Hospitalists frequently diagnose and treat lower extremity deep venous thrombosis (DVT). Patients presenting with acute DVT or chronic venous stasis of the left leg can have an underlying anatomic anomaly known as iliac vein compression syndrome (ICS), May‐Thurner syndrome, or Cockett syndrome in Europe. In this condition, the right iliac artery overlies the left iliac vein, causing extrinsic compression of the vein (Figure 1). 1 This compression and accompanying intraluminal changes predisposes patients to left‐sided lower extremity DVT.2 Failure to recognize and treat this anomaly in patients with acute thrombosis can result in serious vascular sequelae and chronic left leg symptoms.3 A high clinical suspicion should be maintained in young individuals presenting with proximal left leg DVT with or without hypercoagulable risk factors. The following report is a case of ICS in a young male recognized and treated early by aggressive diagnostic and therapeutic interventions.

Figure 1

Case Report

A 19‐year‐old man presented to the ER with sudden onset of left lower extremity swelling and pain 5 days after a fall. He had no known risk factors for DVT. On physical examination his left leg was dusky, swollen, and tender from his groin to his ankle, with good arterial pulses. Duplex ultra‐sonogram of the leg showed a clot in the femoral vein extending up the popliteal vein. Following a venogram, he underwent mechanical thrombectomy and regional thrombolysis. A repeat venogram showed an irregular narrowing of the left iliac vein and a tubular filling defect at the junction of the inferior vena cava and common iliac veins, suggestive of external compression from the right common iliac artery. The patient underwent successful angioplasty and stenting of the common iliac vein. He was treated with intravenous heparin, warfarin and clopidogrel. His hypercoagulable work‐up was inconclusive.

Discussion

In 1956, May and Thurner 1 brought clinical attention to ICS. They hypothesized that an abnormal compression of the left iliac vein by an overriding right iliac arterypresent in 22% of a series of 430 cadaversled to an intraluminal filling defect in the vein. The chronic extrinsic compression and pulsing force from the overlying artery results in endothelial irritation and formation of venous spurs (fibrous vascular lesions) in the intimal layer of the vein.1 Following the principles of Virchow's triad, this endothelial injury propagates the formation of a thrombus. Subsequent studies by Kim et al.4 suggest that there are 3 stages involved in the pathogenesis of thrombosis in ICS: asymptomatic vein compression, venous spur formation, and finally DVT formation.4, 5 It is estimated that 1 to 3 out of 1000 individuals with this malformation develop DVT each year.5, 6

Patients with ICS may present to the emergency or ambulatory setting in either an acute or chronic phase. The acute phase is the actual episode of thrombosis. Symptoms include left leg pain and swelling up to the groin. In rare cases, pulmonary emboli may be the initial presentation. A lifelong chronic phase can follow if undiagnosed, resulting in pain and swelling of the entire left leg, venous claudication, recurrent thrombosis, pigmentation changes, and ulceration. 3

The typical ICS patient is a woman between 18 and 30 years old, 3 possibly due to the developmental changes in the pelvic structures in preparation for child‐bearing.2 Many patients also present after pregnancy; increased lordosis during pregnancy may put additional strain on the anatomic lesion.3 Nevertheless, Steinberg and Jacocks7 reported that out of 127 patients, 38 (30%) were male. Thus, it is critical not to overlook ICS as a possible cause of thrombosis in male patients.

The urgency in diagnosing this anatomic variation lies in the distinct need for more aggressive treatment than that required for a typical DVT. While Doppler ultrasound is typically the first diagnostic test performed in this patient population, it is not specific. For patients with physical exam findings highly suspicious of ICS, venography and magnetic resonance venography are superior modalities to make a definitive diagnosis of the syndrome. 8 In ICS, these studies will reveal left common iliac vein narrowing with intraluminal changes suggestive of spur formation.2

Due to the mechanical nature of ICS pathology, anticoagulation therapy alone is ineffective. ICS prevents recanalization in 70% to 80% of patients and up to 40% will have continued clot propagation. 5, 7 More aggressive treatment using endovascular techniques such as the combination of thrombectomy, angioplasty, and intraluminal stenting have proven to be the most efficacious treatment modality for ICS.9 A study by AbuRahma et al.10 demonstrated that one year following this aggressive combination, patency rate was 83% (vs. 24% following thrombectomy alone).

Conclusion

The anatomic anomaly present in ICS was identified by CT in as many as two‐thirds of an asymptomatic patient population studied by Kibbe et al. 12 Although a common structural anomaly, it is important to note that only 1 to 3 out of 1000 individuals with this malformation develop DVT annually. ICS should be included in the differential diagnosis of all young individuals presenting with proximal left leg DVT with or without hypercoagulable risk factors. If the mechanical compression is not diagnosed and treated, the syndrome can develop into a life‐long chronic phase with multiple complications.2 It is therefore critical that aggressive diagnostic and therapeutic interventions be implemented immediately upon suspicion of ICS.

Hospitalists frequently diagnose and treat lower extremity deep venous thrombosis (DVT). Patients presenting with acute DVT or chronic venous stasis of the left leg can have an underlying anatomic anomaly known as iliac vein compression syndrome (ICS), May‐Thurner syndrome, or Cockett syndrome in Europe. In this condition, the right iliac artery overlies the left iliac vein, causing extrinsic compression of the vein (Figure 1). 1 This compression and accompanying intraluminal changes predisposes patients to left‐sided lower extremity DVT.2 Failure to recognize and treat this anomaly in patients with acute thrombosis can result in serious vascular sequelae and chronic left leg symptoms.3 A high clinical suspicion should be maintained in young individuals presenting with proximal left leg DVT with or without hypercoagulable risk factors. The following report is a case of ICS in a young male recognized and treated early by aggressive diagnostic and therapeutic interventions.

Figure 1

Case Report

A 19‐year‐old man presented to the ER with sudden onset of left lower extremity swelling and pain 5 days after a fall. He had no known risk factors for DVT. On physical examination his left leg was dusky, swollen, and tender from his groin to his ankle, with good arterial pulses. Duplex ultra‐sonogram of the leg showed a clot in the femoral vein extending up the popliteal vein. Following a venogram, he underwent mechanical thrombectomy and regional thrombolysis. A repeat venogram showed an irregular narrowing of the left iliac vein and a tubular filling defect at the junction of the inferior vena cava and common iliac veins, suggestive of external compression from the right common iliac artery. The patient underwent successful angioplasty and stenting of the common iliac vein. He was treated with intravenous heparin, warfarin and clopidogrel. His hypercoagulable work‐up was inconclusive.

Discussion

In 1956, May and Thurner 1 brought clinical attention to ICS. They hypothesized that an abnormal compression of the left iliac vein by an overriding right iliac arterypresent in 22% of a series of 430 cadaversled to an intraluminal filling defect in the vein. The chronic extrinsic compression and pulsing force from the overlying artery results in endothelial irritation and formation of venous spurs (fibrous vascular lesions) in the intimal layer of the vein.1 Following the principles of Virchow's triad, this endothelial injury propagates the formation of a thrombus. Subsequent studies by Kim et al.4 suggest that there are 3 stages involved in the pathogenesis of thrombosis in ICS: asymptomatic vein compression, venous spur formation, and finally DVT formation.4, 5 It is estimated that 1 to 3 out of 1000 individuals with this malformation develop DVT each year.5, 6

Patients with ICS may present to the emergency or ambulatory setting in either an acute or chronic phase. The acute phase is the actual episode of thrombosis. Symptoms include left leg pain and swelling up to the groin. In rare cases, pulmonary emboli may be the initial presentation. A lifelong chronic phase can follow if undiagnosed, resulting in pain and swelling of the entire left leg, venous claudication, recurrent thrombosis, pigmentation changes, and ulceration. 3

The typical ICS patient is a woman between 18 and 30 years old, 3 possibly due to the developmental changes in the pelvic structures in preparation for child‐bearing.2 Many patients also present after pregnancy; increased lordosis during pregnancy may put additional strain on the anatomic lesion.3 Nevertheless, Steinberg and Jacocks7 reported that out of 127 patients, 38 (30%) were male. Thus, it is critical not to overlook ICS as a possible cause of thrombosis in male patients.

The urgency in diagnosing this anatomic variation lies in the distinct need for more aggressive treatment than that required for a typical DVT. While Doppler ultrasound is typically the first diagnostic test performed in this patient population, it is not specific. For patients with physical exam findings highly suspicious of ICS, venography and magnetic resonance venography are superior modalities to make a definitive diagnosis of the syndrome. 8 In ICS, these studies will reveal left common iliac vein narrowing with intraluminal changes suggestive of spur formation.2

Due to the mechanical nature of ICS pathology, anticoagulation therapy alone is ineffective. ICS prevents recanalization in 70% to 80% of patients and up to 40% will have continued clot propagation. 5, 7 More aggressive treatment using endovascular techniques such as the combination of thrombectomy, angioplasty, and intraluminal stenting have proven to be the most efficacious treatment modality for ICS.9 A study by AbuRahma et al.10 demonstrated that one year following this aggressive combination, patency rate was 83% (vs. 24% following thrombectomy alone).

Conclusion

The anatomic anomaly present in ICS was identified by CT in as many as two‐thirds of an asymptomatic patient population studied by Kibbe et al. 12 Although a common structural anomaly, it is important to note that only 1 to 3 out of 1000 individuals with this malformation develop DVT annually. ICS should be included in the differential diagnosis of all young individuals presenting with proximal left leg DVT with or without hypercoagulable risk factors. If the mechanical compression is not diagnosed and treated, the syndrome can develop into a life‐long chronic phase with multiple complications.2 It is therefore critical that aggressive diagnostic and therapeutic interventions be implemented immediately upon suspicion of ICS.

Hospitalists frequently diagnose and treat lower extremity deep venous thrombosis (DVT). Patients presenting with acute DVT or chronic venous stasis of the left leg can have an underlying anatomic anomaly known as iliac vein compression syndrome (ICS), May‐Thurner syndrome, or Cockett syndrome in Europe. In this condition, the right iliac artery overlies the left iliac vein, causing extrinsic compression of the vein (Figure 1). 1 This compression and accompanying intraluminal changes predisposes patients to left‐sided lower extremity DVT.2 Failure to recognize and treat this anomaly in patients with acute thrombosis can result in serious vascular sequelae and chronic left leg symptoms.3 A high clinical suspicion should be maintained in young individuals presenting with proximal left leg DVT with or without hypercoagulable risk factors. The following report is a case of ICS in a young male recognized and treated early by aggressive diagnostic and therapeutic interventions.

Figure 1

Case Report

A 19‐year‐old man presented to the ER with sudden onset of left lower extremity swelling and pain 5 days after a fall. He had no known risk factors for DVT. On physical examination his left leg was dusky, swollen, and tender from his groin to his ankle, with good arterial pulses. Duplex ultra‐sonogram of the leg showed a clot in the femoral vein extending up the popliteal vein. Following a venogram, he underwent mechanical thrombectomy and regional thrombolysis. A repeat venogram showed an irregular narrowing of the left iliac vein and a tubular filling defect at the junction of the inferior vena cava and common iliac veins, suggestive of external compression from the right common iliac artery. The patient underwent successful angioplasty and stenting of the common iliac vein. He was treated with intravenous heparin, warfarin and clopidogrel. His hypercoagulable work‐up was inconclusive.

Discussion

In 1956, May and Thurner 1 brought clinical attention to ICS. They hypothesized that an abnormal compression of the left iliac vein by an overriding right iliac arterypresent in 22% of a series of 430 cadaversled to an intraluminal filling defect in the vein. The chronic extrinsic compression and pulsing force from the overlying artery results in endothelial irritation and formation of venous spurs (fibrous vascular lesions) in the intimal layer of the vein.1 Following the principles of Virchow's triad, this endothelial injury propagates the formation of a thrombus. Subsequent studies by Kim et al.4 suggest that there are 3 stages involved in the pathogenesis of thrombosis in ICS: asymptomatic vein compression, venous spur formation, and finally DVT formation.4, 5 It is estimated that 1 to 3 out of 1000 individuals with this malformation develop DVT each year.5, 6

Patients with ICS may present to the emergency or ambulatory setting in either an acute or chronic phase. The acute phase is the actual episode of thrombosis. Symptoms include left leg pain and swelling up to the groin. In rare cases, pulmonary emboli may be the initial presentation. A lifelong chronic phase can follow if undiagnosed, resulting in pain and swelling of the entire left leg, venous claudication, recurrent thrombosis, pigmentation changes, and ulceration. 3

The typical ICS patient is a woman between 18 and 30 years old, 3 possibly due to the developmental changes in the pelvic structures in preparation for child‐bearing.2 Many patients also present after pregnancy; increased lordosis during pregnancy may put additional strain on the anatomic lesion.3 Nevertheless, Steinberg and Jacocks7 reported that out of 127 patients, 38 (30%) were male. Thus, it is critical not to overlook ICS as a possible cause of thrombosis in male patients.

The urgency in diagnosing this anatomic variation lies in the distinct need for more aggressive treatment than that required for a typical DVT. While Doppler ultrasound is typically the first diagnostic test performed in this patient population, it is not specific. For patients with physical exam findings highly suspicious of ICS, venography and magnetic resonance venography are superior modalities to make a definitive diagnosis of the syndrome. 8 In ICS, these studies will reveal left common iliac vein narrowing with intraluminal changes suggestive of spur formation.2

Due to the mechanical nature of ICS pathology, anticoagulation therapy alone is ineffective. ICS prevents recanalization in 70% to 80% of patients and up to 40% will have continued clot propagation. 5, 7 More aggressive treatment using endovascular techniques such as the combination of thrombectomy, angioplasty, and intraluminal stenting have proven to be the most efficacious treatment modality for ICS.9 A study by AbuRahma et al.10 demonstrated that one year following this aggressive combination, patency rate was 83% (vs. 24% following thrombectomy alone).

Conclusion

The anatomic anomaly present in ICS was identified by CT in as many as two‐thirds of an asymptomatic patient population studied by Kibbe et al. 12 Although a common structural anomaly, it is important to note that only 1 to 3 out of 1000 individuals with this malformation develop DVT annually. ICS should be included in the differential diagnosis of all young individuals presenting with proximal left leg DVT with or without hypercoagulable risk factors. If the mechanical compression is not diagnosed and treated, the syndrome can develop into a life‐long chronic phase with multiple complications.2 It is therefore critical that aggressive diagnostic and therapeutic interventions be implemented immediately upon suspicion of ICS.

A 15‐year‐old male was hospitalized with painful blisters on the lips and ulcers in the oral mucosa that were preceded by upper respiratory infection symptoms for 1 week. He had not been treated with antimicrobials. He subsequently developed conjunctival injection and painful blisters at the urethral meatus and symmetric scattered target lesions in the extremities. Examination demonstrated low‐grade fever, mild conjunctival injection (Figure 2), and oral vesicular lesions affecting the lips (Figure 1) and both the hard and soft palate; he had vesicular lesions affecting the glans penis, a ruptured vesicle at the urethral meatus and target lesions in the arms (Figure 3) and legs (Figure 4). His cardiopulmonary exam was normal. He was started on acyclovir and azithromycin, and symptomatic treatment with oral lidocaine and morphine. Serologies for Epstein‐Barr virus (EBV), cytomegalovirus (CMV) and Coxsackievirus and cultures for herpes simplex virus (HSV) were negative. Mycoplasma pneumoniae immunoglobulin G (IgG) and IgM titers were significantly elevated (>4‐fold) and the diagnosis made of Stevens‐Johnson syndrome (SJS) secondary to Mycoplasma pneumoniae infection. He was able to tolerate oral intake after a 1‐week hospital course.

M. pneumoniae infection can cause mucocutaneous involvement varying from mild mucositis to SJS with significant morbidity and mortality, 1, 2 mostly in the pediatric population. The differential diagnosis includes HSV, Kawasaki, and Streptococcal toxic shock syndrome, as well as other viral infections (eg, Coxsackievirus).3 Pharmacologic causesespecially antibiotics, non steroidal anti‐inflammatory drug (NSAIDS) and anticonvulsantsshould also be considered in the etiology of SJS4 especially in the adult population.

Figure 1

Figure 2

Figure 3

Figure 4

A 15‐year‐old male was hospitalized with painful blisters on the lips and ulcers in the oral mucosa that were preceded by upper respiratory infection symptoms for 1 week. He had not been treated with antimicrobials. He subsequently developed conjunctival injection and painful blisters at the urethral meatus and symmetric scattered target lesions in the extremities. Examination demonstrated low‐grade fever, mild conjunctival injection (Figure 2), and oral vesicular lesions affecting the lips (Figure 1) and both the hard and soft palate; he had vesicular lesions affecting the glans penis, a ruptured vesicle at the urethral meatus and target lesions in the arms (Figure 3) and legs (Figure 4). His cardiopulmonary exam was normal. He was started on acyclovir and azithromycin, and symptomatic treatment with oral lidocaine and morphine. Serologies for Epstein‐Barr virus (EBV), cytomegalovirus (CMV) and Coxsackievirus and cultures for herpes simplex virus (HSV) were negative. Mycoplasma pneumoniae immunoglobulin G (IgG) and IgM titers were significantly elevated (>4‐fold) and the diagnosis made of Stevens‐Johnson syndrome (SJS) secondary to Mycoplasma pneumoniae infection. He was able to tolerate oral intake after a 1‐week hospital course.

M. pneumoniae infection can cause mucocutaneous involvement varying from mild mucositis to SJS with significant morbidity and mortality, 1, 2 mostly in the pediatric population. The differential diagnosis includes HSV, Kawasaki, and Streptococcal toxic shock syndrome, as well as other viral infections (eg, Coxsackievirus).3 Pharmacologic causesespecially antibiotics, non steroidal anti‐inflammatory drug (NSAIDS) and anticonvulsantsshould also be considered in the etiology of SJS4 especially in the adult population.

Figure 1

Figure 2

Figure 3

Figure 4

A 15‐year‐old male was hospitalized with painful blisters on the lips and ulcers in the oral mucosa that were preceded by upper respiratory infection symptoms for 1 week. He had not been treated with antimicrobials. He subsequently developed conjunctival injection and painful blisters at the urethral meatus and symmetric scattered target lesions in the extremities. Examination demonstrated low‐grade fever, mild conjunctival injection (Figure 2), and oral vesicular lesions affecting the lips (Figure 1) and both the hard and soft palate; he had vesicular lesions affecting the glans penis, a ruptured vesicle at the urethral meatus and target lesions in the arms (Figure 3) and legs (Figure 4). His cardiopulmonary exam was normal. He was started on acyclovir and azithromycin, and symptomatic treatment with oral lidocaine and morphine. Serologies for Epstein‐Barr virus (EBV), cytomegalovirus (CMV) and Coxsackievirus and cultures for herpes simplex virus (HSV) were negative. Mycoplasma pneumoniae immunoglobulin G (IgG) and IgM titers were significantly elevated (>4‐fold) and the diagnosis made of Stevens‐Johnson syndrome (SJS) secondary to Mycoplasma pneumoniae infection. He was able to tolerate oral intake after a 1‐week hospital course.

M. pneumoniae infection can cause mucocutaneous involvement varying from mild mucositis to SJS with significant morbidity and mortality, 1, 2 mostly in the pediatric population. The differential diagnosis includes HSV, Kawasaki, and Streptococcal toxic shock syndrome, as well as other viral infections (eg, Coxsackievirus).3 Pharmacologic causesespecially antibiotics, non steroidal anti‐inflammatory drug (NSAIDS) and anticonvulsantsshould also be considered in the etiology of SJS4 especially in the adult population.

Figure 1

Figure 2

Figure 3

Figure 4

With about 1 in 5 working‐age Americans (age 18‐64 years) currently uninsured and a large number relying on Medicaid, adequate access to quality health care services is becoming increasingly difficult.1 Substantial literature has accumulated over the years suggesting that access and quality in health care are closely linked to an individual's health insurance status.211 Some studies indicate that being uninsured or publicly insured is associated with negative health consequences.12, 13 Although the Medicaid program has improved access for qualifying low‐income individuals, significant gaps in access and quality remain.2, 5, 11, 1419 These issues are likely to become more pervasive should there be further modifications to state Medicaid funding in response to the unfolding economic crisis.

Although numerous studies have focused on insurance‐related disparities in the outpatient setting, few nationally representative studies have examined such disparities among hospitalized patients. A cross‐sectional study of a large hospital database from 1987 reported higher risk‐adjusted in‐hospital mortality, shorter length of stay (LOS), and lower procedure use among uninsured patients.9 A more recent analysis, limited to patients admitted with stroke, reported significant variation in hospital care associated with insurance status.15 Other studies reporting myocardial infarction registry and quality improvement program data are biased by the self‐selection of large urban teaching hospitals.1618 To our knowledge, no nationally representative study has focused on the impact of insurance coverage on hospital care for common medical conditions among working‐age Americans, the fastest growing segment of the uninsured population.

To address this gap in knowledge, we analyzed a nationally representative hospital database to determine whether there are significant insurance‐related disparities in in‐hospital mortality, LOS, and cost per hospitalization for 3 common medical conditions among working‐age adults, and, if present, to determine whether these disparities are due to differences in disease severity and comorbidities, and whether these disparities are affected by the proportion of uninsured and Medicaid patients receiving care in each hospital.

Methods

Results

Discussion

In this nationally representative study of working‐age Americans hospitalized for 3 common medical conditions, we found that insurance status was associated with significant variations in in‐hospital mortality and resource use. Whereas privately insured patients experienced comparatively lower in‐hospital mortality in most cases, mortality risk was highest among the uninsured for 2 of the 3 common causes of noncancer inpatient deaths. Although previous studies have examined insurance‐related disparities in inpatient care for individual diagnoses and specific populations, no broad overview of this important issue has been published in the past decade. In light of the current economic recession and national healthcare debate, these findings may be a prescient indication of a widening insurance gap in the quality of hospital care.

There are several potential mechanisms for these disparities. For instance, Hadley et al.9 reported significant underuse of high‐cost or high‐discretion procedures among the uninsured in their analysis of a nationally representative sample of 592,598 hospitalized patients. Similarly, Burstin et al.10 found that among a population of 30,195 hospitalized patients with diverse diagnoses, the uninsured were at greater risk for receiving substandard care regardless of hospital characteristics. These, and other similar findings,7, 8, 19 are suggestive of differences in the way uninsured patients are generally managed in the hospital that may partly explain the disparities reported herein.

More specifically, analyses of national registries of AMI have documented lower rates of utilization of invasive, potentially life‐saving, cardiac interventions among the uninsured.16, 17 Similarly, a lower rate of carotid endarterectomy was reported among uninsured stroke patients from an analysis of the 2002 NIS.15 Other differences in inpatient management unmeasured by administrative data, such as the use of subspecialists and allied health professionals, may also contribute.32 Unfortunately, limitations in the available data prevented us from being able to appropriately address the important issue of insurance related differences in the utilization of specific inpatient procedures.

These disparities may also be indicative of differences in severity of illness that are not captured fully by the MedStat disease staging criteria. The uninsured might have more severe illness at admission, either due to the presence of more advanced chronic disease or delay in seeking care for the acute episode. AMI and stroke are usually the culmination of longstanding atherosclerosis that is amenable to improvement through timely and consistent risk‐factor modification. Not having a usual source of medical care,6, 33 inadequate screening and management of known risk‐factors,3, 34 and difficulties in obtaining specialty care5 among the uninsured likely increases their risk of being hospitalized with more advanced disease. The higher likelihood of being admitted through the emergency department19 and on weekends9 among the uninsured lends credence to the possibility of delays in seeking care. All of these are potential mediators of higher AMI and stroke mortality in uninsured patients.

Finally, these mortality differences could also be due to the additional risks imposed by poorly managed comorbidities among uninsured patients. Although we controlled for the presence of comorbidities in our analysis, we lacked data about the severity of individual comorbidities. A recent study reported significant lapses in follow‐up care after the onset of a chronic condition in uninsured individuals under 65 years of age.34 Other studies have also documented insurance related disparities in the care of chronic diseases3, 35 that were among the most common comorbidities in our cohort.

Most of the reasons for insurance‐related disparities noted above for the uninsured are also applicable to Medicaid patients. Differences in the intensity of inpatient care,7, 8, 1519 limited access to health care services,2, 14 unmet health needs,5 and suboptimal management of chronic medical conditions35 were also reported for Medicaid patients in prior research. These factors likely contributed to the higher in‐hospital mortality in this patient population, evidenced by the sequential decrease in odds after adjusting for comorbidities and disease severity. Medicaid patients hospitalized for stroke were noted to have significantly longer LOS, which could plausibly be due to difficulties with arranging appropriate discharge disposition; the higher likelihood of paralysis among these patients15 would likely necessitate a higher frequency of rehabilitation facility placement. The higher costs for Medicaid patients with stroke and pneumonia may potentially be the result of these patients longer LOS. Although cost differences between the uninsured and privately insured were statistically significant, these were not large enough to be of material significance.

Conclusions

Significant insurance‐related differences in mortality exist for 2 of the leading causes of noncancer inpatient deaths among working‐age Americans. Further studies are needed to determine whether provider sensitivity to insurance status or unmeasured sociodemographic and clinical prognostic factors are responsible for these disparities. Policy makers, hospital administrators, and physicians should be cognizant of these disparities and consider policies to address potential insurance related gaps in the quality of inpatient care.

With about 1 in 5 working‐age Americans (age 18‐64 years) currently uninsured and a large number relying on Medicaid, adequate access to quality health care services is becoming increasingly difficult.1 Substantial literature has accumulated over the years suggesting that access and quality in health care are closely linked to an individual's health insurance status.211 Some studies indicate that being uninsured or publicly insured is associated with negative health consequences.12, 13 Although the Medicaid program has improved access for qualifying low‐income individuals, significant gaps in access and quality remain.2, 5, 11, 1419 These issues are likely to become more pervasive should there be further modifications to state Medicaid funding in response to the unfolding economic crisis.

Although numerous studies have focused on insurance‐related disparities in the outpatient setting, few nationally representative studies have examined such disparities among hospitalized patients. A cross‐sectional study of a large hospital database from 1987 reported higher risk‐adjusted in‐hospital mortality, shorter length of stay (LOS), and lower procedure use among uninsured patients.9 A more recent analysis, limited to patients admitted with stroke, reported significant variation in hospital care associated with insurance status.15 Other studies reporting myocardial infarction registry and quality improvement program data are biased by the self‐selection of large urban teaching hospitals.1618 To our knowledge, no nationally representative study has focused on the impact of insurance coverage on hospital care for common medical conditions among working‐age Americans, the fastest growing segment of the uninsured population.

To address this gap in knowledge, we analyzed a nationally representative hospital database to determine whether there are significant insurance‐related disparities in in‐hospital mortality, LOS, and cost per hospitalization for 3 common medical conditions among working‐age adults, and, if present, to determine whether these disparities are due to differences in disease severity and comorbidities, and whether these disparities are affected by the proportion of uninsured and Medicaid patients receiving care in each hospital.

Methods

Results

Discussion

In this nationally representative study of working‐age Americans hospitalized for 3 common medical conditions, we found that insurance status was associated with significant variations in in‐hospital mortality and resource use. Whereas privately insured patients experienced comparatively lower in‐hospital mortality in most cases, mortality risk was highest among the uninsured for 2 of the 3 common causes of noncancer inpatient deaths. Although previous studies have examined insurance‐related disparities in inpatient care for individual diagnoses and specific populations, no broad overview of this important issue has been published in the past decade. In light of the current economic recession and national healthcare debate, these findings may be a prescient indication of a widening insurance gap in the quality of hospital care.

There are several potential mechanisms for these disparities. For instance, Hadley et al.9 reported significant underuse of high‐cost or high‐discretion procedures among the uninsured in their analysis of a nationally representative sample of 592,598 hospitalized patients. Similarly, Burstin et al.10 found that among a population of 30,195 hospitalized patients with diverse diagnoses, the uninsured were at greater risk for receiving substandard care regardless of hospital characteristics. These, and other similar findings,7, 8, 19 are suggestive of differences in the way uninsured patients are generally managed in the hospital that may partly explain the disparities reported herein.

More specifically, analyses of national registries of AMI have documented lower rates of utilization of invasive, potentially life‐saving, cardiac interventions among the uninsured.16, 17 Similarly, a lower rate of carotid endarterectomy was reported among uninsured stroke patients from an analysis of the 2002 NIS.15 Other differences in inpatient management unmeasured by administrative data, such as the use of subspecialists and allied health professionals, may also contribute.32 Unfortunately, limitations in the available data prevented us from being able to appropriately address the important issue of insurance related differences in the utilization of specific inpatient procedures.

These disparities may also be indicative of differences in severity of illness that are not captured fully by the MedStat disease staging criteria. The uninsured might have more severe illness at admission, either due to the presence of more advanced chronic disease or delay in seeking care for the acute episode. AMI and stroke are usually the culmination of longstanding atherosclerosis that is amenable to improvement through timely and consistent risk‐factor modification. Not having a usual source of medical care,6, 33 inadequate screening and management of known risk‐factors,3, 34 and difficulties in obtaining specialty care5 among the uninsured likely increases their risk of being hospitalized with more advanced disease. The higher likelihood of being admitted through the emergency department19 and on weekends9 among the uninsured lends credence to the possibility of delays in seeking care. All of these are potential mediators of higher AMI and stroke mortality in uninsured patients.

Finally, these mortality differences could also be due to the additional risks imposed by poorly managed comorbidities among uninsured patients. Although we controlled for the presence of comorbidities in our analysis, we lacked data about the severity of individual comorbidities. A recent study reported significant lapses in follow‐up care after the onset of a chronic condition in uninsured individuals under 65 years of age.34 Other studies have also documented insurance related disparities in the care of chronic diseases3, 35 that were among the most common comorbidities in our cohort.

Most of the reasons for insurance‐related disparities noted above for the uninsured are also applicable to Medicaid patients. Differences in the intensity of inpatient care,7, 8, 1519 limited access to health care services,2, 14 unmet health needs,5 and suboptimal management of chronic medical conditions35 were also reported for Medicaid patients in prior research. These factors likely contributed to the higher in‐hospital mortality in this patient population, evidenced by the sequential decrease in odds after adjusting for comorbidities and disease severity. Medicaid patients hospitalized for stroke were noted to have significantly longer LOS, which could plausibly be due to difficulties with arranging appropriate discharge disposition; the higher likelihood of paralysis among these patients15 would likely necessitate a higher frequency of rehabilitation facility placement. The higher costs for Medicaid patients with stroke and pneumonia may potentially be the result of these patients longer LOS. Although cost differences between the uninsured and privately insured were statistically significant, these were not large enough to be of material significance.

Conclusions

Significant insurance‐related differences in mortality exist for 2 of the leading causes of noncancer inpatient deaths among working‐age Americans. Further studies are needed to determine whether provider sensitivity to insurance status or unmeasured sociodemographic and clinical prognostic factors are responsible for these disparities. Policy makers, hospital administrators, and physicians should be cognizant of these disparities and consider policies to address potential insurance related gaps in the quality of inpatient care.

With about 1 in 5 working‐age Americans (age 18‐64 years) currently uninsured and a large number relying on Medicaid, adequate access to quality health care services is becoming increasingly difficult.1 Substantial literature has accumulated over the years suggesting that access and quality in health care are closely linked to an individual's health insurance status.211 Some studies indicate that being uninsured or publicly insured is associated with negative health consequences.12, 13 Although the Medicaid program has improved access for qualifying low‐income individuals, significant gaps in access and quality remain.2, 5, 11, 1419 These issues are likely to become more pervasive should there be further modifications to state Medicaid funding in response to the unfolding economic crisis.

Although numerous studies have focused on insurance‐related disparities in the outpatient setting, few nationally representative studies have examined such disparities among hospitalized patients. A cross‐sectional study of a large hospital database from 1987 reported higher risk‐adjusted in‐hospital mortality, shorter length of stay (LOS), and lower procedure use among uninsured patients.9 A more recent analysis, limited to patients admitted with stroke, reported significant variation in hospital care associated with insurance status.15 Other studies reporting myocardial infarction registry and quality improvement program data are biased by the self‐selection of large urban teaching hospitals.1618 To our knowledge, no nationally representative study has focused on the impact of insurance coverage on hospital care for common medical conditions among working‐age Americans, the fastest growing segment of the uninsured population.

To address this gap in knowledge, we analyzed a nationally representative hospital database to determine whether there are significant insurance‐related disparities in in‐hospital mortality, LOS, and cost per hospitalization for 3 common medical conditions among working‐age adults, and, if present, to determine whether these disparities are due to differences in disease severity and comorbidities, and whether these disparities are affected by the proportion of uninsured and Medicaid patients receiving care in each hospital.

Methods

Results

Discussion

In this nationally representative study of working‐age Americans hospitalized for 3 common medical conditions, we found that insurance status was associated with significant variations in in‐hospital mortality and resource use. Whereas privately insured patients experienced comparatively lower in‐hospital mortality in most cases, mortality risk was highest among the uninsured for 2 of the 3 common causes of noncancer inpatient deaths. Although previous studies have examined insurance‐related disparities in inpatient care for individual diagnoses and specific populations, no broad overview of this important issue has been published in the past decade. In light of the current economic recession and national healthcare debate, these findings may be a prescient indication of a widening insurance gap in the quality of hospital care.

There are several potential mechanisms for these disparities. For instance, Hadley et al.9 reported significant underuse of high‐cost or high‐discretion procedures among the uninsured in their analysis of a nationally representative sample of 592,598 hospitalized patients. Similarly, Burstin et al.10 found that among a population of 30,195 hospitalized patients with diverse diagnoses, the uninsured were at greater risk for receiving substandard care regardless of hospital characteristics. These, and other similar findings,7, 8, 19 are suggestive of differences in the way uninsured patients are generally managed in the hospital that may partly explain the disparities reported herein.

More specifically, analyses of national registries of AMI have documented lower rates of utilization of invasive, potentially life‐saving, cardiac interventions among the uninsured.16, 17 Similarly, a lower rate of carotid endarterectomy was reported among uninsured stroke patients from an analysis of the 2002 NIS.15 Other differences in inpatient management unmeasured by administrative data, such as the use of subspecialists and allied health professionals, may also contribute.32 Unfortunately, limitations in the available data prevented us from being able to appropriately address the important issue of insurance related differences in the utilization of specific inpatient procedures.

These disparities may also be indicative of differences in severity of illness that are not captured fully by the MedStat disease staging criteria. The uninsured might have more severe illness at admission, either due to the presence of more advanced chronic disease or delay in seeking care for the acute episode. AMI and stroke are usually the culmination of longstanding atherosclerosis that is amenable to improvement through timely and consistent risk‐factor modification. Not having a usual source of medical care,6, 33 inadequate screening and management of known risk‐factors,3, 34 and difficulties in obtaining specialty care5 among the uninsured likely increases their risk of being hospitalized with more advanced disease. The higher likelihood of being admitted through the emergency department19 and on weekends9 among the uninsured lends credence to the possibility of delays in seeking care. All of these are potential mediators of higher AMI and stroke mortality in uninsured patients.

Finally, these mortality differences could also be due to the additional risks imposed by poorly managed comorbidities among uninsured patients. Although we controlled for the presence of comorbidities in our analysis, we lacked data about the severity of individual comorbidities. A recent study reported significant lapses in follow‐up care after the onset of a chronic condition in uninsured individuals under 65 years of age.34 Other studies have also documented insurance related disparities in the care of chronic diseases3, 35 that were among the most common comorbidities in our cohort.

Most of the reasons for insurance‐related disparities noted above for the uninsured are also applicable to Medicaid patients. Differences in the intensity of inpatient care,7, 8, 1519 limited access to health care services,2, 14 unmet health needs,5 and suboptimal management of chronic medical conditions35 were also reported for Medicaid patients in prior research. These factors likely contributed to the higher in‐hospital mortality in this patient population, evidenced by the sequential decrease in odds after adjusting for comorbidities and disease severity. Medicaid patients hospitalized for stroke were noted to have significantly longer LOS, which could plausibly be due to difficulties with arranging appropriate discharge disposition; the higher likelihood of paralysis among these patients15 would likely necessitate a higher frequency of rehabilitation facility placement. The higher costs for Medicaid patients with stroke and pneumonia may potentially be the result of these patients longer LOS. Although cost differences between the uninsured and privately insured were statistically significant, these were not large enough to be of material significance.

Conclusions

Significant insurance‐related differences in mortality exist for 2 of the leading causes of noncancer inpatient deaths among working‐age Americans. Further studies are needed to determine whether provider sensitivity to insurance status or unmeasured sociodemographic and clinical prognostic factors are responsible for these disparities. Policy makers, hospital administrators, and physicians should be cognizant of these disparities and consider policies to address potential insurance related gaps in the quality of inpatient care.

The topic of comparative effectiveness research (CER) has recently gained prominence within the context of the national focus on health reform. This article provides a brief overview and history of CER, and discusses the implications of CER for hospitalists in each of four major career roles: research, clinical practice, education and training, and hospital leadership. Both medical journals and lay media have produced a flurry of articles recently on a variety of health reform subjects. One topic that has achieved prominence within this growing body of literature is comparative effectiveness research (CER). For many hospitalists, this particular brand of research may be unfamiliar. As discussions about CER priorities, the controversy surrounding CER, and even the definition of CER gain visibility, hospitalists may be left wondering, What exactly is CER and what does it mean for me?

Until recently no common definition for CER existed, and the very concept was identified only in relatively narrow policy and research circles. However, CER is not a new idea. Its ancestor is the notion of medical technology assessment (MTA), which garnered enthusiasm and support in the 1970s. In 1978, Congress established the National Center for Health Technology Assessment (which, over time, evolved into the Agency for Healthcare Research and Quality [AHRQ]), whose charge was to coordinate efforts within the government to assess the safety, efficacy, effectiveness, and cost‐effectiveness of medical technologies. The recognition of a need for technology assessment at that time is mirrored by the widespread interest in CER seen today. Part of the reason that MTA did not take hold is that then, as now, this type of evaluation is challenging and time consuming, requiring large, well‐designed effectiveness studies. These studies require rigorous methods, typically long‐term follow‐up, and acceptance via editors and the medical literature that effectiveness is as important as efficacy demonstrated in a randomized trial. With the spread of antiregulatory sentiment and the lack of an economic imperative to reduce costs, the national focus on technology assessment waned. The current economic crisis has refocused the government and private sector on the soaring cost of health care and the need to improve quality, and the stimulus package passed in February of 2009 placed CER once again in the forefront. The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for CER.1 On June 30, 2009, 2 reports delineating the strategy and priorities for CER were released. The report from the ARRA‐mandated Federal Coordinating Council (FCC) for CER includes a broad definition of CER and outlines a high‐level strategic framework for priorities and investments in CER.2 Simultaneously, the report from the Institute of Medicine (IOM) lists 100 priority research topics, and gives 10 general recommendations for the CER enterprise going forward.3

So what is CER and why is it important? How is it different from standard research that hospitalists use every day to inform their clinical decision‐making? Unfortunately, patients and providers confront medical decisions daily that are not evidence based. All too frequently it is unclear what therapeutic option works best for which patient under which circumstances. For example, what is the best inpatient diabetes management strategy for an African American woman with multiple medical problems? What is the best discharge process for an elderly man with heart disease in order to prevent readmission? CER seeks to fill the gaps in evidence needed by patients and clinicians in order to make appropriate medical decisions. It differs from standard efficacy research in that it compares interventions or management strategies in real world settings, allows identification of effectiveness in patient subgroups, and is more patient‐centered, focusing on the decisions confronting patients and their physicians. The following definition of CER was developed by the FCC for CER:

CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in real world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence‐based information to patients, clinicians, and other decision‐makers, responding to their expressed needs about which interventions are most effective for which patients under specific circumstances.

• To provide this information, CER must assess a comprehensive array of health‐related outcomes for diverse patient populations and sub‐groups.

• Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change and delivery system strategies.

• This research necessitates the development, expansion and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

While CER is an evolving field requiring continued methodological development (such as enhancement of methods for practical, or pragmatic trials and complex analyses of large, linked databases), examples of rigorous comparative studies do exist. The Veterans Administration (VA) COURAGE trial compared optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) for patients with stable coronary disease, finding that PCI did not reduce the risk of death or cardiovascular events compared to OMT alone.4 Another example is the Diabetes Prevention Program which compared placebo, metformin, and a lifestyle modification program to prevent or delay the onset of type 2 diabetes. This study famously showed that lifestyle modification was more effective than metformin or placebo in reducing the incidence of diabetes.5

CER holds the promise of significantly improving the health of Americans through the ability to target treatments and other interventions to individual patients. As noted by the FCC, CER can allow for the delivery of the right treatment to the right patient at the right time2 even as the field continues to evolve. To quote Fineberg and Hiatt6 in describing technology assessment in 1979, we cannot expect CER to lead to perfect decisions, but we can expect even imperfect methods to facilitate better informed decisions than would otherwise be possible.

CER has important implications for hospitalists in all roles and settings. As the field of hospital medicine has grown, hospitalists have increasingly assumed more responsibilities than just patient care. In academic and community hospitals, hospitalists take on leadership roles, particularly in quality improvement (QI) and patient safety, and educational roles in the training of housestaff, medical students, and physician extenders. The last several years have also seen a significant increase in hospitalists participating in research. The relevance of CER to each of these 4 major activities is described below and in the accompanying Table 1.

Hospitalists and Research

Many comparative effectiveness questions about clinical care, processes of care, and quality of care within the inpatient setting are in need of answers. Hospitalist researchers have the opportunity to make a significant impact on care by pursuing answers to questions that are unique to the field of hospital medicine. With the new availability of funds for CER, now is the time to address many of these questions head‐on. For example, there is a lack of evidence about best practices for a large number of inpatient acute conditions. What is the best strategy to manage acute hospital delirium in an elderly patient? What is the best approach to treating acute pain in an elderly woman on multiple medications? Overwhelmingly the patients that hospitalists care for are elderly and/or have multiple chronic conditions, including children with special health care needs. Many are from racial or ethnic minority backgrounds. These subgroups of patients have been historically under‐represented in clinical trials, yet represent exactly the priority populations that the Federal CER effort targets. The field of hospital medicine can be transformed with a substantial investment in research to address common inpatient clinical conditions in real world settings focused on the kinds of patients hospitalists actually care for.

One of the most vexing and frustrating care delivery issues for hospitalists, clinicians and researchers alike, is the discharge process. This problem received increased attention after a recent article highlighted the high rate of readmissions in the Medicare population.7 Research on the discharge process has grown substantially in recent years, and has become an area of intense focus and attention for hospitalists, nurses, researchers, hospital administrators and policymakers. Without question, hospitalists are uniquely poised to conduct research on this critically important topic, and CER is an ideal vehicle for moving this field forward. In collaboration with nurses, primary care physicians, pharmacists, case managers and others, hospitalists should take advantage of the Federal investment in studying care delivery systems interventions, and develop innovative methods and strategies for studying and improving this crucial transition in care. CER is also applicable to other care transitions, including the admission process, transitions within the hospital, and discharge to nursing facilities. Other examples of comparative effectiveness topics that hospitalist researchers are particularly suited for include comparing methods for implementing inpatient treatment protocols or clinical pathways, comparison of health information technology (IT) systems to reduce medical error, and QI approaches.

What are the methodologies that hospitalists should use to conduct CER? While randomized pragmatic real world trials are appealing, this method may not always be practical. Other methodologies are available for rigorous use, including cohort studies, comparative QI interventions, clustered and factorial design, systematic reviews, and analysis of registries, administrative claims, or other databases. Databases currently available for analysis on priority populations and subgroups are limited, and include the VA and Medicare databases. To address this need, one of the primary Federal investments in CER is for the enhancement and expansion of data infrastructure. Data infrastructure tools that are likely to be available to hospitalist researchers for CER include expanded longitudinal administrative claims databases with linkages to electronic health records (EHRs), expanded patient registries with linkages to other forms of data, and distributed data networks that are populated by EHRs in provider and practice settings. Hospitalist researchers should take advantage of these resources as they become available, as they have tremendous potential to inform decision‐making for providers and patients alike.

Hospitalists and Clinical Practice

As with all providers, hospitalists will be end‐users of CER evidence, and will have the responsibility of translating new knowledge into practice. This process will not be easy. How are hospitalists to reliably access and incorporate new comparative effectiveness information into their daily practice? How should they deal with some of the potential unintended consequences of CER, such as information overload or conflicting evidence? While hospitalists have a professional responsibility to search for and apply CER findings, the future development of CER‐based practice guidelines will encourage evidence translation. The development of a common platform for the dissemination of CER relevant to hospitalists would significantly enhance the uptake of new evidence by practicing hospitalists and other hospital‐based providers such as physician assistants or nurse practitioners. Medical societies such as the Society of Hospital Medicine and the American Academy of Pediatrics should consider developing committees for CER and leading coordinated educational efforts specifically focused on CER results through publications and presentations at local, regional, and national meetings. In addition, other dissemination tools for CER will soon emerge and existing tools will be enhanced, such as the Effective Health Care Program and Eisenberg Center housed at the AHRQ. The coming years will see an expansion of these and other dissemination efforts to both providers and patients, and hospitalists must be vigilant about accessing these resources and integrating comparative effectiveness evidence into practice. As Federal dissemination efforts to consumers spread, patients will increasingly expect physicians to discuss comparative effectiveness evidence in describing options for their individual health needs. Finally, a key lever for translating CER into practice will be payment models that place accountability for performance on physicians and hospitals, with a significant proportion of payment based on the delivery of high quality, efficient care.

Education and Training

Investment in the training and development of a skilled workforce to conduct CER is an important priority. Hospitalist researchers should take advantage of education and training programs to support the development of methodologies and skills for conducting CER that will become available. These programs will enable hospitalists to learn such skills as the use of the newly enhanced data infrastructure discussed above. The national investment in human and scientific capital for CER can promote the training of a corps of hospitalist researchers focused on this research which, in turn, could support the growth of the academic hospitalist field. Hospitalists who have responsibilities in medical education and residency training programs should take the lead in teaching CER concepts that are relevant to inpatient care. They will need to train the next generation of medical students and residents to read and understand comparative effectiveness literature and its application in clinical practice. Hospitalist educators are also best positioned to teach medical trainees comparative effectiveness evidence about inpatient QI methods and care processes.

Hospital Leadership

As front‐line providers and team leaders, hospitalists are well placed to direct the efforts within their hospitals to implement new CER evidence. For example, suppose new comparative effectiveness evidence about best practices for the discharge process for community‐dwelling older adults with multiple chronic conditions were to emerge. Hospitalists could lead efforts within their hospital to establish a multidisciplinary team to address this development, create standard protocols for implementing the new discharge process that align with their hospital's unique systems and organizational structure, advocate for necessary resources for the team to accomplish the goal of safely discharging these patients, ensure a method to track outcomes such as readmissions once the new discharge process is implemented, and provide data feedback to the team, hospital staff, and administrative leadership of the hospital. All of these activities should include a variety of disciplines working together, but as physician leaders, hospitalists can take the initiative to spearhead these endeavors. The inpatient setting is one that requires teamwork and coordination, and as team leaders, hospitalists can strongly influence the spread and adoption of CER results. Similarly, hospitalists are in a position to affect this dissemination and translation process by actively educating and empowering other clinicians and hospital staff within their local environment. Finally, as hospitalists increasingly take on leadership roles in QI departments and as chief medical officers within both community and university‐affiliated hospitals^8, they are in a unique position to lead efforts to implement CER‐based QI activities. These may range from the implementation of IT functions to reduce medical error to strategies to reduce hospital‐acquired infections or falls.

Conclusion

As a result of the stimulus funds directed towards CER, the coming years will see a vast increase in the generation of comparative effectiveness evidence and the application of that evidence into practice.9 The national CER endeavor is particularly germane to the field of hospital medicine, as uncertainty about best practices is common, and the patients hospitalists serve represent priority populations for CER investments. Hospitalists can play a central role in both generating CER and implementing its findings in settings in which patients are highly vulnerable, and existing information is insufficient. In addition to clinical questions, hospitalist researchers are particularly suited to answering important questions about quality of care and inpatient processes such as transitions of care and care coordination. Having evidence on the best practices for care transitions or strategies to reduce medical error, for example, could have a significant impact on patient outcomes, quality of life, and cost of care. However, none of this new evidence will be of any value if it is not used by front‐line providers.10 Practicing hospitalists should lead efforts within their hospital to disseminate new CER findings to their hospitalist and non‐hospitalist colleagues, and to leverage their position as hospital and team leaders to implement inpatient‐based CER findings. All of these combined efforts have the potential to significantly move the field of hospital medicine forward, with the end result being improved health and better outcomes for patients.

The topic of comparative effectiveness research (CER) has recently gained prominence within the context of the national focus on health reform. This article provides a brief overview and history of CER, and discusses the implications of CER for hospitalists in each of four major career roles: research, clinical practice, education and training, and hospital leadership. Both medical journals and lay media have produced a flurry of articles recently on a variety of health reform subjects. One topic that has achieved prominence within this growing body of literature is comparative effectiveness research (CER). For many hospitalists, this particular brand of research may be unfamiliar. As discussions about CER priorities, the controversy surrounding CER, and even the definition of CER gain visibility, hospitalists may be left wondering, What exactly is CER and what does it mean for me?

Until recently no common definition for CER existed, and the very concept was identified only in relatively narrow policy and research circles. However, CER is not a new idea. Its ancestor is the notion of medical technology assessment (MTA), which garnered enthusiasm and support in the 1970s. In 1978, Congress established the National Center for Health Technology Assessment (which, over time, evolved into the Agency for Healthcare Research and Quality [AHRQ]), whose charge was to coordinate efforts within the government to assess the safety, efficacy, effectiveness, and cost‐effectiveness of medical technologies. The recognition of a need for technology assessment at that time is mirrored by the widespread interest in CER seen today. Part of the reason that MTA did not take hold is that then, as now, this type of evaluation is challenging and time consuming, requiring large, well‐designed effectiveness studies. These studies require rigorous methods, typically long‐term follow‐up, and acceptance via editors and the medical literature that effectiveness is as important as efficacy demonstrated in a randomized trial. With the spread of antiregulatory sentiment and the lack of an economic imperative to reduce costs, the national focus on technology assessment waned. The current economic crisis has refocused the government and private sector on the soaring cost of health care and the need to improve quality, and the stimulus package passed in February of 2009 placed CER once again in the forefront. The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for CER.1 On June 30, 2009, 2 reports delineating the strategy and priorities for CER were released. The report from the ARRA‐mandated Federal Coordinating Council (FCC) for CER includes a broad definition of CER and outlines a high‐level strategic framework for priorities and investments in CER.2 Simultaneously, the report from the Institute of Medicine (IOM) lists 100 priority research topics, and gives 10 general recommendations for the CER enterprise going forward.3

So what is CER and why is it important? How is it different from standard research that hospitalists use every day to inform their clinical decision‐making? Unfortunately, patients and providers confront medical decisions daily that are not evidence based. All too frequently it is unclear what therapeutic option works best for which patient under which circumstances. For example, what is the best inpatient diabetes management strategy for an African American woman with multiple medical problems? What is the best discharge process for an elderly man with heart disease in order to prevent readmission? CER seeks to fill the gaps in evidence needed by patients and clinicians in order to make appropriate medical decisions. It differs from standard efficacy research in that it compares interventions or management strategies in real world settings, allows identification of effectiveness in patient subgroups, and is more patient‐centered, focusing on the decisions confronting patients and their physicians. The following definition of CER was developed by the FCC for CER:

CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in real world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence‐based information to patients, clinicians, and other decision‐makers, responding to their expressed needs about which interventions are most effective for which patients under specific circumstances.

• To provide this information, CER must assess a comprehensive array of health‐related outcomes for diverse patient populations and sub‐groups.

• Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change and delivery system strategies.

• This research necessitates the development, expansion and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

While CER is an evolving field requiring continued methodological development (such as enhancement of methods for practical, or pragmatic trials and complex analyses of large, linked databases), examples of rigorous comparative studies do exist. The Veterans Administration (VA) COURAGE trial compared optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) for patients with stable coronary disease, finding that PCI did not reduce the risk of death or cardiovascular events compared to OMT alone.4 Another example is the Diabetes Prevention Program which compared placebo, metformin, and a lifestyle modification program to prevent or delay the onset of type 2 diabetes. This study famously showed that lifestyle modification was more effective than metformin or placebo in reducing the incidence of diabetes.5

CER holds the promise of significantly improving the health of Americans through the ability to target treatments and other interventions to individual patients. As noted by the FCC, CER can allow for the delivery of the right treatment to the right patient at the right time2 even as the field continues to evolve. To quote Fineberg and Hiatt6 in describing technology assessment in 1979, we cannot expect CER to lead to perfect decisions, but we can expect even imperfect methods to facilitate better informed decisions than would otherwise be possible.

CER has important implications for hospitalists in all roles and settings. As the field of hospital medicine has grown, hospitalists have increasingly assumed more responsibilities than just patient care. In academic and community hospitals, hospitalists take on leadership roles, particularly in quality improvement (QI) and patient safety, and educational roles in the training of housestaff, medical students, and physician extenders. The last several years have also seen a significant increase in hospitalists participating in research. The relevance of CER to each of these 4 major activities is described below and in the accompanying Table 1.

Hospitalists and Research

Many comparative effectiveness questions about clinical care, processes of care, and quality of care within the inpatient setting are in need of answers. Hospitalist researchers have the opportunity to make a significant impact on care by pursuing answers to questions that are unique to the field of hospital medicine. With the new availability of funds for CER, now is the time to address many of these questions head‐on. For example, there is a lack of evidence about best practices for a large number of inpatient acute conditions. What is the best strategy to manage acute hospital delirium in an elderly patient? What is the best approach to treating acute pain in an elderly woman on multiple medications? Overwhelmingly the patients that hospitalists care for are elderly and/or have multiple chronic conditions, including children with special health care needs. Many are from racial or ethnic minority backgrounds. These subgroups of patients have been historically under‐represented in clinical trials, yet represent exactly the priority populations that the Federal CER effort targets. The field of hospital medicine can be transformed with a substantial investment in research to address common inpatient clinical conditions in real world settings focused on the kinds of patients hospitalists actually care for.

One of the most vexing and frustrating care delivery issues for hospitalists, clinicians and researchers alike, is the discharge process. This problem received increased attention after a recent article highlighted the high rate of readmissions in the Medicare population.7 Research on the discharge process has grown substantially in recent years, and has become an area of intense focus and attention for hospitalists, nurses, researchers, hospital administrators and policymakers. Without question, hospitalists are uniquely poised to conduct research on this critically important topic, and CER is an ideal vehicle for moving this field forward. In collaboration with nurses, primary care physicians, pharmacists, case managers and others, hospitalists should take advantage of the Federal investment in studying care delivery systems interventions, and develop innovative methods and strategies for studying and improving this crucial transition in care. CER is also applicable to other care transitions, including the admission process, transitions within the hospital, and discharge to nursing facilities. Other examples of comparative effectiveness topics that hospitalist researchers are particularly suited for include comparing methods for implementing inpatient treatment protocols or clinical pathways, comparison of health information technology (IT) systems to reduce medical error, and QI approaches.

What are the methodologies that hospitalists should use to conduct CER? While randomized pragmatic real world trials are appealing, this method may not always be practical. Other methodologies are available for rigorous use, including cohort studies, comparative QI interventions, clustered and factorial design, systematic reviews, and analysis of registries, administrative claims, or other databases. Databases currently available for analysis on priority populations and subgroups are limited, and include the VA and Medicare databases. To address this need, one of the primary Federal investments in CER is for the enhancement and expansion of data infrastructure. Data infrastructure tools that are likely to be available to hospitalist researchers for CER include expanded longitudinal administrative claims databases with linkages to electronic health records (EHRs), expanded patient registries with linkages to other forms of data, and distributed data networks that are populated by EHRs in provider and practice settings. Hospitalist researchers should take advantage of these resources as they become available, as they have tremendous potential to inform decision‐making for providers and patients alike.

Hospitalists and Clinical Practice

As with all providers, hospitalists will be end‐users of CER evidence, and will have the responsibility of translating new knowledge into practice. This process will not be easy. How are hospitalists to reliably access and incorporate new comparative effectiveness information into their daily practice? How should they deal with some of the potential unintended consequences of CER, such as information overload or conflicting evidence? While hospitalists have a professional responsibility to search for and apply CER findings, the future development of CER‐based practice guidelines will encourage evidence translation. The development of a common platform for the dissemination of CER relevant to hospitalists would significantly enhance the uptake of new evidence by practicing hospitalists and other hospital‐based providers such as physician assistants or nurse practitioners. Medical societies such as the Society of Hospital Medicine and the American Academy of Pediatrics should consider developing committees for CER and leading coordinated educational efforts specifically focused on CER results through publications and presentations at local, regional, and national meetings. In addition, other dissemination tools for CER will soon emerge and existing tools will be enhanced, such as the Effective Health Care Program and Eisenberg Center housed at the AHRQ. The coming years will see an expansion of these and other dissemination efforts to both providers and patients, and hospitalists must be vigilant about accessing these resources and integrating comparative effectiveness evidence into practice. As Federal dissemination efforts to consumers spread, patients will increasingly expect physicians to discuss comparative effectiveness evidence in describing options for their individual health needs. Finally, a key lever for translating CER into practice will be payment models that place accountability for performance on physicians and hospitals, with a significant proportion of payment based on the delivery of high quality, efficient care.

Education and Training

Investment in the training and development of a skilled workforce to conduct CER is an important priority. Hospitalist researchers should take advantage of education and training programs to support the development of methodologies and skills for conducting CER that will become available. These programs will enable hospitalists to learn such skills as the use of the newly enhanced data infrastructure discussed above. The national investment in human and scientific capital for CER can promote the training of a corps of hospitalist researchers focused on this research which, in turn, could support the growth of the academic hospitalist field. Hospitalists who have responsibilities in medical education and residency training programs should take the lead in teaching CER concepts that are relevant to inpatient care. They will need to train the next generation of medical students and residents to read and understand comparative effectiveness literature and its application in clinical practice. Hospitalist educators are also best positioned to teach medical trainees comparative effectiveness evidence about inpatient QI methods and care processes.

Hospital Leadership

As front‐line providers and team leaders, hospitalists are well placed to direct the efforts within their hospitals to implement new CER evidence. For example, suppose new comparative effectiveness evidence about best practices for the discharge process for community‐dwelling older adults with multiple chronic conditions were to emerge. Hospitalists could lead efforts within their hospital to establish a multidisciplinary team to address this development, create standard protocols for implementing the new discharge process that align with their hospital's unique systems and organizational structure, advocate for necessary resources for the team to accomplish the goal of safely discharging these patients, ensure a method to track outcomes such as readmissions once the new discharge process is implemented, and provide data feedback to the team, hospital staff, and administrative leadership of the hospital. All of these activities should include a variety of disciplines working together, but as physician leaders, hospitalists can take the initiative to spearhead these endeavors. The inpatient setting is one that requires teamwork and coordination, and as team leaders, hospitalists can strongly influence the spread and adoption of CER results. Similarly, hospitalists are in a position to affect this dissemination and translation process by actively educating and empowering other clinicians and hospital staff within their local environment. Finally, as hospitalists increasingly take on leadership roles in QI departments and as chief medical officers within both community and university‐affiliated hospitals^8, they are in a unique position to lead efforts to implement CER‐based QI activities. These may range from the implementation of IT functions to reduce medical error to strategies to reduce hospital‐acquired infections or falls.

Conclusion

As a result of the stimulus funds directed towards CER, the coming years will see a vast increase in the generation of comparative effectiveness evidence and the application of that evidence into practice.9 The national CER endeavor is particularly germane to the field of hospital medicine, as uncertainty about best practices is common, and the patients hospitalists serve represent priority populations for CER investments. Hospitalists can play a central role in both generating CER and implementing its findings in settings in which patients are highly vulnerable, and existing information is insufficient. In addition to clinical questions, hospitalist researchers are particularly suited to answering important questions about quality of care and inpatient processes such as transitions of care and care coordination. Having evidence on the best practices for care transitions or strategies to reduce medical error, for example, could have a significant impact on patient outcomes, quality of life, and cost of care. However, none of this new evidence will be of any value if it is not used by front‐line providers.10 Practicing hospitalists should lead efforts within their hospital to disseminate new CER findings to their hospitalist and non‐hospitalist colleagues, and to leverage their position as hospital and team leaders to implement inpatient‐based CER findings. All of these combined efforts have the potential to significantly move the field of hospital medicine forward, with the end result being improved health and better outcomes for patients.

The topic of comparative effectiveness research (CER) has recently gained prominence within the context of the national focus on health reform. This article provides a brief overview and history of CER, and discusses the implications of CER for hospitalists in each of four major career roles: research, clinical practice, education and training, and hospital leadership. Both medical journals and lay media have produced a flurry of articles recently on a variety of health reform subjects. One topic that has achieved prominence within this growing body of literature is comparative effectiveness research (CER). For many hospitalists, this particular brand of research may be unfamiliar. As discussions about CER priorities, the controversy surrounding CER, and even the definition of CER gain visibility, hospitalists may be left wondering, What exactly is CER and what does it mean for me?

Until recently no common definition for CER existed, and the very concept was identified only in relatively narrow policy and research circles. However, CER is not a new idea. Its ancestor is the notion of medical technology assessment (MTA), which garnered enthusiasm and support in the 1970s. In 1978, Congress established the National Center for Health Technology Assessment (which, over time, evolved into the Agency for Healthcare Research and Quality [AHRQ]), whose charge was to coordinate efforts within the government to assess the safety, efficacy, effectiveness, and cost‐effectiveness of medical technologies. The recognition of a need for technology assessment at that time is mirrored by the widespread interest in CER seen today. Part of the reason that MTA did not take hold is that then, as now, this type of evaluation is challenging and time consuming, requiring large, well‐designed effectiveness studies. These studies require rigorous methods, typically long‐term follow‐up, and acceptance via editors and the medical literature that effectiveness is as important as efficacy demonstrated in a randomized trial. With the spread of antiregulatory sentiment and the lack of an economic imperative to reduce costs, the national focus on technology assessment waned. The current economic crisis has refocused the government and private sector on the soaring cost of health care and the need to improve quality, and the stimulus package passed in February of 2009 placed CER once again in the forefront. The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for CER.1 On June 30, 2009, 2 reports delineating the strategy and priorities for CER were released. The report from the ARRA‐mandated Federal Coordinating Council (FCC) for CER includes a broad definition of CER and outlines a high‐level strategic framework for priorities and investments in CER.2 Simultaneously, the report from the Institute of Medicine (IOM) lists 100 priority research topics, and gives 10 general recommendations for the CER enterprise going forward.3

So what is CER and why is it important? How is it different from standard research that hospitalists use every day to inform their clinical decision‐making? Unfortunately, patients and providers confront medical decisions daily that are not evidence based. All too frequently it is unclear what therapeutic option works best for which patient under which circumstances. For example, what is the best inpatient diabetes management strategy for an African American woman with multiple medical problems? What is the best discharge process for an elderly man with heart disease in order to prevent readmission? CER seeks to fill the gaps in evidence needed by patients and clinicians in order to make appropriate medical decisions. It differs from standard efficacy research in that it compares interventions or management strategies in real world settings, allows identification of effectiveness in patient subgroups, and is more patient‐centered, focusing on the decisions confronting patients and their physicians. The following definition of CER was developed by the FCC for CER:

CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in real world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence‐based information to patients, clinicians, and other decision‐makers, responding to their expressed needs about which interventions are most effective for which patients under specific circumstances.

• To provide this information, CER must assess a comprehensive array of health‐related outcomes for diverse patient populations and sub‐groups.

• Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change and delivery system strategies.

• This research necessitates the development, expansion and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

While CER is an evolving field requiring continued methodological development (such as enhancement of methods for practical, or pragmatic trials and complex analyses of large, linked databases), examples of rigorous comparative studies do exist. The Veterans Administration (VA) COURAGE trial compared optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) for patients with stable coronary disease, finding that PCI did not reduce the risk of death or cardiovascular events compared to OMT alone.4 Another example is the Diabetes Prevention Program which compared placebo, metformin, and a lifestyle modification program to prevent or delay the onset of type 2 diabetes. This study famously showed that lifestyle modification was more effective than metformin or placebo in reducing the incidence of diabetes.5

CER holds the promise of significantly improving the health of Americans through the ability to target treatments and other interventions to individual patients. As noted by the FCC, CER can allow for the delivery of the right treatment to the right patient at the right time2 even as the field continues to evolve. To quote Fineberg and Hiatt6 in describing technology assessment in 1979, we cannot expect CER to lead to perfect decisions, but we can expect even imperfect methods to facilitate better informed decisions than would otherwise be possible.

CER has important implications for hospitalists in all roles and settings. As the field of hospital medicine has grown, hospitalists have increasingly assumed more responsibilities than just patient care. In academic and community hospitals, hospitalists take on leadership roles, particularly in quality improvement (QI) and patient safety, and educational roles in the training of housestaff, medical students, and physician extenders. The last several years have also seen a significant increase in hospitalists participating in research. The relevance of CER to each of these 4 major activities is described below and in the accompanying Table 1.

Hospitalists and Research

Many comparative effectiveness questions about clinical care, processes of care, and quality of care within the inpatient setting are in need of answers. Hospitalist researchers have the opportunity to make a significant impact on care by pursuing answers to questions that are unique to the field of hospital medicine. With the new availability of funds for CER, now is the time to address many of these questions head‐on. For example, there is a lack of evidence about best practices for a large number of inpatient acute conditions. What is the best strategy to manage acute hospital delirium in an elderly patient? What is the best approach to treating acute pain in an elderly woman on multiple medications? Overwhelmingly the patients that hospitalists care for are elderly and/or have multiple chronic conditions, including children with special health care needs. Many are from racial or ethnic minority backgrounds. These subgroups of patients have been historically under‐represented in clinical trials, yet represent exactly the priority populations that the Federal CER effort targets. The field of hospital medicine can be transformed with a substantial investment in research to address common inpatient clinical conditions in real world settings focused on the kinds of patients hospitalists actually care for.

One of the most vexing and frustrating care delivery issues for hospitalists, clinicians and researchers alike, is the discharge process. This problem received increased attention after a recent article highlighted the high rate of readmissions in the Medicare population.7 Research on the discharge process has grown substantially in recent years, and has become an area of intense focus and attention for hospitalists, nurses, researchers, hospital administrators and policymakers. Without question, hospitalists are uniquely poised to conduct research on this critically important topic, and CER is an ideal vehicle for moving this field forward. In collaboration with nurses, primary care physicians, pharmacists, case managers and others, hospitalists should take advantage of the Federal investment in studying care delivery systems interventions, and develop innovative methods and strategies for studying and improving this crucial transition in care. CER is also applicable to other care transitions, including the admission process, transitions within the hospital, and discharge to nursing facilities. Other examples of comparative effectiveness topics that hospitalist researchers are particularly suited for include comparing methods for implementing inpatient treatment protocols or clinical pathways, comparison of health information technology (IT) systems to reduce medical error, and QI approaches.

What are the methodologies that hospitalists should use to conduct CER? While randomized pragmatic real world trials are appealing, this method may not always be practical. Other methodologies are available for rigorous use, including cohort studies, comparative QI interventions, clustered and factorial design, systematic reviews, and analysis of registries, administrative claims, or other databases. Databases currently available for analysis on priority populations and subgroups are limited, and include the VA and Medicare databases. To address this need, one of the primary Federal investments in CER is for the enhancement and expansion of data infrastructure. Data infrastructure tools that are likely to be available to hospitalist researchers for CER include expanded longitudinal administrative claims databases with linkages to electronic health records (EHRs), expanded patient registries with linkages to other forms of data, and distributed data networks that are populated by EHRs in provider and practice settings. Hospitalist researchers should take advantage of these resources as they become available, as they have tremendous potential to inform decision‐making for providers and patients alike.

Hospitalists and Clinical Practice

As with all providers, hospitalists will be end‐users of CER evidence, and will have the responsibility of translating new knowledge into practice. This process will not be easy. How are hospitalists to reliably access and incorporate new comparative effectiveness information into their daily practice? How should they deal with some of the potential unintended consequences of CER, such as information overload or conflicting evidence? While hospitalists have a professional responsibility to search for and apply CER findings, the future development of CER‐based practice guidelines will encourage evidence translation. The development of a common platform for the dissemination of CER relevant to hospitalists would significantly enhance the uptake of new evidence by practicing hospitalists and other hospital‐based providers such as physician assistants or nurse practitioners. Medical societies such as the Society of Hospital Medicine and the American Academy of Pediatrics should consider developing committees for CER and leading coordinated educational efforts specifically focused on CER results through publications and presentations at local, regional, and national meetings. In addition, other dissemination tools for CER will soon emerge and existing tools will be enhanced, such as the Effective Health Care Program and Eisenberg Center housed at the AHRQ. The coming years will see an expansion of these and other dissemination efforts to both providers and patients, and hospitalists must be vigilant about accessing these resources and integrating comparative effectiveness evidence into practice. As Federal dissemination efforts to consumers spread, patients will increasingly expect physicians to discuss comparative effectiveness evidence in describing options for their individual health needs. Finally, a key lever for translating CER into practice will be payment models that place accountability for performance on physicians and hospitals, with a significant proportion of payment based on the delivery of high quality, efficient care.

Education and Training

Investment in the training and development of a skilled workforce to conduct CER is an important priority. Hospitalist researchers should take advantage of education and training programs to support the development of methodologies and skills for conducting CER that will become available. These programs will enable hospitalists to learn such skills as the use of the newly enhanced data infrastructure discussed above. The national investment in human and scientific capital for CER can promote the training of a corps of hospitalist researchers focused on this research which, in turn, could support the growth of the academic hospitalist field. Hospitalists who have responsibilities in medical education and residency training programs should take the lead in teaching CER concepts that are relevant to inpatient care. They will need to train the next generation of medical students and residents to read and understand comparative effectiveness literature and its application in clinical practice. Hospitalist educators are also best positioned to teach medical trainees comparative effectiveness evidence about inpatient QI methods and care processes.

Hospital Leadership

As front‐line providers and team leaders, hospitalists are well placed to direct the efforts within their hospitals to implement new CER evidence. For example, suppose new comparative effectiveness evidence about best practices for the discharge process for community‐dwelling older adults with multiple chronic conditions were to emerge. Hospitalists could lead efforts within their hospital to establish a multidisciplinary team to address this development, create standard protocols for implementing the new discharge process that align with their hospital's unique systems and organizational structure, advocate for necessary resources for the team to accomplish the goal of safely discharging these patients, ensure a method to track outcomes such as readmissions once the new discharge process is implemented, and provide data feedback to the team, hospital staff, and administrative leadership of the hospital. All of these activities should include a variety of disciplines working together, but as physician leaders, hospitalists can take the initiative to spearhead these endeavors. The inpatient setting is one that requires teamwork and coordination, and as team leaders, hospitalists can strongly influence the spread and adoption of CER results. Similarly, hospitalists are in a position to affect this dissemination and translation process by actively educating and empowering other clinicians and hospital staff within their local environment. Finally, as hospitalists increasingly take on leadership roles in QI departments and as chief medical officers within both community and university‐affiliated hospitals^8, they are in a unique position to lead efforts to implement CER‐based QI activities. These may range from the implementation of IT functions to reduce medical error to strategies to reduce hospital‐acquired infections or falls.

Conclusion

As a result of the stimulus funds directed towards CER, the coming years will see a vast increase in the generation of comparative effectiveness evidence and the application of that evidence into practice.9 The national CER endeavor is particularly germane to the field of hospital medicine, as uncertainty about best practices is common, and the patients hospitalists serve represent priority populations for CER investments. Hospitalists can play a central role in both generating CER and implementing its findings in settings in which patients are highly vulnerable, and existing information is insufficient. In addition to clinical questions, hospitalist researchers are particularly suited to answering important questions about quality of care and inpatient processes such as transitions of care and care coordination. Having evidence on the best practices for care transitions or strategies to reduce medical error, for example, could have a significant impact on patient outcomes, quality of life, and cost of care. However, none of this new evidence will be of any value if it is not used by front‐line providers.10 Practicing hospitalists should lead efforts within their hospital to disseminate new CER findings to their hospitalist and non‐hospitalist colleagues, and to leverage their position as hospital and team leaders to implement inpatient‐based CER findings. All of these combined efforts have the potential to significantly move the field of hospital medicine forward, with the end result being improved health and better outcomes for patients.

A 41‐year‐old woman with menorrhagia presented with dysphagia and fatigue. An examination revealed koilonychia (Figure 1), cheilosis, atrophic glossitis, and conjunctival pallor. The hemoglobin level was 4.3 g/dL, the mean corpuscular volume was 48.3, the iron level was 6 g/dL, and the ferritin level was undetectable (1 ng/mL). A barium esophagram demonstrated probable esophageal webs (Figure 2). Esophageal webs were confirmed by upper endoscopy (Figure 3) and successfully dilated with a balloon dilator sequentially at 8, 9, and 10 mm. She was transfused, treated for menorrhagia, and given ferrous sulfate and ascorbic acid (to improve iron absorption).

Figure 1

Figure 2

Figure 3

Koilonychia (or spoon nails) is derived from the Greek word for hollow nails. Spoon nails are associated with iron deficiency, thyroid dysfunction, trauma, chronic solvent exposure, and nail‐patella syndrome, but they can be normal in infants.1 Patterson and Kelly independently described the triad of iron‐deficiency anemia, dysphagia, and upper esophageal webs in 1919 following Plummer's (1912) and Vinson's (1919) similar but less comprehensive descriptions of hysterical dysphagia.2 Plummer‐Vinson syndrome is rare, but precise prevalence data are unavailable.2 Whether iron deficiency truly causes esophageal webs is debated, but iron deficiency is thought to weaken esophageal musculature and cause epithelial cell atrophy.2 Autoimmunity and genetic predisposition are other putative causes. Dilation of esophageal webs is usually curative, although their association with an increased risk of upper alimentary cancers may justify surveillance endoscopy.3

A 41‐year‐old woman with menorrhagia presented with dysphagia and fatigue. An examination revealed koilonychia (Figure 1), cheilosis, atrophic glossitis, and conjunctival pallor. The hemoglobin level was 4.3 g/dL, the mean corpuscular volume was 48.3, the iron level was 6 g/dL, and the ferritin level was undetectable (1 ng/mL). A barium esophagram demonstrated probable esophageal webs (Figure 2). Esophageal webs were confirmed by upper endoscopy (Figure 3) and successfully dilated with a balloon dilator sequentially at 8, 9, and 10 mm. She was transfused, treated for menorrhagia, and given ferrous sulfate and ascorbic acid (to improve iron absorption).

Figure 1

Figure 2

Figure 3

Koilonychia (or spoon nails) is derived from the Greek word for hollow nails. Spoon nails are associated with iron deficiency, thyroid dysfunction, trauma, chronic solvent exposure, and nail‐patella syndrome, but they can be normal in infants.1 Patterson and Kelly independently described the triad of iron‐deficiency anemia, dysphagia, and upper esophageal webs in 1919 following Plummer's (1912) and Vinson's (1919) similar but less comprehensive descriptions of hysterical dysphagia.2 Plummer‐Vinson syndrome is rare, but precise prevalence data are unavailable.2 Whether iron deficiency truly causes esophageal webs is debated, but iron deficiency is thought to weaken esophageal musculature and cause epithelial cell atrophy.2 Autoimmunity and genetic predisposition are other putative causes. Dilation of esophageal webs is usually curative, although their association with an increased risk of upper alimentary cancers may justify surveillance endoscopy.3

A 41‐year‐old woman with menorrhagia presented with dysphagia and fatigue. An examination revealed koilonychia (Figure 1), cheilosis, atrophic glossitis, and conjunctival pallor. The hemoglobin level was 4.3 g/dL, the mean corpuscular volume was 48.3, the iron level was 6 g/dL, and the ferritin level was undetectable (1 ng/mL). A barium esophagram demonstrated probable esophageal webs (Figure 2). Esophageal webs were confirmed by upper endoscopy (Figure 3) and successfully dilated with a balloon dilator sequentially at 8, 9, and 10 mm. She was transfused, treated for menorrhagia, and given ferrous sulfate and ascorbic acid (to improve iron absorption).

Figure 1

Figure 2

Figure 3

Koilonychia (or spoon nails) is derived from the Greek word for hollow nails. Spoon nails are associated with iron deficiency, thyroid dysfunction, trauma, chronic solvent exposure, and nail‐patella syndrome, but they can be normal in infants.1 Patterson and Kelly independently described the triad of iron‐deficiency anemia, dysphagia, and upper esophageal webs in 1919 following Plummer's (1912) and Vinson's (1919) similar but less comprehensive descriptions of hysterical dysphagia.2 Plummer‐Vinson syndrome is rare, but precise prevalence data are unavailable.2 Whether iron deficiency truly causes esophageal webs is debated, but iron deficiency is thought to weaken esophageal musculature and cause epithelial cell atrophy.2 Autoimmunity and genetic predisposition are other putative causes. Dilation of esophageal webs is usually curative, although their association with an increased risk of upper alimentary cancers may justify surveillance endoscopy.3