation status, as hospitals fear bounty-hunting recovery audit contractors (RACs) in pursuit of “Medicare fraud.”

Under H.R. 876, the situation is further intensified for both clinicians and patients. Picture yourself in the middle of a busy day at your hospital, admitting and discharging patients, stabilizing critically ill patients, and discussing goals of care with patients given life-altering diagnoses. Your pager goes off.

“Mrs. H. on 6th Floor East wants to talk to you right away,” the conversation starts. Mrs. H is in tears, and her family is angry. “We were just told that Grandma is observation status, not admitted to the hospital! This makes no sense!”

Forty-five minutes later, you have agreed, commiserated, and let them know you have absolutely no control over the designation. To you, Mrs. H. is medically ill enough to require hospitalization, and she and her family agree, but Medicare regulations and fear of RAC audits keep her on observation status. What have you accomplished during that time?

H.R. 876 is not the problem, and it is clearly well intentioned. I regularly inform patients when I’m aware of their observation status, because it’s a lousy situation for the patient. We should all be doing as much.

But H.R. 876 is not the solution, either, because it does not address the core problems with observation policy. Now is the time for us all to step forward, voicing our support of SHM as it works to change observation status as we now know it. It is not an easy task. The ultimate goal is to be able to consider all hospitalized medical patients what they really are: inpatients.

Dr. Johnson is clinical associate professor in the department of internal medicine at the University of Iowa Carver College of Medicine. She is a member of the SHM Public Policy Committee and was one of the authors of the SHM PPC white paper on observation status released in July 2014.

SHM’s new Engagement Benchmarking Service helps hospital medicine groups (HMGs) better understand how to engage their physicians for increased retention and performance. Now, SHM is offering the service free to SHM members as a way to build a database and familiarize HMGs with the value of the service. For details, visit www.hospitalmedicine.org/engage.

SHM’s new Engagement Benchmarking Service helps hospital medicine groups (HMGs) better understand how to engage their physicians for increased retention and performance. Now, SHM is offering the service free to SHM members as a way to build a database and familiarize HMGs with the value of the service. For details, visit www.hospitalmedicine.org/engage.

SHM’s new Engagement Benchmarking Service helps hospital medicine groups (HMGs) better understand how to engage their physicians for increased retention and performance. Now, SHM is offering the service free to SHM members as a way to build a database and familiarize HMGs with the value of the service. For details, visit www.hospitalmedicine.org/engage.

More than 7,000 hospitalists have logged in to HMX to ask questions and share successes. These are the top topics hospitalists are discussing on HMX:

• PICC Line in IV Drug Users;
• Hospitalists Who Do Procedures;
• Census Cap Policies;
• Case Logs for Treating Patients on the Floors; and
• Medication Reconciliation.

Join the discussion—or start your own—today at www.hmxchange.org.

More than 7,000 hospitalists have logged in to HMX to ask questions and share successes. These are the top topics hospitalists are discussing on HMX:

• PICC Line in IV Drug Users;
• Hospitalists Who Do Procedures;
• Census Cap Policies;
• Case Logs for Treating Patients on the Floors; and
• Medication Reconciliation.

Join the discussion—or start your own—today at www.hmxchange.org.

More than 7,000 hospitalists have logged in to HMX to ask questions and share successes. These are the top topics hospitalists are discussing on HMX:

• PICC Line in IV Drug Users;
• Hospitalists Who Do Procedures;
• Census Cap Policies;
• Case Logs for Treating Patients on the Floors; and
• Medication Reconciliation.

Join the discussion—or start your own—today at www.hmxchange.org.

New Patient Experience Community and Resources

SHM’s new Patient Experience Committee has begun convening resources and people to help hospitalists address the patient experience. In addition to new resources on the SHM website, SHM has set up an HMX community specifically dedicated to the many issues related to the experience of patients in the hospital. To get involved, visit www.hospitalmedicine.org/patientexperience.

Project BOOST On-Demand Webinar Available

It’s never too late—or too early—to think about improving processes to reduce readmissions. SHM’s Project BOOST now accepts program applications throughout the year, and the recent webinar with Project BOOST program leaders is now available for free online. www.hospitalmedicine.org/boost.

Glycemic Control Implementation Guide available in June.

Glycemic control and the management of diabetic patients can be challenging for hospitalists. That’s why SHM is presenting the new Glycemic Control Implementation Guide. Recent webinars are available, too, at www.hospitalmedicine.org/qi.

Free CME on Acute Coronary Syndrome

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die because of an acute myocardial infarction. Now, SHM is presenting a free self-directed web-based activity designed to help hospitalists evaluate practices and strategies to affect outcomes. For details, visit www.hospitalmedicine.org/qi.

This educational initiative is supported by an educational grant from AstraZeneca.

New Patient Experience Community and Resources

SHM’s new Patient Experience Committee has begun convening resources and people to help hospitalists address the patient experience. In addition to new resources on the SHM website, SHM has set up an HMX community specifically dedicated to the many issues related to the experience of patients in the hospital. To get involved, visit www.hospitalmedicine.org/patientexperience.

Project BOOST On-Demand Webinar Available

It’s never too late—or too early—to think about improving processes to reduce readmissions. SHM’s Project BOOST now accepts program applications throughout the year, and the recent webinar with Project BOOST program leaders is now available for free online. www.hospitalmedicine.org/boost.

Glycemic Control Implementation Guide available in June.

Glycemic control and the management of diabetic patients can be challenging for hospitalists. That’s why SHM is presenting the new Glycemic Control Implementation Guide. Recent webinars are available, too, at www.hospitalmedicine.org/qi.

Free CME on Acute Coronary Syndrome

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die because of an acute myocardial infarction. Now, SHM is presenting a free self-directed web-based activity designed to help hospitalists evaluate practices and strategies to affect outcomes. For details, visit www.hospitalmedicine.org/qi.

This educational initiative is supported by an educational grant from AstraZeneca.

New Patient Experience Community and Resources

SHM’s new Patient Experience Committee has begun convening resources and people to help hospitalists address the patient experience. In addition to new resources on the SHM website, SHM has set up an HMX community specifically dedicated to the many issues related to the experience of patients in the hospital. To get involved, visit www.hospitalmedicine.org/patientexperience.

Project BOOST On-Demand Webinar Available

It’s never too late—or too early—to think about improving processes to reduce readmissions. SHM’s Project BOOST now accepts program applications throughout the year, and the recent webinar with Project BOOST program leaders is now available for free online. www.hospitalmedicine.org/boost.

Glycemic Control Implementation Guide available in June.

Glycemic control and the management of diabetic patients can be challenging for hospitalists. That’s why SHM is presenting the new Glycemic Control Implementation Guide. Recent webinars are available, too, at www.hospitalmedicine.org/qi.

Free CME on Acute Coronary Syndrome

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die because of an acute myocardial infarction. Now, SHM is presenting a free self-directed web-based activity designed to help hospitalists evaluate practices and strategies to affect outcomes. For details, visit www.hospitalmedicine.org/qi.

This educational initiative is supported by an educational grant from AstraZeneca.