When his hospital’s board of trustees was considering a palliative-care program seven years ago, hospitalist Stephen Bekanich, MD, wasn’t sure what to expect. What he did know was that his hospitalist group could provide the University of Utah Health System in Salt Lake City answers to staffing and financial issues surrounding the addition of a palliative-care service.

Dr. Bekanich

“They looked around and decided the hospitalist group would be the best place to house [the service], based on our experience with a range of medical management issues and the fact that we’re around 24 hours, seven days a week,” says Dr. Bekanich, who in 2006 became the first medical director of the palliative-care service at University of Utah Hospital.

The hospital board eventually selected palliative care as one of its annual projects, Dr. Bekanich says, not just because it was the right thing to do, but also because palliative care increasingly is used as a quality marker for hospitals. Dr. Bekanich says he took the assignment because it provides a nice buffer and change of pace from the stress of full-time HM service. Several colleagues joined him in rotating through palliative care coverage, although he continued to carry a pager most days and nights to support the physicians, advanced practice nurses, social worker, and chaplain with challenging cases.

After six months of operation, Dr. Bekanich went before his hospital board to discuss the program. He presented hospital data that showed the service had helped save the hospital $600,000, along with “thank-you letters” from grateful families and mentions in obituaries.

“A couple of months later, I realized that we needed another nurse practitioner to staff the growing caseload,” he explains. “I went to the chief medical officer and he said to me, ‘I don’t need to see the numbers. I know you’re doing a great job. Just tell me what you need.’ ”

Widely extolled for relieving the physical suffering and emotional distress of seriously ill patients, palliative care has seen rapid advancement in recent years, not only as a humanitarian impulse, but also as a legitimate and recognized medical subspecialty and career choice. Palliative care has its own board certification, fellowships, and training opportunities. For working hospitalists, this subspecialty can complement a career path and enhance job satisfaction. For HM groups, it represents diversification and an additional, albeit modest, income stream, as well as opportunities to improve the quality of hospital care.

“Palliative medicine is recognized by the American Board of Medical Specialties [ABMS] and nine of its medical specialty boards, which is very significant,” says Steven Pantilat, MD, SFHM, a hospitalist at the University of California at San Francisco (UCSF) Medical Center, medical director of UCSF’s palliative-care service. “Along with that come fellowships.”

The Basics

Palliative care’s focus is managing patients’ symptoms, maximizing quality of life, and clarifying treatment goals—regardless of diagnosis or other treatments they might be receiving. It is not hospice care, which is defined by Medicare as treatment for patients with a terminal prognosis of six months or less (see “Hospice and Palliative: End-of-Life Care Siblings,” p. 21). Palliative care and hospice care utilize many of the same techniques, and are combined in the ABMS program for certifying subspecialist physicians.

The interdisciplinary consultation service, where a palliative care consultant rounds with a team that might include physicians, nurses, social workers, pharmacists, and chaplains, is the most common palliative-care model in the hospital setting, but other approaches include dedicated units and community-based programs.

The latest data from the American Hospital Association (AHA) and the Center to Advance Palliative Care (CAPC) count 1,486 operational palliative-care programs in U.S. acute-care hospitals, more than twice as many as a decade before.¹ Currently, the demand for physicians certified in hospice and palliative medicine outstrips the supply, which poses challenges to those trying to hire as well as bona fide opportunities for qualified physicians hoping to pursue their dream jobs in the field, says Dr. Pantilat, a past president of SHM.

“A few years ago, it was cutting-edge for hospitals to just have a palliative care program,” Dr. Pantilat says, “but now the focus is on quality and the qualifications of the palliative care physicians and other professionals. Expectations for what palliative care will deliver will only go up.”

UCSF’s palliative care service “lives” within its HM division. Five of the six palliative care attending physicians are hospitalists. They divide weeklong assignments on the service into seven-day commitments at the hospital; each shift includes an on-call pager for night coverage.

A palliative-care shift can be just as emotionally demanding as an HM shift, although usually with fewer patients. One big difference: More time is needed for each palliative care consult, Dr. Pantilat says. A typical consult consists of an intense conversation with the patient and family to explore the patient’s prognosis, family values, and goals for treatment and pain relief.

Additionally, palliative care physicians routinely discuss the psychosocial and spiritual distress that the patient and family normally encounter.

Know When to Call for Help

Hospitalist involvement in palliative care varies by service, individual experience, and institution guidelines. Generally, though, it starts with an understanding of what the service provides and determining when is the right time to call a palliative-care consultant for help (see “Your Page Is Welcomed,” p. 22).

Hospitalists can obtain basic training and incorporate palliative-care principles and practices into the care of all hospitalized patients (see “Training Opportunities,” p. 22). If your hospital has a palliative-care service, hospitalists could join an advisory committee or provide backup coverage. If no such service exists, hospitalists could advocate with other physicians and hospital administrators to start one, Dr. Pantilat says.

Some hospitalists go deeper, developing subspecialty expertise and board certification in palliative medicine.

For HM groups, integration with a palliative-care service could mean taking on medical management of the service. If your group chooses to go this route, experts suggest you research how busy the service could be and gauge the interest of physicians in your group. Also check on the willingness of hospitalists in the group who are not interested in working on the palliative care service; they could help free up time for those who want to do it.

Dr. Bekanich

What Every Hospitalist Should Know

The basic clinical skills needed to perform palliative medicine include:

• Titrating opioid analgesics;
• Using adjuvant pain medications;
• Managing nonpain-related symptoms, including nausea, vomiting, constipation, dyspnea, seizures, and anorexia;
• Managing delirium, anxiety, and depression;
• Communicating sensitive information;
• Working with cultural issues and differences; and
• Bereavement support for families.

“Every hospitalist should know how to elicit a patient’s goals of care and incorporate them into routine treatment, be fluid and comfortable discussing advance-care planning, and possess basic skills in pain management,” says Jeanie Youngwerth, MD, hospitalist and director of the palliative-care service at the University of Colorado Denver. “Unfortunately, we’re not there yet as a field, given current residency training in internal medicine. Our center has a hospitalist residency training track, and those residents all get dedicated, palliative care experience.”

Knowing when to refer a patient to a palliative-care specialist is another important skill, Dr. Youngwerth explains. The CARING criteria, developed by Dr. Youngwerth’s colleagues at UC Denver, are a simple set of prognostic markers that identify patients with limited life expectancy at the time of hospital admission. The CARING criteria are a set of prognostic criteria that incorporate cancer diagnosis, repeated hospital admissions, ICU stays with multi-organ failure, residence in a nursing home, and meeting non-cancer hospice guidelines developed by the National Hospice Organization, which collectively correlate with the need for a palliative-care consultation (see Table 1, above).²

A simpler way to initially assess a patient’s need for palliative care is to ask yourself: Would you be surprised if you found out this patient had died within a year? “If physicians don’t think the patient is going to be alive in a year, then they should incorporate palliative care into the care plan,” Dr. Youngwerth says. “The next question is: Should I do it myself, or refer for a palliative-care consultation?”

Dr. Bekanich, who starting this month will head a new palliative care program at the University of Miami that features a 10-bed inpatient unit, encourages hospitalists to avoid focusing only on terminally ill patients when considering a palliative consult. Any seriously ill patient with unmet needs could benefit from a referral, he says.

“Lots of hospitalists are good at controlling nausea and vomiting, but if the symptoms are refractory or have uncommon presentations, I would like to get on board as the palliative care consultant,” Dr. Bekanich says. “I have also tried to emphasize to my group the importance of timely family meetings.

“If they don’t have the time or the skills, or if they expect a difficult meeting, for example, due to religious or cultural differences, send these patients our way. And when there are ethical issues that need to be addressed, or a particular need for educating patients and families about the disease process and what to expect, I like consultations like that.”

Bad Business or New Revenue Stream?

The traditional business model for palliative-care services has focused on the potential contributions to the hospital’s bottom line through reduced length of stay and cost avoidance for a group of patients who can be among the hospital’s most challenging and expensive. Palliative care saves time and money by working with patients and their families to clarify their values and treatment preferences, which routinely differ from standard treatment modes.

A recent multisite study of palliative care by Morrison et al found that the use of palliative care services saved from $1,700 to $4,900 per admission in direct costs, compared with similar patients who did not receive palliative care.³ The savings were realized primarily through reduced laboratory, pharmacy, and ICU costs.

Cost avoidance, combined with palliative care’s contributions to quality and patient satisfaction, is essential to the field’s growth. Even though physician consultation visits are billable, a palliative-care service rarely covers its staffing costs solely with billing revenue. A service requires nonbillable support from administration and midlevel providers, including nurses and social workers.

“Integrating palliative care into the work of hospitalists is a great idea,” says Jean Kutner, MD, head of the division of general internal medicine at the University of Colorado Denver. However, there are important issues related to scheduling, availability, and commitment that need to be explored before a group launches a new service. “I’d want to have discussions about how the palliative-care business model fits with our hospital medicine model and an agreement with the hospital on goals and metrics,” she says.

Hospitalists Fill a Need

Whether a full-fledged palliative-care service fits your group’s dynamic or not, hospitalists as a whole should be competent in basic palliative care. Community and rural hospitals need HM to bridge this gap and deliver quality care to seriously ill patients.

Dr. Harris

“I started at a community hospital, Eden Medical Center in Castro Valley, California. I had a personal interest in palliative care and realized there’s a tremendous need for it in community hospitals,” says Heather A. Harris, MD, a hospitalist at San Francisco General Hospital who previously worked with Dr. Pantilat’s palliative care service at UCSF. “We deal with end-of-life issues on a regular basis—whether recognized or not—based on our caseloads and requests for consultations.

“I got a little perspective about palliative care while a resident at UCSF. But as I’ve gotten further into this, I have come to realize that there is an actual skill set that needs to be learned to do it properly.”

Dr. Harris says there is a big difference between physicians helping patients with end-of-life issues the best they can and being part of a “dedicated, interdisciplinary team.”

“Palliative care is a wonderful opportunity for hospitalists,” she says. “It’s already part of your practice. Why not do it in a more organized fashion?” TH

Larry Beresford is a freelance medical writer based in Oakland, Calif.

References

1. Palliative care programs continue rapid growth in U.S. hospitals. Center to Advance Palliative Care website. Available at: www.capc.org/news-and-events/releases/04-05-10. Accessed July 15, 2010.
2. Fischer SM, Gozansky WS, Sauaia A, Min SJ, Kutner JS, Kramer A. A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria. J Pain Symptom Manage. 2006;31(4):285-292.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.

When his hospital’s board of trustees was considering a palliative-care program seven years ago, hospitalist Stephen Bekanich, MD, wasn’t sure what to expect. What he did know was that his hospitalist group could provide the University of Utah Health System in Salt Lake City answers to staffing and financial issues surrounding the addition of a palliative-care service.

Dr. Bekanich

“They looked around and decided the hospitalist group would be the best place to house [the service], based on our experience with a range of medical management issues and the fact that we’re around 24 hours, seven days a week,” says Dr. Bekanich, who in 2006 became the first medical director of the palliative-care service at University of Utah Hospital.

The hospital board eventually selected palliative care as one of its annual projects, Dr. Bekanich says, not just because it was the right thing to do, but also because palliative care increasingly is used as a quality marker for hospitals. Dr. Bekanich says he took the assignment because it provides a nice buffer and change of pace from the stress of full-time HM service. Several colleagues joined him in rotating through palliative care coverage, although he continued to carry a pager most days and nights to support the physicians, advanced practice nurses, social worker, and chaplain with challenging cases.

After six months of operation, Dr. Bekanich went before his hospital board to discuss the program. He presented hospital data that showed the service had helped save the hospital $600,000, along with “thank-you letters” from grateful families and mentions in obituaries.

“A couple of months later, I realized that we needed another nurse practitioner to staff the growing caseload,” he explains. “I went to the chief medical officer and he said to me, ‘I don’t need to see the numbers. I know you’re doing a great job. Just tell me what you need.’ ”

Widely extolled for relieving the physical suffering and emotional distress of seriously ill patients, palliative care has seen rapid advancement in recent years, not only as a humanitarian impulse, but also as a legitimate and recognized medical subspecialty and career choice. Palliative care has its own board certification, fellowships, and training opportunities. For working hospitalists, this subspecialty can complement a career path and enhance job satisfaction. For HM groups, it represents diversification and an additional, albeit modest, income stream, as well as opportunities to improve the quality of hospital care.

“Palliative medicine is recognized by the American Board of Medical Specialties [ABMS] and nine of its medical specialty boards, which is very significant,” says Steven Pantilat, MD, SFHM, a hospitalist at the University of California at San Francisco (UCSF) Medical Center, medical director of UCSF’s palliative-care service. “Along with that come fellowships.”

The Basics

Palliative care’s focus is managing patients’ symptoms, maximizing quality of life, and clarifying treatment goals—regardless of diagnosis or other treatments they might be receiving. It is not hospice care, which is defined by Medicare as treatment for patients with a terminal prognosis of six months or less (see “Hospice and Palliative: End-of-Life Care Siblings,” p. 21). Palliative care and hospice care utilize many of the same techniques, and are combined in the ABMS program for certifying subspecialist physicians.

The interdisciplinary consultation service, where a palliative care consultant rounds with a team that might include physicians, nurses, social workers, pharmacists, and chaplains, is the most common palliative-care model in the hospital setting, but other approaches include dedicated units and community-based programs.

The latest data from the American Hospital Association (AHA) and the Center to Advance Palliative Care (CAPC) count 1,486 operational palliative-care programs in U.S. acute-care hospitals, more than twice as many as a decade before.¹ Currently, the demand for physicians certified in hospice and palliative medicine outstrips the supply, which poses challenges to those trying to hire as well as bona fide opportunities for qualified physicians hoping to pursue their dream jobs in the field, says Dr. Pantilat, a past president of SHM.

“A few years ago, it was cutting-edge for hospitals to just have a palliative care program,” Dr. Pantilat says, “but now the focus is on quality and the qualifications of the palliative care physicians and other professionals. Expectations for what palliative care will deliver will only go up.”

UCSF’s palliative care service “lives” within its HM division. Five of the six palliative care attending physicians are hospitalists. They divide weeklong assignments on the service into seven-day commitments at the hospital; each shift includes an on-call pager for night coverage.

A palliative-care shift can be just as emotionally demanding as an HM shift, although usually with fewer patients. One big difference: More time is needed for each palliative care consult, Dr. Pantilat says. A typical consult consists of an intense conversation with the patient and family to explore the patient’s prognosis, family values, and goals for treatment and pain relief.

Additionally, palliative care physicians routinely discuss the psychosocial and spiritual distress that the patient and family normally encounter.

Know When to Call for Help

Hospitalist involvement in palliative care varies by service, individual experience, and institution guidelines. Generally, though, it starts with an understanding of what the service provides and determining when is the right time to call a palliative-care consultant for help (see “Your Page Is Welcomed,” p. 22).

Hospitalists can obtain basic training and incorporate palliative-care principles and practices into the care of all hospitalized patients (see “Training Opportunities,” p. 22). If your hospital has a palliative-care service, hospitalists could join an advisory committee or provide backup coverage. If no such service exists, hospitalists could advocate with other physicians and hospital administrators to start one, Dr. Pantilat says.

Some hospitalists go deeper, developing subspecialty expertise and board certification in palliative medicine.

For HM groups, integration with a palliative-care service could mean taking on medical management of the service. If your group chooses to go this route, experts suggest you research how busy the service could be and gauge the interest of physicians in your group. Also check on the willingness of hospitalists in the group who are not interested in working on the palliative care service; they could help free up time for those who want to do it.

Dr. Bekanich

What Every Hospitalist Should Know

The basic clinical skills needed to perform palliative medicine include:

• Titrating opioid analgesics;
• Using adjuvant pain medications;
• Managing nonpain-related symptoms, including nausea, vomiting, constipation, dyspnea, seizures, and anorexia;
• Managing delirium, anxiety, and depression;
• Communicating sensitive information;
• Working with cultural issues and differences; and
• Bereavement support for families.

“Every hospitalist should know how to elicit a patient’s goals of care and incorporate them into routine treatment, be fluid and comfortable discussing advance-care planning, and possess basic skills in pain management,” says Jeanie Youngwerth, MD, hospitalist and director of the palliative-care service at the University of Colorado Denver. “Unfortunately, we’re not there yet as a field, given current residency training in internal medicine. Our center has a hospitalist residency training track, and those residents all get dedicated, palliative care experience.”

Knowing when to refer a patient to a palliative-care specialist is another important skill, Dr. Youngwerth explains. The CARING criteria, developed by Dr. Youngwerth’s colleagues at UC Denver, are a simple set of prognostic markers that identify patients with limited life expectancy at the time of hospital admission. The CARING criteria are a set of prognostic criteria that incorporate cancer diagnosis, repeated hospital admissions, ICU stays with multi-organ failure, residence in a nursing home, and meeting non-cancer hospice guidelines developed by the National Hospice Organization, which collectively correlate with the need for a palliative-care consultation (see Table 1, above).²

A simpler way to initially assess a patient’s need for palliative care is to ask yourself: Would you be surprised if you found out this patient had died within a year? “If physicians don’t think the patient is going to be alive in a year, then they should incorporate palliative care into the care plan,” Dr. Youngwerth says. “The next question is: Should I do it myself, or refer for a palliative-care consultation?”

Dr. Bekanich, who starting this month will head a new palliative care program at the University of Miami that features a 10-bed inpatient unit, encourages hospitalists to avoid focusing only on terminally ill patients when considering a palliative consult. Any seriously ill patient with unmet needs could benefit from a referral, he says.

“Lots of hospitalists are good at controlling nausea and vomiting, but if the symptoms are refractory or have uncommon presentations, I would like to get on board as the palliative care consultant,” Dr. Bekanich says. “I have also tried to emphasize to my group the importance of timely family meetings.

“If they don’t have the time or the skills, or if they expect a difficult meeting, for example, due to religious or cultural differences, send these patients our way. And when there are ethical issues that need to be addressed, or a particular need for educating patients and families about the disease process and what to expect, I like consultations like that.”

Bad Business or New Revenue Stream?

The traditional business model for palliative-care services has focused on the potential contributions to the hospital’s bottom line through reduced length of stay and cost avoidance for a group of patients who can be among the hospital’s most challenging and expensive. Palliative care saves time and money by working with patients and their families to clarify their values and treatment preferences, which routinely differ from standard treatment modes.

A recent multisite study of palliative care by Morrison et al found that the use of palliative care services saved from $1,700 to $4,900 per admission in direct costs, compared with similar patients who did not receive palliative care.³ The savings were realized primarily through reduced laboratory, pharmacy, and ICU costs.

Cost avoidance, combined with palliative care’s contributions to quality and patient satisfaction, is essential to the field’s growth. Even though physician consultation visits are billable, a palliative-care service rarely covers its staffing costs solely with billing revenue. A service requires nonbillable support from administration and midlevel providers, including nurses and social workers.

“Integrating palliative care into the work of hospitalists is a great idea,” says Jean Kutner, MD, head of the division of general internal medicine at the University of Colorado Denver. However, there are important issues related to scheduling, availability, and commitment that need to be explored before a group launches a new service. “I’d want to have discussions about how the palliative-care business model fits with our hospital medicine model and an agreement with the hospital on goals and metrics,” she says.

Hospitalists Fill a Need

Whether a full-fledged palliative-care service fits your group’s dynamic or not, hospitalists as a whole should be competent in basic palliative care. Community and rural hospitals need HM to bridge this gap and deliver quality care to seriously ill patients.

Dr. Harris

“I started at a community hospital, Eden Medical Center in Castro Valley, California. I had a personal interest in palliative care and realized there’s a tremendous need for it in community hospitals,” says Heather A. Harris, MD, a hospitalist at San Francisco General Hospital who previously worked with Dr. Pantilat’s palliative care service at UCSF. “We deal with end-of-life issues on a regular basis—whether recognized or not—based on our caseloads and requests for consultations.

“I got a little perspective about palliative care while a resident at UCSF. But as I’ve gotten further into this, I have come to realize that there is an actual skill set that needs to be learned to do it properly.”

Dr. Harris says there is a big difference between physicians helping patients with end-of-life issues the best they can and being part of a “dedicated, interdisciplinary team.”

“Palliative care is a wonderful opportunity for hospitalists,” she says. “It’s already part of your practice. Why not do it in a more organized fashion?” TH

Larry Beresford is a freelance medical writer based in Oakland, Calif.

References

1. Palliative care programs continue rapid growth in U.S. hospitals. Center to Advance Palliative Care website. Available at: www.capc.org/news-and-events/releases/04-05-10. Accessed July 15, 2010.
2. Fischer SM, Gozansky WS, Sauaia A, Min SJ, Kutner JS, Kramer A. A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria. J Pain Symptom Manage. 2006;31(4):285-292.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.

When his hospital’s board of trustees was considering a palliative-care program seven years ago, hospitalist Stephen Bekanich, MD, wasn’t sure what to expect. What he did know was that his hospitalist group could provide the University of Utah Health System in Salt Lake City answers to staffing and financial issues surrounding the addition of a palliative-care service.

Dr. Bekanich

“They looked around and decided the hospitalist group would be the best place to house [the service], based on our experience with a range of medical management issues and the fact that we’re around 24 hours, seven days a week,” says Dr. Bekanich, who in 2006 became the first medical director of the palliative-care service at University of Utah Hospital.

The hospital board eventually selected palliative care as one of its annual projects, Dr. Bekanich says, not just because it was the right thing to do, but also because palliative care increasingly is used as a quality marker for hospitals. Dr. Bekanich says he took the assignment because it provides a nice buffer and change of pace from the stress of full-time HM service. Several colleagues joined him in rotating through palliative care coverage, although he continued to carry a pager most days and nights to support the physicians, advanced practice nurses, social worker, and chaplain with challenging cases.

After six months of operation, Dr. Bekanich went before his hospital board to discuss the program. He presented hospital data that showed the service had helped save the hospital $600,000, along with “thank-you letters” from grateful families and mentions in obituaries.

“A couple of months later, I realized that we needed another nurse practitioner to staff the growing caseload,” he explains. “I went to the chief medical officer and he said to me, ‘I don’t need to see the numbers. I know you’re doing a great job. Just tell me what you need.’ ”

Widely extolled for relieving the physical suffering and emotional distress of seriously ill patients, palliative care has seen rapid advancement in recent years, not only as a humanitarian impulse, but also as a legitimate and recognized medical subspecialty and career choice. Palliative care has its own board certification, fellowships, and training opportunities. For working hospitalists, this subspecialty can complement a career path and enhance job satisfaction. For HM groups, it represents diversification and an additional, albeit modest, income stream, as well as opportunities to improve the quality of hospital care.

“Palliative medicine is recognized by the American Board of Medical Specialties [ABMS] and nine of its medical specialty boards, which is very significant,” says Steven Pantilat, MD, SFHM, a hospitalist at the University of California at San Francisco (UCSF) Medical Center, medical director of UCSF’s palliative-care service. “Along with that come fellowships.”

The Basics

Palliative care’s focus is managing patients’ symptoms, maximizing quality of life, and clarifying treatment goals—regardless of diagnosis or other treatments they might be receiving. It is not hospice care, which is defined by Medicare as treatment for patients with a terminal prognosis of six months or less (see “Hospice and Palliative: End-of-Life Care Siblings,” p. 21). Palliative care and hospice care utilize many of the same techniques, and are combined in the ABMS program for certifying subspecialist physicians.

The interdisciplinary consultation service, where a palliative care consultant rounds with a team that might include physicians, nurses, social workers, pharmacists, and chaplains, is the most common palliative-care model in the hospital setting, but other approaches include dedicated units and community-based programs.

The latest data from the American Hospital Association (AHA) and the Center to Advance Palliative Care (CAPC) count 1,486 operational palliative-care programs in U.S. acute-care hospitals, more than twice as many as a decade before.¹ Currently, the demand for physicians certified in hospice and palliative medicine outstrips the supply, which poses challenges to those trying to hire as well as bona fide opportunities for qualified physicians hoping to pursue their dream jobs in the field, says Dr. Pantilat, a past president of SHM.

“A few years ago, it was cutting-edge for hospitals to just have a palliative care program,” Dr. Pantilat says, “but now the focus is on quality and the qualifications of the palliative care physicians and other professionals. Expectations for what palliative care will deliver will only go up.”

UCSF’s palliative care service “lives” within its HM division. Five of the six palliative care attending physicians are hospitalists. They divide weeklong assignments on the service into seven-day commitments at the hospital; each shift includes an on-call pager for night coverage.

A palliative-care shift can be just as emotionally demanding as an HM shift, although usually with fewer patients. One big difference: More time is needed for each palliative care consult, Dr. Pantilat says. A typical consult consists of an intense conversation with the patient and family to explore the patient’s prognosis, family values, and goals for treatment and pain relief.

Additionally, palliative care physicians routinely discuss the psychosocial and spiritual distress that the patient and family normally encounter.

Know When to Call for Help

Hospitalist involvement in palliative care varies by service, individual experience, and institution guidelines. Generally, though, it starts with an understanding of what the service provides and determining when is the right time to call a palliative-care consultant for help (see “Your Page Is Welcomed,” p. 22).

Hospitalists can obtain basic training and incorporate palliative-care principles and practices into the care of all hospitalized patients (see “Training Opportunities,” p. 22). If your hospital has a palliative-care service, hospitalists could join an advisory committee or provide backup coverage. If no such service exists, hospitalists could advocate with other physicians and hospital administrators to start one, Dr. Pantilat says.

Some hospitalists go deeper, developing subspecialty expertise and board certification in palliative medicine.

For HM groups, integration with a palliative-care service could mean taking on medical management of the service. If your group chooses to go this route, experts suggest you research how busy the service could be and gauge the interest of physicians in your group. Also check on the willingness of hospitalists in the group who are not interested in working on the palliative care service; they could help free up time for those who want to do it.

Dr. Bekanich

What Every Hospitalist Should Know

The basic clinical skills needed to perform palliative medicine include:

• Titrating opioid analgesics;
• Using adjuvant pain medications;
• Managing nonpain-related symptoms, including nausea, vomiting, constipation, dyspnea, seizures, and anorexia;
• Managing delirium, anxiety, and depression;
• Communicating sensitive information;
• Working with cultural issues and differences; and
• Bereavement support for families.

“Every hospitalist should know how to elicit a patient’s goals of care and incorporate them into routine treatment, be fluid and comfortable discussing advance-care planning, and possess basic skills in pain management,” says Jeanie Youngwerth, MD, hospitalist and director of the palliative-care service at the University of Colorado Denver. “Unfortunately, we’re not there yet as a field, given current residency training in internal medicine. Our center has a hospitalist residency training track, and those residents all get dedicated, palliative care experience.”

Knowing when to refer a patient to a palliative-care specialist is another important skill, Dr. Youngwerth explains. The CARING criteria, developed by Dr. Youngwerth’s colleagues at UC Denver, are a simple set of prognostic markers that identify patients with limited life expectancy at the time of hospital admission. The CARING criteria are a set of prognostic criteria that incorporate cancer diagnosis, repeated hospital admissions, ICU stays with multi-organ failure, residence in a nursing home, and meeting non-cancer hospice guidelines developed by the National Hospice Organization, which collectively correlate with the need for a palliative-care consultation (see Table 1, above).²

A simpler way to initially assess a patient’s need for palliative care is to ask yourself: Would you be surprised if you found out this patient had died within a year? “If physicians don’t think the patient is going to be alive in a year, then they should incorporate palliative care into the care plan,” Dr. Youngwerth says. “The next question is: Should I do it myself, or refer for a palliative-care consultation?”

Dr. Bekanich, who starting this month will head a new palliative care program at the University of Miami that features a 10-bed inpatient unit, encourages hospitalists to avoid focusing only on terminally ill patients when considering a palliative consult. Any seriously ill patient with unmet needs could benefit from a referral, he says.

“Lots of hospitalists are good at controlling nausea and vomiting, but if the symptoms are refractory or have uncommon presentations, I would like to get on board as the palliative care consultant,” Dr. Bekanich says. “I have also tried to emphasize to my group the importance of timely family meetings.

“If they don’t have the time or the skills, or if they expect a difficult meeting, for example, due to religious or cultural differences, send these patients our way. And when there are ethical issues that need to be addressed, or a particular need for educating patients and families about the disease process and what to expect, I like consultations like that.”

Bad Business or New Revenue Stream?

The traditional business model for palliative-care services has focused on the potential contributions to the hospital’s bottom line through reduced length of stay and cost avoidance for a group of patients who can be among the hospital’s most challenging and expensive. Palliative care saves time and money by working with patients and their families to clarify their values and treatment preferences, which routinely differ from standard treatment modes.

A recent multisite study of palliative care by Morrison et al found that the use of palliative care services saved from $1,700 to $4,900 per admission in direct costs, compared with similar patients who did not receive palliative care.³ The savings were realized primarily through reduced laboratory, pharmacy, and ICU costs.

Cost avoidance, combined with palliative care’s contributions to quality and patient satisfaction, is essential to the field’s growth. Even though physician consultation visits are billable, a palliative-care service rarely covers its staffing costs solely with billing revenue. A service requires nonbillable support from administration and midlevel providers, including nurses and social workers.

“Integrating palliative care into the work of hospitalists is a great idea,” says Jean Kutner, MD, head of the division of general internal medicine at the University of Colorado Denver. However, there are important issues related to scheduling, availability, and commitment that need to be explored before a group launches a new service. “I’d want to have discussions about how the palliative-care business model fits with our hospital medicine model and an agreement with the hospital on goals and metrics,” she says.

Hospitalists Fill a Need

Whether a full-fledged palliative-care service fits your group’s dynamic or not, hospitalists as a whole should be competent in basic palliative care. Community and rural hospitals need HM to bridge this gap and deliver quality care to seriously ill patients.

Dr. Harris

“I started at a community hospital, Eden Medical Center in Castro Valley, California. I had a personal interest in palliative care and realized there’s a tremendous need for it in community hospitals,” says Heather A. Harris, MD, a hospitalist at San Francisco General Hospital who previously worked with Dr. Pantilat’s palliative care service at UCSF. “We deal with end-of-life issues on a regular basis—whether recognized or not—based on our caseloads and requests for consultations.

“I got a little perspective about palliative care while a resident at UCSF. But as I’ve gotten further into this, I have come to realize that there is an actual skill set that needs to be learned to do it properly.”

Dr. Harris says there is a big difference between physicians helping patients with end-of-life issues the best they can and being part of a “dedicated, interdisciplinary team.”

“Palliative care is a wonderful opportunity for hospitalists,” she says. “It’s already part of your practice. Why not do it in a more organized fashion?” TH

Larry Beresford is a freelance medical writer based in Oakland, Calif.

References

1. Palliative care programs continue rapid growth in U.S. hospitals. Center to Advance Palliative Care website. Available at: www.capc.org/news-and-events/releases/04-05-10. Accessed July 15, 2010.
2. Fischer SM, Gozansky WS, Sauaia A, Min SJ, Kutner JS, Kramer A. A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria. J Pain Symptom Manage. 2006;31(4):285-292.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.

Click here to listen to the interview with Dr. Flanders.

Click here to listen to the interview with Dr. Share.

Click here to listen to the interview with Dr. Flanders.

Click here to listen to the interview with Dr. Share.

Click here to listen to the interview with Dr. Flanders.

Click here to listen to the interview with Dr. Share.

Advocates for SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) presented a standing-room-only policy briefing June 8 on Capitol Hill to explain an innovative quality-improvement (QI) initiative and new collaboration with Blue Cross Blue Shield of Michigan (BCBSM) to increase patient safety and reduce preventable hospital readmissions.

“The room was packed,” says David Share, MD, BCBSM’s executive medical director for healthcare quality. About 60 people were in attendance, mostly House and Senate legislative aides, along with a few representatives of third-party health organizations. Dr. Share, one of the presenters, says many of the staffers were well aware of the challenges of hospital-based practice. “I would say the crowd was remarkably attentive during our presentation,” he says.

SHM developed BOOST in 2008 to help hospitals and hospitalists systematically improve discharge processes through evidence-based interventions, management tools and resources, and expert mentoring. In January, BOOST was implemented in 15 Michigan hospitals with financial support from BCBSM. A 20-hospital partnership with the California HealthCare Foundation was announced in April, and more than 60 hospitals in 24 states now participate.

“These legislative staffers, who are responsible for crafting health-reform legislation, were given an in-depth understanding of how the provider community can take ownership of the challenges of transforming systems of care,” Dr. Share says. “I hope what they learned was that when payors … establish incentives for providers to transform healthcare systems, providers can do that very creatively and effectively in ways that affect patient care, patient well-being, and patient outcomes—both in terms of quality and cost.”

Hospitalist Scott Flanders, MD, SFHM, professor of medicine and director of the inpatient program at the University of Michigan in Ann Arbor, also spoke at the briefing. “I think our Michigan collaborative is a nice example of a local, provider-based, payor-supported quality initiative that will tackle an important problem and lead to a lot of collaboration and learning,” says Dr. Flanders, SHM’s immediate past president.

Also speaking at the briefing were Project BOOST principal investigator Mark Williams, MD, FHM, chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, and representatives of the national Blue Cross/Blue Shield Association and the American Hospital Association, who discussed other initiatives that have successfully targeted the hospital readmission problem. “Not all readmissions are preventable. Some are necessary and important,” Dr. Flanders says, adding that the challenge is to distinguish between the necessary and the avoidable.

While there are no current legislative proposals involving Project BOOST, the initiative is aligned with a number of provisions aimed at reducing readmissions and improving care transitions, which are contained in the Patient Protection and Affordable Care Act passed in March. “Given the costs of readmissions, directly supporting demonstration projects like this would be a wise investment in improving healthcare quality,” says Dr. Flanders, adding that he heard suggestions at the briefing that the Centers for Medicare & Medicaid Services’ (CMS) Center for Innovation should consider supporting initiatives like BOOST.

Dr. Share, who calls payor support for the BOOST collaboration an example of its incentive programs with physician groups, says hospitalists are essential to partnerships with other providers, including PCPs, and the systems improvements necessary in the hospital setting.

“We’re actually bridging the gap between the hospital and the medical office,” he says. TH

Advocates for SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) presented a standing-room-only policy briefing June 8 on Capitol Hill to explain an innovative quality-improvement (QI) initiative and new collaboration with Blue Cross Blue Shield of Michigan (BCBSM) to increase patient safety and reduce preventable hospital readmissions.

“The room was packed,” says David Share, MD, BCBSM’s executive medical director for healthcare quality. About 60 people were in attendance, mostly House and Senate legislative aides, along with a few representatives of third-party health organizations. Dr. Share, one of the presenters, says many of the staffers were well aware of the challenges of hospital-based practice. “I would say the crowd was remarkably attentive during our presentation,” he says.

SHM developed BOOST in 2008 to help hospitals and hospitalists systematically improve discharge processes through evidence-based interventions, management tools and resources, and expert mentoring. In January, BOOST was implemented in 15 Michigan hospitals with financial support from BCBSM. A 20-hospital partnership with the California HealthCare Foundation was announced in April, and more than 60 hospitals in 24 states now participate.

“These legislative staffers, who are responsible for crafting health-reform legislation, were given an in-depth understanding of how the provider community can take ownership of the challenges of transforming systems of care,” Dr. Share says. “I hope what they learned was that when payors … establish incentives for providers to transform healthcare systems, providers can do that very creatively and effectively in ways that affect patient care, patient well-being, and patient outcomes—both in terms of quality and cost.”

Hospitalist Scott Flanders, MD, SFHM, professor of medicine and director of the inpatient program at the University of Michigan in Ann Arbor, also spoke at the briefing. “I think our Michigan collaborative is a nice example of a local, provider-based, payor-supported quality initiative that will tackle an important problem and lead to a lot of collaboration and learning,” says Dr. Flanders, SHM’s immediate past president.

Also speaking at the briefing were Project BOOST principal investigator Mark Williams, MD, FHM, chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, and representatives of the national Blue Cross/Blue Shield Association and the American Hospital Association, who discussed other initiatives that have successfully targeted the hospital readmission problem. “Not all readmissions are preventable. Some are necessary and important,” Dr. Flanders says, adding that the challenge is to distinguish between the necessary and the avoidable.

While there are no current legislative proposals involving Project BOOST, the initiative is aligned with a number of provisions aimed at reducing readmissions and improving care transitions, which are contained in the Patient Protection and Affordable Care Act passed in March. “Given the costs of readmissions, directly supporting demonstration projects like this would be a wise investment in improving healthcare quality,” says Dr. Flanders, adding that he heard suggestions at the briefing that the Centers for Medicare & Medicaid Services’ (CMS) Center for Innovation should consider supporting initiatives like BOOST.

Dr. Share, who calls payor support for the BOOST collaboration an example of its incentive programs with physician groups, says hospitalists are essential to partnerships with other providers, including PCPs, and the systems improvements necessary in the hospital setting.

“We’re actually bridging the gap between the hospital and the medical office,” he says. TH

Advocates for SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) presented a standing-room-only policy briefing June 8 on Capitol Hill to explain an innovative quality-improvement (QI) initiative and new collaboration with Blue Cross Blue Shield of Michigan (BCBSM) to increase patient safety and reduce preventable hospital readmissions.

“The room was packed,” says David Share, MD, BCBSM’s executive medical director for healthcare quality. About 60 people were in attendance, mostly House and Senate legislative aides, along with a few representatives of third-party health organizations. Dr. Share, one of the presenters, says many of the staffers were well aware of the challenges of hospital-based practice. “I would say the crowd was remarkably attentive during our presentation,” he says.

SHM developed BOOST in 2008 to help hospitals and hospitalists systematically improve discharge processes through evidence-based interventions, management tools and resources, and expert mentoring. In January, BOOST was implemented in 15 Michigan hospitals with financial support from BCBSM. A 20-hospital partnership with the California HealthCare Foundation was announced in April, and more than 60 hospitals in 24 states now participate.

“These legislative staffers, who are responsible for crafting health-reform legislation, were given an in-depth understanding of how the provider community can take ownership of the challenges of transforming systems of care,” Dr. Share says. “I hope what they learned was that when payors … establish incentives for providers to transform healthcare systems, providers can do that very creatively and effectively in ways that affect patient care, patient well-being, and patient outcomes—both in terms of quality and cost.”

Hospitalist Scott Flanders, MD, SFHM, professor of medicine and director of the inpatient program at the University of Michigan in Ann Arbor, also spoke at the briefing. “I think our Michigan collaborative is a nice example of a local, provider-based, payor-supported quality initiative that will tackle an important problem and lead to a lot of collaboration and learning,” says Dr. Flanders, SHM’s immediate past president.

Also speaking at the briefing were Project BOOST principal investigator Mark Williams, MD, FHM, chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, and representatives of the national Blue Cross/Blue Shield Association and the American Hospital Association, who discussed other initiatives that have successfully targeted the hospital readmission problem. “Not all readmissions are preventable. Some are necessary and important,” Dr. Flanders says, adding that the challenge is to distinguish between the necessary and the avoidable.

While there are no current legislative proposals involving Project BOOST, the initiative is aligned with a number of provisions aimed at reducing readmissions and improving care transitions, which are contained in the Patient Protection and Affordable Care Act passed in March. “Given the costs of readmissions, directly supporting demonstration projects like this would be a wise investment in improving healthcare quality,” says Dr. Flanders, adding that he heard suggestions at the briefing that the Centers for Medicare & Medicaid Services’ (CMS) Center for Innovation should consider supporting initiatives like BOOST.

Dr. Share, who calls payor support for the BOOST collaboration an example of its incentive programs with physician groups, says hospitalists are essential to partnerships with other providers, including PCPs, and the systems improvements necessary in the hospital setting.

“We’re actually bridging the gap between the hospital and the medical office,” he says. TH

The Coming Challenges—and Opportunities—of Value-Based Purchasing

The Patient Protection and Affordable Care Act was signed into law in March, furthering the federal government’s commitment to increasing the efficiency of the U.S. healthcare system by decreasing cost and improving quality. An expansion of the “value-based purchasing” model, this law mandates that ratings and reimbursements to physicians and hospitals be increasingly tied to measured quality of care.

In this system, a physician’s quality profile will be determined by a variety of factors, including reported quality data, severity-adjusted clinical outcome measures, patient-safety indicators, and hospital-acquired conditions (HACs). Since all of these are, to a large extent, documentation issues, physicians are now forced to pay close attention to how they identify and describe diagnoses and procedures.

Medicare will, in effect, attempt to determine: “Did the clinical team correctly identify and appropriately treat all relevant patient conditions—without causing any adverse conditions—and do so safely, efficiently, and with good outcomes?”

The patient chart must “tell the story” of the episode of care in the hospital. It must accurately describe all of the patient’s conditions and demonstrate the complexity of medical decision-making and establishment of risk. Upon discharge, this risk must “match up” with the diagnoses that are being coded and the Medicare Severity Diagnostic Related Group (MS-DRGs) being assigned. Often, the information is present in the chart but is inconsistent from provider to provider, or documented in a way that is misunderstood by hospital coders.

If successful in improving our documentation skills, the reward will be a higher rating and increased reimbursement.

Medicare also is ramping up its claims denial and recovery business to help “clean up” the system. This includes the national rollout of the Recovery Audit Contactor (RAC) initiative (see “Attention to Detail,” April 2010, p. 1), as well as the new Medicare administrative contractors (MACs). Both rely on accurate documentation. The RACs will penalize hospitals and physicians financially for documentation lacking in specificity and accuracy; the MACs will deny payment for claims erroneously submitted (technical errors) or lacking documentation of medical necessity.

What makes many physicians even more uncomfortable in this new environment is that Medicare is striving to better align the priorities and financial incentives of hospitals and physicians. Alliances between the two are strongly encouraged through such programs as the Acute Care Episode (ACE) Demonstration Project (the precursor to hospital-physician bundled payments), and the establishment of accountable care organizations (ACOs).

This emerging environment presents a unique set of challenges and opportunities to HM groups. Hospitalists are historically more aligned with hospital administrations, as compared with most other specialties. Hospitalists also are asked to participate in the care of an increasingly large percentage of patients across all specialties. This could well be an opportunity to be rewarded for embracing both of these trends.

Hospitalists are uniquely positioned to function as the documentation improvement clinical team leaders, working closely with other physicians across all specialties and the administration to fulfill all documentation requirements—and to be rewarded for doing so. Though hospitalists should have a general understanding of the language and rules of documentation, a system must be in place that helps them identify and capture all the pertinent aspects of the medical record without the need to become coders themselves. To this end, a clinical documentation improvement (CDI) program is critical.

But it might not be enough.

What is needed is a clinical integration program, an enhancement of traditional CDI. This approach requires participation from ED physicians, along with clinical integration specialists, to document accurately and completely from the start. The clinical integration specialist ensures that medical necessity for inpatient admission and patient risk is being addressed and established, conditions are appropriately identified as being present on admission (POA), and all diagnoses are properly recognized and documented thoroughly and accurately. Clinical integration through collaborative documentation then continues throughout the hospitalization, with diagnostic authority and oversight from the hospitalist, all the way through discharge.

Hospitalists should welcome and champion this type of program. As documentation becomes the key to survival, a complete medical record will stand up to any and all scrutiny by Medicare or others.

As for the negatives, there are none.

Andrew H. Dombro, MD, national medical director, and Paul Weygandt, MD, JD, vice president of physician services, J.A. Thomas & Associates, Atlanta

The Coming Challenges—and Opportunities—of Value-Based Purchasing

The Patient Protection and Affordable Care Act was signed into law in March, furthering the federal government’s commitment to increasing the efficiency of the U.S. healthcare system by decreasing cost and improving quality. An expansion of the “value-based purchasing” model, this law mandates that ratings and reimbursements to physicians and hospitals be increasingly tied to measured quality of care.

In this system, a physician’s quality profile will be determined by a variety of factors, including reported quality data, severity-adjusted clinical outcome measures, patient-safety indicators, and hospital-acquired conditions (HACs). Since all of these are, to a large extent, documentation issues, physicians are now forced to pay close attention to how they identify and describe diagnoses and procedures.

Medicare will, in effect, attempt to determine: “Did the clinical team correctly identify and appropriately treat all relevant patient conditions—without causing any adverse conditions—and do so safely, efficiently, and with good outcomes?”

The patient chart must “tell the story” of the episode of care in the hospital. It must accurately describe all of the patient’s conditions and demonstrate the complexity of medical decision-making and establishment of risk. Upon discharge, this risk must “match up” with the diagnoses that are being coded and the Medicare Severity Diagnostic Related Group (MS-DRGs) being assigned. Often, the information is present in the chart but is inconsistent from provider to provider, or documented in a way that is misunderstood by hospital coders.

If successful in improving our documentation skills, the reward will be a higher rating and increased reimbursement.

Medicare also is ramping up its claims denial and recovery business to help “clean up” the system. This includes the national rollout of the Recovery Audit Contactor (RAC) initiative (see “Attention to Detail,” April 2010, p. 1), as well as the new Medicare administrative contractors (MACs). Both rely on accurate documentation. The RACs will penalize hospitals and physicians financially for documentation lacking in specificity and accuracy; the MACs will deny payment for claims erroneously submitted (technical errors) or lacking documentation of medical necessity.

What makes many physicians even more uncomfortable in this new environment is that Medicare is striving to better align the priorities and financial incentives of hospitals and physicians. Alliances between the two are strongly encouraged through such programs as the Acute Care Episode (ACE) Demonstration Project (the precursor to hospital-physician bundled payments), and the establishment of accountable care organizations (ACOs).

This emerging environment presents a unique set of challenges and opportunities to HM groups. Hospitalists are historically more aligned with hospital administrations, as compared with most other specialties. Hospitalists also are asked to participate in the care of an increasingly large percentage of patients across all specialties. This could well be an opportunity to be rewarded for embracing both of these trends.

Hospitalists are uniquely positioned to function as the documentation improvement clinical team leaders, working closely with other physicians across all specialties and the administration to fulfill all documentation requirements—and to be rewarded for doing so. Though hospitalists should have a general understanding of the language and rules of documentation, a system must be in place that helps them identify and capture all the pertinent aspects of the medical record without the need to become coders themselves. To this end, a clinical documentation improvement (CDI) program is critical.

But it might not be enough.

What is needed is a clinical integration program, an enhancement of traditional CDI. This approach requires participation from ED physicians, along with clinical integration specialists, to document accurately and completely from the start. The clinical integration specialist ensures that medical necessity for inpatient admission and patient risk is being addressed and established, conditions are appropriately identified as being present on admission (POA), and all diagnoses are properly recognized and documented thoroughly and accurately. Clinical integration through collaborative documentation then continues throughout the hospitalization, with diagnostic authority and oversight from the hospitalist, all the way through discharge.

Hospitalists should welcome and champion this type of program. As documentation becomes the key to survival, a complete medical record will stand up to any and all scrutiny by Medicare or others.

As for the negatives, there are none.

Andrew H. Dombro, MD, national medical director, and Paul Weygandt, MD, JD, vice president of physician services, J.A. Thomas & Associates, Atlanta

The Coming Challenges—and Opportunities—of Value-Based Purchasing

The Patient Protection and Affordable Care Act was signed into law in March, furthering the federal government’s commitment to increasing the efficiency of the U.S. healthcare system by decreasing cost and improving quality. An expansion of the “value-based purchasing” model, this law mandates that ratings and reimbursements to physicians and hospitals be increasingly tied to measured quality of care.

In this system, a physician’s quality profile will be determined by a variety of factors, including reported quality data, severity-adjusted clinical outcome measures, patient-safety indicators, and hospital-acquired conditions (HACs). Since all of these are, to a large extent, documentation issues, physicians are now forced to pay close attention to how they identify and describe diagnoses and procedures.

Medicare will, in effect, attempt to determine: “Did the clinical team correctly identify and appropriately treat all relevant patient conditions—without causing any adverse conditions—and do so safely, efficiently, and with good outcomes?”

The patient chart must “tell the story” of the episode of care in the hospital. It must accurately describe all of the patient’s conditions and demonstrate the complexity of medical decision-making and establishment of risk. Upon discharge, this risk must “match up” with the diagnoses that are being coded and the Medicare Severity Diagnostic Related Group (MS-DRGs) being assigned. Often, the information is present in the chart but is inconsistent from provider to provider, or documented in a way that is misunderstood by hospital coders.

If successful in improving our documentation skills, the reward will be a higher rating and increased reimbursement.

Medicare also is ramping up its claims denial and recovery business to help “clean up” the system. This includes the national rollout of the Recovery Audit Contactor (RAC) initiative (see “Attention to Detail,” April 2010, p. 1), as well as the new Medicare administrative contractors (MACs). Both rely on accurate documentation. The RACs will penalize hospitals and physicians financially for documentation lacking in specificity and accuracy; the MACs will deny payment for claims erroneously submitted (technical errors) or lacking documentation of medical necessity.

What makes many physicians even more uncomfortable in this new environment is that Medicare is striving to better align the priorities and financial incentives of hospitals and physicians. Alliances between the two are strongly encouraged through such programs as the Acute Care Episode (ACE) Demonstration Project (the precursor to hospital-physician bundled payments), and the establishment of accountable care organizations (ACOs).

This emerging environment presents a unique set of challenges and opportunities to HM groups. Hospitalists are historically more aligned with hospital administrations, as compared with most other specialties. Hospitalists also are asked to participate in the care of an increasingly large percentage of patients across all specialties. This could well be an opportunity to be rewarded for embracing both of these trends.

Hospitalists are uniquely positioned to function as the documentation improvement clinical team leaders, working closely with other physicians across all specialties and the administration to fulfill all documentation requirements—and to be rewarded for doing so. Though hospitalists should have a general understanding of the language and rules of documentation, a system must be in place that helps them identify and capture all the pertinent aspects of the medical record without the need to become coders themselves. To this end, a clinical documentation improvement (CDI) program is critical.

But it might not be enough.

What is needed is a clinical integration program, an enhancement of traditional CDI. This approach requires participation from ED physicians, along with clinical integration specialists, to document accurately and completely from the start. The clinical integration specialist ensures that medical necessity for inpatient admission and patient risk is being addressed and established, conditions are appropriately identified as being present on admission (POA), and all diagnoses are properly recognized and documented thoroughly and accurately. Clinical integration through collaborative documentation then continues throughout the hospitalization, with diagnostic authority and oversight from the hospitalist, all the way through discharge.

Hospitalists should welcome and champion this type of program. As documentation becomes the key to survival, a complete medical record will stand up to any and all scrutiny by Medicare or others.

As for the negatives, there are none.

Andrew H. Dombro, MD, national medical director, and Paul Weygandt, MD, JD, vice president of physician services, J.A. Thomas & Associates, Atlanta

Every year, hospitalists across the country receive SHM membership renewal notices in the mail. For the vast majority of them, the decision to renew is an easy one.

For the others, hospitalist Mike Hawkins, MD, FACP, FHM, recommends a tried-and-true approach in the field: Evaluate the risk-to-benefit ratio.

“As they say in medicine, the risk-to-benefit ratio is a no-brainer,” says Dr. Hawkins, the Southeast region medical director for Brentwood, Tenn.-based Cogent Healthcare.

Dr. Hawkins should know about membership benefits; he’s been an SHM member since 1996. In fact, he was one of the first 200 members of SHM’s original incarnation, the National Association of Inpatient Physicians. He joined for the resources that helped his new hospitalist program grow and for the access to people who were doing the same thing he was in his hospital. He also recognized the potential for networking and the sharing of ideas from such industry leaders as Bob Wachter, MD, MHM, and John Nelson, MD, MHM.

Since then, the membership benefits that Dr. Hawkins and more than 10,000 other hospitalists receive have evolved along with their careers and the specialty as a whole.

SHM membership and the HM specialty have become nearly synonymous to most hospitalists. “I can’t imagine a true hospitalist that wouldn’t be an SHM member,” Dr. Hawkins says. “Most of the hospitalists on my teams are members. As a company, we strongly encourage our physicians to be SHM members.”

Membership: The Basics

Hawkins’ enthusiasm for becoming an SHM member is no surprise to Todd Von Deak, MBA, CAE, vice president of operations and general manager for SHM.

“Thousands of hospitalists join SHM for the many tangible benefits like discounts or subscriptions to the Journal of Hospital Medicine and The Hospitalist,” Von Deak says.

As SHM has evolved, so have the benefits it offers to members. The original society publication sent to members was only four pages; today, members receive both The Hospitalist and the Journal of Hospital Medicine, one of the top peer-reviewed journals in healthcare—and the only peer-reviewed journal for HM.

A Hospitalist Voice on Capitol Hill

Access to other hospitalists and leaders in healthcare is just the beginning for SHM members. SHM membership also gives members a chance to bring their professional perspectives straight to Capitol Hill.

With the critical role that hospitals play in healthcare reform, members of Congress and others in Washington are eager to hear from experts like hospitalists. In May, members of SHM’s Public Policy Committee took their message directly to members of Congress. Hospitalists engaged in a series of one-on-one meetings with legislators, relating their personal experiences in patient care and QI to the continued public dialogue over healthcare reform.

In early June, SHM past president Scott Flanders, MD, SFHM, along with representatives of Blue Cross Blue Shield Michigan and the American Hospital Association, conducted a briefing with about 50 legislative aides. The briefing was intended to educate members of Congress and their staffs about Project BOOST and the need to reduce unplanned readmissions.

“Hospitalists bring a very important perspective to the policy conversation about improving healthcare in America,” says Eric Siegal, MD, SFHM, an SHM board member and former chair of the Public Policy Committee. “SHM helps to facilitate that conversation.”

Even if they can’t make it to Washington, SHM members can stay on top of the issues affecting them and make their opinions known, Dr. Siegal says. Members can use SHM’s Legislative Action Center in the advocacy section of www.hospitalmedicine.org to learn more about current legislation and activities by the members of Congress in their area. The Legislative Action Center also makes contacting members of Congress easy by supplying contact information and tips for effective outreach.

“This is an important time to be a hospitalist,” Siegal says. “As a unified society, we can influence decisions that will shape healthcare for decades to come.”

The evolution of services to members has helped members establish credibility with their peers. Last year, SHM introduced the Fellow in Hospital Medicine designation to its members. This year, it expanded the fellowship program to include the new Senior Fellow in Hospital Medicine and the Master in Hospital Medicine programs.

“Many of our members are younger than the average physician, and in an emerging specialty,” Von Deak says. “That’s why so many of SHM’s benefits help members to establish themselves within healthcare. Our fellowship program has only been around for two years and we’ve already inducted nearly 1,000 members.”

The products and events—all offered to members at reduced rates—have all grown with SHM and its members. This year’s annual meeting attracted more than 2,500 of the most dedicated hospitalists from around the world.

Eugene Chu, MD, FHM, hospitalist and director of hospital medicine at the Denver Health Medical Center, remembers when he first joined SHM eight years ago. At the time, he says the member discount for the annual meeting was one of the deciding factors. “Financially, it made a lot of sense. The meeting discount and the member fee were close,” he says. “I’m glad it did, as SHM has offered a lot of additional benefits since then.”

Join the Movement

Over time, Dr. Chu found that the discounts for events and products were just the beginning. He now sees value in the energy that SHM brings to its members.

“Being a member brings you into the community of hospitalists,” he says. “It’s hard to quantify, but every time I come back from the spring meeting, I come back really charged up and enthusiastic about where hospital medicine is going.”

Dr. Chu isn’t alone. Many hospitalists become SHM members for financial reasons but end up renewing for the intangibles, Von Deak says.

“As members, they discover a lot more: the ability to network with peers in a growing specialty, a unified voice on critical issues, and, above all, the feeling that they are part of a real movement made up of dedicated professionals just like them,” Von Deak says.

The movement is equal parts human capital and mission. In recent years, SHM members and leadership have created new quality-improvement (QI) programs that have benefited hospitals and patients alike. The Project BOOST (Better Outcomes for Older Adults through Safer Transitions) initiative, for example, is helping more than 60 hospitals improve their discharge processes. Programs like Project BOOST, which was created in 2008, have raised the profiles of both SHM and its members within hospitals and all of healthcare.

SHM members also have ample opportunities for leadership development; like the movement, those opportunities go beyond HM. SHM’s online resource centers and mentored QI programs bring the very best of the specialty to aspiring hospitalist leaders in hospitals across the country.

For Aziz Ansari, DO, an assistant professor in hospital medicine and associate director for Loyola University Medical Center’s hospital medicine practice in Chicago, joining SHM was part of the natural progression in his career. He became an SHM member near the end of his first year as a hospitalist. Since then, Ansari’s appreciation of SHM membership has changed.

“As I progressed into leadership positions in hospital medicine, I found that the society brings credibility to the specialty,” Dr. Ansari explains. “To be established, the society needs members.”

Dr. Ansari can’t imagine not being an active member. “In fact, I haven’t met a nonmember who is as invested in their career and the specialty as SHM’s members are,” he says. TH

Brendon Shank is a freelance writer based in Philadelphia.

Every year, hospitalists across the country receive SHM membership renewal notices in the mail. For the vast majority of them, the decision to renew is an easy one.

For the others, hospitalist Mike Hawkins, MD, FACP, FHM, recommends a tried-and-true approach in the field: Evaluate the risk-to-benefit ratio.

“As they say in medicine, the risk-to-benefit ratio is a no-brainer,” says Dr. Hawkins, the Southeast region medical director for Brentwood, Tenn.-based Cogent Healthcare.

Dr. Hawkins should know about membership benefits; he’s been an SHM member since 1996. In fact, he was one of the first 200 members of SHM’s original incarnation, the National Association of Inpatient Physicians. He joined for the resources that helped his new hospitalist program grow and for the access to people who were doing the same thing he was in his hospital. He also recognized the potential for networking and the sharing of ideas from such industry leaders as Bob Wachter, MD, MHM, and John Nelson, MD, MHM.

Since then, the membership benefits that Dr. Hawkins and more than 10,000 other hospitalists receive have evolved along with their careers and the specialty as a whole.

SHM membership and the HM specialty have become nearly synonymous to most hospitalists. “I can’t imagine a true hospitalist that wouldn’t be an SHM member,” Dr. Hawkins says. “Most of the hospitalists on my teams are members. As a company, we strongly encourage our physicians to be SHM members.”

Membership: The Basics

Hawkins’ enthusiasm for becoming an SHM member is no surprise to Todd Von Deak, MBA, CAE, vice president of operations and general manager for SHM.

“Thousands of hospitalists join SHM for the many tangible benefits like discounts or subscriptions to the Journal of Hospital Medicine and The Hospitalist,” Von Deak says.

As SHM has evolved, so have the benefits it offers to members. The original society publication sent to members was only four pages; today, members receive both The Hospitalist and the Journal of Hospital Medicine, one of the top peer-reviewed journals in healthcare—and the only peer-reviewed journal for HM.

A Hospitalist Voice on Capitol Hill

Access to other hospitalists and leaders in healthcare is just the beginning for SHM members. SHM membership also gives members a chance to bring their professional perspectives straight to Capitol Hill.

With the critical role that hospitals play in healthcare reform, members of Congress and others in Washington are eager to hear from experts like hospitalists. In May, members of SHM’s Public Policy Committee took their message directly to members of Congress. Hospitalists engaged in a series of one-on-one meetings with legislators, relating their personal experiences in patient care and QI to the continued public dialogue over healthcare reform.

In early June, SHM past president Scott Flanders, MD, SFHM, along with representatives of Blue Cross Blue Shield Michigan and the American Hospital Association, conducted a briefing with about 50 legislative aides. The briefing was intended to educate members of Congress and their staffs about Project BOOST and the need to reduce unplanned readmissions.

“Hospitalists bring a very important perspective to the policy conversation about improving healthcare in America,” says Eric Siegal, MD, SFHM, an SHM board member and former chair of the Public Policy Committee. “SHM helps to facilitate that conversation.”

Even if they can’t make it to Washington, SHM members can stay on top of the issues affecting them and make their opinions known, Dr. Siegal says. Members can use SHM’s Legislative Action Center in the advocacy section of www.hospitalmedicine.org to learn more about current legislation and activities by the members of Congress in their area. The Legislative Action Center also makes contacting members of Congress easy by supplying contact information and tips for effective outreach.

“This is an important time to be a hospitalist,” Siegal says. “As a unified society, we can influence decisions that will shape healthcare for decades to come.”

The evolution of services to members has helped members establish credibility with their peers. Last year, SHM introduced the Fellow in Hospital Medicine designation to its members. This year, it expanded the fellowship program to include the new Senior Fellow in Hospital Medicine and the Master in Hospital Medicine programs.

“Many of our members are younger than the average physician, and in an emerging specialty,” Von Deak says. “That’s why so many of SHM’s benefits help members to establish themselves within healthcare. Our fellowship program has only been around for two years and we’ve already inducted nearly 1,000 members.”

The products and events—all offered to members at reduced rates—have all grown with SHM and its members. This year’s annual meeting attracted more than 2,500 of the most dedicated hospitalists from around the world.

Eugene Chu, MD, FHM, hospitalist and director of hospital medicine at the Denver Health Medical Center, remembers when he first joined SHM eight years ago. At the time, he says the member discount for the annual meeting was one of the deciding factors. “Financially, it made a lot of sense. The meeting discount and the member fee were close,” he says. “I’m glad it did, as SHM has offered a lot of additional benefits since then.”

Join the Movement

Over time, Dr. Chu found that the discounts for events and products were just the beginning. He now sees value in the energy that SHM brings to its members.

“Being a member brings you into the community of hospitalists,” he says. “It’s hard to quantify, but every time I come back from the spring meeting, I come back really charged up and enthusiastic about where hospital medicine is going.”

Dr. Chu isn’t alone. Many hospitalists become SHM members for financial reasons but end up renewing for the intangibles, Von Deak says.

“As members, they discover a lot more: the ability to network with peers in a growing specialty, a unified voice on critical issues, and, above all, the feeling that they are part of a real movement made up of dedicated professionals just like them,” Von Deak says.

The movement is equal parts human capital and mission. In recent years, SHM members and leadership have created new quality-improvement (QI) programs that have benefited hospitals and patients alike. The Project BOOST (Better Outcomes for Older Adults through Safer Transitions) initiative, for example, is helping more than 60 hospitals improve their discharge processes. Programs like Project BOOST, which was created in 2008, have raised the profiles of both SHM and its members within hospitals and all of healthcare.

SHM members also have ample opportunities for leadership development; like the movement, those opportunities go beyond HM. SHM’s online resource centers and mentored QI programs bring the very best of the specialty to aspiring hospitalist leaders in hospitals across the country.

For Aziz Ansari, DO, an assistant professor in hospital medicine and associate director for Loyola University Medical Center’s hospital medicine practice in Chicago, joining SHM was part of the natural progression in his career. He became an SHM member near the end of his first year as a hospitalist. Since then, Ansari’s appreciation of SHM membership has changed.

“As I progressed into leadership positions in hospital medicine, I found that the society brings credibility to the specialty,” Dr. Ansari explains. “To be established, the society needs members.”

Dr. Ansari can’t imagine not being an active member. “In fact, I haven’t met a nonmember who is as invested in their career and the specialty as SHM’s members are,” he says. TH

Brendon Shank is a freelance writer based in Philadelphia.

Every year, hospitalists across the country receive SHM membership renewal notices in the mail. For the vast majority of them, the decision to renew is an easy one.

For the others, hospitalist Mike Hawkins, MD, FACP, FHM, recommends a tried-and-true approach in the field: Evaluate the risk-to-benefit ratio.

“As they say in medicine, the risk-to-benefit ratio is a no-brainer,” says Dr. Hawkins, the Southeast region medical director for Brentwood, Tenn.-based Cogent Healthcare.

Dr. Hawkins should know about membership benefits; he’s been an SHM member since 1996. In fact, he was one of the first 200 members of SHM’s original incarnation, the National Association of Inpatient Physicians. He joined for the resources that helped his new hospitalist program grow and for the access to people who were doing the same thing he was in his hospital. He also recognized the potential for networking and the sharing of ideas from such industry leaders as Bob Wachter, MD, MHM, and John Nelson, MD, MHM.

Since then, the membership benefits that Dr. Hawkins and more than 10,000 other hospitalists receive have evolved along with their careers and the specialty as a whole.

SHM membership and the HM specialty have become nearly synonymous to most hospitalists. “I can’t imagine a true hospitalist that wouldn’t be an SHM member,” Dr. Hawkins says. “Most of the hospitalists on my teams are members. As a company, we strongly encourage our physicians to be SHM members.”

Membership: The Basics

Hawkins’ enthusiasm for becoming an SHM member is no surprise to Todd Von Deak, MBA, CAE, vice president of operations and general manager for SHM.

“Thousands of hospitalists join SHM for the many tangible benefits like discounts or subscriptions to the Journal of Hospital Medicine and The Hospitalist,” Von Deak says.

As SHM has evolved, so have the benefits it offers to members. The original society publication sent to members was only four pages; today, members receive both The Hospitalist and the Journal of Hospital Medicine, one of the top peer-reviewed journals in healthcare—and the only peer-reviewed journal for HM.

A Hospitalist Voice on Capitol Hill

Access to other hospitalists and leaders in healthcare is just the beginning for SHM members. SHM membership also gives members a chance to bring their professional perspectives straight to Capitol Hill.

With the critical role that hospitals play in healthcare reform, members of Congress and others in Washington are eager to hear from experts like hospitalists. In May, members of SHM’s Public Policy Committee took their message directly to members of Congress. Hospitalists engaged in a series of one-on-one meetings with legislators, relating their personal experiences in patient care and QI to the continued public dialogue over healthcare reform.

In early June, SHM past president Scott Flanders, MD, SFHM, along with representatives of Blue Cross Blue Shield Michigan and the American Hospital Association, conducted a briefing with about 50 legislative aides. The briefing was intended to educate members of Congress and their staffs about Project BOOST and the need to reduce unplanned readmissions.

“Hospitalists bring a very important perspective to the policy conversation about improving healthcare in America,” says Eric Siegal, MD, SFHM, an SHM board member and former chair of the Public Policy Committee. “SHM helps to facilitate that conversation.”

Even if they can’t make it to Washington, SHM members can stay on top of the issues affecting them and make their opinions known, Dr. Siegal says. Members can use SHM’s Legislative Action Center in the advocacy section of www.hospitalmedicine.org to learn more about current legislation and activities by the members of Congress in their area. The Legislative Action Center also makes contacting members of Congress easy by supplying contact information and tips for effective outreach.

“This is an important time to be a hospitalist,” Siegal says. “As a unified society, we can influence decisions that will shape healthcare for decades to come.”

The evolution of services to members has helped members establish credibility with their peers. Last year, SHM introduced the Fellow in Hospital Medicine designation to its members. This year, it expanded the fellowship program to include the new Senior Fellow in Hospital Medicine and the Master in Hospital Medicine programs.

“Many of our members are younger than the average physician, and in an emerging specialty,” Von Deak says. “That’s why so many of SHM’s benefits help members to establish themselves within healthcare. Our fellowship program has only been around for two years and we’ve already inducted nearly 1,000 members.”

The products and events—all offered to members at reduced rates—have all grown with SHM and its members. This year’s annual meeting attracted more than 2,500 of the most dedicated hospitalists from around the world.

Eugene Chu, MD, FHM, hospitalist and director of hospital medicine at the Denver Health Medical Center, remembers when he first joined SHM eight years ago. At the time, he says the member discount for the annual meeting was one of the deciding factors. “Financially, it made a lot of sense. The meeting discount and the member fee were close,” he says. “I’m glad it did, as SHM has offered a lot of additional benefits since then.”

Join the Movement

Over time, Dr. Chu found that the discounts for events and products were just the beginning. He now sees value in the energy that SHM brings to its members.

“Being a member brings you into the community of hospitalists,” he says. “It’s hard to quantify, but every time I come back from the spring meeting, I come back really charged up and enthusiastic about where hospital medicine is going.”

Dr. Chu isn’t alone. Many hospitalists become SHM members for financial reasons but end up renewing for the intangibles, Von Deak says.

“As members, they discover a lot more: the ability to network with peers in a growing specialty, a unified voice on critical issues, and, above all, the feeling that they are part of a real movement made up of dedicated professionals just like them,” Von Deak says.

The movement is equal parts human capital and mission. In recent years, SHM members and leadership have created new quality-improvement (QI) programs that have benefited hospitals and patients alike. The Project BOOST (Better Outcomes for Older Adults through Safer Transitions) initiative, for example, is helping more than 60 hospitals improve their discharge processes. Programs like Project BOOST, which was created in 2008, have raised the profiles of both SHM and its members within hospitals and all of healthcare.

SHM members also have ample opportunities for leadership development; like the movement, those opportunities go beyond HM. SHM’s online resource centers and mentored QI programs bring the very best of the specialty to aspiring hospitalist leaders in hospitals across the country.

For Aziz Ansari, DO, an assistant professor in hospital medicine and associate director for Loyola University Medical Center’s hospital medicine practice in Chicago, joining SHM was part of the natural progression in his career. He became an SHM member near the end of his first year as a hospitalist. Since then, Ansari’s appreciation of SHM membership has changed.

“As I progressed into leadership positions in hospital medicine, I found that the society brings credibility to the specialty,” Dr. Ansari explains. “To be established, the society needs members.”

Dr. Ansari can’t imagine not being an active member. “In fact, I haven’t met a nonmember who is as invested in their career and the specialty as SHM’s members are,” he says. TH

Brendon Shank is a freelance writer based in Philadelphia.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Risk factors for iatrogenic pneumothorax
• Residency acceptance and use of pharmaceutical industry funding
• Early cholecystectomy outcomes for gallstone pancreatitis
• Use of microbial DNA in sepsis
• Adding rifampicin to vancomycin in MRSA pneumonia
• Rate and outcomes of culture-negative severe sepsis
• Rates of surgical comanagement in U.S. hospitals
• Probiotics and rates of ventilator-associated pneumonia

Ultrasound Guidance and Operator Experience Decrease Risk of Pneumothorax Following Thoracentesis

Clinical question: How often does pneumothorax happen following thoracentesis, and what factors are associated with increased risk of this complication?

Background: Procedural complications are an important source of adverse events in the hospital. Iatrogenic pneumothorax after thoracentesis results in increased hospital length of stay, morbidity, and mortality. Large variation exists in reported pneumothorax rates, and little is known about procedure- and patient-specific factors associated with development of this complication.

Study design: Systematic review and meta-analysis.

Setting: Review of 24 MEDLINE-indexed studies from January 1966 to April 2009.

Synopsis: A total of 349 pneumothoraces were reported after 6,605 thoracenteses (overall incidence 6.0%). Chest-tube insertion was required in 34.1% of the cases. Risk for pneumothorax was significantly higher when larger needles or catheters were used compared with needles smaller than 20-gauge (odds ratio 2.5, 95% confidence interval [CI], 1.1-6.0) and after therapeutic thoracentesis compared with diagnostic procedures (OR 2.6, 95% CI, 1.8-3.8).

Procedures requiring two or more needle passes did not significantly increase pneumothorax risk (OR 2.5, 95% CI, 0.3-20.1). In contrast, pneumothorax rates were significantly lower when using ultrasound guidance (OR 0.3, 95% CI, 0.2-0.7) and with experienced operators (3.9% vs. 8.5%, P=0.04).

Examining patient risk factors, pneumothorax rates were similar regardless of effusion size and patient gender. Additionally, rates were similar among non-ICU inpatients, ICU inpatients, and outpatients. Data did show a trend toward increased risk of pneumothorax with mechanical ventilation (OR 4.0, 95% CI, 0.95-16.8), although no study directly compared rates in ICU patients with and without mechanical ventilation.

Bottom line: Ultrasound guidance is a modifiable factor that decreases the risk of post-thoracentesis pneumothorax. Pneumothorax rates are lower when performed by experienced clinicians, providing an important opportunity to reduce procedure-related complications by increasing direct trainee supervision.

Citation: Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332-339.

Pharmaceutical Industry Support Is Common in U.S. Internal-Medicine Residency Programs

Clinical question: What are the current attitudes of program directors regarding pharmaceutical industry support of internal-medicine residency activities? What are the potential associations between program characteristics and acceptance of industry support?

Background: Increasing evidence suggests that interactions with the pharmaceutical industry influence physician attitudes and practices. Recently, the Association of American Medical Colleges (AAMC) proposed that academic medical centers prohibit the acceptance of all gifts and restrict access by pharmaceutical industry representatives.

Study design: Survey of U.S. internal-medicine residency program directors.

Setting: Web-based survey of residency program directors in 388 U.S. internal-medicine residency programs.

Synopsis: Of the 236 program directors responding to the survey, 132 (55.9%) reported accepting some kind of support from the pharmaceutical industry. Support was most commonly provided in the form of food for conferences (90.9%), educational materials (83.3%), office supplies (68.9%), and drug samples (57.6%).

When programs reported accepting pharmaceutical industry support, 67.9% cited a lack of other funding sources as the reason for acceptance. Only 22.7% of programs with a program director who thinks pharmaceutical support is unacceptable actually accepted industry support. The likelihood of accepting support was associated with location in the Southern U.S. and was inversely associated with the three-year rolling American Board of Internal Medicine (ABIM) pass rates (each 1% decrease in the pass rate was associated with a 21% increase in the odds of accepting pharmaceutical industry support).

Bottom line: While most program directors did not find pharmaceutical industry support desirable, more than half reported acceptance of such support, with most citing lack of other funding resources as the reason for acceptance.

Citation: Loertscher LL, Halvorsen AJ, Beasley BW, Holmboe ES, Kolars JC, McDonald FS. Pharmaceutical industry support and residency education: a survey of internal medicine program directors. Arch Intern Med. 2010;170(4):356-362.

Early Cholecystectomy Safely Decreases Hospital Stay in Patients with Mild Gallstone Pancreatitis

Clinical question: Can laparoscopic cholecystectomy performed within 48 hours of admission for mild gallstone pancreatitis reduce hospital length of stay without increasing perioperative complications?

Background: Although there is a clear consensus that patients who present with gallstone pancreatitis should undergo cholecystectomy to prevent recurrence, precise timing of surgery remains controversial.

Study design: Randomized prospective trial.

Setting: Harbor-UCLA Medical Center, a Los Angeles County public teaching hospital and Level I trauma center.

Synopsis: Patients were prospectively randomized to an early group and a control group. Inclusion criteria consisted of adults from the ages of 18 to 100 with mild gallstone pancreatitis and three or fewer Ranson criteria. The primary endpoint was length of hospital stay. The secondary endpoint was a composite of complications, including the need for conversion to open cholecystectomy, readmission within 30 days, bleeding requiring transfusion, bile duct injury, or wound infection.

The study was terminated after 50 patients, as there was a difference in the length of hospital stay with a predefined alpha level of 0.005. Patients in the early group were taken to the operating room at a mean of 35.1 hours after admission, compared with 77.8 hours in the control group. The overall length of hospital stay was shorter in the early group (mean 3.5 days, 95% CI, 2.7-4.3), compared with the control group (mean 5.8, 95% CI, 3.8-7.9). All cholecystectomies were completed laparoscopically, without conversion to open. No statistically significant difference existed in secondary endpoints (P=0.48, OR 1.66, 95% CI, 0.41-6.78).

Bottom line: Laparoscopic cholecystectomy performed within 48 hours of admission, irrespective of normalization of laboratory values or clinical progress, safely decreases the overall length of stay, compared with delaying laparoscopic cholecystectomy until laboratory values and clinical condition normalize.

Citation: Aboulian A, Chan T, Yaghoubian A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. 2010;251(4): 615-619.

Presence of Microbial DNA in Blood Correlates with Disease Severity

Clinical question: Is the presence of microbial DNA in the blood associated with disease severity in severe sepsis, and how does detection of this microbial DNA by polymerase chain reaction (PCR) compare with blood cultures (BC)?

Background: Inadequate antibiotic therapy is a strong and independent predictor of poor outcomes in sepsis. Diagnostic uncertainty regarding the causative micro-organism is compensated for by liberal use of broad-spectrum antibiotics. As a result, resistance to antibiotics is an increasing public-health problem.

Study design: Prospective multicenter controlled observational study.

Setting: Three ICUs in Germany and France.

Synopsis: From 2005 to 2007, 63 patients were enrolled in the control group and 142 patients were enrolled in the sepsis group. In control patients, blood cultures and specimens were drawn daily at a maximum of three days after admission. In the sepsis group, blood samples were obtained on the day severe sepsis was suspected. Consecutive samples for the next two days after study inclusion were taken.

Taking BC as the laboratory comparison method, the sensitivity of PCR to detect culture-positive bacteremia in sepsis was 0.80 with a specificity of 0.77. PCR detected 29 of 41 microorganisms (70.3%) found in the BC. The highest recovery rate was observed for gram-negative bacteria (78.6%), fungi (50.0%), and gram-positive bacteria (47.6%). PCR from septic patients correlated well with markers of host response (IL-6 and PCT) and disease severity (SOFA score), even when the BC remained negative.

The appropriateness of antimicrobial therapy based on culture-based methods was not recorded, so it’s impossible to conclude whether or not the PCR would have contributed to a more effective therapy.

Bottom line: Concordance between BC and PCR is moderate in septic patients. PCR-based pathogen detection correlated with disease severity even if the BC remained negative, suggesting that the presence of microbial DNA in the bloodstream is a clinically significant event.

Citation: Bloos F, Hinder F, Becker K, et al. A multicenter trial to compare blood culture with polymerase chain reaction in severe human sepsis. Intensive Care Med. 2010;36(2):241-247.

Adding Rifampicin to Vancomycin Improves Outcomes in MRSA Pneumonia

Clinical question: Does adding rifampicin to vancomycin improve outcomes in patients with hospital-acquired MRSA pneumonia?

Background: Hospital-acquired MRSA pneumonia has a mortality of more than 20%. Vancomycin penetrates the lung tissue poorly. The value of adding rifampicin, an antibiotic with broad-spectrum coverage and good tissue penetration, was investigated.

Study design: Randomized open-label trial.

Setting: Medical ICU patients at Ulsan College of Medicine, Asan Medical Center, South Korea.

Synopsis: Patients older than 18 years of age with clinical symptoms suggestive of nosocomial pneumonia were randomized to receive vancomycin alone (V) or vancomycin plus rifampicin (VR). Clinicians could add additional antibiotics for gram-negative coverage as needed.

Of the 183 patients screened, 93 met the inclusion criteria and were randomized in a 1:1 ratio. MRSA infection was microbiologically confirmed. Clinical cure rate in VR patients was significantly greater at day 14 compared with the V group (53.7% vs. 31.0%, P=0.047) based on a modified intention-to-treat model. The overall mortality at day 28 did not significantly differ between the groups (22.0% vs. 38.1%, P=0.15), although the 60-day mortality was lower in the VR group (26.8% vs. 50.0%, P=0.042). Mortality from MRSA pneumonia had a trend toward a decrease in the VR group (14.7% vs. 28.6%, P=0.18).

The trial was limited because it was a single-site study and lacked statistical power to assess certain outcomes. Additionally, treatment protocols were not compared with other antimicrobial therapies.

Bottom line: Vancomycin plus rifampicin improves MRSA pneumonia outcomes in ICU patients.

Citation: Jung YJ, Koh Y, Hong SB, et al. Effect of vancomycin plus rifampicin in the treatment of nosocomial MRSA pneumonia. Crit Care Med. 2010;38(1):175-180.

Severe Sepsis Syndromes Are Not Always Caused by Bacteremia

Clinical question: What are the common causes of clinical sepsis?

Background: When sepsis is defined by systemic inflammatory response syndrome (SIRS) criteria, the etiology is not always infectious. Rapid initiation of antimicrobial therapy for infectious SIRS is a priority, but it could result in treating a significant number of patients who are not bacteremic.

Study design: Prospective secondary analysis of a registry of patients created to evaluate an institutional standard-of-care protocol.

Setting: Urban, 850-bed, tertiary-care teaching institution in North Carolina.

Synopsis: ED cases meeting the criteria for severe sepsis underwent a secondary review that looked at the cause of the sepsis. Only 45% of patients identified as having severe sepsis were blood-culture-positive during that episode of care. The culture-positive group was more likely to have central lines, malignancies, or reside in a nursing home.

Of the subgroup of culture-negative patients, 52% had another infectious etiology, most commonly pneumonia. Other “noninfectious mimics,” including inflammatory colitis, myocardial infarction, and pulmonary embolism, were noted in 32% of patients in the subgroup, and the cause was not identified in 16% of the patients.

In-hospital mortality was higher in the culture-positive group than in the culture-negative group (25% vs. 4%, P=0.05). There was no evidence of harm in patients with culture-negative sepsis treated for a systemic infection.

Bottom line: Many patients with a clinical picture of severe sepsis will not have positive blood cultures or an infectious etiology.

Citation: Heffner AC, Horton JM, Marchick MR, Jones AE. Etiology of illness in patients with severe sepsis admitted to the hospital from the emergency department. Clin Infect Dis. 2010;50(6):814-820.

Comanagement of Surgical Inpatients by Hospitalists Is Rapidly Expanding

Clinical question: What is the prevalence and nature of comanagement of surgical patients by medicine physicians?

Background: Comanagement of surgical patients is a common clinical role for hospitalists, but the relationship is not well characterized in the literature in terms of numbers of patients or types of physicians involved in this practice.

Study design: Retrospective cohort.

Setting: Cross-section of hospitals from a Medicare database.

Synopsis: During the study period, 35.2% of patients were comanaged by a medicine physician—23.7% by a generalist and 14% by a subspecialist. Cardiothoracic surgery patients were more likely to be comanaged by a subspecialist, whereas all other patients were more likely to be comanaged by a generalist.

Although subspecialist comanagement actually declined during the study period, overall comanagement increased from 33.3% in 1996 to 40.8% in 2006. This increase is entirely attributable to the increase in comanagement by hospitalists. Most of this growth occurred with orthopedic patients.

Patient factors associated with comanagement include advanced age, emergency admissions, and increasing comorbidities. Teaching hospitals had less comanagement, while midsize, nonteaching, and for-profit hospitals had more comanagement.

Bottom line: Comanagement of surgical patients by medicine physicians is a common and growing clinical relationship. Hospitalists are responsible for increasing numbers of comanaged surgical patients.

Citation: Sharma G, Kuo YF, Freeman J, Zhang DD, Goodwin JS. Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med. 2010;170(4):363-368.

Probiotics Might Decrease Risk of Ventilator-Associated Pneumonia

Clinical question: Does the administration of probiotics decrease the incidence of ventilator-associated pneumonia in critically ill patients?

Background: Ventilator-associated pneumonia (VAP) is a major nosocomial infection in ICUs. Probiotics are thought to decrease colonization and, therefore, infection with serious hospital-acquired pathogens.

Study design: Meta-analysis of five randomized controlled trials.

Setting: ICU patients on mechanical ventilation for at least 24 hours.

Synopsis: Five trials met the inclusion criteria of comparing probiotics to placebo in critically ill patients on mechanical ventilation and reporting the outcome of VAP. Administration of probiotics decreased the incidence of VAP (odds ratio 0.61, 95% CI, 0.41-0.91) and colonization of the respiratory tract with Pseudomonas aeruginosa (OR 0.35, 95% CI, 0.13-0.93).

Length of ICU stay was decreased in the probiotic arm, although this effect was not statistically significant in all analyses. Probiotics had no effect on such outcomes as ICU mortality, in-hospital mortality, or duration of mechanical ventilation.

Bottom line: Probiotics might be an effective strategy to reduce the risk of VAP, even if they do not appear to impact such outcomes as mortality.

Citation: Siempos II, Ntaidou TK, Falagas ME. Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. Crit Care Med. 2010;38(3):954-962. TH

PEDIATRIC HM LITERATURE

By Mark Shen, MD

Renal Ultrasound Identifies Children with High-Grade Vesicoureteral Reflux

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the diagnostic accuracy of specific renal ultrasound (US) criterion for detection of vesicoureteral reflux (VUR)?

Background: Based on the paradigm that undetected and untreated VUR might lead to long-term complications, voiding cystography traditionally has been recommended for all young children with a first urinary tract infection (UTI). An increasing base of evidence suggests that antibiotic prophylaxis for low-grade VUR might be unnecessary. However, less-invasive methods of screening for high-grade reflux have not yet been identified.

Study design: Secondary analysis of data from a prior prospective study.

Setting: Nephrology department of a French teaching hospital.

Synopsis: One hundred seventeen children (0-16 years) with a UTI were included and underwent renal US and voiding cystography. Patients with a known uropathy or those who had received antibiotics within the past 48 hours were excluded. A generalized linear multilevel model was used to analyze the relationship between standardized renal US criterion and VUR.

Twenty-seven percent of children had VUR and 8% had high-grade VUR (grade ≥3). Pelvic, ureteral, and urinary tract dilatation were significantly associated with high-grade VUR. Ureteral dilatation offered the best combination of standardized criterion, sensitivity (75%), and specificity (88%).

Significant limitations of this study include the use of bag urine cultures and the lack of consensus-based US criterion for ureteral and pelvic dilatation. The authors appropriately caution that these renal US criteria do not identify all children with high-grade VUR and are merely one step toward an intermediate screening strategy for high-grade VUR in order to mitigate adverse effects of universal voiding cystography. Further validation of this work in a clinically representative population will be needed.

Bottom line: Ureteral dilatation accurately identifies children with high-grade VUR.

Citation: Leroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman A. Vesicoureteral reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria. Radiology. 2010;255(3):890-898.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Risk factors for iatrogenic pneumothorax
• Residency acceptance and use of pharmaceutical industry funding
• Early cholecystectomy outcomes for gallstone pancreatitis
• Use of microbial DNA in sepsis
• Adding rifampicin to vancomycin in MRSA pneumonia
• Rate and outcomes of culture-negative severe sepsis
• Rates of surgical comanagement in U.S. hospitals
• Probiotics and rates of ventilator-associated pneumonia

Ultrasound Guidance and Operator Experience Decrease Risk of Pneumothorax Following Thoracentesis

Clinical question: How often does pneumothorax happen following thoracentesis, and what factors are associated with increased risk of this complication?

Background: Procedural complications are an important source of adverse events in the hospital. Iatrogenic pneumothorax after thoracentesis results in increased hospital length of stay, morbidity, and mortality. Large variation exists in reported pneumothorax rates, and little is known about procedure- and patient-specific factors associated with development of this complication.

Study design: Systematic review and meta-analysis.

Setting: Review of 24 MEDLINE-indexed studies from January 1966 to April 2009.

Synopsis: A total of 349 pneumothoraces were reported after 6,605 thoracenteses (overall incidence 6.0%). Chest-tube insertion was required in 34.1% of the cases. Risk for pneumothorax was significantly higher when larger needles or catheters were used compared with needles smaller than 20-gauge (odds ratio 2.5, 95% confidence interval [CI], 1.1-6.0) and after therapeutic thoracentesis compared with diagnostic procedures (OR 2.6, 95% CI, 1.8-3.8).

Procedures requiring two or more needle passes did not significantly increase pneumothorax risk (OR 2.5, 95% CI, 0.3-20.1). In contrast, pneumothorax rates were significantly lower when using ultrasound guidance (OR 0.3, 95% CI, 0.2-0.7) and with experienced operators (3.9% vs. 8.5%, P=0.04).

Examining patient risk factors, pneumothorax rates were similar regardless of effusion size and patient gender. Additionally, rates were similar among non-ICU inpatients, ICU inpatients, and outpatients. Data did show a trend toward increased risk of pneumothorax with mechanical ventilation (OR 4.0, 95% CI, 0.95-16.8), although no study directly compared rates in ICU patients with and without mechanical ventilation.

Bottom line: Ultrasound guidance is a modifiable factor that decreases the risk of post-thoracentesis pneumothorax. Pneumothorax rates are lower when performed by experienced clinicians, providing an important opportunity to reduce procedure-related complications by increasing direct trainee supervision.

Citation: Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332-339.

Pharmaceutical Industry Support Is Common in U.S. Internal-Medicine Residency Programs

Clinical question: What are the current attitudes of program directors regarding pharmaceutical industry support of internal-medicine residency activities? What are the potential associations between program characteristics and acceptance of industry support?

Background: Increasing evidence suggests that interactions with the pharmaceutical industry influence physician attitudes and practices. Recently, the Association of American Medical Colleges (AAMC) proposed that academic medical centers prohibit the acceptance of all gifts and restrict access by pharmaceutical industry representatives.

Study design: Survey of U.S. internal-medicine residency program directors.

Setting: Web-based survey of residency program directors in 388 U.S. internal-medicine residency programs.

Synopsis: Of the 236 program directors responding to the survey, 132 (55.9%) reported accepting some kind of support from the pharmaceutical industry. Support was most commonly provided in the form of food for conferences (90.9%), educational materials (83.3%), office supplies (68.9%), and drug samples (57.6%).

When programs reported accepting pharmaceutical industry support, 67.9% cited a lack of other funding sources as the reason for acceptance. Only 22.7% of programs with a program director who thinks pharmaceutical support is unacceptable actually accepted industry support. The likelihood of accepting support was associated with location in the Southern U.S. and was inversely associated with the three-year rolling American Board of Internal Medicine (ABIM) pass rates (each 1% decrease in the pass rate was associated with a 21% increase in the odds of accepting pharmaceutical industry support).

Bottom line: While most program directors did not find pharmaceutical industry support desirable, more than half reported acceptance of such support, with most citing lack of other funding resources as the reason for acceptance.

Citation: Loertscher LL, Halvorsen AJ, Beasley BW, Holmboe ES, Kolars JC, McDonald FS. Pharmaceutical industry support and residency education: a survey of internal medicine program directors. Arch Intern Med. 2010;170(4):356-362.

Early Cholecystectomy Safely Decreases Hospital Stay in Patients with Mild Gallstone Pancreatitis

Clinical question: Can laparoscopic cholecystectomy performed within 48 hours of admission for mild gallstone pancreatitis reduce hospital length of stay without increasing perioperative complications?

Background: Although there is a clear consensus that patients who present with gallstone pancreatitis should undergo cholecystectomy to prevent recurrence, precise timing of surgery remains controversial.

Study design: Randomized prospective trial.

Setting: Harbor-UCLA Medical Center, a Los Angeles County public teaching hospital and Level I trauma center.

Synopsis: Patients were prospectively randomized to an early group and a control group. Inclusion criteria consisted of adults from the ages of 18 to 100 with mild gallstone pancreatitis and three or fewer Ranson criteria. The primary endpoint was length of hospital stay. The secondary endpoint was a composite of complications, including the need for conversion to open cholecystectomy, readmission within 30 days, bleeding requiring transfusion, bile duct injury, or wound infection.

The study was terminated after 50 patients, as there was a difference in the length of hospital stay with a predefined alpha level of 0.005. Patients in the early group were taken to the operating room at a mean of 35.1 hours after admission, compared with 77.8 hours in the control group. The overall length of hospital stay was shorter in the early group (mean 3.5 days, 95% CI, 2.7-4.3), compared with the control group (mean 5.8, 95% CI, 3.8-7.9). All cholecystectomies were completed laparoscopically, without conversion to open. No statistically significant difference existed in secondary endpoints (P=0.48, OR 1.66, 95% CI, 0.41-6.78).

Bottom line: Laparoscopic cholecystectomy performed within 48 hours of admission, irrespective of normalization of laboratory values or clinical progress, safely decreases the overall length of stay, compared with delaying laparoscopic cholecystectomy until laboratory values and clinical condition normalize.

Citation: Aboulian A, Chan T, Yaghoubian A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. 2010;251(4): 615-619.

Presence of Microbial DNA in Blood Correlates with Disease Severity

Clinical question: Is the presence of microbial DNA in the blood associated with disease severity in severe sepsis, and how does detection of this microbial DNA by polymerase chain reaction (PCR) compare with blood cultures (BC)?

Background: Inadequate antibiotic therapy is a strong and independent predictor of poor outcomes in sepsis. Diagnostic uncertainty regarding the causative micro-organism is compensated for by liberal use of broad-spectrum antibiotics. As a result, resistance to antibiotics is an increasing public-health problem.

Study design: Prospective multicenter controlled observational study.

Setting: Three ICUs in Germany and France.

Synopsis: From 2005 to 2007, 63 patients were enrolled in the control group and 142 patients were enrolled in the sepsis group. In control patients, blood cultures and specimens were drawn daily at a maximum of three days after admission. In the sepsis group, blood samples were obtained on the day severe sepsis was suspected. Consecutive samples for the next two days after study inclusion were taken.

Taking BC as the laboratory comparison method, the sensitivity of PCR to detect culture-positive bacteremia in sepsis was 0.80 with a specificity of 0.77. PCR detected 29 of 41 microorganisms (70.3%) found in the BC. The highest recovery rate was observed for gram-negative bacteria (78.6%), fungi (50.0%), and gram-positive bacteria (47.6%). PCR from septic patients correlated well with markers of host response (IL-6 and PCT) and disease severity (SOFA score), even when the BC remained negative.

The appropriateness of antimicrobial therapy based on culture-based methods was not recorded, so it’s impossible to conclude whether or not the PCR would have contributed to a more effective therapy.

Bottom line: Concordance between BC and PCR is moderate in septic patients. PCR-based pathogen detection correlated with disease severity even if the BC remained negative, suggesting that the presence of microbial DNA in the bloodstream is a clinically significant event.

Citation: Bloos F, Hinder F, Becker K, et al. A multicenter trial to compare blood culture with polymerase chain reaction in severe human sepsis. Intensive Care Med. 2010;36(2):241-247.

Adding Rifampicin to Vancomycin Improves Outcomes in MRSA Pneumonia

Clinical question: Does adding rifampicin to vancomycin improve outcomes in patients with hospital-acquired MRSA pneumonia?

Background: Hospital-acquired MRSA pneumonia has a mortality of more than 20%. Vancomycin penetrates the lung tissue poorly. The value of adding rifampicin, an antibiotic with broad-spectrum coverage and good tissue penetration, was investigated.

Study design: Randomized open-label trial.

Setting: Medical ICU patients at Ulsan College of Medicine, Asan Medical Center, South Korea.

Synopsis: Patients older than 18 years of age with clinical symptoms suggestive of nosocomial pneumonia were randomized to receive vancomycin alone (V) or vancomycin plus rifampicin (VR). Clinicians could add additional antibiotics for gram-negative coverage as needed.

Of the 183 patients screened, 93 met the inclusion criteria and were randomized in a 1:1 ratio. MRSA infection was microbiologically confirmed. Clinical cure rate in VR patients was significantly greater at day 14 compared with the V group (53.7% vs. 31.0%, P=0.047) based on a modified intention-to-treat model. The overall mortality at day 28 did not significantly differ between the groups (22.0% vs. 38.1%, P=0.15), although the 60-day mortality was lower in the VR group (26.8% vs. 50.0%, P=0.042). Mortality from MRSA pneumonia had a trend toward a decrease in the VR group (14.7% vs. 28.6%, P=0.18).

The trial was limited because it was a single-site study and lacked statistical power to assess certain outcomes. Additionally, treatment protocols were not compared with other antimicrobial therapies.

Bottom line: Vancomycin plus rifampicin improves MRSA pneumonia outcomes in ICU patients.

Citation: Jung YJ, Koh Y, Hong SB, et al. Effect of vancomycin plus rifampicin in the treatment of nosocomial MRSA pneumonia. Crit Care Med. 2010;38(1):175-180.

Severe Sepsis Syndromes Are Not Always Caused by Bacteremia

Clinical question: What are the common causes of clinical sepsis?

Background: When sepsis is defined by systemic inflammatory response syndrome (SIRS) criteria, the etiology is not always infectious. Rapid initiation of antimicrobial therapy for infectious SIRS is a priority, but it could result in treating a significant number of patients who are not bacteremic.

Study design: Prospective secondary analysis of a registry of patients created to evaluate an institutional standard-of-care protocol.

Setting: Urban, 850-bed, tertiary-care teaching institution in North Carolina.

Synopsis: ED cases meeting the criteria for severe sepsis underwent a secondary review that looked at the cause of the sepsis. Only 45% of patients identified as having severe sepsis were blood-culture-positive during that episode of care. The culture-positive group was more likely to have central lines, malignancies, or reside in a nursing home.

Of the subgroup of culture-negative patients, 52% had another infectious etiology, most commonly pneumonia. Other “noninfectious mimics,” including inflammatory colitis, myocardial infarction, and pulmonary embolism, were noted in 32% of patients in the subgroup, and the cause was not identified in 16% of the patients.

In-hospital mortality was higher in the culture-positive group than in the culture-negative group (25% vs. 4%, P=0.05). There was no evidence of harm in patients with culture-negative sepsis treated for a systemic infection.

Bottom line: Many patients with a clinical picture of severe sepsis will not have positive blood cultures or an infectious etiology.

Citation: Heffner AC, Horton JM, Marchick MR, Jones AE. Etiology of illness in patients with severe sepsis admitted to the hospital from the emergency department. Clin Infect Dis. 2010;50(6):814-820.

Comanagement of Surgical Inpatients by Hospitalists Is Rapidly Expanding

Clinical question: What is the prevalence and nature of comanagement of surgical patients by medicine physicians?

Background: Comanagement of surgical patients is a common clinical role for hospitalists, but the relationship is not well characterized in the literature in terms of numbers of patients or types of physicians involved in this practice.

Study design: Retrospective cohort.

Setting: Cross-section of hospitals from a Medicare database.

Synopsis: During the study period, 35.2% of patients were comanaged by a medicine physician—23.7% by a generalist and 14% by a subspecialist. Cardiothoracic surgery patients were more likely to be comanaged by a subspecialist, whereas all other patients were more likely to be comanaged by a generalist.

Although subspecialist comanagement actually declined during the study period, overall comanagement increased from 33.3% in 1996 to 40.8% in 2006. This increase is entirely attributable to the increase in comanagement by hospitalists. Most of this growth occurred with orthopedic patients.

Patient factors associated with comanagement include advanced age, emergency admissions, and increasing comorbidities. Teaching hospitals had less comanagement, while midsize, nonteaching, and for-profit hospitals had more comanagement.

Bottom line: Comanagement of surgical patients by medicine physicians is a common and growing clinical relationship. Hospitalists are responsible for increasing numbers of comanaged surgical patients.

Citation: Sharma G, Kuo YF, Freeman J, Zhang DD, Goodwin JS. Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med. 2010;170(4):363-368.

Probiotics Might Decrease Risk of Ventilator-Associated Pneumonia

Clinical question: Does the administration of probiotics decrease the incidence of ventilator-associated pneumonia in critically ill patients?

Background: Ventilator-associated pneumonia (VAP) is a major nosocomial infection in ICUs. Probiotics are thought to decrease colonization and, therefore, infection with serious hospital-acquired pathogens.

Study design: Meta-analysis of five randomized controlled trials.

Setting: ICU patients on mechanical ventilation for at least 24 hours.

Synopsis: Five trials met the inclusion criteria of comparing probiotics to placebo in critically ill patients on mechanical ventilation and reporting the outcome of VAP. Administration of probiotics decreased the incidence of VAP (odds ratio 0.61, 95% CI, 0.41-0.91) and colonization of the respiratory tract with Pseudomonas aeruginosa (OR 0.35, 95% CI, 0.13-0.93).

Length of ICU stay was decreased in the probiotic arm, although this effect was not statistically significant in all analyses. Probiotics had no effect on such outcomes as ICU mortality, in-hospital mortality, or duration of mechanical ventilation.

Bottom line: Probiotics might be an effective strategy to reduce the risk of VAP, even if they do not appear to impact such outcomes as mortality.

Citation: Siempos II, Ntaidou TK, Falagas ME. Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. Crit Care Med. 2010;38(3):954-962. TH

PEDIATRIC HM LITERATURE

By Mark Shen, MD

Renal Ultrasound Identifies Children with High-Grade Vesicoureteral Reflux

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the diagnostic accuracy of specific renal ultrasound (US) criterion for detection of vesicoureteral reflux (VUR)?

Background: Based on the paradigm that undetected and untreated VUR might lead to long-term complications, voiding cystography traditionally has been recommended for all young children with a first urinary tract infection (UTI). An increasing base of evidence suggests that antibiotic prophylaxis for low-grade VUR might be unnecessary. However, less-invasive methods of screening for high-grade reflux have not yet been identified.

Study design: Secondary analysis of data from a prior prospective study.

Setting: Nephrology department of a French teaching hospital.

Synopsis: One hundred seventeen children (0-16 years) with a UTI were included and underwent renal US and voiding cystography. Patients with a known uropathy or those who had received antibiotics within the past 48 hours were excluded. A generalized linear multilevel model was used to analyze the relationship between standardized renal US criterion and VUR.

Twenty-seven percent of children had VUR and 8% had high-grade VUR (grade ≥3). Pelvic, ureteral, and urinary tract dilatation were significantly associated with high-grade VUR. Ureteral dilatation offered the best combination of standardized criterion, sensitivity (75%), and specificity (88%).

Significant limitations of this study include the use of bag urine cultures and the lack of consensus-based US criterion for ureteral and pelvic dilatation. The authors appropriately caution that these renal US criteria do not identify all children with high-grade VUR and are merely one step toward an intermediate screening strategy for high-grade VUR in order to mitigate adverse effects of universal voiding cystography. Further validation of this work in a clinically representative population will be needed.

Bottom line: Ureteral dilatation accurately identifies children with high-grade VUR.

Citation: Leroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman A. Vesicoureteral reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria. Radiology. 2010;255(3):890-898.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Risk factors for iatrogenic pneumothorax
• Residency acceptance and use of pharmaceutical industry funding
• Early cholecystectomy outcomes for gallstone pancreatitis
• Use of microbial DNA in sepsis
• Adding rifampicin to vancomycin in MRSA pneumonia
• Rate and outcomes of culture-negative severe sepsis
• Rates of surgical comanagement in U.S. hospitals
• Probiotics and rates of ventilator-associated pneumonia

Ultrasound Guidance and Operator Experience Decrease Risk of Pneumothorax Following Thoracentesis

Clinical question: How often does pneumothorax happen following thoracentesis, and what factors are associated with increased risk of this complication?

Background: Procedural complications are an important source of adverse events in the hospital. Iatrogenic pneumothorax after thoracentesis results in increased hospital length of stay, morbidity, and mortality. Large variation exists in reported pneumothorax rates, and little is known about procedure- and patient-specific factors associated with development of this complication.

Study design: Systematic review and meta-analysis.

Setting: Review of 24 MEDLINE-indexed studies from January 1966 to April 2009.

Synopsis: A total of 349 pneumothoraces were reported after 6,605 thoracenteses (overall incidence 6.0%). Chest-tube insertion was required in 34.1% of the cases. Risk for pneumothorax was significantly higher when larger needles or catheters were used compared with needles smaller than 20-gauge (odds ratio 2.5, 95% confidence interval [CI], 1.1-6.0) and after therapeutic thoracentesis compared with diagnostic procedures (OR 2.6, 95% CI, 1.8-3.8).

Procedures requiring two or more needle passes did not significantly increase pneumothorax risk (OR 2.5, 95% CI, 0.3-20.1). In contrast, pneumothorax rates were significantly lower when using ultrasound guidance (OR 0.3, 95% CI, 0.2-0.7) and with experienced operators (3.9% vs. 8.5%, P=0.04).

Examining patient risk factors, pneumothorax rates were similar regardless of effusion size and patient gender. Additionally, rates were similar among non-ICU inpatients, ICU inpatients, and outpatients. Data did show a trend toward increased risk of pneumothorax with mechanical ventilation (OR 4.0, 95% CI, 0.95-16.8), although no study directly compared rates in ICU patients with and without mechanical ventilation.

Bottom line: Ultrasound guidance is a modifiable factor that decreases the risk of post-thoracentesis pneumothorax. Pneumothorax rates are lower when performed by experienced clinicians, providing an important opportunity to reduce procedure-related complications by increasing direct trainee supervision.

Citation: Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332-339.

Pharmaceutical Industry Support Is Common in U.S. Internal-Medicine Residency Programs

Clinical question: What are the current attitudes of program directors regarding pharmaceutical industry support of internal-medicine residency activities? What are the potential associations between program characteristics and acceptance of industry support?

Background: Increasing evidence suggests that interactions with the pharmaceutical industry influence physician attitudes and practices. Recently, the Association of American Medical Colleges (AAMC) proposed that academic medical centers prohibit the acceptance of all gifts and restrict access by pharmaceutical industry representatives.

Study design: Survey of U.S. internal-medicine residency program directors.

Setting: Web-based survey of residency program directors in 388 U.S. internal-medicine residency programs.

Synopsis: Of the 236 program directors responding to the survey, 132 (55.9%) reported accepting some kind of support from the pharmaceutical industry. Support was most commonly provided in the form of food for conferences (90.9%), educational materials (83.3%), office supplies (68.9%), and drug samples (57.6%).

When programs reported accepting pharmaceutical industry support, 67.9% cited a lack of other funding sources as the reason for acceptance. Only 22.7% of programs with a program director who thinks pharmaceutical support is unacceptable actually accepted industry support. The likelihood of accepting support was associated with location in the Southern U.S. and was inversely associated with the three-year rolling American Board of Internal Medicine (ABIM) pass rates (each 1% decrease in the pass rate was associated with a 21% increase in the odds of accepting pharmaceutical industry support).

Bottom line: While most program directors did not find pharmaceutical industry support desirable, more than half reported acceptance of such support, with most citing lack of other funding resources as the reason for acceptance.

Citation: Loertscher LL, Halvorsen AJ, Beasley BW, Holmboe ES, Kolars JC, McDonald FS. Pharmaceutical industry support and residency education: a survey of internal medicine program directors. Arch Intern Med. 2010;170(4):356-362.

Early Cholecystectomy Safely Decreases Hospital Stay in Patients with Mild Gallstone Pancreatitis

Clinical question: Can laparoscopic cholecystectomy performed within 48 hours of admission for mild gallstone pancreatitis reduce hospital length of stay without increasing perioperative complications?

Background: Although there is a clear consensus that patients who present with gallstone pancreatitis should undergo cholecystectomy to prevent recurrence, precise timing of surgery remains controversial.

Study design: Randomized prospective trial.

Setting: Harbor-UCLA Medical Center, a Los Angeles County public teaching hospital and Level I trauma center.

Synopsis: Patients were prospectively randomized to an early group and a control group. Inclusion criteria consisted of adults from the ages of 18 to 100 with mild gallstone pancreatitis and three or fewer Ranson criteria. The primary endpoint was length of hospital stay. The secondary endpoint was a composite of complications, including the need for conversion to open cholecystectomy, readmission within 30 days, bleeding requiring transfusion, bile duct injury, or wound infection.

The study was terminated after 50 patients, as there was a difference in the length of hospital stay with a predefined alpha level of 0.005. Patients in the early group were taken to the operating room at a mean of 35.1 hours after admission, compared with 77.8 hours in the control group. The overall length of hospital stay was shorter in the early group (mean 3.5 days, 95% CI, 2.7-4.3), compared with the control group (mean 5.8, 95% CI, 3.8-7.9). All cholecystectomies were completed laparoscopically, without conversion to open. No statistically significant difference existed in secondary endpoints (P=0.48, OR 1.66, 95% CI, 0.41-6.78).

Bottom line: Laparoscopic cholecystectomy performed within 48 hours of admission, irrespective of normalization of laboratory values or clinical progress, safely decreases the overall length of stay, compared with delaying laparoscopic cholecystectomy until laboratory values and clinical condition normalize.

Citation: Aboulian A, Chan T, Yaghoubian A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. 2010;251(4): 615-619.

Presence of Microbial DNA in Blood Correlates with Disease Severity

Clinical question: Is the presence of microbial DNA in the blood associated with disease severity in severe sepsis, and how does detection of this microbial DNA by polymerase chain reaction (PCR) compare with blood cultures (BC)?

Background: Inadequate antibiotic therapy is a strong and independent predictor of poor outcomes in sepsis. Diagnostic uncertainty regarding the causative micro-organism is compensated for by liberal use of broad-spectrum antibiotics. As a result, resistance to antibiotics is an increasing public-health problem.

Study design: Prospective multicenter controlled observational study.

Setting: Three ICUs in Germany and France.

Synopsis: From 2005 to 2007, 63 patients were enrolled in the control group and 142 patients were enrolled in the sepsis group. In control patients, blood cultures and specimens were drawn daily at a maximum of three days after admission. In the sepsis group, blood samples were obtained on the day severe sepsis was suspected. Consecutive samples for the next two days after study inclusion were taken.

Taking BC as the laboratory comparison method, the sensitivity of PCR to detect culture-positive bacteremia in sepsis was 0.80 with a specificity of 0.77. PCR detected 29 of 41 microorganisms (70.3%) found in the BC. The highest recovery rate was observed for gram-negative bacteria (78.6%), fungi (50.0%), and gram-positive bacteria (47.6%). PCR from septic patients correlated well with markers of host response (IL-6 and PCT) and disease severity (SOFA score), even when the BC remained negative.

The appropriateness of antimicrobial therapy based on culture-based methods was not recorded, so it’s impossible to conclude whether or not the PCR would have contributed to a more effective therapy.

Bottom line: Concordance between BC and PCR is moderate in septic patients. PCR-based pathogen detection correlated with disease severity even if the BC remained negative, suggesting that the presence of microbial DNA in the bloodstream is a clinically significant event.

Citation: Bloos F, Hinder F, Becker K, et al. A multicenter trial to compare blood culture with polymerase chain reaction in severe human sepsis. Intensive Care Med. 2010;36(2):241-247.

Adding Rifampicin to Vancomycin Improves Outcomes in MRSA Pneumonia

Clinical question: Does adding rifampicin to vancomycin improve outcomes in patients with hospital-acquired MRSA pneumonia?

Background: Hospital-acquired MRSA pneumonia has a mortality of more than 20%. Vancomycin penetrates the lung tissue poorly. The value of adding rifampicin, an antibiotic with broad-spectrum coverage and good tissue penetration, was investigated.

Study design: Randomized open-label trial.

Setting: Medical ICU patients at Ulsan College of Medicine, Asan Medical Center, South Korea.

Synopsis: Patients older than 18 years of age with clinical symptoms suggestive of nosocomial pneumonia were randomized to receive vancomycin alone (V) or vancomycin plus rifampicin (VR). Clinicians could add additional antibiotics for gram-negative coverage as needed.

Of the 183 patients screened, 93 met the inclusion criteria and were randomized in a 1:1 ratio. MRSA infection was microbiologically confirmed. Clinical cure rate in VR patients was significantly greater at day 14 compared with the V group (53.7% vs. 31.0%, P=0.047) based on a modified intention-to-treat model. The overall mortality at day 28 did not significantly differ between the groups (22.0% vs. 38.1%, P=0.15), although the 60-day mortality was lower in the VR group (26.8% vs. 50.0%, P=0.042). Mortality from MRSA pneumonia had a trend toward a decrease in the VR group (14.7% vs. 28.6%, P=0.18).

The trial was limited because it was a single-site study and lacked statistical power to assess certain outcomes. Additionally, treatment protocols were not compared with other antimicrobial therapies.

Bottom line: Vancomycin plus rifampicin improves MRSA pneumonia outcomes in ICU patients.

Citation: Jung YJ, Koh Y, Hong SB, et al. Effect of vancomycin plus rifampicin in the treatment of nosocomial MRSA pneumonia. Crit Care Med. 2010;38(1):175-180.

Severe Sepsis Syndromes Are Not Always Caused by Bacteremia

Clinical question: What are the common causes of clinical sepsis?

Background: When sepsis is defined by systemic inflammatory response syndrome (SIRS) criteria, the etiology is not always infectious. Rapid initiation of antimicrobial therapy for infectious SIRS is a priority, but it could result in treating a significant number of patients who are not bacteremic.

Study design: Prospective secondary analysis of a registry of patients created to evaluate an institutional standard-of-care protocol.

Setting: Urban, 850-bed, tertiary-care teaching institution in North Carolina.

Synopsis: ED cases meeting the criteria for severe sepsis underwent a secondary review that looked at the cause of the sepsis. Only 45% of patients identified as having severe sepsis were blood-culture-positive during that episode of care. The culture-positive group was more likely to have central lines, malignancies, or reside in a nursing home.

Of the subgroup of culture-negative patients, 52% had another infectious etiology, most commonly pneumonia. Other “noninfectious mimics,” including inflammatory colitis, myocardial infarction, and pulmonary embolism, were noted in 32% of patients in the subgroup, and the cause was not identified in 16% of the patients.

In-hospital mortality was higher in the culture-positive group than in the culture-negative group (25% vs. 4%, P=0.05). There was no evidence of harm in patients with culture-negative sepsis treated for a systemic infection.

Bottom line: Many patients with a clinical picture of severe sepsis will not have positive blood cultures or an infectious etiology.

Citation: Heffner AC, Horton JM, Marchick MR, Jones AE. Etiology of illness in patients with severe sepsis admitted to the hospital from the emergency department. Clin Infect Dis. 2010;50(6):814-820.

Comanagement of Surgical Inpatients by Hospitalists Is Rapidly Expanding

Clinical question: What is the prevalence and nature of comanagement of surgical patients by medicine physicians?

Background: Comanagement of surgical patients is a common clinical role for hospitalists, but the relationship is not well characterized in the literature in terms of numbers of patients or types of physicians involved in this practice.

Study design: Retrospective cohort.

Setting: Cross-section of hospitals from a Medicare database.

Synopsis: During the study period, 35.2% of patients were comanaged by a medicine physician—23.7% by a generalist and 14% by a subspecialist. Cardiothoracic surgery patients were more likely to be comanaged by a subspecialist, whereas all other patients were more likely to be comanaged by a generalist.

Although subspecialist comanagement actually declined during the study period, overall comanagement increased from 33.3% in 1996 to 40.8% in 2006. This increase is entirely attributable to the increase in comanagement by hospitalists. Most of this growth occurred with orthopedic patients.

Patient factors associated with comanagement include advanced age, emergency admissions, and increasing comorbidities. Teaching hospitals had less comanagement, while midsize, nonteaching, and for-profit hospitals had more comanagement.

Bottom line: Comanagement of surgical patients by medicine physicians is a common and growing clinical relationship. Hospitalists are responsible for increasing numbers of comanaged surgical patients.

Citation: Sharma G, Kuo YF, Freeman J, Zhang DD, Goodwin JS. Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med. 2010;170(4):363-368.

Probiotics Might Decrease Risk of Ventilator-Associated Pneumonia

Clinical question: Does the administration of probiotics decrease the incidence of ventilator-associated pneumonia in critically ill patients?

Background: Ventilator-associated pneumonia (VAP) is a major nosocomial infection in ICUs. Probiotics are thought to decrease colonization and, therefore, infection with serious hospital-acquired pathogens.

Study design: Meta-analysis of five randomized controlled trials.

Setting: ICU patients on mechanical ventilation for at least 24 hours.

Synopsis: Five trials met the inclusion criteria of comparing probiotics to placebo in critically ill patients on mechanical ventilation and reporting the outcome of VAP. Administration of probiotics decreased the incidence of VAP (odds ratio 0.61, 95% CI, 0.41-0.91) and colonization of the respiratory tract with Pseudomonas aeruginosa (OR 0.35, 95% CI, 0.13-0.93).

Length of ICU stay was decreased in the probiotic arm, although this effect was not statistically significant in all analyses. Probiotics had no effect on such outcomes as ICU mortality, in-hospital mortality, or duration of mechanical ventilation.

Bottom line: Probiotics might be an effective strategy to reduce the risk of VAP, even if they do not appear to impact such outcomes as mortality.

Citation: Siempos II, Ntaidou TK, Falagas ME. Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. Crit Care Med. 2010;38(3):954-962. TH

PEDIATRIC HM LITERATURE

By Mark Shen, MD

Renal Ultrasound Identifies Children with High-Grade Vesicoureteral Reflux

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the diagnostic accuracy of specific renal ultrasound (US) criterion for detection of vesicoureteral reflux (VUR)?

Background: Based on the paradigm that undetected and untreated VUR might lead to long-term complications, voiding cystography traditionally has been recommended for all young children with a first urinary tract infection (UTI). An increasing base of evidence suggests that antibiotic prophylaxis for low-grade VUR might be unnecessary. However, less-invasive methods of screening for high-grade reflux have not yet been identified.

Study design: Secondary analysis of data from a prior prospective study.

Setting: Nephrology department of a French teaching hospital.

Synopsis: One hundred seventeen children (0-16 years) with a UTI were included and underwent renal US and voiding cystography. Patients with a known uropathy or those who had received antibiotics within the past 48 hours were excluded. A generalized linear multilevel model was used to analyze the relationship between standardized renal US criterion and VUR.

Twenty-seven percent of children had VUR and 8% had high-grade VUR (grade ≥3). Pelvic, ureteral, and urinary tract dilatation were significantly associated with high-grade VUR. Ureteral dilatation offered the best combination of standardized criterion, sensitivity (75%), and specificity (88%).

Significant limitations of this study include the use of bag urine cultures and the lack of consensus-based US criterion for ureteral and pelvic dilatation. The authors appropriately caution that these renal US criteria do not identify all children with high-grade VUR and are merely one step toward an intermediate screening strategy for high-grade VUR in order to mitigate adverse effects of universal voiding cystography. Further validation of this work in a clinically representative population will be needed.

Bottom line: Ureteral dilatation accurately identifies children with high-grade VUR.

Citation: Leroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman A. Vesicoureteral reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria. Radiology. 2010;255(3):890-898.

New Drugs, Indications, Dosage Forms, and Approvals

• Hydromorphone extended-release tablets (Exalgo) have been approved by the FDA as a once-daily treatment for managing moderate to severe pain in opioid-tolerant patients needing continuous opioid analgesia for an extended period of time.¹ This formulation uses the OROS osmotic delivery system to control the release rate. It is a CII controlled substance and is accompanied by a comprehensive Risk Evaluation and Mitigation Strategy (REMS) to ensure that the medication’s benefits outweigh its risks.
• IMGN910 has received orphan drug status for treating Merkel cell carcinoma, a skin cancer that usually occurs on the head or neck.² It is in early-stage clinical trials.
• Immune globulin subcutaneous (human) 20% liquid (Hizentra) has been approved by the FDA as a once-weekly immunoglobulin replacement therapy for patients with primary immunodeficiency.³ It’s the first 20% subcutaneous immunoglobulin to receive FDA approval. This high-concentration product is stabilized with L-proline, a naturally occurring amino acid, which allows it to be stored at room temperature (up to 25°C [77°F]). Some adverse reactions include injection site bruising, pain, cysts, eczema, irritation, headache, cough, diarrhea, and fatigue.⁴
• Velaglucerase alfa for injection (VPRIV) has been approved by the FDA to treat adults and children with the rare genetic disorder Gaucher disease.⁵ Patients with Gaucher disease have a deficiency of the glucocerebrosidase enzyme. This enzyme prevents lipids from building up in the liver, spleen, bone marrow, and nervous system, which prevents them from working properly. VPRIV, a long-term replacement therapy, is approved for Type 1 Gaucher disease, the most common form, and is an alternative to imiglucerase (Cerezyme), which is in short supply. The most common reactions seen in clinical trials were allergic reactions, headache, dizziness, abdominal and back pain, nausea, fatigue/weakness, fever, and prolonged activated partial thromboplastin time.

Pipeline

• Betrixaban is a once-daily oral anticoagulant in Phase 2 clinical studies.⁶ Compared with warfarin in the EXPLORE-Xa study, betrixaban decreased the bleeding incidence in patients with nonvalvular atrial fibrillation or atrial flutter who had at least one stroke risk factor. The major and clinically relevant nonmajor bleeding episodes occurred less frequently in betrixaban-treated patients.
• Dabigatran etexilate is an oral anticoagulant in Phase 3 clinical trials.⁷ At the recent American College of Cardiology meeting in Ingelheim, Germany, dabigatran demonstrated consistent stroke prevention in patients with atrial fibrillation. It also reduced the number of strokes in patients with atrial fibrillation, compared with warfarin therapy. Additionally, dabigatran etexilate 110 mg and 150 mg twice daily was associated with a lower rate of major bleeding compared with warfarin in atrial fibrillation patients at low risk of stroke.
• Fentanyl sublingual spray (SL Spray) is in Phase 3 clinical trials to treat breakthrough pain in cancer patients. Sublingual administration of this product showed rapid, effective pain relief within five minutes.⁸
• Ketamine intranasal (Ereska) is a nonopioid NMDA receptor antagonist analgesic, which is undergoing Phase 3 clinical trials for managing moderate to severe acute pain.⁹ Studies have shown rapid, statistically significant relief of moderate to severe acute postoperative pain following dental surgery, following a variety of major orthopedic surgical procedures, and in cancer breakthrough pain.
• Lu AA21004 and Lu AA24530 are undergoing Phase 3 clinical trials for treating major depressive disorder (MDD).¹⁰ Lu AA21004 is a 5-HT3, 5-HT7 and 5-HT1B receptor antagonist, 5HT1A receptor agonist, and 5-HT transporter inhibitor. To date, it has shown a low propensity for drug-drug interactions and is extensively metabolized in the liver. Lu AA24530 has shown activity as a multimodal enhancer with reuptake inhibition at monoamine transporters, and having 5-HT3 and 5-HT2c receptor antagonist activity.
• Lurasidone is an atypical antipsychotic with high affinity and antagonist effects at the dopamine D2, serotonin 5-HT2, and serotonin 5-HT7 receptors.¹¹ It is a partial agonist at serotonin 5HT1A receptor. The NDA was filed for this agent Dec. 30, 2009.
• Mipomersen, an apo-B synthesis inhibitor, is in Phase 3 clinical trials for treating patients with homozygous familial hypercholesterolemia (HoFM).¹² This agent is proposed to reduce LDL-C by preventing the development of atherogenic lipids. In a study published in Lancet, mipomersen reduced LDL-C levels by an average of more than 100 mg/dL in HoFM patients.¹³
• Oxycodone/niacin (Acurox), an abuse deterrent formulation for this popular opioid, has been rejected by the FDA.¹⁴ According to the FDA and its review committee, the rejection was due to the “flushing” from the niacin, which was deemed ineffective as an abuse deterrent. In addition, the FDA said the “flushing” could be overcome by food intake or administration with over-the-counter pain relievers.
• Vilanterol/fluticasone is a combination of the inhaled corticosteroid fluticasone and the long-acting beta-agonist (LABA) vilanterol.¹⁵ It is in Phase 3 clinical trials for treating asthma. TH