In This Edition

Literature at a Glance

A guide to this month’s studies

• Statins and postoperative cardiac outcomes
• Cardiac resynchronization therapy in patients with mild CHF symptoms
• Oral direct thrombin inhibitor versus warfarin for stroke prevention in atrial fibrillation
• Association of fatigue and medical error
• Effects of chronic inhaled steroid and beta-agonist use in COPD
• Dialysis and functional status in nursing home patients
• Outcomes with different insulin-dosing regimens
• Understanding of disease severity and outcomes in advanced dementia

Fluvastatin Improves Postoperative Cardiac Outcomes in Patients Undergoing Vascular Surgery

Clinical question: Does perioperative fluvastatin decrease adverse cardiac events after vascular surgery?

Background: Patients with atherosclerotic vascular disease who undergo vascular surgery are at high risk for postoperative cardiac events. Studies in nonsurgical populations have shown the beneficial effects of statin therapy on cardiac outcomes. However, no placebo-controlled trials have addressed the effect of statins on postoperative cardiac outcomes.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Single large academic medical center in the Netherlands.

Synopsis: The study looked at 497 statin-naïve patients 40 years or older undergoing non-cardiac vascular surgery. The patients were randomized to 80 mg of extended-release fluvastatin versus placebo; all patients received a beta-blocker. Therapy began preoperatively (median of 37 days) and continued for at least 30 days after surgery. Outcomes were assessed at 30 days post-surgery.

Postoperative myocardial infarction (MI) was significantly less common in the fluvastatin group than with placebo (10.8% vs. 19%, hazard ratio (HR) 0.55, P=0.01). In addition, the treatment group had a lower frequency of death from cardiovascular causes (4.8% vs. 10.1%, HR 0.47, P=0.03). Statin therapy was not associated with an increased rate of adverse events.

Notably, all of the patients enrolled in this study were high-risk patients undergoing high-risk (vascular) surgery. Patients already on statins were excluded.

Further studies are needed to determine whether the findings can be extrapolated to other populations, including nonvascular surgery patients.

Bottom line: Perioperative statin therapy resulted in a significant decrease in postoperative MI and death within 30 days of vascular surgery.

Citation: Schouten O, Boersma E, Hoeks SE, et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med. 2009;361(10):980-989.

Cardiac Resynchronization Therapy with Implantable Cardioverter Defibrillator Placement Decreases Heart Failure

Clinical question: Does cardiac resynchronization therapy (CRT) with biventricular pacing decrease cardiac events in patients with reduced ejection fraction (EF) and wide QRS complex but only mild cardiac symptoms?

Background: In patients with severely reduced EF, implantable cardioverter defibrillators (ICDs) have been shown to improve survival. Meanwhile, CRT decreases heart-failure-related hospitalizations for patients with advanced heart-failure symptoms, EF less than 35%, and intraventricular conduction delay. It is not as clear whether patients with less-severe symptoms benefit from CRT.

Study design: Randomized, controlled trial.

Setting: 110 medical centers in the U.S., Canada, and Europe.

Synopsis: This Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) study randomly assigned 1,820 adults with EF less than 30%, New York Health Association Class I or II congestive heart failure, and in sinus rhythm with QRS greater than 130 msec to receive ICD with CRT or ICD alone. The primary endpoint was all-cause mortality or nonfatal heart-failure events. Average followup was 2.4 years.

A 34% reduction in the primary endpoint was found in the ICD-CRT group when compared with the ICD-only group, primarily due to a 41% reduction in heart-failure events. In a subgroup analysis, women and patients with QRS greater than 150 msec experienced particular benefit. Echocardiography one year after device implantation demonstrated significant reductions in left ventricular end-systolic and end-diastolic volume, and a significant increase in EF with ICD-CRT versus ICD-only (P<0.001).

Bottom line: Compared with ICD alone, CRT in combination with ICD prevented heart-failure events in relatively asymptomatic heart-failure patients with low EF and prolonged QRS.

Citation: Moss AJ, Hall WJ, Cannom DS, et al. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med. 2009;361(14):1329-1338.

Dabigatran Is Not Inferior to Warfarin in Atrial Fibrillation

Clinical question: Is dabigatran, an oral thrombin inhibitor, an effective and safe alternative to warfarin in patients with atrial fibrillation?

Background: Warfarin reduces the risk of stroke among patients with atrial fibrillation (AF) but requires frequent laboratory monitoring. Dabigatran is an oral direct thrombin inhibitor given in fixed dosages without laboratory monitoring.

Study design: Randomized, multicenter, open-label, noninferiority trial.

Setting: 951 clinical centers in 44 countries.

Synopsis: More than 18,000 patients 65 and older with AF and at least one stroke risk factor were enrolled. The average CHADS2 score was 2.1. Patients were randomized to receive fixed doses of dabigatran (110 mg or 150 mg, twice daily) or warfarin adjusted to an INR of 2.0-3.0. The primary outcomes were a) stroke or systemic embolism and b) major hemorrhage. Median followup was two years.

The annual rates of stroke or systemic embolism for both doses of dabigatran were noninferior to warfarin (P<0.001); higher-dose dabigatran was statistically superior to warfarin (relative risk (RR)=0.66, P<0.001). The annual rate of major hemorrhage was lowest in the lower-dose dabigatran group (RR=0.80, P=0.003 compared with warfarin); the higher-dose dabigatran and warfarin groups had equivalent rates of major bleeding. No increased risk of liver function abnormalities was noted.

Bottom line: Dabigatran appears to be an effective and safe alternative to warfarin in AF patients. If the drug were to be FDA-approved, appropriate patient selection and cost will need to be established.

Citation: Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-1151.

Resident Fatigue and Distress Contribute to Perceived Medical Errors

Clinical question: Do resident fatigue and distress contribute to medical errors?

Background: In recent years, such measures as work-hour limitations have been implemented to decrease resident fatigue and, it is presumed, medical errors. However, few studies address the relationship between residents’ well-being and self-reported medical errors.

Study design: Prospective six-year longitudinal cohort study.

Setting: Single academic medical center.

Synopsis: The authors had 380 internal-medicine residents complete quarterly surveys to assess fatigue, quality of life, burnout, symptoms of depression, and frequency of perceived medical errors. In a univariate analysis, fatigue/sleepiness, burnout, depression, and overall quality of life measures correlated significantly with self-reported major medical errors. Fatigue/sleepiness and measures of distress additively increased the risk of self-reported errors. Increases in one or both domains were estimated to increase the risk of self-reported errors by as much as 15% to 28%.

The authors studied only self-reported medical errors. It is difficult to know whether these errors directly affected patient outcomes. Additionally, results of this single-site study might not be able to be generalized.

Bottom line: Fatigue and distress contribute to self-perceived medical errors among residents.

Citation: West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-1300.

Inhaled Corticosteroids Decrease Inflammation in Moderate to Severe COPD

Clinical question: Does long-term inhaled corticosteroid therapy, with and without long-acting beta-agonists, decrease airway inflammation and improve lung function in patients with moderate to severe chronic obstructive pulmonary disease (COPD)?

Background: Guideline-recommended treatment of COPD with inhaled corticosteroids and long-acting beta-agonists improves symptoms and exacerbation rates; little is known about the impact of these therapies on inflammation and long-term lung function.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Two university medical centers in the Netherlands.

Synopsis: One hundred one steroid-naïve patients, ages 45 to 75 who were current or former smokers with moderate to severe COPD, were randomized to one of four regimens: 1) fluticasone for six months, then placebo for 24 months; 2) fluticasone for 30 months; 3) fluticasone and salmeterol for 30 months; or 4) placebo for 30 months. The primary outcome was inflammatory cell counts in bronchial biopsies/induced sputum. Secondary outcomes included postbronchodilator spirometry, methacholine hyperresponsiveness, and self-reported symptoms and health status. Patients with asthma were excluded.

Short-term fluticasone therapy decreased inflammation and improved forced expiratory volume in one second (FEV1). Long-term therapy also decreased the rate of FEV1 decline, reduced dyspnea, and improved health status. Discontinuation of therapy at six months led to inflammation relapse with worsened symptoms and increased rate of FEV1 decline. The addition of long-acting beta-agonists did not provide additional anti-inflammatory benefits, but it did improve FEV1 and dyspnea at six months.

Additional studies are needed to further define clinical outcomes and assess the cost benefit of these therapies.

Bottom line: Inhaled corticosteroids decrease inflammation in steroid-naïve patients with moderate to severe COPD and might decrease the rate of lung function decline. Long-acting beta-agonists do not offer additional anti-inflammatory benefit.

Citation: Lapperre TS, Snoeck-Stroband JB, Gosman MM, et al. Effect of fluticasone with and without salmeterol on pulmonary outcomes in chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2009;151(8):517-527.

Initiation of Dialysis Does Not Help Maintain Functional Status in Elderly

Clinical question: Is functional status in the elderly maintained over time after initiating long-term dialysis?

Background: Quality-of-life maintenance often is used as a goal when initiating long-term dialysis in elderly patients with end-stage renal disease. More elderly patients are being offered long-term dialysis treatment. Little is known about the functional status of elderly patients on long-term dialysis.

Study design: Retrospective cohort study.

Setting: U.S. nursing homes.

Synopsis: By cross-linking data from two population-based administrative datasets, this study identified 3,702 nursing home patients (mean 73.4 years) who had started long-term dialysis and whose functional status had been assessed. Activities of daily living assessments before and at three-month intervals after dialysis initiation were compared to see if functional status was maintained.

Within three months of starting dialysis, 61% of patients had a decline in functional status or had died. By one year, only 1 in 8 patients had maintained their pre-dialysis functional status.

Decline in functional status cannot be attributed solely to dialysis because study patients were not compared to patients with chronic kidney disease who were not dialyzed. In addition, these results might not apply to all elderly patients on dialysis, as the functional status of elderly nursing home patients might differ significantly from those living at home.

Bottom line: Functional status is not maintained in most elderly nursing home patients in the first 12 months after long-term dialysis is initiated. Elderly patients considering dialysis treatment should be aware that dialysis might not help maintain functional status and quality of life.

Citation: Kurella Tamura MK, Covinsky KE, Chertow GM, Yaffe C, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361(16):1539-1547.

Adding Basal Insulin to Oral Agents in Type 2 Diabetes Might Offer Best Glycemic Control

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Advanced Dementia Is a Terminal Illness with High Morbidity and Mortality

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

PEDIATRIC HM LITerature

By Mark Shen, MD

Antibiotic Prophylaxis Might Prevent Recurrent UTIs

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

Clinical question: Does antibiotic prophylaxis prevent future episodes of urinary tract infections?

Background: Recurrent urinary tract infections (UTI) in children might be associated with renal scarring and subsequent clinical consequences associated with long-term morbidity. Historically, antibiotic prophylaxis has been recommended for children who might have risk factors for recurrent infection, most commonly vesicoureteral reflux. However, scars may be present in the absence of known risk factors and upon first UTI. The efficacy of antibiotic prophylaxis in preventing recurrent UTIs is unclear.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Four centers in Australia.

Synopsis: The study looked at 576 children under the age of 18 with a history of at least one symptomatic UTI. The patients were randomized to receive trimethoprim-sulfamethoxazole (TMP-SMX) or placebo for 12 months. Children with vesicoureteral reflux were included, but those with known neurologic, skeletal, or urologic predispositions were excluded.

Thirteen percent of patients in the antibiotic group developed a UTI compared with 19% of patients in the placebo group (P=0.02). The authors calculate that at 12 months, 14 patients would need to be treated to prevent one UTI.

This study was unable to enroll the planned number of children but remained adequately powered to show a reduction in the primary outcome (rate of symptomatic UTI). However, a significant number of patients (approximately 28%) in each arm stopped taking the medication, the majority for undisclosed reasons. Despite an intention-to-treat analysis, this degree of dropout raises questions about the true effect size. Additionally, this study does not answer the more important clinical question regarding the effect of prophylaxis on potential future renal damage, specifically in children with vesicoureteral reflux.

Bottom line: Antibiotic prophylaxis might be modestly effective in preventing recurrent UTIs.

Citation: Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Statins and postoperative cardiac outcomes
• Cardiac resynchronization therapy in patients with mild CHF symptoms
• Oral direct thrombin inhibitor versus warfarin for stroke prevention in atrial fibrillation
• Association of fatigue and medical error
• Effects of chronic inhaled steroid and beta-agonist use in COPD
• Dialysis and functional status in nursing home patients
• Outcomes with different insulin-dosing regimens
• Understanding of disease severity and outcomes in advanced dementia

Fluvastatin Improves Postoperative Cardiac Outcomes in Patients Undergoing Vascular Surgery

Clinical question: Does perioperative fluvastatin decrease adverse cardiac events after vascular surgery?

Background: Patients with atherosclerotic vascular disease who undergo vascular surgery are at high risk for postoperative cardiac events. Studies in nonsurgical populations have shown the beneficial effects of statin therapy on cardiac outcomes. However, no placebo-controlled trials have addressed the effect of statins on postoperative cardiac outcomes.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Single large academic medical center in the Netherlands.

Synopsis: The study looked at 497 statin-naïve patients 40 years or older undergoing non-cardiac vascular surgery. The patients were randomized to 80 mg of extended-release fluvastatin versus placebo; all patients received a beta-blocker. Therapy began preoperatively (median of 37 days) and continued for at least 30 days after surgery. Outcomes were assessed at 30 days post-surgery.

Postoperative myocardial infarction (MI) was significantly less common in the fluvastatin group than with placebo (10.8% vs. 19%, hazard ratio (HR) 0.55, P=0.01). In addition, the treatment group had a lower frequency of death from cardiovascular causes (4.8% vs. 10.1%, HR 0.47, P=0.03). Statin therapy was not associated with an increased rate of adverse events.

Notably, all of the patients enrolled in this study were high-risk patients undergoing high-risk (vascular) surgery. Patients already on statins were excluded.

Further studies are needed to determine whether the findings can be extrapolated to other populations, including nonvascular surgery patients.

Bottom line: Perioperative statin therapy resulted in a significant decrease in postoperative MI and death within 30 days of vascular surgery.

Citation: Schouten O, Boersma E, Hoeks SE, et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med. 2009;361(10):980-989.

Cardiac Resynchronization Therapy with Implantable Cardioverter Defibrillator Placement Decreases Heart Failure

Clinical question: Does cardiac resynchronization therapy (CRT) with biventricular pacing decrease cardiac events in patients with reduced ejection fraction (EF) and wide QRS complex but only mild cardiac symptoms?

Background: In patients with severely reduced EF, implantable cardioverter defibrillators (ICDs) have been shown to improve survival. Meanwhile, CRT decreases heart-failure-related hospitalizations for patients with advanced heart-failure symptoms, EF less than 35%, and intraventricular conduction delay. It is not as clear whether patients with less-severe symptoms benefit from CRT.

Study design: Randomized, controlled trial.

Setting: 110 medical centers in the U.S., Canada, and Europe.

Synopsis: This Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) study randomly assigned 1,820 adults with EF less than 30%, New York Health Association Class I or II congestive heart failure, and in sinus rhythm with QRS greater than 130 msec to receive ICD with CRT or ICD alone. The primary endpoint was all-cause mortality or nonfatal heart-failure events. Average followup was 2.4 years.

A 34% reduction in the primary endpoint was found in the ICD-CRT group when compared with the ICD-only group, primarily due to a 41% reduction in heart-failure events. In a subgroup analysis, women and patients with QRS greater than 150 msec experienced particular benefit. Echocardiography one year after device implantation demonstrated significant reductions in left ventricular end-systolic and end-diastolic volume, and a significant increase in EF with ICD-CRT versus ICD-only (P<0.001).

Bottom line: Compared with ICD alone, CRT in combination with ICD prevented heart-failure events in relatively asymptomatic heart-failure patients with low EF and prolonged QRS.

Citation: Moss AJ, Hall WJ, Cannom DS, et al. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med. 2009;361(14):1329-1338.

Dabigatran Is Not Inferior to Warfarin in Atrial Fibrillation

Clinical question: Is dabigatran, an oral thrombin inhibitor, an effective and safe alternative to warfarin in patients with atrial fibrillation?

Background: Warfarin reduces the risk of stroke among patients with atrial fibrillation (AF) but requires frequent laboratory monitoring. Dabigatran is an oral direct thrombin inhibitor given in fixed dosages without laboratory monitoring.

Study design: Randomized, multicenter, open-label, noninferiority trial.

Setting: 951 clinical centers in 44 countries.

Synopsis: More than 18,000 patients 65 and older with AF and at least one stroke risk factor were enrolled. The average CHADS2 score was 2.1. Patients were randomized to receive fixed doses of dabigatran (110 mg or 150 mg, twice daily) or warfarin adjusted to an INR of 2.0-3.0. The primary outcomes were a) stroke or systemic embolism and b) major hemorrhage. Median followup was two years.

The annual rates of stroke or systemic embolism for both doses of dabigatran were noninferior to warfarin (P<0.001); higher-dose dabigatran was statistically superior to warfarin (relative risk (RR)=0.66, P<0.001). The annual rate of major hemorrhage was lowest in the lower-dose dabigatran group (RR=0.80, P=0.003 compared with warfarin); the higher-dose dabigatran and warfarin groups had equivalent rates of major bleeding. No increased risk of liver function abnormalities was noted.

Bottom line: Dabigatran appears to be an effective and safe alternative to warfarin in AF patients. If the drug were to be FDA-approved, appropriate patient selection and cost will need to be established.

Citation: Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-1151.

Resident Fatigue and Distress Contribute to Perceived Medical Errors

Clinical question: Do resident fatigue and distress contribute to medical errors?

Background: In recent years, such measures as work-hour limitations have been implemented to decrease resident fatigue and, it is presumed, medical errors. However, few studies address the relationship between residents’ well-being and self-reported medical errors.

Study design: Prospective six-year longitudinal cohort study.

Setting: Single academic medical center.

Synopsis: The authors had 380 internal-medicine residents complete quarterly surveys to assess fatigue, quality of life, burnout, symptoms of depression, and frequency of perceived medical errors. In a univariate analysis, fatigue/sleepiness, burnout, depression, and overall quality of life measures correlated significantly with self-reported major medical errors. Fatigue/sleepiness and measures of distress additively increased the risk of self-reported errors. Increases in one or both domains were estimated to increase the risk of self-reported errors by as much as 15% to 28%.

The authors studied only self-reported medical errors. It is difficult to know whether these errors directly affected patient outcomes. Additionally, results of this single-site study might not be able to be generalized.

Bottom line: Fatigue and distress contribute to self-perceived medical errors among residents.

Citation: West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-1300.

Inhaled Corticosteroids Decrease Inflammation in Moderate to Severe COPD

Clinical question: Does long-term inhaled corticosteroid therapy, with and without long-acting beta-agonists, decrease airway inflammation and improve lung function in patients with moderate to severe chronic obstructive pulmonary disease (COPD)?

Background: Guideline-recommended treatment of COPD with inhaled corticosteroids and long-acting beta-agonists improves symptoms and exacerbation rates; little is known about the impact of these therapies on inflammation and long-term lung function.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Two university medical centers in the Netherlands.

Synopsis: One hundred one steroid-naïve patients, ages 45 to 75 who were current or former smokers with moderate to severe COPD, were randomized to one of four regimens: 1) fluticasone for six months, then placebo for 24 months; 2) fluticasone for 30 months; 3) fluticasone and salmeterol for 30 months; or 4) placebo for 30 months. The primary outcome was inflammatory cell counts in bronchial biopsies/induced sputum. Secondary outcomes included postbronchodilator spirometry, methacholine hyperresponsiveness, and self-reported symptoms and health status. Patients with asthma were excluded.

Short-term fluticasone therapy decreased inflammation and improved forced expiratory volume in one second (FEV1). Long-term therapy also decreased the rate of FEV1 decline, reduced dyspnea, and improved health status. Discontinuation of therapy at six months led to inflammation relapse with worsened symptoms and increased rate of FEV1 decline. The addition of long-acting beta-agonists did not provide additional anti-inflammatory benefits, but it did improve FEV1 and dyspnea at six months.

Additional studies are needed to further define clinical outcomes and assess the cost benefit of these therapies.

Bottom line: Inhaled corticosteroids decrease inflammation in steroid-naïve patients with moderate to severe COPD and might decrease the rate of lung function decline. Long-acting beta-agonists do not offer additional anti-inflammatory benefit.

Citation: Lapperre TS, Snoeck-Stroband JB, Gosman MM, et al. Effect of fluticasone with and without salmeterol on pulmonary outcomes in chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2009;151(8):517-527.

Initiation of Dialysis Does Not Help Maintain Functional Status in Elderly

Clinical question: Is functional status in the elderly maintained over time after initiating long-term dialysis?

Background: Quality-of-life maintenance often is used as a goal when initiating long-term dialysis in elderly patients with end-stage renal disease. More elderly patients are being offered long-term dialysis treatment. Little is known about the functional status of elderly patients on long-term dialysis.

Study design: Retrospective cohort study.

Setting: U.S. nursing homes.

Synopsis: By cross-linking data from two population-based administrative datasets, this study identified 3,702 nursing home patients (mean 73.4 years) who had started long-term dialysis and whose functional status had been assessed. Activities of daily living assessments before and at three-month intervals after dialysis initiation were compared to see if functional status was maintained.

Within three months of starting dialysis, 61% of patients had a decline in functional status or had died. By one year, only 1 in 8 patients had maintained their pre-dialysis functional status.

Decline in functional status cannot be attributed solely to dialysis because study patients were not compared to patients with chronic kidney disease who were not dialyzed. In addition, these results might not apply to all elderly patients on dialysis, as the functional status of elderly nursing home patients might differ significantly from those living at home.

Bottom line: Functional status is not maintained in most elderly nursing home patients in the first 12 months after long-term dialysis is initiated. Elderly patients considering dialysis treatment should be aware that dialysis might not help maintain functional status and quality of life.

Citation: Kurella Tamura MK, Covinsky KE, Chertow GM, Yaffe C, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361(16):1539-1547.

Adding Basal Insulin to Oral Agents in Type 2 Diabetes Might Offer Best Glycemic Control

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Advanced Dementia Is a Terminal Illness with High Morbidity and Mortality

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

PEDIATRIC HM LITerature

By Mark Shen, MD

Antibiotic Prophylaxis Might Prevent Recurrent UTIs

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

Clinical question: Does antibiotic prophylaxis prevent future episodes of urinary tract infections?

Background: Recurrent urinary tract infections (UTI) in children might be associated with renal scarring and subsequent clinical consequences associated with long-term morbidity. Historically, antibiotic prophylaxis has been recommended for children who might have risk factors for recurrent infection, most commonly vesicoureteral reflux. However, scars may be present in the absence of known risk factors and upon first UTI. The efficacy of antibiotic prophylaxis in preventing recurrent UTIs is unclear.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Four centers in Australia.

Synopsis: The study looked at 576 children under the age of 18 with a history of at least one symptomatic UTI. The patients were randomized to receive trimethoprim-sulfamethoxazole (TMP-SMX) or placebo for 12 months. Children with vesicoureteral reflux were included, but those with known neurologic, skeletal, or urologic predispositions were excluded.

Thirteen percent of patients in the antibiotic group developed a UTI compared with 19% of patients in the placebo group (P=0.02). The authors calculate that at 12 months, 14 patients would need to be treated to prevent one UTI.

This study was unable to enroll the planned number of children but remained adequately powered to show a reduction in the primary outcome (rate of symptomatic UTI). However, a significant number of patients (approximately 28%) in each arm stopped taking the medication, the majority for undisclosed reasons. Despite an intention-to-treat analysis, this degree of dropout raises questions about the true effect size. Additionally, this study does not answer the more important clinical question regarding the effect of prophylaxis on potential future renal damage, specifically in children with vesicoureteral reflux.

Bottom line: Antibiotic prophylaxis might be modestly effective in preventing recurrent UTIs.

Citation: Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Statins and postoperative cardiac outcomes
• Cardiac resynchronization therapy in patients with mild CHF symptoms
• Oral direct thrombin inhibitor versus warfarin for stroke prevention in atrial fibrillation
• Association of fatigue and medical error
• Effects of chronic inhaled steroid and beta-agonist use in COPD
• Dialysis and functional status in nursing home patients
• Outcomes with different insulin-dosing regimens
• Understanding of disease severity and outcomes in advanced dementia

Fluvastatin Improves Postoperative Cardiac Outcomes in Patients Undergoing Vascular Surgery

Clinical question: Does perioperative fluvastatin decrease adverse cardiac events after vascular surgery?

Background: Patients with atherosclerotic vascular disease who undergo vascular surgery are at high risk for postoperative cardiac events. Studies in nonsurgical populations have shown the beneficial effects of statin therapy on cardiac outcomes. However, no placebo-controlled trials have addressed the effect of statins on postoperative cardiac outcomes.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Single large academic medical center in the Netherlands.

Synopsis: The study looked at 497 statin-naïve patients 40 years or older undergoing non-cardiac vascular surgery. The patients were randomized to 80 mg of extended-release fluvastatin versus placebo; all patients received a beta-blocker. Therapy began preoperatively (median of 37 days) and continued for at least 30 days after surgery. Outcomes were assessed at 30 days post-surgery.

Postoperative myocardial infarction (MI) was significantly less common in the fluvastatin group than with placebo (10.8% vs. 19%, hazard ratio (HR) 0.55, P=0.01). In addition, the treatment group had a lower frequency of death from cardiovascular causes (4.8% vs. 10.1%, HR 0.47, P=0.03). Statin therapy was not associated with an increased rate of adverse events.

Notably, all of the patients enrolled in this study were high-risk patients undergoing high-risk (vascular) surgery. Patients already on statins were excluded.

Further studies are needed to determine whether the findings can be extrapolated to other populations, including nonvascular surgery patients.

Bottom line: Perioperative statin therapy resulted in a significant decrease in postoperative MI and death within 30 days of vascular surgery.

Citation: Schouten O, Boersma E, Hoeks SE, et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med. 2009;361(10):980-989.

Cardiac Resynchronization Therapy with Implantable Cardioverter Defibrillator Placement Decreases Heart Failure

Clinical question: Does cardiac resynchronization therapy (CRT) with biventricular pacing decrease cardiac events in patients with reduced ejection fraction (EF) and wide QRS complex but only mild cardiac symptoms?

Background: In patients with severely reduced EF, implantable cardioverter defibrillators (ICDs) have been shown to improve survival. Meanwhile, CRT decreases heart-failure-related hospitalizations for patients with advanced heart-failure symptoms, EF less than 35%, and intraventricular conduction delay. It is not as clear whether patients with less-severe symptoms benefit from CRT.

Study design: Randomized, controlled trial.

Setting: 110 medical centers in the U.S., Canada, and Europe.

Synopsis: This Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) study randomly assigned 1,820 adults with EF less than 30%, New York Health Association Class I or II congestive heart failure, and in sinus rhythm with QRS greater than 130 msec to receive ICD with CRT or ICD alone. The primary endpoint was all-cause mortality or nonfatal heart-failure events. Average followup was 2.4 years.

A 34% reduction in the primary endpoint was found in the ICD-CRT group when compared with the ICD-only group, primarily due to a 41% reduction in heart-failure events. In a subgroup analysis, women and patients with QRS greater than 150 msec experienced particular benefit. Echocardiography one year after device implantation demonstrated significant reductions in left ventricular end-systolic and end-diastolic volume, and a significant increase in EF with ICD-CRT versus ICD-only (P<0.001).

Bottom line: Compared with ICD alone, CRT in combination with ICD prevented heart-failure events in relatively asymptomatic heart-failure patients with low EF and prolonged QRS.

Citation: Moss AJ, Hall WJ, Cannom DS, et al. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med. 2009;361(14):1329-1338.

Dabigatran Is Not Inferior to Warfarin in Atrial Fibrillation

Clinical question: Is dabigatran, an oral thrombin inhibitor, an effective and safe alternative to warfarin in patients with atrial fibrillation?

Background: Warfarin reduces the risk of stroke among patients with atrial fibrillation (AF) but requires frequent laboratory monitoring. Dabigatran is an oral direct thrombin inhibitor given in fixed dosages without laboratory monitoring.

Study design: Randomized, multicenter, open-label, noninferiority trial.

Setting: 951 clinical centers in 44 countries.

Synopsis: More than 18,000 patients 65 and older with AF and at least one stroke risk factor were enrolled. The average CHADS2 score was 2.1. Patients were randomized to receive fixed doses of dabigatran (110 mg or 150 mg, twice daily) or warfarin adjusted to an INR of 2.0-3.0. The primary outcomes were a) stroke or systemic embolism and b) major hemorrhage. Median followup was two years.

The annual rates of stroke or systemic embolism for both doses of dabigatran were noninferior to warfarin (P<0.001); higher-dose dabigatran was statistically superior to warfarin (relative risk (RR)=0.66, P<0.001). The annual rate of major hemorrhage was lowest in the lower-dose dabigatran group (RR=0.80, P=0.003 compared with warfarin); the higher-dose dabigatran and warfarin groups had equivalent rates of major bleeding. No increased risk of liver function abnormalities was noted.

Bottom line: Dabigatran appears to be an effective and safe alternative to warfarin in AF patients. If the drug were to be FDA-approved, appropriate patient selection and cost will need to be established.

Citation: Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-1151.

Resident Fatigue and Distress Contribute to Perceived Medical Errors

Clinical question: Do resident fatigue and distress contribute to medical errors?

Background: In recent years, such measures as work-hour limitations have been implemented to decrease resident fatigue and, it is presumed, medical errors. However, few studies address the relationship between residents’ well-being and self-reported medical errors.

Study design: Prospective six-year longitudinal cohort study.

Setting: Single academic medical center.

Synopsis: The authors had 380 internal-medicine residents complete quarterly surveys to assess fatigue, quality of life, burnout, symptoms of depression, and frequency of perceived medical errors. In a univariate analysis, fatigue/sleepiness, burnout, depression, and overall quality of life measures correlated significantly with self-reported major medical errors. Fatigue/sleepiness and measures of distress additively increased the risk of self-reported errors. Increases in one or both domains were estimated to increase the risk of self-reported errors by as much as 15% to 28%.

The authors studied only self-reported medical errors. It is difficult to know whether these errors directly affected patient outcomes. Additionally, results of this single-site study might not be able to be generalized.

Bottom line: Fatigue and distress contribute to self-perceived medical errors among residents.

Citation: West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-1300.

Inhaled Corticosteroids Decrease Inflammation in Moderate to Severe COPD

Clinical question: Does long-term inhaled corticosteroid therapy, with and without long-acting beta-agonists, decrease airway inflammation and improve lung function in patients with moderate to severe chronic obstructive pulmonary disease (COPD)?

Background: Guideline-recommended treatment of COPD with inhaled corticosteroids and long-acting beta-agonists improves symptoms and exacerbation rates; little is known about the impact of these therapies on inflammation and long-term lung function.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Two university medical centers in the Netherlands.

Synopsis: One hundred one steroid-naïve patients, ages 45 to 75 who were current or former smokers with moderate to severe COPD, were randomized to one of four regimens: 1) fluticasone for six months, then placebo for 24 months; 2) fluticasone for 30 months; 3) fluticasone and salmeterol for 30 months; or 4) placebo for 30 months. The primary outcome was inflammatory cell counts in bronchial biopsies/induced sputum. Secondary outcomes included postbronchodilator spirometry, methacholine hyperresponsiveness, and self-reported symptoms and health status. Patients with asthma were excluded.

Short-term fluticasone therapy decreased inflammation and improved forced expiratory volume in one second (FEV1). Long-term therapy also decreased the rate of FEV1 decline, reduced dyspnea, and improved health status. Discontinuation of therapy at six months led to inflammation relapse with worsened symptoms and increased rate of FEV1 decline. The addition of long-acting beta-agonists did not provide additional anti-inflammatory benefits, but it did improve FEV1 and dyspnea at six months.

Additional studies are needed to further define clinical outcomes and assess the cost benefit of these therapies.

Bottom line: Inhaled corticosteroids decrease inflammation in steroid-naïve patients with moderate to severe COPD and might decrease the rate of lung function decline. Long-acting beta-agonists do not offer additional anti-inflammatory benefit.

Citation: Lapperre TS, Snoeck-Stroband JB, Gosman MM, et al. Effect of fluticasone with and without salmeterol on pulmonary outcomes in chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2009;151(8):517-527.

Initiation of Dialysis Does Not Help Maintain Functional Status in Elderly

Clinical question: Is functional status in the elderly maintained over time after initiating long-term dialysis?

Background: Quality-of-life maintenance often is used as a goal when initiating long-term dialysis in elderly patients with end-stage renal disease. More elderly patients are being offered long-term dialysis treatment. Little is known about the functional status of elderly patients on long-term dialysis.

Study design: Retrospective cohort study.

Setting: U.S. nursing homes.

Synopsis: By cross-linking data from two population-based administrative datasets, this study identified 3,702 nursing home patients (mean 73.4 years) who had started long-term dialysis and whose functional status had been assessed. Activities of daily living assessments before and at three-month intervals after dialysis initiation were compared to see if functional status was maintained.

Within three months of starting dialysis, 61% of patients had a decline in functional status or had died. By one year, only 1 in 8 patients had maintained their pre-dialysis functional status.

Decline in functional status cannot be attributed solely to dialysis because study patients were not compared to patients with chronic kidney disease who were not dialyzed. In addition, these results might not apply to all elderly patients on dialysis, as the functional status of elderly nursing home patients might differ significantly from those living at home.

Bottom line: Functional status is not maintained in most elderly nursing home patients in the first 12 months after long-term dialysis is initiated. Elderly patients considering dialysis treatment should be aware that dialysis might not help maintain functional status and quality of life.

Citation: Kurella Tamura MK, Covinsky KE, Chertow GM, Yaffe C, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361(16):1539-1547.

Adding Basal Insulin to Oral Agents in Type 2 Diabetes Might Offer Best Glycemic Control

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Advanced Dementia Is a Terminal Illness with High Morbidity and Mortality

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

PEDIATRIC HM LITerature

By Mark Shen, MD

Antibiotic Prophylaxis Might Prevent Recurrent UTIs

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

Clinical question: Does antibiotic prophylaxis prevent future episodes of urinary tract infections?

Background: Recurrent urinary tract infections (UTI) in children might be associated with renal scarring and subsequent clinical consequences associated with long-term morbidity. Historically, antibiotic prophylaxis has been recommended for children who might have risk factors for recurrent infection, most commonly vesicoureteral reflux. However, scars may be present in the absence of known risk factors and upon first UTI. The efficacy of antibiotic prophylaxis in preventing recurrent UTIs is unclear.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Four centers in Australia.

Synopsis: The study looked at 576 children under the age of 18 with a history of at least one symptomatic UTI. The patients were randomized to receive trimethoprim-sulfamethoxazole (TMP-SMX) or placebo for 12 months. Children with vesicoureteral reflux were included, but those with known neurologic, skeletal, or urologic predispositions were excluded.

Thirteen percent of patients in the antibiotic group developed a UTI compared with 19% of patients in the placebo group (P=0.02). The authors calculate that at 12 months, 14 patients would need to be treated to prevent one UTI.

This study was unable to enroll the planned number of children but remained adequately powered to show a reduction in the primary outcome (rate of symptomatic UTI). However, a significant number of patients (approximately 28%) in each arm stopped taking the medication, the majority for undisclosed reasons. Despite an intention-to-treat analysis, this degree of dropout raises questions about the true effect size. Additionally, this study does not answer the more important clinical question regarding the effect of prophylaxis on potential future renal damage, specifically in children with vesicoureteral reflux.

Bottom line: Antibiotic prophylaxis might be modestly effective in preventing recurrent UTIs.

Citation: Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759.

Like so many things in HM, the story of how hospitalists first learned about the focused practice program is a modern one.

It started with a text message, which led to a blog post, which reached thousands of readers, many of them hospitalists interested in how to bolster their bona fides in a specialty known for its explosive growth in recent years.

Now, hospitalists certified in internal medicine have the opportunity to reinforce their commitment to the specialty by maintaining their certification through the Focused Practice in Hospital Medicine pathway offered by the American Board of Internal Medicine (ABIM). The Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program enables hospitalists to distinguish their practice within the larger specialty of internal medicine.

The Evolution of FPHM

The new pathway has been years in the making, and it reflects the growing influence of HM in healthcare, according to ABIM Chief Medical Officer Eric Holmboe, MD. He sees the FPHM as the result of a combination of factors, including the fact that the specialty now has more than 30,000 hospitalists practicing nationwide. “If you look at the past years, this has been a viable and vibrant practice,” he says. “If you look at the number of people doing hospital medicine, it’s a factor.”

For Holmboe, it also is a shift in how individuals are recognized based on their practice areas. “This is an acknowledgement by ABIM and the American Board of Medical Specialties to look at Maintenance of Certification in terms of what the individual actually does,” he explains. “Hospitalists play a very important role in the hospital.”

He also credits the leadership of the HM movement—especially pioneers like Robert Wachter, MD, FHM. One of HM’s most ardent champions, Dr. Wachter, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, worked with ABIM to find a way to recognize hospitalists’ specialized skill sets and their commitment to inpatient medicine. After more than a decade of advocating for a board-certified process to recognize the field, Dr. Wachter, an ABIM board member, began receiving multiple text messages from colleagues announcing that ABIM had approved the focused-practice program. He wrote a post on his blog, Wachter’s World (www.wachtersworld.com), that outlined the need for the FPHM and the significance for aspiring hospitalists.

“In any case, this is an important milestone for the field,” Dr. Wachter wrote in his Sept. 23, 2009, blog entry, “Board Certification for Hospitalists: It’s Heeeere!” “In fact, when I first began speaking to groups of hospitalists nearly 15 years ago, I often showed a slide listing the elements of a true specialty, and one by one we’ve ticked them off,” wrote Dr. Wachter, a former SHM president. “The only unchecked box was recognition of the field as a legitimate ‘specialty,’ as codified by the ABMS board certification process.”

Unchecked, that is, until now.

In early 2011, the medical world will be introduced to the first internists recognized for their focus in HM. For Holmboe, the FPHM is the beginning of an even larger movement.

“The goal is continued interest: getting people involved in quality in their hospital and encouraging people to change behaviors and be recognized by patients and credentialists as valuable,” he says. “That’s the primary mission of ABIM: using certification to improve care.”

Fellow in Hospital Medicine Spotlight

O’Neil Pyke, MD, FHM

Dr. Pyke is a clinical instructor at Commonwealth Medical College and a medical director at the Wyoming Valley Health Care System in Wilkes-Barre, Pa. He also serves as a consultant for various hospitalist programs, most actively for his own private consulting company, AMP Hospitalist Consulting, which partners with Salem, N.H.-based physician staffing company Medicus Healthcare Solutions.

Undergraduate Education: Queens College, City University of New York, Flushing, N.Y.

Medical School: Ohio State University College of Medicine and Public Health, Columbus

Notable: Dr. Pyke was born in Jamaica and moved to New York during high school. He says he owes everything to his parents. His parents, who had no education beyond high school, pushed Dr. Pyke and his siblings to achieve more than they did. His sister is an OB-GYN and his brother is pursuing a medical degree.

FYI: Dr. Pyke enjoys playing golf, cheering for his beloved Ohio State Buckeyes, and spends every Friday night with his wife and two daughters—he even admits to watching “chick flicks” on family night.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

Requirements and Process

Shortly after the program’s approval, ABIM, which administers the FPHM program, went to work in defining the process for the FPHM application and building infrastructure to support the tests. Holmboe expects ABIM will be ready to process pre-applications by April or May. While some details may change, the FPHM application will dovetail with ABIM’s MOC process.

Although hospitalists’ MOC must be current in order to apply for FPHM, hospitalists can begin the FPHM application process at any time. Hospitalists do not need to wait until their next MOC renewal.

Before beginning the application process, hospitalists should ensure that they are eligible. ABIM requires FPHM candidates to have:

• A current or previous ABIM certification in internal medicine;
• A valid, unrestricted medical license and confirmation of good standing in the local practice community;
• ACLS certification; and
• At least three years of hospital medicine practice experience.

Candidates who meet the requirements can then begin the enrollment process by:

1. Submitting attestations. Both the hospitalist and a senior officer at the hospital must provide attestations that demonstrate the hospitalist’s experience in HM and his or her commitment to the principles of the specialty.
2. Performing a self-assessment. Hospitalists must quantify their experience in HM through an MOC self-assessment. Candidates must achieve at least 100 MOC points. Successful applicants must submit a new self-assessment every three years. The self-assessment can be conducted before or after the exam.
3. Taking the MOC examination in Hospital Medicine. Registration for the first HM examination will begin in May. The exam will be conducted in October, and diplomates can take the exam at any time in the process.

Passing the exam and completing the other requirements will earn ABIM diplomats recognition as “Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.” ABIM will notify successful applicants in late 2010 and ship personalized certificates in early 2011. TH

Brendon Shank is a freelance writer based in Philadelphia.

Like so many things in HM, the story of how hospitalists first learned about the focused practice program is a modern one.

It started with a text message, which led to a blog post, which reached thousands of readers, many of them hospitalists interested in how to bolster their bona fides in a specialty known for its explosive growth in recent years.

Now, hospitalists certified in internal medicine have the opportunity to reinforce their commitment to the specialty by maintaining their certification through the Focused Practice in Hospital Medicine pathway offered by the American Board of Internal Medicine (ABIM). The Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program enables hospitalists to distinguish their practice within the larger specialty of internal medicine.

The Evolution of FPHM

The new pathway has been years in the making, and it reflects the growing influence of HM in healthcare, according to ABIM Chief Medical Officer Eric Holmboe, MD. He sees the FPHM as the result of a combination of factors, including the fact that the specialty now has more than 30,000 hospitalists practicing nationwide. “If you look at the past years, this has been a viable and vibrant practice,” he says. “If you look at the number of people doing hospital medicine, it’s a factor.”

For Holmboe, it also is a shift in how individuals are recognized based on their practice areas. “This is an acknowledgement by ABIM and the American Board of Medical Specialties to look at Maintenance of Certification in terms of what the individual actually does,” he explains. “Hospitalists play a very important role in the hospital.”

He also credits the leadership of the HM movement—especially pioneers like Robert Wachter, MD, FHM. One of HM’s most ardent champions, Dr. Wachter, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, worked with ABIM to find a way to recognize hospitalists’ specialized skill sets and their commitment to inpatient medicine. After more than a decade of advocating for a board-certified process to recognize the field, Dr. Wachter, an ABIM board member, began receiving multiple text messages from colleagues announcing that ABIM had approved the focused-practice program. He wrote a post on his blog, Wachter’s World (www.wachtersworld.com), that outlined the need for the FPHM and the significance for aspiring hospitalists.

“In any case, this is an important milestone for the field,” Dr. Wachter wrote in his Sept. 23, 2009, blog entry, “Board Certification for Hospitalists: It’s Heeeere!” “In fact, when I first began speaking to groups of hospitalists nearly 15 years ago, I often showed a slide listing the elements of a true specialty, and one by one we’ve ticked them off,” wrote Dr. Wachter, a former SHM president. “The only unchecked box was recognition of the field as a legitimate ‘specialty,’ as codified by the ABMS board certification process.”

Unchecked, that is, until now.

In early 2011, the medical world will be introduced to the first internists recognized for their focus in HM. For Holmboe, the FPHM is the beginning of an even larger movement.

“The goal is continued interest: getting people involved in quality in their hospital and encouraging people to change behaviors and be recognized by patients and credentialists as valuable,” he says. “That’s the primary mission of ABIM: using certification to improve care.”

Fellow in Hospital Medicine Spotlight

O’Neil Pyke, MD, FHM

Dr. Pyke is a clinical instructor at Commonwealth Medical College and a medical director at the Wyoming Valley Health Care System in Wilkes-Barre, Pa. He also serves as a consultant for various hospitalist programs, most actively for his own private consulting company, AMP Hospitalist Consulting, which partners with Salem, N.H.-based physician staffing company Medicus Healthcare Solutions.

Undergraduate Education: Queens College, City University of New York, Flushing, N.Y.

Medical School: Ohio State University College of Medicine and Public Health, Columbus

Notable: Dr. Pyke was born in Jamaica and moved to New York during high school. He says he owes everything to his parents. His parents, who had no education beyond high school, pushed Dr. Pyke and his siblings to achieve more than they did. His sister is an OB-GYN and his brother is pursuing a medical degree.

FYI: Dr. Pyke enjoys playing golf, cheering for his beloved Ohio State Buckeyes, and spends every Friday night with his wife and two daughters—he even admits to watching “chick flicks” on family night.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

Requirements and Process

Shortly after the program’s approval, ABIM, which administers the FPHM program, went to work in defining the process for the FPHM application and building infrastructure to support the tests. Holmboe expects ABIM will be ready to process pre-applications by April or May. While some details may change, the FPHM application will dovetail with ABIM’s MOC process.

Although hospitalists’ MOC must be current in order to apply for FPHM, hospitalists can begin the FPHM application process at any time. Hospitalists do not need to wait until their next MOC renewal.

Before beginning the application process, hospitalists should ensure that they are eligible. ABIM requires FPHM candidates to have:

• A current or previous ABIM certification in internal medicine;
• A valid, unrestricted medical license and confirmation of good standing in the local practice community;
• ACLS certification; and
• At least three years of hospital medicine practice experience.

Candidates who meet the requirements can then begin the enrollment process by:

1. Submitting attestations. Both the hospitalist and a senior officer at the hospital must provide attestations that demonstrate the hospitalist’s experience in HM and his or her commitment to the principles of the specialty.
2. Performing a self-assessment. Hospitalists must quantify their experience in HM through an MOC self-assessment. Candidates must achieve at least 100 MOC points. Successful applicants must submit a new self-assessment every three years. The self-assessment can be conducted before or after the exam.
3. Taking the MOC examination in Hospital Medicine. Registration for the first HM examination will begin in May. The exam will be conducted in October, and diplomates can take the exam at any time in the process.

Passing the exam and completing the other requirements will earn ABIM diplomats recognition as “Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.” ABIM will notify successful applicants in late 2010 and ship personalized certificates in early 2011. TH

Brendon Shank is a freelance writer based in Philadelphia.

Like so many things in HM, the story of how hospitalists first learned about the focused practice program is a modern one.

It started with a text message, which led to a blog post, which reached thousands of readers, many of them hospitalists interested in how to bolster their bona fides in a specialty known for its explosive growth in recent years.

Now, hospitalists certified in internal medicine have the opportunity to reinforce their commitment to the specialty by maintaining their certification through the Focused Practice in Hospital Medicine pathway offered by the American Board of Internal Medicine (ABIM). The Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program enables hospitalists to distinguish their practice within the larger specialty of internal medicine.

The Evolution of FPHM

The new pathway has been years in the making, and it reflects the growing influence of HM in healthcare, according to ABIM Chief Medical Officer Eric Holmboe, MD. He sees the FPHM as the result of a combination of factors, including the fact that the specialty now has more than 30,000 hospitalists practicing nationwide. “If you look at the past years, this has been a viable and vibrant practice,” he says. “If you look at the number of people doing hospital medicine, it’s a factor.”

For Holmboe, it also is a shift in how individuals are recognized based on their practice areas. “This is an acknowledgement by ABIM and the American Board of Medical Specialties to look at Maintenance of Certification in terms of what the individual actually does,” he explains. “Hospitalists play a very important role in the hospital.”

He also credits the leadership of the HM movement—especially pioneers like Robert Wachter, MD, FHM. One of HM’s most ardent champions, Dr. Wachter, chief of the hospital medicine division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco, worked with ABIM to find a way to recognize hospitalists’ specialized skill sets and their commitment to inpatient medicine. After more than a decade of advocating for a board-certified process to recognize the field, Dr. Wachter, an ABIM board member, began receiving multiple text messages from colleagues announcing that ABIM had approved the focused-practice program. He wrote a post on his blog, Wachter’s World (www.wachtersworld.com), that outlined the need for the FPHM and the significance for aspiring hospitalists.

“In any case, this is an important milestone for the field,” Dr. Wachter wrote in his Sept. 23, 2009, blog entry, “Board Certification for Hospitalists: It’s Heeeere!” “In fact, when I first began speaking to groups of hospitalists nearly 15 years ago, I often showed a slide listing the elements of a true specialty, and one by one we’ve ticked them off,” wrote Dr. Wachter, a former SHM president. “The only unchecked box was recognition of the field as a legitimate ‘specialty,’ as codified by the ABMS board certification process.”

Unchecked, that is, until now.

In early 2011, the medical world will be introduced to the first internists recognized for their focus in HM. For Holmboe, the FPHM is the beginning of an even larger movement.

“The goal is continued interest: getting people involved in quality in their hospital and encouraging people to change behaviors and be recognized by patients and credentialists as valuable,” he says. “That’s the primary mission of ABIM: using certification to improve care.”

Fellow in Hospital Medicine Spotlight

O’Neil Pyke, MD, FHM

Dr. Pyke is a clinical instructor at Commonwealth Medical College and a medical director at the Wyoming Valley Health Care System in Wilkes-Barre, Pa. He also serves as a consultant for various hospitalist programs, most actively for his own private consulting company, AMP Hospitalist Consulting, which partners with Salem, N.H.-based physician staffing company Medicus Healthcare Solutions.

Undergraduate Education: Queens College, City University of New York, Flushing, N.Y.

Medical School: Ohio State University College of Medicine and Public Health, Columbus

Notable: Dr. Pyke was born in Jamaica and moved to New York during high school. He says he owes everything to his parents. His parents, who had no education beyond high school, pushed Dr. Pyke and his siblings to achieve more than they did. His sister is an OB-GYN and his brother is pursuing a medical degree.

FYI: Dr. Pyke enjoys playing golf, cheering for his beloved Ohio State Buckeyes, and spends every Friday night with his wife and two daughters—he even admits to watching “chick flicks” on family night.

For more information about the FHM designation, visit www.hospitalmedicine.org/fellows.

Requirements and Process

Shortly after the program’s approval, ABIM, which administers the FPHM program, went to work in defining the process for the FPHM application and building infrastructure to support the tests. Holmboe expects ABIM will be ready to process pre-applications by April or May. While some details may change, the FPHM application will dovetail with ABIM’s MOC process.

Although hospitalists’ MOC must be current in order to apply for FPHM, hospitalists can begin the FPHM application process at any time. Hospitalists do not need to wait until their next MOC renewal.

Before beginning the application process, hospitalists should ensure that they are eligible. ABIM requires FPHM candidates to have:

• A current or previous ABIM certification in internal medicine;
• A valid, unrestricted medical license and confirmation of good standing in the local practice community;
• ACLS certification; and
• At least three years of hospital medicine practice experience.

Candidates who meet the requirements can then begin the enrollment process by:

1. Submitting attestations. Both the hospitalist and a senior officer at the hospital must provide attestations that demonstrate the hospitalist’s experience in HM and his or her commitment to the principles of the specialty.
2. Performing a self-assessment. Hospitalists must quantify their experience in HM through an MOC self-assessment. Candidates must achieve at least 100 MOC points. Successful applicants must submit a new self-assessment every three years. The self-assessment can be conducted before or after the exam.
3. Taking the MOC examination in Hospital Medicine. Registration for the first HM examination will begin in May. The exam will be conducted in October, and diplomates can take the exam at any time in the process.

Passing the exam and completing the other requirements will earn ABIM diplomats recognition as “Board Certified in Internal Medicine with a Focused Practice in Hospital Medicine.” ABIM will notify successful applicants in late 2010 and ship personalized certificates in early 2011. TH

Brendon Shank is a freelance writer based in Philadelphia.

Whether hospitalists like it or not, the art of negotiation has a significant impact on their daily activities. Negotiations take place with consultants over what the perceived optimal plan of care should be. Discussions are held with patients on how best to overcome the social, financial, and psychological barriers that may impede their health. Hospitalists negotiate with administrators over schedules, benefits, and responsibilities.

Quite frequently, negotiation is viewed as a process where one party wins and the other loses, a zero-sum game, like chess. The spoils may be financial (e.g., better reimbursements) or they may be cognitive (e.g., success in convincing someone of your particular viewpoint). Significant value that could potentially benefit both parties may be lost if the negotiation is approached with a win-loss mentality. However, with proper preparation and insight, a hospitalist can create value in a negotiation that otherwise may be lost by shifting their negotiation paradigm to a collaborative strategy.

A collaborative strategy is when the relationship—and not just the outcome—is important. This would apply to most negotiations that hospitalists take part in.

A significant part of this strategy involves listening and allowing the other side to divulge their interests and positions. Information must flow freely. Once the problem is identified, it must then be detailed further, ensuring both parties understand each other.

Only once both party’s issues are presented can an alternative solution be contemplated that will be win-win in nature. The parties then must both agree to choose that solution and move forward.

The optimal result is that the chosen solution appeases both parties and has a greater total value than if both sides were solely vying for their own interests.

Riyad Fares, MD,

hospitalist,

Adventist Hospital, Portland, Ore.

Whether hospitalists like it or not, the art of negotiation has a significant impact on their daily activities. Negotiations take place with consultants over what the perceived optimal plan of care should be. Discussions are held with patients on how best to overcome the social, financial, and psychological barriers that may impede their health. Hospitalists negotiate with administrators over schedules, benefits, and responsibilities.

Quite frequently, negotiation is viewed as a process where one party wins and the other loses, a zero-sum game, like chess. The spoils may be financial (e.g., better reimbursements) or they may be cognitive (e.g., success in convincing someone of your particular viewpoint). Significant value that could potentially benefit both parties may be lost if the negotiation is approached with a win-loss mentality. However, with proper preparation and insight, a hospitalist can create value in a negotiation that otherwise may be lost by shifting their negotiation paradigm to a collaborative strategy.

A collaborative strategy is when the relationship—and not just the outcome—is important. This would apply to most negotiations that hospitalists take part in.

A significant part of this strategy involves listening and allowing the other side to divulge their interests and positions. Information must flow freely. Once the problem is identified, it must then be detailed further, ensuring both parties understand each other.

Only once both party’s issues are presented can an alternative solution be contemplated that will be win-win in nature. The parties then must both agree to choose that solution and move forward.

The optimal result is that the chosen solution appeases both parties and has a greater total value than if both sides were solely vying for their own interests.

Riyad Fares, MD,

hospitalist,

Adventist Hospital, Portland, Ore.

Whether hospitalists like it or not, the art of negotiation has a significant impact on their daily activities. Negotiations take place with consultants over what the perceived optimal plan of care should be. Discussions are held with patients on how best to overcome the social, financial, and psychological barriers that may impede their health. Hospitalists negotiate with administrators over schedules, benefits, and responsibilities.

Quite frequently, negotiation is viewed as a process where one party wins and the other loses, a zero-sum game, like chess. The spoils may be financial (e.g., better reimbursements) or they may be cognitive (e.g., success in convincing someone of your particular viewpoint). Significant value that could potentially benefit both parties may be lost if the negotiation is approached with a win-loss mentality. However, with proper preparation and insight, a hospitalist can create value in a negotiation that otherwise may be lost by shifting their negotiation paradigm to a collaborative strategy.

A collaborative strategy is when the relationship—and not just the outcome—is important. This would apply to most negotiations that hospitalists take part in.

A significant part of this strategy involves listening and allowing the other side to divulge their interests and positions. Information must flow freely. Once the problem is identified, it must then be detailed further, ensuring both parties understand each other.

Only once both party’s issues are presented can an alternative solution be contemplated that will be win-win in nature. The parties then must both agree to choose that solution and move forward.

The optimal result is that the chosen solution appeases both parties and has a greater total value than if both sides were solely vying for their own interests.

Riyad Fares, MD,

hospitalist,

Adventist Hospital, Portland, Ore.

Three U.S. medical centers have been recognized for innovative approaches to preventing DVT and its potentially fatal complications, which include pulmonary embolism (PE). Central to each of the DVT prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.

The University of California at San Diego (UCSD) Medical Center, Johns Hopkins Hospital in Baltimore, and the Veterans Affairs (VA) Medical Center in Washington, D.C., each received the first DVTeamCare Hospital Award. The North American Thrombosis Forum (NATF), in conjunction with pharmaceutical company Eisai Inc., recognized each center’s accomplishment based upon an evaluation by an independent panel of expert judges.

Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues.

—Gregory A. Maynard, MD, FHM, hospital medicine division chief, University of California at San Diego

The award reflects NATF’s goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD. Dr. Sussman notes that DVT affects more than 600,000 Americans annually, kills more than 100,000, and is one of the leading causes of preventable deaths in hospitals. Preventable DVT-related complication is on Medicare’s list of “never events,” for which hospitals will no longer be reimbursed.

UCSD, representing medical centers with more than 200 beds, imbedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, FHM, hospital medicine division chief. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based. Prompting concurrent intervention is a central component of UCSD’s implementation strategy, “identifying in real-time patients who are not receiving the right DVT prophylaxis and having a front-line nurse or pharmacist intervene appropriately,” Dr. Maynard explains.

The percent of UCSD’s patients on adequate prophylaxis rose to more than 98% in the past two years, up from about 50% before the intervention, while preventable VTE dropped by 85%—about 50 fewer cases per year in a hospital with fewer than 300 beds. “Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues,” Dr. Maynard says.

UCSD has partnered with SHM to develop DVT prevention toolkits and mentored collaboratives, with which hospitalists can take the lead on QI projects at their local institutions. SHM’s online VTE Implementation Guide is available at www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.

Dr. Streiff

Johns Hopkins Hospital, representing medical centers with more than 200 beds, developed a mandatory computer-based decision-support system to facilitate specialty-specific risk-factor assessment and the application of risk-appropriate VTE prophylaxis, says Michael Streiff, MD, FACP, director of Johns Hopkins’ Anticoagulation Management Service and Outpatient Clinic, and a member of its Evidence-Based Practice Center. Before a physician can issue any orders—medications, lab tests, nursing instructions, etc.—using a physician transfer order set, the computerized order-entry system automatically guides them through a concise set of questions about a patient’s DVT risk factors, contraindications for blood thinners, and guideline-recommended prophylaxis choices, Dr. Streiff says.

Dr. Streiff

Since implementing the system, the percent of patients being DVT-risk-stratified within 24 hours of hospital admission rose to more than 90%, and nearly 9 in 10 of the appropriate patients are now receiving risk-appropriate, American College of Chest Physicians-approved DVT prophylaxis, up from about 26% before the intervention, Dr. Streiff notes.

The VA Medical Center in Washington, D.C., representing medical centers with fewer than 200 beds, participated in a mentorship collaborative with UCSD’s Dr. Maynard and designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy, says Divya Shroff, MD, associate chief of staff, Informatics. The guideline-driven steps are integrated into the VA’s computerized patient medical record system and take no more than 60 seconds to follow, says pharmacy practice resident Jovonne H. Jones, PharmD. The steps include:

• Assess patient DVT risk level;
• Educate patient about the order;
• Identify contraindications, if any;
• Choose prophylaxis drug or device;
• Accept order for drug or device;
• Check if additional prophylactic method is needed; and
• Accept the final order.

Jovonne Jones

After the intervention, the rate at which patients receive appropriate prophylaxis upon admission more than doubled. Twenty VA medical centers around the country are in the process of implementing the system, Jones says.

The award-winning protocols will be presented at an NATF-hosted program April 9 at Harvard Medical School. The protocols and implementation plans will be made available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Three U.S. medical centers have been recognized for innovative approaches to preventing DVT and its potentially fatal complications, which include pulmonary embolism (PE). Central to each of the DVT prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.

The University of California at San Diego (UCSD) Medical Center, Johns Hopkins Hospital in Baltimore, and the Veterans Affairs (VA) Medical Center in Washington, D.C., each received the first DVTeamCare Hospital Award. The North American Thrombosis Forum (NATF), in conjunction with pharmaceutical company Eisai Inc., recognized each center’s accomplishment based upon an evaluation by an independent panel of expert judges.

Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues.

—Gregory A. Maynard, MD, FHM, hospital medicine division chief, University of California at San Diego

The award reflects NATF’s goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD. Dr. Sussman notes that DVT affects more than 600,000 Americans annually, kills more than 100,000, and is one of the leading causes of preventable deaths in hospitals. Preventable DVT-related complication is on Medicare’s list of “never events,” for which hospitals will no longer be reimbursed.

UCSD, representing medical centers with more than 200 beds, imbedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, FHM, hospital medicine division chief. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based. Prompting concurrent intervention is a central component of UCSD’s implementation strategy, “identifying in real-time patients who are not receiving the right DVT prophylaxis and having a front-line nurse or pharmacist intervene appropriately,” Dr. Maynard explains.

The percent of UCSD’s patients on adequate prophylaxis rose to more than 98% in the past two years, up from about 50% before the intervention, while preventable VTE dropped by 85%—about 50 fewer cases per year in a hospital with fewer than 300 beds. “Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues,” Dr. Maynard says.

UCSD has partnered with SHM to develop DVT prevention toolkits and mentored collaboratives, with which hospitalists can take the lead on QI projects at their local institutions. SHM’s online VTE Implementation Guide is available at www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.

Dr. Streiff

Johns Hopkins Hospital, representing medical centers with more than 200 beds, developed a mandatory computer-based decision-support system to facilitate specialty-specific risk-factor assessment and the application of risk-appropriate VTE prophylaxis, says Michael Streiff, MD, FACP, director of Johns Hopkins’ Anticoagulation Management Service and Outpatient Clinic, and a member of its Evidence-Based Practice Center. Before a physician can issue any orders—medications, lab tests, nursing instructions, etc.—using a physician transfer order set, the computerized order-entry system automatically guides them through a concise set of questions about a patient’s DVT risk factors, contraindications for blood thinners, and guideline-recommended prophylaxis choices, Dr. Streiff says.

Dr. Streiff

Since implementing the system, the percent of patients being DVT-risk-stratified within 24 hours of hospital admission rose to more than 90%, and nearly 9 in 10 of the appropriate patients are now receiving risk-appropriate, American College of Chest Physicians-approved DVT prophylaxis, up from about 26% before the intervention, Dr. Streiff notes.

The VA Medical Center in Washington, D.C., representing medical centers with fewer than 200 beds, participated in a mentorship collaborative with UCSD’s Dr. Maynard and designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy, says Divya Shroff, MD, associate chief of staff, Informatics. The guideline-driven steps are integrated into the VA’s computerized patient medical record system and take no more than 60 seconds to follow, says pharmacy practice resident Jovonne H. Jones, PharmD. The steps include:

• Assess patient DVT risk level;
• Educate patient about the order;
• Identify contraindications, if any;
• Choose prophylaxis drug or device;
• Accept order for drug or device;
• Check if additional prophylactic method is needed; and
• Accept the final order.

Jovonne Jones

After the intervention, the rate at which patients receive appropriate prophylaxis upon admission more than doubled. Twenty VA medical centers around the country are in the process of implementing the system, Jones says.

The award-winning protocols will be presented at an NATF-hosted program April 9 at Harvard Medical School. The protocols and implementation plans will be made available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

Three U.S. medical centers have been recognized for innovative approaches to preventing DVT and its potentially fatal complications, which include pulmonary embolism (PE). Central to each of the DVT prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.

The University of California at San Diego (UCSD) Medical Center, Johns Hopkins Hospital in Baltimore, and the Veterans Affairs (VA) Medical Center in Washington, D.C., each received the first DVTeamCare Hospital Award. The North American Thrombosis Forum (NATF), in conjunction with pharmaceutical company Eisai Inc., recognized each center’s accomplishment based upon an evaluation by an independent panel of expert judges.

Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues.

—Gregory A. Maynard, MD, FHM, hospital medicine division chief, University of California at San Diego

The award reflects NATF’s goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD. Dr. Sussman notes that DVT affects more than 600,000 Americans annually, kills more than 100,000, and is one of the leading causes of preventable deaths in hospitals. Preventable DVT-related complication is on Medicare’s list of “never events,” for which hospitals will no longer be reimbursed.

UCSD, representing medical centers with more than 200 beds, imbedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, FHM, hospital medicine division chief. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based. Prompting concurrent intervention is a central component of UCSD’s implementation strategy, “identifying in real-time patients who are not receiving the right DVT prophylaxis and having a front-line nurse or pharmacist intervene appropriately,” Dr. Maynard explains.

The percent of UCSD’s patients on adequate prophylaxis rose to more than 98% in the past two years, up from about 50% before the intervention, while preventable VTE dropped by 85%—about 50 fewer cases per year in a hospital with fewer than 300 beds. “Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues,” Dr. Maynard says.

UCSD has partnered with SHM to develop DVT prevention toolkits and mentored collaboratives, with which hospitalists can take the lead on QI projects at their local institutions. SHM’s online VTE Implementation Guide is available at www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.

Dr. Streiff

Johns Hopkins Hospital, representing medical centers with more than 200 beds, developed a mandatory computer-based decision-support system to facilitate specialty-specific risk-factor assessment and the application of risk-appropriate VTE prophylaxis, says Michael Streiff, MD, FACP, director of Johns Hopkins’ Anticoagulation Management Service and Outpatient Clinic, and a member of its Evidence-Based Practice Center. Before a physician can issue any orders—medications, lab tests, nursing instructions, etc.—using a physician transfer order set, the computerized order-entry system automatically guides them through a concise set of questions about a patient’s DVT risk factors, contraindications for blood thinners, and guideline-recommended prophylaxis choices, Dr. Streiff says.

Dr. Streiff

Since implementing the system, the percent of patients being DVT-risk-stratified within 24 hours of hospital admission rose to more than 90%, and nearly 9 in 10 of the appropriate patients are now receiving risk-appropriate, American College of Chest Physicians-approved DVT prophylaxis, up from about 26% before the intervention, Dr. Streiff notes.

The VA Medical Center in Washington, D.C., representing medical centers with fewer than 200 beds, participated in a mentorship collaborative with UCSD’s Dr. Maynard and designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy, says Divya Shroff, MD, associate chief of staff, Informatics. The guideline-driven steps are integrated into the VA’s computerized patient medical record system and take no more than 60 seconds to follow, says pharmacy practice resident Jovonne H. Jones, PharmD. The steps include:

• Assess patient DVT risk level;
• Educate patient about the order;
• Identify contraindications, if any;
• Choose prophylaxis drug or device;
• Accept order for drug or device;
• Check if additional prophylactic method is needed; and
• Accept the final order.

Jovonne Jones

After the intervention, the rate at which patients receive appropriate prophylaxis upon admission more than doubled. Twenty VA medical centers around the country are in the process of implementing the system, Jones says.

The award-winning protocols will be presented at an NATF-hosted program April 9 at Harvard Medical School. The protocols and implementation plans will be made available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

HM10 is planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services (BFMS) and SHM. BFMS is accredited by ACCME to provide CME for physicians.

Regular registration is available on SHM’s Web site (www.hospitalmedicine.org) and remains available until March 28. SHM also permits walk-up registration during HM10 at the Gaylord National Resort & Convention Center in National Harbor, Md. However, remember that last year’s meeting sold out a couple weeks ahead of time.

BFMS designates the educational activity for SHM’s annual meeting at a maximum of 20 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit they actually spend in each educational activity. BFMS has designated a credit schedule for HM10’s pre-courses on April 8 as follows:

• ABIM MOC learning session, 6.5 credits;
• Critical Care, 7.25 credits;
• Documentation and Coding, 7.5 credits;
• Early Career Hospitalist, 7.5 credits;
• Essential Neurology, 7.25 credits;
• Essential Procedures, 3.75 credits;
• Practice Management, 7.5 credits; and
• Quality Improvement Skills, 7.75 credits.

Source: www.hospitalmedicine.org

PHOTO MATT FENSTERMACHER

HM10 is planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services (BFMS) and SHM. BFMS is accredited by ACCME to provide CME for physicians.

Regular registration is available on SHM’s Web site (www.hospitalmedicine.org) and remains available until March 28. SHM also permits walk-up registration during HM10 at the Gaylord National Resort & Convention Center in National Harbor, Md. However, remember that last year’s meeting sold out a couple weeks ahead of time.

BFMS designates the educational activity for SHM’s annual meeting at a maximum of 20 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit they actually spend in each educational activity. BFMS has designated a credit schedule for HM10’s pre-courses on April 8 as follows:

• ABIM MOC learning session, 6.5 credits;
• Critical Care, 7.25 credits;
• Documentation and Coding, 7.5 credits;
• Early Career Hospitalist, 7.5 credits;
• Essential Neurology, 7.25 credits;
• Essential Procedures, 3.75 credits;
• Practice Management, 7.5 credits; and
• Quality Improvement Skills, 7.75 credits.

Source: www.hospitalmedicine.org

PHOTO MATT FENSTERMACHER

HM10 is planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services (BFMS) and SHM. BFMS is accredited by ACCME to provide CME for physicians.

Regular registration is available on SHM’s Web site (www.hospitalmedicine.org) and remains available until March 28. SHM also permits walk-up registration during HM10 at the Gaylord National Resort & Convention Center in National Harbor, Md. However, remember that last year’s meeting sold out a couple weeks ahead of time.

BFMS designates the educational activity for SHM’s annual meeting at a maximum of 20 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit they actually spend in each educational activity. BFMS has designated a credit schedule for HM10’s pre-courses on April 8 as follows:

• ABIM MOC learning session, 6.5 credits;
• Critical Care, 7.25 credits;
• Documentation and Coding, 7.5 credits;
• Early Career Hospitalist, 7.5 credits;
• Essential Neurology, 7.25 credits;
• Essential Procedures, 3.75 credits;
• Practice Management, 7.5 credits; and
• Quality Improvement Skills, 7.75 credits.

Source: www.hospitalmedicine.org

PHOTO MATT FENSTERMACHER

It’s often said that only death and taxes are certainties. Add to that short list the beauty of Washington’s National Cherry Blossom Festival in early April.

This year’s festival parade is April 10, which happens to be the third day of HM10 at the Gaylord National Resort & Convention Center in National Harbor, Md., along the banks of the Potomac River outside the nation’s capital. This year’s two-week festival celebrates the 98th anniversary of Tokyo donating 3,000 cherry trees to the people of Washington.

“It gets a little bit crowded, but it’s definitely impressive,” says pediatric hospitalist Patrick Conway, MD, a chief medical officer at U.S. Department of Health and Human Services in Washington. “It’s pretty cool.”

HM10 is the perfect opportunity to get to know D.C., which offers a plethora of museums and attractions for those with time to explore. One of the most famous is the National Mall, which extends from the Lincoln Memorial to the U.S. Capitol. In between is a catalog of American history—the Washington Monument, the National Gallery of Art, and the Smithsonian Institution.

“The good thing about the National Mall is it’s pretty walkable,” says Dr. Conway, who also uses the city’s subway system, known as the Metro, to get around the city.

Closer to the host hotel, HM10 attendees can take a water taxi from the Potomac Riverboat Co. to visit Old Town Alexandria, George Washington’s Home at Mount Vernon Estate & Gardens, and historic Georgetown. Arlington National Cemetery and its landmark Tomb of the Unknowns is also nearby. “It’s sort of a somber thought, but we took our family there,” Dr. Conway says. “We thought it was moving.”

The Gaylord offers an assortment of casual and upscale restaurants, along with the two-story Pose Ultra Lounge, an infusion bar with nightly entertainment. For those looking for a night on the town, Dr. Conway suggests Zaytinya, a Mediterranean tapas restaurant at the corner of 9th and G streets; BLT Steak off Farragut Square; and Vidalia, an eatery that specializes in Southern cuisine, at 1990 M Street NW (try the shrimp and grits). For a nightcap, get a drink at the Rooftop Sky Terrace at the Hotel Washington, which overlooks the White House.

“We love D.C.,” Dr. Conway says. “There’s a ton to do. It’s very metropolitan. It’s very easy to get around and doesn’t feel like a massive city.”

The average high temperature in April is 66 degrees, so plan to bring a jacket. For more information, visit www.washington.org or www.frommers.com (see “72 Hours in D.C.,” p. 10). For information about HM10’s Family Programs, visit www.hospitalmedicine.org/HM10family.

Richard Quinn is a freelance writer based in New Jersey.

IMAGES SOURCE: TDOES1/DREAMSTIME.COM

It’s often said that only death and taxes are certainties. Add to that short list the beauty of Washington’s National Cherry Blossom Festival in early April.

This year’s festival parade is April 10, which happens to be the third day of HM10 at the Gaylord National Resort & Convention Center in National Harbor, Md., along the banks of the Potomac River outside the nation’s capital. This year’s two-week festival celebrates the 98th anniversary of Tokyo donating 3,000 cherry trees to the people of Washington.

“It gets a little bit crowded, but it’s definitely impressive,” says pediatric hospitalist Patrick Conway, MD, a chief medical officer at U.S. Department of Health and Human Services in Washington. “It’s pretty cool.”

HM10 is the perfect opportunity to get to know D.C., which offers a plethora of museums and attractions for those with time to explore. One of the most famous is the National Mall, which extends from the Lincoln Memorial to the U.S. Capitol. In between is a catalog of American history—the Washington Monument, the National Gallery of Art, and the Smithsonian Institution.

“The good thing about the National Mall is it’s pretty walkable,” says Dr. Conway, who also uses the city’s subway system, known as the Metro, to get around the city.

Closer to the host hotel, HM10 attendees can take a water taxi from the Potomac Riverboat Co. to visit Old Town Alexandria, George Washington’s Home at Mount Vernon Estate & Gardens, and historic Georgetown. Arlington National Cemetery and its landmark Tomb of the Unknowns is also nearby. “It’s sort of a somber thought, but we took our family there,” Dr. Conway says. “We thought it was moving.”

The Gaylord offers an assortment of casual and upscale restaurants, along with the two-story Pose Ultra Lounge, an infusion bar with nightly entertainment. For those looking for a night on the town, Dr. Conway suggests Zaytinya, a Mediterranean tapas restaurant at the corner of 9th and G streets; BLT Steak off Farragut Square; and Vidalia, an eatery that specializes in Southern cuisine, at 1990 M Street NW (try the shrimp and grits). For a nightcap, get a drink at the Rooftop Sky Terrace at the Hotel Washington, which overlooks the White House.

“We love D.C.,” Dr. Conway says. “There’s a ton to do. It’s very metropolitan. It’s very easy to get around and doesn’t feel like a massive city.”

The average high temperature in April is 66 degrees, so plan to bring a jacket. For more information, visit www.washington.org or www.frommers.com (see “72 Hours in D.C.,” p. 10). For information about HM10’s Family Programs, visit www.hospitalmedicine.org/HM10family.

Richard Quinn is a freelance writer based in New Jersey.

IMAGES SOURCE: TDOES1/DREAMSTIME.COM

It’s often said that only death and taxes are certainties. Add to that short list the beauty of Washington’s National Cherry Blossom Festival in early April.

This year’s festival parade is April 10, which happens to be the third day of HM10 at the Gaylord National Resort & Convention Center in National Harbor, Md., along the banks of the Potomac River outside the nation’s capital. This year’s two-week festival celebrates the 98th anniversary of Tokyo donating 3,000 cherry trees to the people of Washington.

“It gets a little bit crowded, but it’s definitely impressive,” says pediatric hospitalist Patrick Conway, MD, a chief medical officer at U.S. Department of Health and Human Services in Washington. “It’s pretty cool.”

HM10 is the perfect opportunity to get to know D.C., which offers a plethora of museums and attractions for those with time to explore. One of the most famous is the National Mall, which extends from the Lincoln Memorial to the U.S. Capitol. In between is a catalog of American history—the Washington Monument, the National Gallery of Art, and the Smithsonian Institution.

“The good thing about the National Mall is it’s pretty walkable,” says Dr. Conway, who also uses the city’s subway system, known as the Metro, to get around the city.

Closer to the host hotel, HM10 attendees can take a water taxi from the Potomac Riverboat Co. to visit Old Town Alexandria, George Washington’s Home at Mount Vernon Estate & Gardens, and historic Georgetown. Arlington National Cemetery and its landmark Tomb of the Unknowns is also nearby. “It’s sort of a somber thought, but we took our family there,” Dr. Conway says. “We thought it was moving.”

The Gaylord offers an assortment of casual and upscale restaurants, along with the two-story Pose Ultra Lounge, an infusion bar with nightly entertainment. For those looking for a night on the town, Dr. Conway suggests Zaytinya, a Mediterranean tapas restaurant at the corner of 9th and G streets; BLT Steak off Farragut Square; and Vidalia, an eatery that specializes in Southern cuisine, at 1990 M Street NW (try the shrimp and grits). For a nightcap, get a drink at the Rooftop Sky Terrace at the Hotel Washington, which overlooks the White House.

“We love D.C.,” Dr. Conway says. “There’s a ton to do. It’s very metropolitan. It’s very easy to get around and doesn’t feel like a massive city.”

The average high temperature in April is 66 degrees, so plan to bring a jacket. For more information, visit www.washington.org or www.frommers.com (see “72 Hours in D.C.,” p. 10). For information about HM10’s Family Programs, visit www.hospitalmedicine.org/HM10family.

Richard Quinn is a freelance writer based in New Jersey.

IMAGES SOURCE: TDOES1/DREAMSTIME.COM

When you’re a fixture on the HM speaking circuit, it can be challenging to hold the attention of the crowd year after year—especially when your address is at lunchtime on the final day of SHM’s annual powwow, when a fair number of physicians will be checked out or looking to catch a cab to the airport.

The circumstances rarely faze Robert Wachter, MD, FHM, chief of the hospitalist division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco. In fact, since helping pioneer the use of the term “hospitalist,” Dr. Wachter has become the signature closing presenter at SHM’s annual meetings. Sometimes the talk is a window into patient-safety issues; sometimes it’s an oral white paper on policy issues; and, just once, it was a message in a bottle from the future.

This year, though, Dr. Wachter, former SHM president and author of the blog Wachter’s World (www.wachters world.com), is keeping it local.

“It just strikes me that this year, more than any other in recent memory, what is happening in Washington will have a major impact on what hospitalists do for a living and what hospitalists will do for a living,” he says.

Few would disagree.

“Bob has his fingers on the pulse of how hospital medicine is evolving, where hospital medicine started,” says Amir Jaffer, MD, FHM, chair of the annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine. “Bob’s really been great in terms of predicting what happens next.”

In light of the fluid realities of healthcare reform, Dr. Wachter’s exact words are likely to change several times before he speaks. Still, his themes have remained relatively constant over the years: He boasts of HM’s growth as a specialty and challenges hospitalists to act as leaders.

“I’ve always seen our field as not just reactive, but at the cutting edge of moving things forward,” he says. “This is an extremely important time because if (hospitalists) can be motivational, they can move the whole system forward.”

Hospitalists and group leaders will have to navigate the intricacies of Washington’s reform package. With that in mind, Dr. Wachter will speak about a number of hot policy topics:

• The future of bundled payments. Hospitalists are wary of how the government will reimburse the industry for delivery of care. Whether a new payment system rewards hospitals directly or physicians continue to bill for their services, HM leaders will need to keep abreast of changes.
• Continued migration toward “accountable-care organizations,” also known as ACOs, where providers partner and share responsibility for both the quality and cost of healthcare for a specific population of beneficiaries.
• Healthcare IT improvements. As the industry continues to embrace electronic health records, and industrywide metrics solidify, hospitalists can take leading roles as quality-improvement (QI) leaders.
• Dr. Watcher says hospitalists should use the changing nature of healthcare reform as an opportunity to take a leading role in the discussion.

“It’s not entirely clear how this will play out, but it is clear some piece of the legislation will push for more efficiency,” he says, “and hospitalists will be a major leader in that area.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTOS MATT FENSTERMACHER

When you’re a fixture on the HM speaking circuit, it can be challenging to hold the attention of the crowd year after year—especially when your address is at lunchtime on the final day of SHM’s annual powwow, when a fair number of physicians will be checked out or looking to catch a cab to the airport.

The circumstances rarely faze Robert Wachter, MD, FHM, chief of the hospitalist division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco. In fact, since helping pioneer the use of the term “hospitalist,” Dr. Wachter has become the signature closing presenter at SHM’s annual meetings. Sometimes the talk is a window into patient-safety issues; sometimes it’s an oral white paper on policy issues; and, just once, it was a message in a bottle from the future.

This year, though, Dr. Wachter, former SHM president and author of the blog Wachter’s World (www.wachters world.com), is keeping it local.

“It just strikes me that this year, more than any other in recent memory, what is happening in Washington will have a major impact on what hospitalists do for a living and what hospitalists will do for a living,” he says.

Few would disagree.

“Bob has his fingers on the pulse of how hospital medicine is evolving, where hospital medicine started,” says Amir Jaffer, MD, FHM, chair of the annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine. “Bob’s really been great in terms of predicting what happens next.”

In light of the fluid realities of healthcare reform, Dr. Wachter’s exact words are likely to change several times before he speaks. Still, his themes have remained relatively constant over the years: He boasts of HM’s growth as a specialty and challenges hospitalists to act as leaders.

“I’ve always seen our field as not just reactive, but at the cutting edge of moving things forward,” he says. “This is an extremely important time because if (hospitalists) can be motivational, they can move the whole system forward.”

Hospitalists and group leaders will have to navigate the intricacies of Washington’s reform package. With that in mind, Dr. Wachter will speak about a number of hot policy topics:

• The future of bundled payments. Hospitalists are wary of how the government will reimburse the industry for delivery of care. Whether a new payment system rewards hospitals directly or physicians continue to bill for their services, HM leaders will need to keep abreast of changes.
• Continued migration toward “accountable-care organizations,” also known as ACOs, where providers partner and share responsibility for both the quality and cost of healthcare for a specific population of beneficiaries.
• Healthcare IT improvements. As the industry continues to embrace electronic health records, and industrywide metrics solidify, hospitalists can take leading roles as quality-improvement (QI) leaders.
• Dr. Watcher says hospitalists should use the changing nature of healthcare reform as an opportunity to take a leading role in the discussion.

“It’s not entirely clear how this will play out, but it is clear some piece of the legislation will push for more efficiency,” he says, “and hospitalists will be a major leader in that area.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTOS MATT FENSTERMACHER

When you’re a fixture on the HM speaking circuit, it can be challenging to hold the attention of the crowd year after year—especially when your address is at lunchtime on the final day of SHM’s annual powwow, when a fair number of physicians will be checked out or looking to catch a cab to the airport.

The circumstances rarely faze Robert Wachter, MD, FHM, chief of the hospitalist division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco. In fact, since helping pioneer the use of the term “hospitalist,” Dr. Wachter has become the signature closing presenter at SHM’s annual meetings. Sometimes the talk is a window into patient-safety issues; sometimes it’s an oral white paper on policy issues; and, just once, it was a message in a bottle from the future.

This year, though, Dr. Wachter, former SHM president and author of the blog Wachter’s World (www.wachters world.com), is keeping it local.

“It just strikes me that this year, more than any other in recent memory, what is happening in Washington will have a major impact on what hospitalists do for a living and what hospitalists will do for a living,” he says.

Few would disagree.

“Bob has his fingers on the pulse of how hospital medicine is evolving, where hospital medicine started,” says Amir Jaffer, MD, FHM, chair of the annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine. “Bob’s really been great in terms of predicting what happens next.”

In light of the fluid realities of healthcare reform, Dr. Wachter’s exact words are likely to change several times before he speaks. Still, his themes have remained relatively constant over the years: He boasts of HM’s growth as a specialty and challenges hospitalists to act as leaders.

“I’ve always seen our field as not just reactive, but at the cutting edge of moving things forward,” he says. “This is an extremely important time because if (hospitalists) can be motivational, they can move the whole system forward.”

Hospitalists and group leaders will have to navigate the intricacies of Washington’s reform package. With that in mind, Dr. Wachter will speak about a number of hot policy topics:

• The future of bundled payments. Hospitalists are wary of how the government will reimburse the industry for delivery of care. Whether a new payment system rewards hospitals directly or physicians continue to bill for their services, HM leaders will need to keep abreast of changes.
• Continued migration toward “accountable-care organizations,” also known as ACOs, where providers partner and share responsibility for both the quality and cost of healthcare for a specific population of beneficiaries.
• Healthcare IT improvements. As the industry continues to embrace electronic health records, and industrywide metrics solidify, hospitalists can take leading roles as quality-improvement (QI) leaders.
• Dr. Watcher says hospitalists should use the changing nature of healthcare reform as an opportunity to take a leading role in the discussion.

“It’s not entirely clear how this will play out, but it is clear some piece of the legislation will push for more efficiency,” he says, “and hospitalists will be a major leader in that area.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTOS MATT FENSTERMACHER

He’s not a hospitalist. He’s not even a doctor. In fact, less than a decade ago, he was executive director of a Massachusetts water resources board and best known for his views on how to best clean up Boston Bay. But from his perch as president and CEO of Beth Israel Deaconess Medical Center in Boston, Paul Levy is a leading voice in contemporary healthcare, quality measures, and transparency.

HM10’s keynote speaker is most well-known in both medical and management circles for launching a blog in 2006 about the daily operations of his institution, aptly found at www.runningahospital.blogspot.com. Levy, whose address is at 9 a.m. Friday, April 9, spoke to The Hospitalist about his views on the role HM practitioners can play in quality improvement (QI), the importance of communication in medicine, and what he hopes hospitalists can learn from the experiences of his hospital.

Question: What made you accept the offer to be the keynote speaker at HM10?

Answer: I have tremendous respect for the hospital medicine industry. They are positioned to be an exceptionally important part of the care delivery system. In terms of working alongside them, they’re also interesting people. I enjoy working with them.

Q: Why are you looking forward to speaking?

A: I’d like to share our experience with qualitative care improvements and process improvements. The hospitalists, because of their position within the hospital and their relationships (with specialists and with administrators in the C-suite), are on the vanguard of being able to truly improve how we deliver care.

Q: Your address is titled “The Hospitalist’s Role in the Hospital of the Future.” Can you provide an overview of the topics you plan to talk about?

A: It's a classic discussion on how you do process improvement. How do you standardize care? Once you standardize care ... how do you measure that? Hospitalists are in an excellent position to do that because they work on all of the different floors of their hospitals. They are in a position to make meaningful impacts on multiple floors.

Q: How do you encourage your HM physicians to do that?

A: I don’t have to. They do it. We have found it very valuable, and in our place, it’s led to better outcomes. That means better patient care.

Q: Can you give an example of that value to the institution?

A: We initiated a rapid-response program several years ago we call “Triggers.” When a patient displays certain symptoms—changes in heart rate, blood pressure, oxygen saturation, etc.—there is an automatic trigger that calls in a senior nurse and a senior attending physician. We have already demonstrated a reduction in fatalities and a reduction in mortality rates because of this. We have so few codes right now on our on floors that we had to move our codes to our simulators because residents were not getting enough training. It’s a good problem to have.

Q: Do you see more physicians, hospitalists particularly, embracing technology in the hopes of improving care delivery and process administration?

A: Sure. We have a group of residents who created some type of Wiki with their work. I’m not even sure how it works; it just happens. I know there are some hospitals out there preventing this from happening. I think that’s just stupid. It’s a fear that something proprietary or private will be posted for everyone to see. I don’t particularly think it’s founded. We’ve all heard stories about someone who leaves a folder full of files on the subway. Are we going to stop people from riding the subway?

Q: What do you think HM’s outlook is?

A: I think it’s bright. I’m kind of new to medicine. I’ve only been here about eight years. I kind of wonder what used to happen before hospitalists. I guess primary-care physicians came in early in the morning and late at night. That doesn’t sound like an efficient system to deliver care.

Q: What do you want conference attendees to take away from your words?

A: I just hope the stories I tell about process improvements help everyone in their institutions. It’s up to them.

Richard Quinn is a freelance writer based in New Jersey.

PHOTOS MATT FENSTERMACHER

He’s not a hospitalist. He’s not even a doctor. In fact, less than a decade ago, he was executive director of a Massachusetts water resources board and best known for his views on how to best clean up Boston Bay. But from his perch as president and CEO of Beth Israel Deaconess Medical Center in Boston, Paul Levy is a leading voice in contemporary healthcare, quality measures, and transparency.

HM10’s keynote speaker is most well-known in both medical and management circles for launching a blog in 2006 about the daily operations of his institution, aptly found at www.runningahospital.blogspot.com. Levy, whose address is at 9 a.m. Friday, April 9, spoke to The Hospitalist about his views on the role HM practitioners can play in quality improvement (QI), the importance of communication in medicine, and what he hopes hospitalists can learn from the experiences of his hospital.

Question: What made you accept the offer to be the keynote speaker at HM10?

Answer: I have tremendous respect for the hospital medicine industry. They are positioned to be an exceptionally important part of the care delivery system. In terms of working alongside them, they’re also interesting people. I enjoy working with them.

Q: Why are you looking forward to speaking?

A: I’d like to share our experience with qualitative care improvements and process improvements. The hospitalists, because of their position within the hospital and their relationships (with specialists and with administrators in the C-suite), are on the vanguard of being able to truly improve how we deliver care.

Q: Your address is titled “The Hospitalist’s Role in the Hospital of the Future.” Can you provide an overview of the topics you plan to talk about?

A: It's a classic discussion on how you do process improvement. How do you standardize care? Once you standardize care ... how do you measure that? Hospitalists are in an excellent position to do that because they work on all of the different floors of their hospitals. They are in a position to make meaningful impacts on multiple floors.

Q: How do you encourage your HM physicians to do that?

A: I don’t have to. They do it. We have found it very valuable, and in our place, it’s led to better outcomes. That means better patient care.

Q: Can you give an example of that value to the institution?

A: We initiated a rapid-response program several years ago we call “Triggers.” When a patient displays certain symptoms—changes in heart rate, blood pressure, oxygen saturation, etc.—there is an automatic trigger that calls in a senior nurse and a senior attending physician. We have already demonstrated a reduction in fatalities and a reduction in mortality rates because of this. We have so few codes right now on our on floors that we had to move our codes to our simulators because residents were not getting enough training. It’s a good problem to have.

Q: Do you see more physicians, hospitalists particularly, embracing technology in the hopes of improving care delivery and process administration?

A: Sure. We have a group of residents who created some type of Wiki with their work. I’m not even sure how it works; it just happens. I know there are some hospitals out there preventing this from happening. I think that’s just stupid. It’s a fear that something proprietary or private will be posted for everyone to see. I don’t particularly think it’s founded. We’ve all heard stories about someone who leaves a folder full of files on the subway. Are we going to stop people from riding the subway?

Q: What do you think HM’s outlook is?

A: I think it’s bright. I’m kind of new to medicine. I’ve only been here about eight years. I kind of wonder what used to happen before hospitalists. I guess primary-care physicians came in early in the morning and late at night. That doesn’t sound like an efficient system to deliver care.

Q: What do you want conference attendees to take away from your words?

A: I just hope the stories I tell about process improvements help everyone in their institutions. It’s up to them.

Richard Quinn is a freelance writer based in New Jersey.

PHOTOS MATT FENSTERMACHER

He’s not a hospitalist. He’s not even a doctor. In fact, less than a decade ago, he was executive director of a Massachusetts water resources board and best known for his views on how to best clean up Boston Bay. But from his perch as president and CEO of Beth Israel Deaconess Medical Center in Boston, Paul Levy is a leading voice in contemporary healthcare, quality measures, and transparency.

HM10’s keynote speaker is most well-known in both medical and management circles for launching a blog in 2006 about the daily operations of his institution, aptly found at www.runningahospital.blogspot.com. Levy, whose address is at 9 a.m. Friday, April 9, spoke to The Hospitalist about his views on the role HM practitioners can play in quality improvement (QI), the importance of communication in medicine, and what he hopes hospitalists can learn from the experiences of his hospital.

Question: What made you accept the offer to be the keynote speaker at HM10?

Answer: I have tremendous respect for the hospital medicine industry. They are positioned to be an exceptionally important part of the care delivery system. In terms of working alongside them, they’re also interesting people. I enjoy working with them.

Q: Why are you looking forward to speaking?

A: I’d like to share our experience with qualitative care improvements and process improvements. The hospitalists, because of their position within the hospital and their relationships (with specialists and with administrators in the C-suite), are on the vanguard of being able to truly improve how we deliver care.

Q: Your address is titled “The Hospitalist’s Role in the Hospital of the Future.” Can you provide an overview of the topics you plan to talk about?

A: It's a classic discussion on how you do process improvement. How do you standardize care? Once you standardize care ... how do you measure that? Hospitalists are in an excellent position to do that because they work on all of the different floors of their hospitals. They are in a position to make meaningful impacts on multiple floors.

Q: How do you encourage your HM physicians to do that?

A: I don’t have to. They do it. We have found it very valuable, and in our place, it’s led to better outcomes. That means better patient care.

Q: Can you give an example of that value to the institution?

A: We initiated a rapid-response program several years ago we call “Triggers.” When a patient displays certain symptoms—changes in heart rate, blood pressure, oxygen saturation, etc.—there is an automatic trigger that calls in a senior nurse and a senior attending physician. We have already demonstrated a reduction in fatalities and a reduction in mortality rates because of this. We have so few codes right now on our on floors that we had to move our codes to our simulators because residents were not getting enough training. It’s a good problem to have.

Q: Do you see more physicians, hospitalists particularly, embracing technology in the hopes of improving care delivery and process administration?

A: Sure. We have a group of residents who created some type of Wiki with their work. I’m not even sure how it works; it just happens. I know there are some hospitals out there preventing this from happening. I think that’s just stupid. It’s a fear that something proprietary or private will be posted for everyone to see. I don’t particularly think it’s founded. We’ve all heard stories about someone who leaves a folder full of files on the subway. Are we going to stop people from riding the subway?

Q: What do you think HM’s outlook is?

A: I think it’s bright. I’m kind of new to medicine. I’ve only been here about eight years. I kind of wonder what used to happen before hospitalists. I guess primary-care physicians came in early in the morning and late at night. That doesn’t sound like an efficient system to deliver care.

Q: What do you want conference attendees to take away from your words?

A: I just hope the stories I tell about process improvements help everyone in their institutions. It’s up to them.

Richard Quinn is a freelance writer based in New Jersey.

PHOTOS MATT FENSTERMACHER

If a medical meeting of the minds is only as good as its CME options, then HM10 will be the best SHM annual meeting yet.

A pair of new pre-courses—“Essential Neurology for the Hospitalist” and “Early Career Hospitalist: Skills for Success”—will debut at HM10, which kicks off April 8 at the Gaylord National Resort & Convention Center in National Harbor, Md., outside of Washington, D.C. The new learning sessions boost to 20 the number of Category 1 credits physicians can earn toward the American Medical Association’s (AMA) Physician Recognition Award. Last year, hospitalists could earn a maximum of 15 credits.

While both of the new pre-courses drew heavy interest among early registrants, the latter was particularly intriguing, says Amir Jaffer, MD, FHM, chair of SHM’s annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine in Florida.

“It’s really going to allow our early-career hospitalists to acquire some of the skills they don’t necessarily acquire during residency, such as billing and coding and understanding of quality measures,” Dr. Jaffer boasts, “as well as how best to communicate with consultants, patients, and families. They’ll have a better understanding of how important some of these issues are. … They form the background, as well as the foundation, for one’s career as a hospitalist.”

Also new this year is the added attention being paid to the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) learning session, which led all pre-courses in early registration. The class is in its second year but is more appealing this year because of the new Recognition of Focused Practice in Hospital Medicine via MOC. Working in conjunction with ABIM, the pre-course offers the opportunity for ABIM-certified physicians the chance to earn 20 points toward the Self-Evaluation of Medical Knowledge requirement of the MOC program. Two modules will be presented: Internal Medicine-Office Based and Internal Medicine-Hospital Based.

“There’s an updated module,” says Geri Barnes, SHM senior director of education and meetings. “(Attendees) should get really good information there.”

Also new this year is a series of interactive workshops SHM launched to provide topic-specific information from experts. Spread over three days, the 18 workshops include “Improving Care for the Hospitalized Elder,” “Ultrasound Imaging Skills for Invasive Beside Procedures,” and “Blood Management: Hospitalists in a New Role.”

The workshops, which are limited to 100 participants, are an attempt to engage a new class of HM devotees by recruiting a new class of speakers and leaders. “In previous years, we were not getting all our membership involved with the annual meeting,” Dr. Jaffer says. “We were really handpicking our speakers on experience, expertise, and how well they were known in their field and how good of speakers they were. This year, we really reached out.”

HM10 also features “special-interest forums” at 4:45 p.m. Friday, April 9. The informal sessions—on 18 topics ranging from “Information Technology” to “Women in HM”—afford hospitalists direct access to SHM board members, committee members, and staff. Barnes says the information gathered in last year’s sessions was discussed by SHM. For instance, the “Early Career Hospitalist” forum was the inspiration for one of the new pre-courses.

“We’re not real good at getting that message across, but I would say that those (forums) are extremely valuable,” Barnes says. “The same thing goes for the town hall (1 p.m. Sunday, April 11). That’s an opportunity to meet with the executive committee and board members, and ask them anything you want to.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTO MATT FENSTERMACHER

If a medical meeting of the minds is only as good as its CME options, then HM10 will be the best SHM annual meeting yet.

A pair of new pre-courses—“Essential Neurology for the Hospitalist” and “Early Career Hospitalist: Skills for Success”—will debut at HM10, which kicks off April 8 at the Gaylord National Resort & Convention Center in National Harbor, Md., outside of Washington, D.C. The new learning sessions boost to 20 the number of Category 1 credits physicians can earn toward the American Medical Association’s (AMA) Physician Recognition Award. Last year, hospitalists could earn a maximum of 15 credits.

While both of the new pre-courses drew heavy interest among early registrants, the latter was particularly intriguing, says Amir Jaffer, MD, FHM, chair of SHM’s annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine in Florida.

“It’s really going to allow our early-career hospitalists to acquire some of the skills they don’t necessarily acquire during residency, such as billing and coding and understanding of quality measures,” Dr. Jaffer boasts, “as well as how best to communicate with consultants, patients, and families. They’ll have a better understanding of how important some of these issues are. … They form the background, as well as the foundation, for one’s career as a hospitalist.”

Also new this year is the added attention being paid to the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) learning session, which led all pre-courses in early registration. The class is in its second year but is more appealing this year because of the new Recognition of Focused Practice in Hospital Medicine via MOC. Working in conjunction with ABIM, the pre-course offers the opportunity for ABIM-certified physicians the chance to earn 20 points toward the Self-Evaluation of Medical Knowledge requirement of the MOC program. Two modules will be presented: Internal Medicine-Office Based and Internal Medicine-Hospital Based.

“There’s an updated module,” says Geri Barnes, SHM senior director of education and meetings. “(Attendees) should get really good information there.”

Also new this year is a series of interactive workshops SHM launched to provide topic-specific information from experts. Spread over three days, the 18 workshops include “Improving Care for the Hospitalized Elder,” “Ultrasound Imaging Skills for Invasive Beside Procedures,” and “Blood Management: Hospitalists in a New Role.”

The workshops, which are limited to 100 participants, are an attempt to engage a new class of HM devotees by recruiting a new class of speakers and leaders. “In previous years, we were not getting all our membership involved with the annual meeting,” Dr. Jaffer says. “We were really handpicking our speakers on experience, expertise, and how well they were known in their field and how good of speakers they were. This year, we really reached out.”

HM10 also features “special-interest forums” at 4:45 p.m. Friday, April 9. The informal sessions—on 18 topics ranging from “Information Technology” to “Women in HM”—afford hospitalists direct access to SHM board members, committee members, and staff. Barnes says the information gathered in last year’s sessions was discussed by SHM. For instance, the “Early Career Hospitalist” forum was the inspiration for one of the new pre-courses.

“We’re not real good at getting that message across, but I would say that those (forums) are extremely valuable,” Barnes says. “The same thing goes for the town hall (1 p.m. Sunday, April 11). That’s an opportunity to meet with the executive committee and board members, and ask them anything you want to.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTO MATT FENSTERMACHER

If a medical meeting of the minds is only as good as its CME options, then HM10 will be the best SHM annual meeting yet.

A pair of new pre-courses—“Essential Neurology for the Hospitalist” and “Early Career Hospitalist: Skills for Success”—will debut at HM10, which kicks off April 8 at the Gaylord National Resort & Convention Center in National Harbor, Md., outside of Washington, D.C. The new learning sessions boost to 20 the number of Category 1 credits physicians can earn toward the American Medical Association’s (AMA) Physician Recognition Award. Last year, hospitalists could earn a maximum of 15 credits.

While both of the new pre-courses drew heavy interest among early registrants, the latter was particularly intriguing, says Amir Jaffer, MD, FHM, chair of SHM’s annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine in Florida.

“It’s really going to allow our early-career hospitalists to acquire some of the skills they don’t necessarily acquire during residency, such as billing and coding and understanding of quality measures,” Dr. Jaffer boasts, “as well as how best to communicate with consultants, patients, and families. They’ll have a better understanding of how important some of these issues are. … They form the background, as well as the foundation, for one’s career as a hospitalist.”

Also new this year is the added attention being paid to the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) learning session, which led all pre-courses in early registration. The class is in its second year but is more appealing this year because of the new Recognition of Focused Practice in Hospital Medicine via MOC. Working in conjunction with ABIM, the pre-course offers the opportunity for ABIM-certified physicians the chance to earn 20 points toward the Self-Evaluation of Medical Knowledge requirement of the MOC program. Two modules will be presented: Internal Medicine-Office Based and Internal Medicine-Hospital Based.

“There’s an updated module,” says Geri Barnes, SHM senior director of education and meetings. “(Attendees) should get really good information there.”

Also new this year is a series of interactive workshops SHM launched to provide topic-specific information from experts. Spread over three days, the 18 workshops include “Improving Care for the Hospitalized Elder,” “Ultrasound Imaging Skills for Invasive Beside Procedures,” and “Blood Management: Hospitalists in a New Role.”

The workshops, which are limited to 100 participants, are an attempt to engage a new class of HM devotees by recruiting a new class of speakers and leaders. “In previous years, we were not getting all our membership involved with the annual meeting,” Dr. Jaffer says. “We were really handpicking our speakers on experience, expertise, and how well they were known in their field and how good of speakers they were. This year, we really reached out.”

HM10 also features “special-interest forums” at 4:45 p.m. Friday, April 9. The informal sessions—on 18 topics ranging from “Information Technology” to “Women in HM”—afford hospitalists direct access to SHM board members, committee members, and staff. Barnes says the information gathered in last year’s sessions was discussed by SHM. For instance, the “Early Career Hospitalist” forum was the inspiration for one of the new pre-courses.

“We’re not real good at getting that message across, but I would say that those (forums) are extremely valuable,” Barnes says. “The same thing goes for the town hall (1 p.m. Sunday, April 11). That’s an opportunity to meet with the executive committee and board members, and ask them anything you want to.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTO MATT FENSTERMACHER

The National Association of Inpatient Physicians (NAIP)—now known as SHM—first held an annual meeting in the spring of 1998 in San Diego. Some 100 hospitalists attended the largest gathering of the nascent field. A little more than a decade later, 2,000-plus hospitalists crowded together in Chicago for HM09.

That exponential growth is tied to a host of factors, mostly the swelling ranks of hospitalists. But in terms of conventioneers, the year-over-year spikes in attendance mean that more and more first-timers are attending SHM’s annual gathering. In fact, SHM estimates that 30% of attendees are first-timers.

“Over the last five years, we’ve seen a significant increase in attendance over each year, with the culmination being that 2009 sold out,” says Geri Barnes, SHM senior director of education and meetings. “There are those who return year after year, and new members. It’s primarily new members.”

The growth in the annual meeting attendance confirms that HM is growing in numbers and influence. More and more physicians are making HM a career, and the annual meeting is the perfect place to learn more about the specialty and all it has to offer.

“Sometimes new physicians become hospitalists thinking that it might be a transition time for them. By going to these meetings, they can really cement in their minds the excitement and enthusiasm for being a hospital medicine physician,” says Brian Bossard, MD, FACP, FHM, founder of Inpatient Physicians Associations, a Lincoln, Neb.-based operator of three HM groups. “If they were thinking about transitioning out of HM into a fellowship, this might really encourage them to think twice about that.”

A four-day conference with more than 90 educational sessions can be intimidating to the first-time attendee. How does a rookie navigate all that “excitement and enthusiasm”? Which sessions does one attend? How does a young hospitalist get matched up with a mentor? What should a veteran hospitalist be learning that they can relay to their colleagues back home?

“First and foremost, they get to interact with colleagues from all over the country, as well as we now have hospitalists from other parts of the world actually coming to our annual meeting,” says Amir Jaffer, MD, FHM, chair of SHM’s annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine. “So one is the ability to interact and talk about the fast-changing field of hospital medicine. Two is that they get to learn about both clinical topics as well as other areas in HM that are more practical, either related to operations, quality improvement, patient safety, research.

“The third thing is that you get a chance to present your work, whether you’re a researcher, a QI guru, [or] you’re an educator. You get a chance to present your work in the form of a poster or an oral presentation. Fourth, you also get a chance to see a lot of the work that our colleagues from all across the country and the world are doing in HM to actually change it.”

The key to extracting all that information is preparation, according to those who have attended the meeting in the past. That includes checking out the pre-course schedule online, prioritizing meetings that relate to one’s day-to-day responsibilities, picking the educational tracks that appeal most, and taking advantage of the exhibit hall, which runs the length of the conference.

Femi Adewunmi, MD, MBA, FHM, has been to five SHM annual meetings, and has attended three pre-courses in that time. As medical director of the hospitalist service at Johnston Medical Center in Smithfield, N.C., he has found the learning sessions on practice management and billing and coding to be the most helpful. He recommends both to first-timers looking to accumulate real-world tips they can apply to their HM practices.

There is “a constant battle that we face trying to justify why you’re asking for more resources,” Dr. Adewunmi says. “To be able to do that convincingly, you need to be able to demonstrate your worth. … For people who have never gone to any of the pre-courses, any of them are a great tool. The amount of knowledge you come away with is pretty phenomenal. You’re given the little nuggets you need to do whatever you need to do.”

Dr. Bossard, a member of Team Hospitalist, estimates he’s been to 10 of the 13 annual meetings. He usually travels with colleagues and makes sure to coordinate educational tracks before the conference begins so that the group avoids redundancy by splitting up sessions.

“Divide and conquer,” Dr. Bossard adds. “We always bring it back to our group in smaller, bullet-type fashion. We all get a taste of sessions we weren’t able to attend.”

Barnes agrees that planning ahead is the key to success. “Do it based on what your primary role is,” she says. “Is your primary role research? Are you an academic hospitalist? Do you have an important role leading quality initiatives? Are you a group leader? At the end of the day, you can follow a track all the way down or you can jump across tracks—whatever is appealing.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTO MATT FENSTERMACHER

The National Association of Inpatient Physicians (NAIP)—now known as SHM—first held an annual meeting in the spring of 1998 in San Diego. Some 100 hospitalists attended the largest gathering of the nascent field. A little more than a decade later, 2,000-plus hospitalists crowded together in Chicago for HM09.

That exponential growth is tied to a host of factors, mostly the swelling ranks of hospitalists. But in terms of conventioneers, the year-over-year spikes in attendance mean that more and more first-timers are attending SHM’s annual gathering. In fact, SHM estimates that 30% of attendees are first-timers.

“Over the last five years, we’ve seen a significant increase in attendance over each year, with the culmination being that 2009 sold out,” says Geri Barnes, SHM senior director of education and meetings. “There are those who return year after year, and new members. It’s primarily new members.”

The growth in the annual meeting attendance confirms that HM is growing in numbers and influence. More and more physicians are making HM a career, and the annual meeting is the perfect place to learn more about the specialty and all it has to offer.

“Sometimes new physicians become hospitalists thinking that it might be a transition time for them. By going to these meetings, they can really cement in their minds the excitement and enthusiasm for being a hospital medicine physician,” says Brian Bossard, MD, FACP, FHM, founder of Inpatient Physicians Associations, a Lincoln, Neb.-based operator of three HM groups. “If they were thinking about transitioning out of HM into a fellowship, this might really encourage them to think twice about that.”

A four-day conference with more than 90 educational sessions can be intimidating to the first-time attendee. How does a rookie navigate all that “excitement and enthusiasm”? Which sessions does one attend? How does a young hospitalist get matched up with a mentor? What should a veteran hospitalist be learning that they can relay to their colleagues back home?

“First and foremost, they get to interact with colleagues from all over the country, as well as we now have hospitalists from other parts of the world actually coming to our annual meeting,” says Amir Jaffer, MD, FHM, chair of SHM’s annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine. “So one is the ability to interact and talk about the fast-changing field of hospital medicine. Two is that they get to learn about both clinical topics as well as other areas in HM that are more practical, either related to operations, quality improvement, patient safety, research.

“The third thing is that you get a chance to present your work, whether you’re a researcher, a QI guru, [or] you’re an educator. You get a chance to present your work in the form of a poster or an oral presentation. Fourth, you also get a chance to see a lot of the work that our colleagues from all across the country and the world are doing in HM to actually change it.”

The key to extracting all that information is preparation, according to those who have attended the meeting in the past. That includes checking out the pre-course schedule online, prioritizing meetings that relate to one’s day-to-day responsibilities, picking the educational tracks that appeal most, and taking advantage of the exhibit hall, which runs the length of the conference.

Femi Adewunmi, MD, MBA, FHM, has been to five SHM annual meetings, and has attended three pre-courses in that time. As medical director of the hospitalist service at Johnston Medical Center in Smithfield, N.C., he has found the learning sessions on practice management and billing and coding to be the most helpful. He recommends both to first-timers looking to accumulate real-world tips they can apply to their HM practices.

There is “a constant battle that we face trying to justify why you’re asking for more resources,” Dr. Adewunmi says. “To be able to do that convincingly, you need to be able to demonstrate your worth. … For people who have never gone to any of the pre-courses, any of them are a great tool. The amount of knowledge you come away with is pretty phenomenal. You’re given the little nuggets you need to do whatever you need to do.”

Dr. Bossard, a member of Team Hospitalist, estimates he’s been to 10 of the 13 annual meetings. He usually travels with colleagues and makes sure to coordinate educational tracks before the conference begins so that the group avoids redundancy by splitting up sessions.

“Divide and conquer,” Dr. Bossard adds. “We always bring it back to our group in smaller, bullet-type fashion. We all get a taste of sessions we weren’t able to attend.”

Barnes agrees that planning ahead is the key to success. “Do it based on what your primary role is,” she says. “Is your primary role research? Are you an academic hospitalist? Do you have an important role leading quality initiatives? Are you a group leader? At the end of the day, you can follow a track all the way down or you can jump across tracks—whatever is appealing.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTO MATT FENSTERMACHER

The National Association of Inpatient Physicians (NAIP)—now known as SHM—first held an annual meeting in the spring of 1998 in San Diego. Some 100 hospitalists attended the largest gathering of the nascent field. A little more than a decade later, 2,000-plus hospitalists crowded together in Chicago for HM09.

That exponential growth is tied to a host of factors, mostly the swelling ranks of hospitalists. But in terms of conventioneers, the year-over-year spikes in attendance mean that more and more first-timers are attending SHM’s annual gathering. In fact, SHM estimates that 30% of attendees are first-timers.

“Over the last five years, we’ve seen a significant increase in attendance over each year, with the culmination being that 2009 sold out,” says Geri Barnes, SHM senior director of education and meetings. “There are those who return year after year, and new members. It’s primarily new members.”

The growth in the annual meeting attendance confirms that HM is growing in numbers and influence. More and more physicians are making HM a career, and the annual meeting is the perfect place to learn more about the specialty and all it has to offer.

“Sometimes new physicians become hospitalists thinking that it might be a transition time for them. By going to these meetings, they can really cement in their minds the excitement and enthusiasm for being a hospital medicine physician,” says Brian Bossard, MD, FACP, FHM, founder of Inpatient Physicians Associations, a Lincoln, Neb.-based operator of three HM groups. “If they were thinking about transitioning out of HM into a fellowship, this might really encourage them to think twice about that.”

A four-day conference with more than 90 educational sessions can be intimidating to the first-time attendee. How does a rookie navigate all that “excitement and enthusiasm”? Which sessions does one attend? How does a young hospitalist get matched up with a mentor? What should a veteran hospitalist be learning that they can relay to their colleagues back home?

“First and foremost, they get to interact with colleagues from all over the country, as well as we now have hospitalists from other parts of the world actually coming to our annual meeting,” says Amir Jaffer, MD, FHM, chair of SHM’s annual meeting committee, associate professor, and division chief of hospital medicine at the University of Miami Miller School of Medicine. “So one is the ability to interact and talk about the fast-changing field of hospital medicine. Two is that they get to learn about both clinical topics as well as other areas in HM that are more practical, either related to operations, quality improvement, patient safety, research.

“The third thing is that you get a chance to present your work, whether you’re a researcher, a QI guru, [or] you’re an educator. You get a chance to present your work in the form of a poster or an oral presentation. Fourth, you also get a chance to see a lot of the work that our colleagues from all across the country and the world are doing in HM to actually change it.”

The key to extracting all that information is preparation, according to those who have attended the meeting in the past. That includes checking out the pre-course schedule online, prioritizing meetings that relate to one’s day-to-day responsibilities, picking the educational tracks that appeal most, and taking advantage of the exhibit hall, which runs the length of the conference.

Femi Adewunmi, MD, MBA, FHM, has been to five SHM annual meetings, and has attended three pre-courses in that time. As medical director of the hospitalist service at Johnston Medical Center in Smithfield, N.C., he has found the learning sessions on practice management and billing and coding to be the most helpful. He recommends both to first-timers looking to accumulate real-world tips they can apply to their HM practices.

There is “a constant battle that we face trying to justify why you’re asking for more resources,” Dr. Adewunmi says. “To be able to do that convincingly, you need to be able to demonstrate your worth. … For people who have never gone to any of the pre-courses, any of them are a great tool. The amount of knowledge you come away with is pretty phenomenal. You’re given the little nuggets you need to do whatever you need to do.”

Dr. Bossard, a member of Team Hospitalist, estimates he’s been to 10 of the 13 annual meetings. He usually travels with colleagues and makes sure to coordinate educational tracks before the conference begins so that the group avoids redundancy by splitting up sessions.

“Divide and conquer,” Dr. Bossard adds. “We always bring it back to our group in smaller, bullet-type fashion. We all get a taste of sessions we weren’t able to attend.”

Barnes agrees that planning ahead is the key to success. “Do it based on what your primary role is,” she says. “Is your primary role research? Are you an academic hospitalist? Do you have an important role leading quality initiatives? Are you a group leader? At the end of the day, you can follow a track all the way down or you can jump across tracks—whatever is appealing.”

Richard Quinn is a freelance writer based in New Jersey.

PHOTO MATT FENSTERMACHER