At a hospital at which I work, every patient who presents to the emergency department with a suspected stroke or transient ischemic attack is evaluated by the stroke team. Per protocol, the team rapidly assesses each patient, orders diagnostic and therapeutic interventions and then refers each and every patient to the hospitalist service for admission and medical comanagement. At no point is any consideration given to whether the patients actually have medical comorbidities, or if a hospitalist will have anything meaningful to add to the care. The firmly set expectation is that hospitalists admit all stroke patients for the purposes of comanagement, while the neurologists consult.

Comanagement has become a mainstay of hospital medicine.1 It is predicated upon the assumption that surgical and specialty patients benefit when their medical comorbidities are managed by hospitalists. It differs conceptually from traditional medical consultation in that hospitalists collaboratively manage patients with surgeons or specialists, sharing responsibility and authority. In practice, however, comanagement varies widely, ranging from a model of care indistinguishable from traditional medical consultation to one where hospitalists admit and assume primary responsibility for surgical and specialty patients. This variability makes it difficult to study and make generalizations about the role and impact of hospitalist comanagement. Nonetheless, recent evidence suggests that hospitalist consultation and comanagement may not be as effective as originally anticipated.

In a 2008 observational cohort study of patients undergoing surgery at an academic medical center, Auerbach et al demonstrated that medical consultation (provided by hospitalists) did not improve glycemic control or increase the likelihood of perioperative beta‐blockade and venous thromboembolism prophylaxis.2 Patients who received consultation had longer adjusted lengths of stay (12.98% longer; 95% confidence interval, 1.61%‐25.61%) and higher adjusted costs (24.36% higher; 95% confidence interval, 13.54%‐36.34%). Notwithstanding the limited generalizability of this study to community hospitals, it has raised concerns that hospitalist consultation does not automatically improve quality of care or cost effectiveness.3

Several other recent trials have also helped to define where hospitalist comanagement may work well and where it may not. In 2004, Huddleston et al published the Hospitalist Orthopedic Team (HOT) trial, the first randomized prospective trial comparing hospitalist‐surgical comanagement to standard care.4 A total of 526 patients undergoing elective hip or knee replacement surgery at the Mayo Clinic were randomized to either standard orthopedic care with consultation as needed, or immediate hospitalist comanagement. The outcomes were disappointing. Hospitalist comanagement reduced minor complications (such as incidence of urinary tract infections, fever, and hyponatremia) but had no effect on moderate or major complications. The HOT intervention modestly reduced adjusted length of stay (LOS), defined as the point at which patients were deemed stable for discharge, by 0.5 days, but had no impact on actual LOS or cost per case. Not surprisingly, orthopedic surgeons and nurses preferred the HOT model of care over the standard model. One year later, Phy et al analyzed outcomes for patients admitted with hip fracture at the same institution.5 This retrospective cohort study compared patients who were admitted to either a standard orthopedic service or to a hospitalist team. In contrast to the HOT trial, hospitalist comanagement of hip fracture patients decreased time to surgery and lowered LOS by 2.2 days without compromising patient outcomes.

How did two trials that occurred roughly simultaneously at the same hospital, involving the same hospitalists and orthopedic surgeons generate such different outcomes? A likely answer is patient selection. Patients who undergo elective joint replacement are usually relatively healthy. They are almost always ambulatory and their comorbidities, when present, are generally reasonably compensated. As a rule, they fare well postoperatively, as evidenced by the 1.3% major complication rate demonstrated in the HOT trial.3 In contrast, hip fracture patients are older, have greater comorbidity and are at remarkably high risk for developing perioperative delirium.3, 4, 6 By definition, their urgent/emergent hip surgery stratifies them to a higher operative risk category than patients who undergo elective joint replacement.7 Half of hip fracture patients do not return to premorbid levels of function, and the 1‐year mortality rate has been estimated to be as high as 25%.6, 8 Given these differences, it is not surprising that hip fracture patients are more likely than elective joint replacement patients to respond favorably to hospitalist comanagement.

In 2007, Simon et al published a retrospective study of 739 pediatric spinal fusion patients at Childrens' Hospital in Denver.9 Beginning in 2004, hospitalists comanaged selected, high‐risk surgical patients (14 of 115 spinal fusion patients, or 12%). Over the course of the study, the mean LOS for low‐risk patients decreased by 21% but the mean LOS for the high‐risk, hospitalist‐comanaged patients decreased by 28%; a 33% relative reduction favoring hospitalist‐managed patients. By targeting selected high‐risk patients, pediatric hospitalists were able to improve upon LOS reductions that occurred systemically across the entire spinal fusion program. Also in 2007, Southern et al compared outcomes for 2,913 patients admitted by full‐time teaching hospitalists vs 6,124 patients admitted by nonhospitalists at Montefiore Medical Center, Bronx, New York.10 Mean LOS for patients admitted to the hospitalist service was 5.01 days vs 5.87 days for the nonhospitalists. Subgroup analysis demonstrated the greatest LOS differentials for patients requiring close clinical monitoring (heart failure, stroke, asthma, or pneumonia) or complex discharge planning.

Although these studies, performed at large academic medical centers, may have limited generalizability, they support the common‐sense notion that hospitalists most benefit patients who are sick, frail, and medically or socially complex. As a corollary, hospitalists probably offer relatively little benefit to surgical and specialty patients who are young or have compensated medical comorbidities and/or straightforward disposition plans. The enormous variability across healthcare institutions makes it difficult if not impossible to define a patient acuity or complexity cutoff below which hospitalist comanagement is unlikely to be beneficial. Nonetheless, some degree of common sense can be applied. As a case in point, a hospitalist probably adds little value to the care of a basically healthy patient with a hemodynamically stable upper gastrointestinal bleed. Despite this, in many institutions, hospitalists admit or comanage all gastroenterology patients, irrespective of their diagnosis, acuity, or complexity.11

One can even hypothesize that hospitalist comanagement may potentially inject risk into patient care. Admitting that patient with a stable upper gastrointestinal bleed to a hospitalist service may delay the gastroenterologist's involvement and initiation of the necessary endoscopy. Having assumed that the hospitalist is running the show, the gastroenterologist may pay insufficient attention to the patient. The hospitalist and gastroenterologist may give conflicting orders and reports that confuse patients, families, and hospital staff, ultimately increasing the likelihood of medical errors.

Ultimately, the risks inherent in adding complexity into patient care must be balanced against the potential benefits. For patients who are sick, frail, or complicated, the risk‐benefit ratio probably tilts in favor of comanagement. However, for generally healthy patients, it is conceivable that adding complexity negates (or worse yet, exceeds) the putative benefits of comanagement.

Given the potential limitations of hospitalist comanagement, why are hospitalists admitting or managing broad and unselected populations of surgical and specialty patients? Hospital leaders have suggested that hospitalist comanagement may protect overstretched surgeons and specialists and extend their capacity. A hospital with only one neurosurgeon on staff might reasonably ask its hospitalists to primarily manage carefully selected low‐acuity neurosurgical patients, allowing the neurosurgeon to serve as a consultant. However, in communities where specialists and surgeons are abundant, this justification is less credible. In such cases, it is difficult not to suspect that the primary reason that hospitalists admit surgical and specialty patients is to enhance the income and quality of life of the surgeons and specialists.

Expanding hospitalist comanagement services for no other reason than to keep specialists and surgeons happy might be justifiable if hospital medicine was not faced with its own critical manpower shortage. Hospital medicine is expected to grow from approximately 20,000 current practitioners to more than 40,000 within a decade.12 The growing shortage of qualified hospitalists has become a preoccupation for hospitalist employers across the country.13 At its 2006 strategic planning retreat, the Board of Directors of the Society of Hospital Medicine identified this issue as one of the greatest threats to the future health of hospital medicine.14 Demand for hospitalists will not abate for at least a decade, which will leave many hospitalist programs significantly understaffed for the foreseeable future. Understaffing forces hospitalist programs to lower hiring standards, jeopardizes patient care, accelerates physician burnout, and may ultimately destabilize hospital medicine.15 Understaffed hospitalist programs should be very circumspect about how and where they expand their clinical coverage.

Another principle underlying hospitalist comanagement is that it improves care by allowing surgeons and specialists to focus on their areas of expertise. Surgeons and specialists who do not have to manage their patients' medical issues can presumably spend more time focusing on their own disciplines. Although this argument is conceptually appealing, there is no evidence that this actually occurs. In fact, it is equally conceivable that hospitalist comanagement could jeopardize care by disengaging surgeons and specialists from their patients' progress (or lack thereof). Furthermore, evidence suggests that hospitalists are underprepared to manage diagnoses that have historically been the purview of surgeons and specialists. Practicing hospitalists who manage acute neurological and neurosurgical conditions, orthopedic trauma, and acute psychiatric illnesses have reported relative undertraining in all of these disease states.10, 16 Generally, hospitalists are expected to deliver this care in the absence of any regime to assess their competence, provide targeted training to fill knowledge gaps, and monitor their progress. At minimum, this should raise concerns about the quality and consistency of care that hospitalists provide to nonmedical patients.

Finally, working collaboratively with other specialties should be a major professional benefit of comanagement. In well‐designed comanagement arrangements, hospitalists and specialists work equitably under clearly defined and mutually agreed upon rules of engagement. They share responsibility for patients, collaborate to improve care, and teach and learn from each other. Unfortunately, in many instances, the power structure becomes lopsided, with surgeons and specialists dictating how, when, and why hospitalists manage their patients.17 Emergency departments have learned to default surgical and specialty patient admissions to hospitalists when surgeons and specialists balk. Hospital administrations may tacitly or overtly expect their financially subsidized hospitalists to cheerfully accept any and all referrals, irrespective of how inappropriate they may be. Practicing hospitalists frequently complain about their subordinate status and inability to control their working conditions, both of which are identified risk factors for career dissatisfaction and burnout.14, 16, 18 Once again, as a specialty facing a critical manpower shortage, hospitalist programs should be very attuned to defining work conditions that foster career satisfaction and physician retention.

REFRAMING COMANAGEMENT

The history of healthcare is laden with examples of new ideas that were widely and indiscriminately adopted only to subsequently fail to withstand rigorous scrutiny.19, 20 The unchecked expansion of hospitalist comanagement has the potential to become another case in point. In the absence of clear definitions of comanagement and good evidence to define best practices, hospitalists are left to use their best judgment to define the parameters of their comanagement services. At minimum, hospitalist leaders should ask some basic questions as they ponder potential comanagement relationships:

• Why are we being asked to provide this service?

• Do the patients have comorbidities that require our input?

• Is there a legitimate quality or efficiency case to be made to support our participation?

• Do we have the manpower to provide the service? If not, what will suffer as a result?

• Will the relationship be equitable?

• What might go wrong?

Comanagement is an appealing construct that has grown to fill many niches of healthcare delivery.10 Given compelling reasons to be skeptical about the purported benefits of comanagement, hospitalists should be circumspect about how and where they offer such services. Comanagement should be applied carefully and methodically, paying close attention to the consequences, intended and unintended. Applying comanagement in a rational, evidence‐based, and sustainable fashion will ultimately better serve patients, the healthcare community, and hospital medicine.

At a hospital at which I work, every patient who presents to the emergency department with a suspected stroke or transient ischemic attack is evaluated by the stroke team. Per protocol, the team rapidly assesses each patient, orders diagnostic and therapeutic interventions and then refers each and every patient to the hospitalist service for admission and medical comanagement. At no point is any consideration given to whether the patients actually have medical comorbidities, or if a hospitalist will have anything meaningful to add to the care. The firmly set expectation is that hospitalists admit all stroke patients for the purposes of comanagement, while the neurologists consult.

Comanagement has become a mainstay of hospital medicine.1 It is predicated upon the assumption that surgical and specialty patients benefit when their medical comorbidities are managed by hospitalists. It differs conceptually from traditional medical consultation in that hospitalists collaboratively manage patients with surgeons or specialists, sharing responsibility and authority. In practice, however, comanagement varies widely, ranging from a model of care indistinguishable from traditional medical consultation to one where hospitalists admit and assume primary responsibility for surgical and specialty patients. This variability makes it difficult to study and make generalizations about the role and impact of hospitalist comanagement. Nonetheless, recent evidence suggests that hospitalist consultation and comanagement may not be as effective as originally anticipated.

In a 2008 observational cohort study of patients undergoing surgery at an academic medical center, Auerbach et al demonstrated that medical consultation (provided by hospitalists) did not improve glycemic control or increase the likelihood of perioperative beta‐blockade and venous thromboembolism prophylaxis.2 Patients who received consultation had longer adjusted lengths of stay (12.98% longer; 95% confidence interval, 1.61%‐25.61%) and higher adjusted costs (24.36% higher; 95% confidence interval, 13.54%‐36.34%). Notwithstanding the limited generalizability of this study to community hospitals, it has raised concerns that hospitalist consultation does not automatically improve quality of care or cost effectiveness.3

Several other recent trials have also helped to define where hospitalist comanagement may work well and where it may not. In 2004, Huddleston et al published the Hospitalist Orthopedic Team (HOT) trial, the first randomized prospective trial comparing hospitalist‐surgical comanagement to standard care.4 A total of 526 patients undergoing elective hip or knee replacement surgery at the Mayo Clinic were randomized to either standard orthopedic care with consultation as needed, or immediate hospitalist comanagement. The outcomes were disappointing. Hospitalist comanagement reduced minor complications (such as incidence of urinary tract infections, fever, and hyponatremia) but had no effect on moderate or major complications. The HOT intervention modestly reduced adjusted length of stay (LOS), defined as the point at which patients were deemed stable for discharge, by 0.5 days, but had no impact on actual LOS or cost per case. Not surprisingly, orthopedic surgeons and nurses preferred the HOT model of care over the standard model. One year later, Phy et al analyzed outcomes for patients admitted with hip fracture at the same institution.5 This retrospective cohort study compared patients who were admitted to either a standard orthopedic service or to a hospitalist team. In contrast to the HOT trial, hospitalist comanagement of hip fracture patients decreased time to surgery and lowered LOS by 2.2 days without compromising patient outcomes.

How did two trials that occurred roughly simultaneously at the same hospital, involving the same hospitalists and orthopedic surgeons generate such different outcomes? A likely answer is patient selection. Patients who undergo elective joint replacement are usually relatively healthy. They are almost always ambulatory and their comorbidities, when present, are generally reasonably compensated. As a rule, they fare well postoperatively, as evidenced by the 1.3% major complication rate demonstrated in the HOT trial.3 In contrast, hip fracture patients are older, have greater comorbidity and are at remarkably high risk for developing perioperative delirium.3, 4, 6 By definition, their urgent/emergent hip surgery stratifies them to a higher operative risk category than patients who undergo elective joint replacement.7 Half of hip fracture patients do not return to premorbid levels of function, and the 1‐year mortality rate has been estimated to be as high as 25%.6, 8 Given these differences, it is not surprising that hip fracture patients are more likely than elective joint replacement patients to respond favorably to hospitalist comanagement.

In 2007, Simon et al published a retrospective study of 739 pediatric spinal fusion patients at Childrens' Hospital in Denver.9 Beginning in 2004, hospitalists comanaged selected, high‐risk surgical patients (14 of 115 spinal fusion patients, or 12%). Over the course of the study, the mean LOS for low‐risk patients decreased by 21% but the mean LOS for the high‐risk, hospitalist‐comanaged patients decreased by 28%; a 33% relative reduction favoring hospitalist‐managed patients. By targeting selected high‐risk patients, pediatric hospitalists were able to improve upon LOS reductions that occurred systemically across the entire spinal fusion program. Also in 2007, Southern et al compared outcomes for 2,913 patients admitted by full‐time teaching hospitalists vs 6,124 patients admitted by nonhospitalists at Montefiore Medical Center, Bronx, New York.10 Mean LOS for patients admitted to the hospitalist service was 5.01 days vs 5.87 days for the nonhospitalists. Subgroup analysis demonstrated the greatest LOS differentials for patients requiring close clinical monitoring (heart failure, stroke, asthma, or pneumonia) or complex discharge planning.

Although these studies, performed at large academic medical centers, may have limited generalizability, they support the common‐sense notion that hospitalists most benefit patients who are sick, frail, and medically or socially complex. As a corollary, hospitalists probably offer relatively little benefit to surgical and specialty patients who are young or have compensated medical comorbidities and/or straightforward disposition plans. The enormous variability across healthcare institutions makes it difficult if not impossible to define a patient acuity or complexity cutoff below which hospitalist comanagement is unlikely to be beneficial. Nonetheless, some degree of common sense can be applied. As a case in point, a hospitalist probably adds little value to the care of a basically healthy patient with a hemodynamically stable upper gastrointestinal bleed. Despite this, in many institutions, hospitalists admit or comanage all gastroenterology patients, irrespective of their diagnosis, acuity, or complexity.11

One can even hypothesize that hospitalist comanagement may potentially inject risk into patient care. Admitting that patient with a stable upper gastrointestinal bleed to a hospitalist service may delay the gastroenterologist's involvement and initiation of the necessary endoscopy. Having assumed that the hospitalist is running the show, the gastroenterologist may pay insufficient attention to the patient. The hospitalist and gastroenterologist may give conflicting orders and reports that confuse patients, families, and hospital staff, ultimately increasing the likelihood of medical errors.

Ultimately, the risks inherent in adding complexity into patient care must be balanced against the potential benefits. For patients who are sick, frail, or complicated, the risk‐benefit ratio probably tilts in favor of comanagement. However, for generally healthy patients, it is conceivable that adding complexity negates (or worse yet, exceeds) the putative benefits of comanagement.

Given the potential limitations of hospitalist comanagement, why are hospitalists admitting or managing broad and unselected populations of surgical and specialty patients? Hospital leaders have suggested that hospitalist comanagement may protect overstretched surgeons and specialists and extend their capacity. A hospital with only one neurosurgeon on staff might reasonably ask its hospitalists to primarily manage carefully selected low‐acuity neurosurgical patients, allowing the neurosurgeon to serve as a consultant. However, in communities where specialists and surgeons are abundant, this justification is less credible. In such cases, it is difficult not to suspect that the primary reason that hospitalists admit surgical and specialty patients is to enhance the income and quality of life of the surgeons and specialists.

Expanding hospitalist comanagement services for no other reason than to keep specialists and surgeons happy might be justifiable if hospital medicine was not faced with its own critical manpower shortage. Hospital medicine is expected to grow from approximately 20,000 current practitioners to more than 40,000 within a decade.12 The growing shortage of qualified hospitalists has become a preoccupation for hospitalist employers across the country.13 At its 2006 strategic planning retreat, the Board of Directors of the Society of Hospital Medicine identified this issue as one of the greatest threats to the future health of hospital medicine.14 Demand for hospitalists will not abate for at least a decade, which will leave many hospitalist programs significantly understaffed for the foreseeable future. Understaffing forces hospitalist programs to lower hiring standards, jeopardizes patient care, accelerates physician burnout, and may ultimately destabilize hospital medicine.15 Understaffed hospitalist programs should be very circumspect about how and where they expand their clinical coverage.

Another principle underlying hospitalist comanagement is that it improves care by allowing surgeons and specialists to focus on their areas of expertise. Surgeons and specialists who do not have to manage their patients' medical issues can presumably spend more time focusing on their own disciplines. Although this argument is conceptually appealing, there is no evidence that this actually occurs. In fact, it is equally conceivable that hospitalist comanagement could jeopardize care by disengaging surgeons and specialists from their patients' progress (or lack thereof). Furthermore, evidence suggests that hospitalists are underprepared to manage diagnoses that have historically been the purview of surgeons and specialists. Practicing hospitalists who manage acute neurological and neurosurgical conditions, orthopedic trauma, and acute psychiatric illnesses have reported relative undertraining in all of these disease states.10, 16 Generally, hospitalists are expected to deliver this care in the absence of any regime to assess their competence, provide targeted training to fill knowledge gaps, and monitor their progress. At minimum, this should raise concerns about the quality and consistency of care that hospitalists provide to nonmedical patients.

Finally, working collaboratively with other specialties should be a major professional benefit of comanagement. In well‐designed comanagement arrangements, hospitalists and specialists work equitably under clearly defined and mutually agreed upon rules of engagement. They share responsibility for patients, collaborate to improve care, and teach and learn from each other. Unfortunately, in many instances, the power structure becomes lopsided, with surgeons and specialists dictating how, when, and why hospitalists manage their patients.17 Emergency departments have learned to default surgical and specialty patient admissions to hospitalists when surgeons and specialists balk. Hospital administrations may tacitly or overtly expect their financially subsidized hospitalists to cheerfully accept any and all referrals, irrespective of how inappropriate they may be. Practicing hospitalists frequently complain about their subordinate status and inability to control their working conditions, both of which are identified risk factors for career dissatisfaction and burnout.14, 16, 18 Once again, as a specialty facing a critical manpower shortage, hospitalist programs should be very attuned to defining work conditions that foster career satisfaction and physician retention.

REFRAMING COMANAGEMENT

The history of healthcare is laden with examples of new ideas that were widely and indiscriminately adopted only to subsequently fail to withstand rigorous scrutiny.19, 20 The unchecked expansion of hospitalist comanagement has the potential to become another case in point. In the absence of clear definitions of comanagement and good evidence to define best practices, hospitalists are left to use their best judgment to define the parameters of their comanagement services. At minimum, hospitalist leaders should ask some basic questions as they ponder potential comanagement relationships:

• Why are we being asked to provide this service?

• Do the patients have comorbidities that require our input?

• Is there a legitimate quality or efficiency case to be made to support our participation?

• Do we have the manpower to provide the service? If not, what will suffer as a result?

• Will the relationship be equitable?

• What might go wrong?

Comanagement is an appealing construct that has grown to fill many niches of healthcare delivery.10 Given compelling reasons to be skeptical about the purported benefits of comanagement, hospitalists should be circumspect about how and where they offer such services. Comanagement should be applied carefully and methodically, paying close attention to the consequences, intended and unintended. Applying comanagement in a rational, evidence‐based, and sustainable fashion will ultimately better serve patients, the healthcare community, and hospital medicine.

At a hospital at which I work, every patient who presents to the emergency department with a suspected stroke or transient ischemic attack is evaluated by the stroke team. Per protocol, the team rapidly assesses each patient, orders diagnostic and therapeutic interventions and then refers each and every patient to the hospitalist service for admission and medical comanagement. At no point is any consideration given to whether the patients actually have medical comorbidities, or if a hospitalist will have anything meaningful to add to the care. The firmly set expectation is that hospitalists admit all stroke patients for the purposes of comanagement, while the neurologists consult.

Comanagement has become a mainstay of hospital medicine.1 It is predicated upon the assumption that surgical and specialty patients benefit when their medical comorbidities are managed by hospitalists. It differs conceptually from traditional medical consultation in that hospitalists collaboratively manage patients with surgeons or specialists, sharing responsibility and authority. In practice, however, comanagement varies widely, ranging from a model of care indistinguishable from traditional medical consultation to one where hospitalists admit and assume primary responsibility for surgical and specialty patients. This variability makes it difficult to study and make generalizations about the role and impact of hospitalist comanagement. Nonetheless, recent evidence suggests that hospitalist consultation and comanagement may not be as effective as originally anticipated.

In a 2008 observational cohort study of patients undergoing surgery at an academic medical center, Auerbach et al demonstrated that medical consultation (provided by hospitalists) did not improve glycemic control or increase the likelihood of perioperative beta‐blockade and venous thromboembolism prophylaxis.2 Patients who received consultation had longer adjusted lengths of stay (12.98% longer; 95% confidence interval, 1.61%‐25.61%) and higher adjusted costs (24.36% higher; 95% confidence interval, 13.54%‐36.34%). Notwithstanding the limited generalizability of this study to community hospitals, it has raised concerns that hospitalist consultation does not automatically improve quality of care or cost effectiveness.3

Several other recent trials have also helped to define where hospitalist comanagement may work well and where it may not. In 2004, Huddleston et al published the Hospitalist Orthopedic Team (HOT) trial, the first randomized prospective trial comparing hospitalist‐surgical comanagement to standard care.4 A total of 526 patients undergoing elective hip or knee replacement surgery at the Mayo Clinic were randomized to either standard orthopedic care with consultation as needed, or immediate hospitalist comanagement. The outcomes were disappointing. Hospitalist comanagement reduced minor complications (such as incidence of urinary tract infections, fever, and hyponatremia) but had no effect on moderate or major complications. The HOT intervention modestly reduced adjusted length of stay (LOS), defined as the point at which patients were deemed stable for discharge, by 0.5 days, but had no impact on actual LOS or cost per case. Not surprisingly, orthopedic surgeons and nurses preferred the HOT model of care over the standard model. One year later, Phy et al analyzed outcomes for patients admitted with hip fracture at the same institution.5 This retrospective cohort study compared patients who were admitted to either a standard orthopedic service or to a hospitalist team. In contrast to the HOT trial, hospitalist comanagement of hip fracture patients decreased time to surgery and lowered LOS by 2.2 days without compromising patient outcomes.

How did two trials that occurred roughly simultaneously at the same hospital, involving the same hospitalists and orthopedic surgeons generate such different outcomes? A likely answer is patient selection. Patients who undergo elective joint replacement are usually relatively healthy. They are almost always ambulatory and their comorbidities, when present, are generally reasonably compensated. As a rule, they fare well postoperatively, as evidenced by the 1.3% major complication rate demonstrated in the HOT trial.3 In contrast, hip fracture patients are older, have greater comorbidity and are at remarkably high risk for developing perioperative delirium.3, 4, 6 By definition, their urgent/emergent hip surgery stratifies them to a higher operative risk category than patients who undergo elective joint replacement.7 Half of hip fracture patients do not return to premorbid levels of function, and the 1‐year mortality rate has been estimated to be as high as 25%.6, 8 Given these differences, it is not surprising that hip fracture patients are more likely than elective joint replacement patients to respond favorably to hospitalist comanagement.

In 2007, Simon et al published a retrospective study of 739 pediatric spinal fusion patients at Childrens' Hospital in Denver.9 Beginning in 2004, hospitalists comanaged selected, high‐risk surgical patients (14 of 115 spinal fusion patients, or 12%). Over the course of the study, the mean LOS for low‐risk patients decreased by 21% but the mean LOS for the high‐risk, hospitalist‐comanaged patients decreased by 28%; a 33% relative reduction favoring hospitalist‐managed patients. By targeting selected high‐risk patients, pediatric hospitalists were able to improve upon LOS reductions that occurred systemically across the entire spinal fusion program. Also in 2007, Southern et al compared outcomes for 2,913 patients admitted by full‐time teaching hospitalists vs 6,124 patients admitted by nonhospitalists at Montefiore Medical Center, Bronx, New York.10 Mean LOS for patients admitted to the hospitalist service was 5.01 days vs 5.87 days for the nonhospitalists. Subgroup analysis demonstrated the greatest LOS differentials for patients requiring close clinical monitoring (heart failure, stroke, asthma, or pneumonia) or complex discharge planning.

Although these studies, performed at large academic medical centers, may have limited generalizability, they support the common‐sense notion that hospitalists most benefit patients who are sick, frail, and medically or socially complex. As a corollary, hospitalists probably offer relatively little benefit to surgical and specialty patients who are young or have compensated medical comorbidities and/or straightforward disposition plans. The enormous variability across healthcare institutions makes it difficult if not impossible to define a patient acuity or complexity cutoff below which hospitalist comanagement is unlikely to be beneficial. Nonetheless, some degree of common sense can be applied. As a case in point, a hospitalist probably adds little value to the care of a basically healthy patient with a hemodynamically stable upper gastrointestinal bleed. Despite this, in many institutions, hospitalists admit or comanage all gastroenterology patients, irrespective of their diagnosis, acuity, or complexity.11

One can even hypothesize that hospitalist comanagement may potentially inject risk into patient care. Admitting that patient with a stable upper gastrointestinal bleed to a hospitalist service may delay the gastroenterologist's involvement and initiation of the necessary endoscopy. Having assumed that the hospitalist is running the show, the gastroenterologist may pay insufficient attention to the patient. The hospitalist and gastroenterologist may give conflicting orders and reports that confuse patients, families, and hospital staff, ultimately increasing the likelihood of medical errors.

Ultimately, the risks inherent in adding complexity into patient care must be balanced against the potential benefits. For patients who are sick, frail, or complicated, the risk‐benefit ratio probably tilts in favor of comanagement. However, for generally healthy patients, it is conceivable that adding complexity negates (or worse yet, exceeds) the putative benefits of comanagement.

Given the potential limitations of hospitalist comanagement, why are hospitalists admitting or managing broad and unselected populations of surgical and specialty patients? Hospital leaders have suggested that hospitalist comanagement may protect overstretched surgeons and specialists and extend their capacity. A hospital with only one neurosurgeon on staff might reasonably ask its hospitalists to primarily manage carefully selected low‐acuity neurosurgical patients, allowing the neurosurgeon to serve as a consultant. However, in communities where specialists and surgeons are abundant, this justification is less credible. In such cases, it is difficult not to suspect that the primary reason that hospitalists admit surgical and specialty patients is to enhance the income and quality of life of the surgeons and specialists.

Expanding hospitalist comanagement services for no other reason than to keep specialists and surgeons happy might be justifiable if hospital medicine was not faced with its own critical manpower shortage. Hospital medicine is expected to grow from approximately 20,000 current practitioners to more than 40,000 within a decade.12 The growing shortage of qualified hospitalists has become a preoccupation for hospitalist employers across the country.13 At its 2006 strategic planning retreat, the Board of Directors of the Society of Hospital Medicine identified this issue as one of the greatest threats to the future health of hospital medicine.14 Demand for hospitalists will not abate for at least a decade, which will leave many hospitalist programs significantly understaffed for the foreseeable future. Understaffing forces hospitalist programs to lower hiring standards, jeopardizes patient care, accelerates physician burnout, and may ultimately destabilize hospital medicine.15 Understaffed hospitalist programs should be very circumspect about how and where they expand their clinical coverage.

Another principle underlying hospitalist comanagement is that it improves care by allowing surgeons and specialists to focus on their areas of expertise. Surgeons and specialists who do not have to manage their patients' medical issues can presumably spend more time focusing on their own disciplines. Although this argument is conceptually appealing, there is no evidence that this actually occurs. In fact, it is equally conceivable that hospitalist comanagement could jeopardize care by disengaging surgeons and specialists from their patients' progress (or lack thereof). Furthermore, evidence suggests that hospitalists are underprepared to manage diagnoses that have historically been the purview of surgeons and specialists. Practicing hospitalists who manage acute neurological and neurosurgical conditions, orthopedic trauma, and acute psychiatric illnesses have reported relative undertraining in all of these disease states.10, 16 Generally, hospitalists are expected to deliver this care in the absence of any regime to assess their competence, provide targeted training to fill knowledge gaps, and monitor their progress. At minimum, this should raise concerns about the quality and consistency of care that hospitalists provide to nonmedical patients.

Finally, working collaboratively with other specialties should be a major professional benefit of comanagement. In well‐designed comanagement arrangements, hospitalists and specialists work equitably under clearly defined and mutually agreed upon rules of engagement. They share responsibility for patients, collaborate to improve care, and teach and learn from each other. Unfortunately, in many instances, the power structure becomes lopsided, with surgeons and specialists dictating how, when, and why hospitalists manage their patients.17 Emergency departments have learned to default surgical and specialty patient admissions to hospitalists when surgeons and specialists balk. Hospital administrations may tacitly or overtly expect their financially subsidized hospitalists to cheerfully accept any and all referrals, irrespective of how inappropriate they may be. Practicing hospitalists frequently complain about their subordinate status and inability to control their working conditions, both of which are identified risk factors for career dissatisfaction and burnout.14, 16, 18 Once again, as a specialty facing a critical manpower shortage, hospitalist programs should be very attuned to defining work conditions that foster career satisfaction and physician retention.

REFRAMING COMANAGEMENT

The history of healthcare is laden with examples of new ideas that were widely and indiscriminately adopted only to subsequently fail to withstand rigorous scrutiny.19, 20 The unchecked expansion of hospitalist comanagement has the potential to become another case in point. In the absence of clear definitions of comanagement and good evidence to define best practices, hospitalists are left to use their best judgment to define the parameters of their comanagement services. At minimum, hospitalist leaders should ask some basic questions as they ponder potential comanagement relationships:

• Why are we being asked to provide this service?

• Do the patients have comorbidities that require our input?

• Is there a legitimate quality or efficiency case to be made to support our participation?

• Do we have the manpower to provide the service? If not, what will suffer as a result?

• Will the relationship be equitable?

• What might go wrong?

Comanagement is an appealing construct that has grown to fill many niches of healthcare delivery.10 Given compelling reasons to be skeptical about the purported benefits of comanagement, hospitalists should be circumspect about how and where they offer such services. Comanagement should be applied carefully and methodically, paying close attention to the consequences, intended and unintended. Applying comanagement in a rational, evidence‐based, and sustainable fashion will ultimately better serve patients, the healthcare community, and hospital medicine.

A 90‐year‐old female nursing home resident was admitted for hyponatremia and altered mental status. A Foley catheter was placed on admission. On hospital day 2, the Foley catheter was found to be draining violet urine. Urinalysis showed a pH of 9.0, numerous white cells, leukocyte esterase, and bacteria. Urine culture grew Proteus mirabilis. Purple Urine Bag Syndrome (PUBS) is a rare phenomenon associated with alkaline urine due to a urinary tract infection. The patient was treated with ciprofloxacin, and her urine returned to a pale yellow color. While alarming to patients and providers alike, PUBS is a benign herald of urinary tract infection, often in an elderly woman with constipation. In normal individuals, tryptophan is metabolized to indole by gut flora, which is in turn conjugated to indoxyl sulfate (IS) by the liver. Urine excretion of IS varies by individual. Sulfatase‐containing bacteria, notably Providencia, Klebsiella, and Proteus species, then catabolize IS to indoxyl. In an alkaline environment indoxyl isomers interact to alternately yield indigo or indirubin which jointly create the urine's characteristic violet color.0

Figure 1

A 90‐year‐old female nursing home resident was admitted for hyponatremia and altered mental status. A Foley catheter was placed on admission. On hospital day 2, the Foley catheter was found to be draining violet urine. Urinalysis showed a pH of 9.0, numerous white cells, leukocyte esterase, and bacteria. Urine culture grew Proteus mirabilis. Purple Urine Bag Syndrome (PUBS) is a rare phenomenon associated with alkaline urine due to a urinary tract infection. The patient was treated with ciprofloxacin, and her urine returned to a pale yellow color. While alarming to patients and providers alike, PUBS is a benign herald of urinary tract infection, often in an elderly woman with constipation. In normal individuals, tryptophan is metabolized to indole by gut flora, which is in turn conjugated to indoxyl sulfate (IS) by the liver. Urine excretion of IS varies by individual. Sulfatase‐containing bacteria, notably Providencia, Klebsiella, and Proteus species, then catabolize IS to indoxyl. In an alkaline environment indoxyl isomers interact to alternately yield indigo or indirubin which jointly create the urine's characteristic violet color.0

Figure 1

A 90‐year‐old female nursing home resident was admitted for hyponatremia and altered mental status. A Foley catheter was placed on admission. On hospital day 2, the Foley catheter was found to be draining violet urine. Urinalysis showed a pH of 9.0, numerous white cells, leukocyte esterase, and bacteria. Urine culture grew Proteus mirabilis. Purple Urine Bag Syndrome (PUBS) is a rare phenomenon associated with alkaline urine due to a urinary tract infection. The patient was treated with ciprofloxacin, and her urine returned to a pale yellow color. While alarming to patients and providers alike, PUBS is a benign herald of urinary tract infection, often in an elderly woman with constipation. In normal individuals, tryptophan is metabolized to indole by gut flora, which is in turn conjugated to indoxyl sulfate (IS) by the liver. Urine excretion of IS varies by individual. Sulfatase‐containing bacteria, notably Providencia, Klebsiella, and Proteus species, then catabolize IS to indoxyl. In an alkaline environment indoxyl isomers interact to alternately yield indigo or indirubin which jointly create the urine's characteristic violet color.0

Figure 1

BACKGROUND

Discharges against medical advice (AMA) account for approximately 1% of discharges for general medical patients and up to 10% and 30% for patients afflicted with HIV disease and psychiatric disorders, respectively.17 Patients discharged AMA have higher rates of readmission, longer subsequent hospital stays, and worse health outcomes.3, 5, 811 Not unexpectedly, discharges AMA are associated with overall health costs of up to 50% greater than usual discharges.2

Patients who leave AMA are more likely to have poorer social supports, to abuse alcohol, heroin, and other substances, and often have weighty psychosocial or financial concerns.1218 They are also less likely to have an established relationship with a primary care physician.19 Although studies have found that rates of discharge AMA are higher among some ethnic minorities, one recent study suggests that other patient variables, such as level of income and type of insurance, may be more closely related.7, 20 Unfortunately, many patients who leave AMA have dual sources of distress: compelling personal concerns that fuel one's wish to leave and the illness that initially caused the patient to seek care.

Physicians are often distressed by the clinical and ethical challenges of discharges AMA. How should physicians manage their conflicted obligations to respect patients' choices and to prevent harms from befalling their patients? What are physicians' obligations to their patients who leave accepting only partial or inadequate treatment plans or no treatment at all? When should physicians call into question the decision‐making capacity of patients' who make seemingly unwise or clearly dangerous judgments to leave the hospital? In addition to these sorts of concerns, physicians who discharge patients AMA enjoy no definitive legal protection from the consequences of their patients' choices.2123 In fact, good clinical judgement and careful documentation provide the best liability protection.24

Clearly, discharges AMA are problematic for patients, stressful for physicians, and resource intensive for health facilities. Therefore, efforts to understand, better manage, and ultimately decrease discharges AMA will benefit all parties. Whereas the literature on discharge AMA tends to focus on psychiatric and substance abuse patients, this review examines the professional and ethical implications of discharge AMA more generally.

Summary and Conclusions

Clinicians caring for patients who seek discharge AMA are often faced with emotionally charged and time‐pressured treatment situations. These clinicians must weigh multiple considerations for the benefit of their patients, and maintain professional standards of clinical care. Clinicians presented with these situations should (1) evaluate patients' decision‐making capacity, (2) assess the degree to which their choices are influenced by controlling external influences and mitigate these factors where possible, and (3) encourage and facilitate after‐care (Table 2).

Although discharge AMA accounts for only a small percentage of hospital discharges, its medical, emotional, and resource utilization consequences for patients as well as for physicians and hospitals is disproportionate. The clinical impacts of discharge AMA should be further investigated and specific strategies and interventions to mitigate its health effects should be validated.

BACKGROUND

Discharges against medical advice (AMA) account for approximately 1% of discharges for general medical patients and up to 10% and 30% for patients afflicted with HIV disease and psychiatric disorders, respectively.17 Patients discharged AMA have higher rates of readmission, longer subsequent hospital stays, and worse health outcomes.3, 5, 811 Not unexpectedly, discharges AMA are associated with overall health costs of up to 50% greater than usual discharges.2

Patients who leave AMA are more likely to have poorer social supports, to abuse alcohol, heroin, and other substances, and often have weighty psychosocial or financial concerns.1218 They are also less likely to have an established relationship with a primary care physician.19 Although studies have found that rates of discharge AMA are higher among some ethnic minorities, one recent study suggests that other patient variables, such as level of income and type of insurance, may be more closely related.7, 20 Unfortunately, many patients who leave AMA have dual sources of distress: compelling personal concerns that fuel one's wish to leave and the illness that initially caused the patient to seek care.

Physicians are often distressed by the clinical and ethical challenges of discharges AMA. How should physicians manage their conflicted obligations to respect patients' choices and to prevent harms from befalling their patients? What are physicians' obligations to their patients who leave accepting only partial or inadequate treatment plans or no treatment at all? When should physicians call into question the decision‐making capacity of patients' who make seemingly unwise or clearly dangerous judgments to leave the hospital? In addition to these sorts of concerns, physicians who discharge patients AMA enjoy no definitive legal protection from the consequences of their patients' choices.2123 In fact, good clinical judgement and careful documentation provide the best liability protection.24

Clearly, discharges AMA are problematic for patients, stressful for physicians, and resource intensive for health facilities. Therefore, efforts to understand, better manage, and ultimately decrease discharges AMA will benefit all parties. Whereas the literature on discharge AMA tends to focus on psychiatric and substance abuse patients, this review examines the professional and ethical implications of discharge AMA more generally.

Summary and Conclusions

Clinicians caring for patients who seek discharge AMA are often faced with emotionally charged and time‐pressured treatment situations. These clinicians must weigh multiple considerations for the benefit of their patients, and maintain professional standards of clinical care. Clinicians presented with these situations should (1) evaluate patients' decision‐making capacity, (2) assess the degree to which their choices are influenced by controlling external influences and mitigate these factors where possible, and (3) encourage and facilitate after‐care (Table 2).

Although discharge AMA accounts for only a small percentage of hospital discharges, its medical, emotional, and resource utilization consequences for patients as well as for physicians and hospitals is disproportionate. The clinical impacts of discharge AMA should be further investigated and specific strategies and interventions to mitigate its health effects should be validated.

BACKGROUND

Discharges against medical advice (AMA) account for approximately 1% of discharges for general medical patients and up to 10% and 30% for patients afflicted with HIV disease and psychiatric disorders, respectively.17 Patients discharged AMA have higher rates of readmission, longer subsequent hospital stays, and worse health outcomes.3, 5, 811 Not unexpectedly, discharges AMA are associated with overall health costs of up to 50% greater than usual discharges.2

Patients who leave AMA are more likely to have poorer social supports, to abuse alcohol, heroin, and other substances, and often have weighty psychosocial or financial concerns.1218 They are also less likely to have an established relationship with a primary care physician.19 Although studies have found that rates of discharge AMA are higher among some ethnic minorities, one recent study suggests that other patient variables, such as level of income and type of insurance, may be more closely related.7, 20 Unfortunately, many patients who leave AMA have dual sources of distress: compelling personal concerns that fuel one's wish to leave and the illness that initially caused the patient to seek care.

Physicians are often distressed by the clinical and ethical challenges of discharges AMA. How should physicians manage their conflicted obligations to respect patients' choices and to prevent harms from befalling their patients? What are physicians' obligations to their patients who leave accepting only partial or inadequate treatment plans or no treatment at all? When should physicians call into question the decision‐making capacity of patients' who make seemingly unwise or clearly dangerous judgments to leave the hospital? In addition to these sorts of concerns, physicians who discharge patients AMA enjoy no definitive legal protection from the consequences of their patients' choices.2123 In fact, good clinical judgement and careful documentation provide the best liability protection.24

Clearly, discharges AMA are problematic for patients, stressful for physicians, and resource intensive for health facilities. Therefore, efforts to understand, better manage, and ultimately decrease discharges AMA will benefit all parties. Whereas the literature on discharge AMA tends to focus on psychiatric and substance abuse patients, this review examines the professional and ethical implications of discharge AMA more generally.

Summary and Conclusions

Clinicians caring for patients who seek discharge AMA are often faced with emotionally charged and time‐pressured treatment situations. These clinicians must weigh multiple considerations for the benefit of their patients, and maintain professional standards of clinical care. Clinicians presented with these situations should (1) evaluate patients' decision‐making capacity, (2) assess the degree to which their choices are influenced by controlling external influences and mitigate these factors where possible, and (3) encourage and facilitate after‐care (Table 2).

Although discharge AMA accounts for only a small percentage of hospital discharges, its medical, emotional, and resource utilization consequences for patients as well as for physicians and hospitals is disproportionate. The clinical impacts of discharge AMA should be further investigated and specific strategies and interventions to mitigate its health effects should be validated.

The connection between idiopathic thrombocytopenic purpura (ITP) and Grave's disease is not well known in the Western hemisphere. The immunologic relationship between these 2 conditions is well reported15 but poorly defined in the literature. New‐onset hyperthyroidism in the setting of preexisting ITP can be overlooked and, if untreated, lead to worsening of the ITP, rendering it refractory to standard therapy. Early recognition and treatment of the hyperthyroid state with antithyroid medications can lead to significant improvement in the platelet count.1, 8 We report this rare but critical clinical relationship.

CASE REPORT

A 35‐year‐old Asian woman with a known history of stable ITP for 12 years (baseline platelet count of 40,000/mL) presented to her outpatient provider with a diffuse petechial rash, easy bruisability, and heavy menorrhagia for 2 weeks. Her new platelet count was 7000/mL. She was immediately started on prednisone at a dose of 1 mg/kg without any improvement in her platelet count. At the end of 4 weeks on prednisone, she developed fever, intractable nausea and vomiting, severe headache, hypotension, and tachycardia. She was subsequently hospitalized with the presumptive diagnosis of meningitis and sepsis syndrome. Her clinical syndrome was consistent with systemic inflammatory response syndrome. She was treated aggressively with intravenous fluids and a broad‐spectrum empirical antimicrobial regimen consisting of ceftriaxone, vancomycin, and acyclovir. Lumbar puncture was deferred because of her low platelet count. The sepsis workup, which included viral, fungal, and bacterial blood cultures, remained negative. Her peripheral smear did not show evidence of microangiopathic hemolytic anemia, therefore ruling out thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. HIV and tuberculosis were also ruled out. After the initial sepsis workup turned out negative, she was started on solumedrol 125 mg IV every 6 hours. Over the next 2 weeks, she received an average of 4‐6 units of platelets per day and multiple blood transfusions to maintain her hemoglobin and platelet counts. The latter remained in the 1000‐5000 platelets/mL range throughout her hospitalization without any significant improvement. Her clinical course was further complicated by multiple small intracranial hemorrhages without major focal neurological deficits. A bone marrow biopsy was eventually done. It showed early dysplastic cells but no definite features of myelodysplasia and few large megakaryocytes. She received 1 dose of vincristine without response in the bone marrow after 2 weeks, and consideration was given to treatment with rituximab for refractory ITP. At that point, she informed her hematologist that 10 years ago, she had been treated for hyperthyroidism with antithyroid medications for 6 months, without further follow‐up. A thyroid panel was then ordered, and she was found to be hyperthyroid, with thyroid‐stimulating hormone (TSH) < 0.01 mU/mL and free T4 of 3.1 ng/dL. She was subsequently started on propylthiouracil at 300 mg per day. Her platelet count dramatically improved and went up to the 50,000/mm³ range without further intervention over the next few months. After her discharge, an outpatient thyroid scan showed diffuse, homogeneous uptake of iodine, thereby confirming the diagnosis of Grave's disease. Retrospectively, her initial clinical syndrome of fever, hypotension, and tachycardia may have been the result of thyrotoxicosis or worsened by it.

DISCUSSION

The association between ITP and Grave's disease is poorly understood. Many hypotheses from observational data have been given in the literature. The leading theory to explain the coexistence of these 2 disorders is the presence of a common autoimmune pathway with production of 2 kinds of antibodies against platelets and TSH receptors. Indeed, autoimmune disorders tend to occur concurrently in individuals or families. Bizzaro et al. reported the coexistence of ITP and Grave's in 4 members of the same family.6 Hymes et al. found elevated levels of platelet‐bound IgG in 44% of 25 study patients with Grave's thyrotoxicosis.7 Most of these patients had easy bruising and/or bleeding, and 12% were thrombocytopenic. Panzer et al. reported the presence of antiplatelet IgG in patients with Grave's as well as improved platelet counts and increased mean platelet volume after successful antithyroid therapy.8

In addition to the coexistence of thyroid‐stimulatingimmunoglobulins (TSIs) and antiplatelet antibodies as a potential mechanism for Grave's‐associated thrombocytopenia, some have postulated that in Grave's patients, TSIs and other thyroid antibodies might actually bind to the platelets themselves. The postulated site for binding would be a truncated actin‐binding protein on the platelets that would link the high‐affinity Fc receptor of immunoglobulin G to the platelets' cytoskeleton, thereby accelerating their destruction.9

Another plausible mechanism is activation of the reticuloendothelial system by thyroid hormones, with increased clearance of platelets by the spleen in thyrotoxic states. This may explain the restoration of the platelet count when euthyroidism is reached.

Finally, thyrotoxicosis seems to alter platelet aggregation, partially by inhibition of myosin light‐chain kinase, and that also improves with restoration of euthyroidism.10

The coexistence of severe hyperthyroidism and thrombocytopenia can mimic severe sepsis in critically ill patients, and the hyperthyroid state in itself can worsen the thrombocytopenia of ITP. We suspect this patient's severe sepsis may actually have been an unrecognized severe thyrotoxicosis, with bone marrow dysfunction secondary to the hyperthyroidism, which might partially explain her lack of response to standard therapy.

CONCLUSIONS

This case underscores the importance of screening for and treating hyperthyroidism in patients with ITP, especially those resistant to steroid therapy, because the literature seems to indicate that treatment of the hyperthyroid state improves platelet count. This might help to prevent devastating clinical complications. Further research is necessary to define this empirical finding.

The connection between idiopathic thrombocytopenic purpura (ITP) and Grave's disease is not well known in the Western hemisphere. The immunologic relationship between these 2 conditions is well reported15 but poorly defined in the literature. New‐onset hyperthyroidism in the setting of preexisting ITP can be overlooked and, if untreated, lead to worsening of the ITP, rendering it refractory to standard therapy. Early recognition and treatment of the hyperthyroid state with antithyroid medications can lead to significant improvement in the platelet count.1, 8 We report this rare but critical clinical relationship.

CASE REPORT

A 35‐year‐old Asian woman with a known history of stable ITP for 12 years (baseline platelet count of 40,000/mL) presented to her outpatient provider with a diffuse petechial rash, easy bruisability, and heavy menorrhagia for 2 weeks. Her new platelet count was 7000/mL. She was immediately started on prednisone at a dose of 1 mg/kg without any improvement in her platelet count. At the end of 4 weeks on prednisone, she developed fever, intractable nausea and vomiting, severe headache, hypotension, and tachycardia. She was subsequently hospitalized with the presumptive diagnosis of meningitis and sepsis syndrome. Her clinical syndrome was consistent with systemic inflammatory response syndrome. She was treated aggressively with intravenous fluids and a broad‐spectrum empirical antimicrobial regimen consisting of ceftriaxone, vancomycin, and acyclovir. Lumbar puncture was deferred because of her low platelet count. The sepsis workup, which included viral, fungal, and bacterial blood cultures, remained negative. Her peripheral smear did not show evidence of microangiopathic hemolytic anemia, therefore ruling out thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. HIV and tuberculosis were also ruled out. After the initial sepsis workup turned out negative, she was started on solumedrol 125 mg IV every 6 hours. Over the next 2 weeks, she received an average of 4‐6 units of platelets per day and multiple blood transfusions to maintain her hemoglobin and platelet counts. The latter remained in the 1000‐5000 platelets/mL range throughout her hospitalization without any significant improvement. Her clinical course was further complicated by multiple small intracranial hemorrhages without major focal neurological deficits. A bone marrow biopsy was eventually done. It showed early dysplastic cells but no definite features of myelodysplasia and few large megakaryocytes. She received 1 dose of vincristine without response in the bone marrow after 2 weeks, and consideration was given to treatment with rituximab for refractory ITP. At that point, she informed her hematologist that 10 years ago, she had been treated for hyperthyroidism with antithyroid medications for 6 months, without further follow‐up. A thyroid panel was then ordered, and she was found to be hyperthyroid, with thyroid‐stimulating hormone (TSH) < 0.01 mU/mL and free T4 of 3.1 ng/dL. She was subsequently started on propylthiouracil at 300 mg per day. Her platelet count dramatically improved and went up to the 50,000/mm³ range without further intervention over the next few months. After her discharge, an outpatient thyroid scan showed diffuse, homogeneous uptake of iodine, thereby confirming the diagnosis of Grave's disease. Retrospectively, her initial clinical syndrome of fever, hypotension, and tachycardia may have been the result of thyrotoxicosis or worsened by it.

DISCUSSION

The association between ITP and Grave's disease is poorly understood. Many hypotheses from observational data have been given in the literature. The leading theory to explain the coexistence of these 2 disorders is the presence of a common autoimmune pathway with production of 2 kinds of antibodies against platelets and TSH receptors. Indeed, autoimmune disorders tend to occur concurrently in individuals or families. Bizzaro et al. reported the coexistence of ITP and Grave's in 4 members of the same family.6 Hymes et al. found elevated levels of platelet‐bound IgG in 44% of 25 study patients with Grave's thyrotoxicosis.7 Most of these patients had easy bruising and/or bleeding, and 12% were thrombocytopenic. Panzer et al. reported the presence of antiplatelet IgG in patients with Grave's as well as improved platelet counts and increased mean platelet volume after successful antithyroid therapy.8

In addition to the coexistence of thyroid‐stimulatingimmunoglobulins (TSIs) and antiplatelet antibodies as a potential mechanism for Grave's‐associated thrombocytopenia, some have postulated that in Grave's patients, TSIs and other thyroid antibodies might actually bind to the platelets themselves. The postulated site for binding would be a truncated actin‐binding protein on the platelets that would link the high‐affinity Fc receptor of immunoglobulin G to the platelets' cytoskeleton, thereby accelerating their destruction.9

Another plausible mechanism is activation of the reticuloendothelial system by thyroid hormones, with increased clearance of platelets by the spleen in thyrotoxic states. This may explain the restoration of the platelet count when euthyroidism is reached.

Finally, thyrotoxicosis seems to alter platelet aggregation, partially by inhibition of myosin light‐chain kinase, and that also improves with restoration of euthyroidism.10

The coexistence of severe hyperthyroidism and thrombocytopenia can mimic severe sepsis in critically ill patients, and the hyperthyroid state in itself can worsen the thrombocytopenia of ITP. We suspect this patient's severe sepsis may actually have been an unrecognized severe thyrotoxicosis, with bone marrow dysfunction secondary to the hyperthyroidism, which might partially explain her lack of response to standard therapy.

CONCLUSIONS

This case underscores the importance of screening for and treating hyperthyroidism in patients with ITP, especially those resistant to steroid therapy, because the literature seems to indicate that treatment of the hyperthyroid state improves platelet count. This might help to prevent devastating clinical complications. Further research is necessary to define this empirical finding.

The connection between idiopathic thrombocytopenic purpura (ITP) and Grave's disease is not well known in the Western hemisphere. The immunologic relationship between these 2 conditions is well reported15 but poorly defined in the literature. New‐onset hyperthyroidism in the setting of preexisting ITP can be overlooked and, if untreated, lead to worsening of the ITP, rendering it refractory to standard therapy. Early recognition and treatment of the hyperthyroid state with antithyroid medications can lead to significant improvement in the platelet count.1, 8 We report this rare but critical clinical relationship.

CASE REPORT

A 35‐year‐old Asian woman with a known history of stable ITP for 12 years (baseline platelet count of 40,000/mL) presented to her outpatient provider with a diffuse petechial rash, easy bruisability, and heavy menorrhagia for 2 weeks. Her new platelet count was 7000/mL. She was immediately started on prednisone at a dose of 1 mg/kg without any improvement in her platelet count. At the end of 4 weeks on prednisone, she developed fever, intractable nausea and vomiting, severe headache, hypotension, and tachycardia. She was subsequently hospitalized with the presumptive diagnosis of meningitis and sepsis syndrome. Her clinical syndrome was consistent with systemic inflammatory response syndrome. She was treated aggressively with intravenous fluids and a broad‐spectrum empirical antimicrobial regimen consisting of ceftriaxone, vancomycin, and acyclovir. Lumbar puncture was deferred because of her low platelet count. The sepsis workup, which included viral, fungal, and bacterial blood cultures, remained negative. Her peripheral smear did not show evidence of microangiopathic hemolytic anemia, therefore ruling out thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. HIV and tuberculosis were also ruled out. After the initial sepsis workup turned out negative, she was started on solumedrol 125 mg IV every 6 hours. Over the next 2 weeks, she received an average of 4‐6 units of platelets per day and multiple blood transfusions to maintain her hemoglobin and platelet counts. The latter remained in the 1000‐5000 platelets/mL range throughout her hospitalization without any significant improvement. Her clinical course was further complicated by multiple small intracranial hemorrhages without major focal neurological deficits. A bone marrow biopsy was eventually done. It showed early dysplastic cells but no definite features of myelodysplasia and few large megakaryocytes. She received 1 dose of vincristine without response in the bone marrow after 2 weeks, and consideration was given to treatment with rituximab for refractory ITP. At that point, she informed her hematologist that 10 years ago, she had been treated for hyperthyroidism with antithyroid medications for 6 months, without further follow‐up. A thyroid panel was then ordered, and she was found to be hyperthyroid, with thyroid‐stimulating hormone (TSH) < 0.01 mU/mL and free T4 of 3.1 ng/dL. She was subsequently started on propylthiouracil at 300 mg per day. Her platelet count dramatically improved and went up to the 50,000/mm³ range without further intervention over the next few months. After her discharge, an outpatient thyroid scan showed diffuse, homogeneous uptake of iodine, thereby confirming the diagnosis of Grave's disease. Retrospectively, her initial clinical syndrome of fever, hypotension, and tachycardia may have been the result of thyrotoxicosis or worsened by it.

DISCUSSION

The association between ITP and Grave's disease is poorly understood. Many hypotheses from observational data have been given in the literature. The leading theory to explain the coexistence of these 2 disorders is the presence of a common autoimmune pathway with production of 2 kinds of antibodies against platelets and TSH receptors. Indeed, autoimmune disorders tend to occur concurrently in individuals or families. Bizzaro et al. reported the coexistence of ITP and Grave's in 4 members of the same family.6 Hymes et al. found elevated levels of platelet‐bound IgG in 44% of 25 study patients with Grave's thyrotoxicosis.7 Most of these patients had easy bruising and/or bleeding, and 12% were thrombocytopenic. Panzer et al. reported the presence of antiplatelet IgG in patients with Grave's as well as improved platelet counts and increased mean platelet volume after successful antithyroid therapy.8

In addition to the coexistence of thyroid‐stimulatingimmunoglobulins (TSIs) and antiplatelet antibodies as a potential mechanism for Grave's‐associated thrombocytopenia, some have postulated that in Grave's patients, TSIs and other thyroid antibodies might actually bind to the platelets themselves. The postulated site for binding would be a truncated actin‐binding protein on the platelets that would link the high‐affinity Fc receptor of immunoglobulin G to the platelets' cytoskeleton, thereby accelerating their destruction.9

Another plausible mechanism is activation of the reticuloendothelial system by thyroid hormones, with increased clearance of platelets by the spleen in thyrotoxic states. This may explain the restoration of the platelet count when euthyroidism is reached.

Finally, thyrotoxicosis seems to alter platelet aggregation, partially by inhibition of myosin light‐chain kinase, and that also improves with restoration of euthyroidism.10

The coexistence of severe hyperthyroidism and thrombocytopenia can mimic severe sepsis in critically ill patients, and the hyperthyroid state in itself can worsen the thrombocytopenia of ITP. We suspect this patient's severe sepsis may actually have been an unrecognized severe thyrotoxicosis, with bone marrow dysfunction secondary to the hyperthyroidism, which might partially explain her lack of response to standard therapy.

CONCLUSIONS

This case underscores the importance of screening for and treating hyperthyroidism in patients with ITP, especially those resistant to steroid therapy, because the literature seems to indicate that treatment of the hyperthyroid state improves platelet count. This might help to prevent devastating clinical complications. Further research is necessary to define this empirical finding.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Her name was Mrs. Carberry, but her readers knew her as Mary Margaret. Two months earlier, she suffered a debilitating stroke that took away her vibrant life. Previously a prolific writer of advice columns and opinion pieces, the blockage of blood to her brain dammed the steady flow of wisdom to her innumerable fans. They never again would benefit from the words of this intelligent, feisty, and self‐proclaimed Cranky Catholic. Unfortunately, I would not know Mary Margaret for her words, but only her numbers: her vital signs, her urine output, her tube feed residuals.

Not able to communicate with us, we wondered did Mrs. Carberry want this tracheostomy that was placed? Did she want this peg tube that fed her continuously? And even if she would have initially agreed to them, would she still want them now? Especially given she was not improving and had little hope for a meaningful recovery.

We posed these difficult questions to her two sons. One son believed that his mother would want an end to these aggressive measures. The other son disagreed; he said his mother would want to make every effort to stay alive.

In the end, Mary Margaret's voice found its way to us and provided us with the answer. She did not tell us in the conventional manner via a lawyer or a living will. Her friends did not come forth and let us know about serious conversations during their afternoon lunches. Instead, Mary Margaret penned it to her audience of devoted readers in a newspaper column written 14 years earlier. Mary Margaret's poignant words were revealed to her doctors by her son who understood its undeniable significance.

Mary Margaret was an essayist in Chicago whose pieces filled many major newspapers and magazines. She had strong opinions on matters large and small, writing articles addressing topics ranging from her Catholic beliefs to gender‐based inequities in the workplace. One article in particular addressed sickness and death and provided her sons the answer they sought. Having witnessed illness strike two loved ones, it was only natural for Mary Margaret to write about it. Her very personal essay was entitled Tough Questions on Life, Death and a Dog Named Bamboo. The words, resurfacing years later, and now having direct meaning to her own life and death, may have been some of the most profound and prophetic words of her career:

Tough Questions on Life, Death and a Dog Named Bamboo

I sat with her that evening while she was dyingrubbing her back, smoothing her head, whispering that I loved her, trying to be of some small comfort as she snuggled closer, looking up with her mysteriously accepting, somehow understanding brown eyes.

Adjusting herself once more, she half rose, then toppled sideways and simply stopped breathing. She died as a lady ought to be able to diequietly, as easily as possible, in her own bed. In my bed actually. She was Bamboo, my Shar‐pei, and it is difficult to write this even several months later without tears starting to roll.

It was not just that last day, of course. For a bit more than a week, Bamboo had been giving signs of a serious problema heavy doggie cough indicating severe congestion and a firm, stubborn decision not to eat. The kitchen offered a parade of small bowls of her favorite people foods with which I hoped to restore her appetite when she determinedly ignored her regular dog food. She had her choice of cottage cheese, scrambled eggs, ground sirloin, cheddar chunks, ice cream, buttered rice and morea virtual buffet for ants.

After I set each dish out, she would go over to look and sniff admiringly, even wag her tail, but then rather reluctantly return to her favorite resting place, a small rug at the top of the stairs to the front door.

She would only drink a lot of water, bowl after bowl, in which she did also get her medicine, mashed and melted. Late on that last afternoon, however she stopped the drinking, too. I couldn't get her to sip even when I brought the water dish to her or offered the ice cubes she once loved to lick. In her own way, she was saying No.

Lately I have been reflecting again on the experience as a result of having heard some discussion about the death of a woman with whom I once shared friendly commuter chitchat as we trained together into the Loop.

Following a stroke, she had been unconscious, vegetative, tragically for almost as long as I had enjoyed the eight years of Bamboo's delightful companionship. Her husband, I learned, had ultimately gone to court and had been granted permission to remove the feeding tube and let nature take its course. A counteraction to prevent this was filed by some well‐intentioned people; but what I believe as good human and legal sense prevailed. So without the tube feeding, this nice long‐suffering woman finally slipped away to God.

People who oppose the dying being released this way argue that they are being starved to death without the feeding tubes. But I don't buy that, especially after having watched Bamboo decide by some deep natural instinct that it was time for her, first, to stop eating even the treats she loved and, finally, to stop drinking while she waited patiently for what was to come, what was inevitable.

There used to be an advertising slogan: It's not nice to fool Mother Nature. If you believe in God and the promise of eternity, perhaps it is equally not nice to fool dying human bodies into a semblance of living when nature is poised to move them beyond the rim of this life. Nature or God, I mean, and absolutely never, of course, a manipulative Dr. Death.

I don't think my puppy was starving those last few days so much as simply stopping. Simply letting herself be folded into an immutable process. At least this is something to ponder in terms of the will of God overwhelming the hopes of man. I am awed and rather apprehensive and yet somehow comfortable with this conclusion.

A couple of months tops with the tubes and no other reasonable hope, I think I'll tell my kids.

Mary Margaret's words struck a cord with both her sons. Her wishes, neatly laid out in a dusty newspaper, were respected. Mary Margaret entered hospice and died peacefully 2 weeks later.

(Tough Questions on Life, Death and a Dog Named Bamboo originally appeared in the The Catholic New World on July 16, 1993. The article was reprinted with their permission.)

Postscript: The author of the essay (my mother) passed away after a week in hospice care and 7 weeks in hospitals following a stroke. She was a published writer for more than 60 years. For her 61st birthday, my brother and I decided to buy her a wrinkly little puppy to keep her company and bark at anyone who came to her house. It ended up being a terrific watchdog as well as my mom's best friend. The last days with her puppy were translated into the essay, which also helped guide me during my mother's final days. My hope is that she and Bamboo are enjoying the promise of eternity in each other's company.

Patrick Carberry

Her name was Mrs. Carberry, but her readers knew her as Mary Margaret. Two months earlier, she suffered a debilitating stroke that took away her vibrant life. Previously a prolific writer of advice columns and opinion pieces, the blockage of blood to her brain dammed the steady flow of wisdom to her innumerable fans. They never again would benefit from the words of this intelligent, feisty, and self‐proclaimed Cranky Catholic. Unfortunately, I would not know Mary Margaret for her words, but only her numbers: her vital signs, her urine output, her tube feed residuals.

Not able to communicate with us, we wondered did Mrs. Carberry want this tracheostomy that was placed? Did she want this peg tube that fed her continuously? And even if she would have initially agreed to them, would she still want them now? Especially given she was not improving and had little hope for a meaningful recovery.

We posed these difficult questions to her two sons. One son believed that his mother would want an end to these aggressive measures. The other son disagreed; he said his mother would want to make every effort to stay alive.

In the end, Mary Margaret's voice found its way to us and provided us with the answer. She did not tell us in the conventional manner via a lawyer or a living will. Her friends did not come forth and let us know about serious conversations during their afternoon lunches. Instead, Mary Margaret penned it to her audience of devoted readers in a newspaper column written 14 years earlier. Mary Margaret's poignant words were revealed to her doctors by her son who understood its undeniable significance.

Mary Margaret was an essayist in Chicago whose pieces filled many major newspapers and magazines. She had strong opinions on matters large and small, writing articles addressing topics ranging from her Catholic beliefs to gender‐based inequities in the workplace. One article in particular addressed sickness and death and provided her sons the answer they sought. Having witnessed illness strike two loved ones, it was only natural for Mary Margaret to write about it. Her very personal essay was entitled Tough Questions on Life, Death and a Dog Named Bamboo. The words, resurfacing years later, and now having direct meaning to her own life and death, may have been some of the most profound and prophetic words of her career:

Tough Questions on Life, Death and a Dog Named Bamboo

I sat with her that evening while she was dyingrubbing her back, smoothing her head, whispering that I loved her, trying to be of some small comfort as she snuggled closer, looking up with her mysteriously accepting, somehow understanding brown eyes.

Adjusting herself once more, she half rose, then toppled sideways and simply stopped breathing. She died as a lady ought to be able to diequietly, as easily as possible, in her own bed. In my bed actually. She was Bamboo, my Shar‐pei, and it is difficult to write this even several months later without tears starting to roll.

It was not just that last day, of course. For a bit more than a week, Bamboo had been giving signs of a serious problema heavy doggie cough indicating severe congestion and a firm, stubborn decision not to eat. The kitchen offered a parade of small bowls of her favorite people foods with which I hoped to restore her appetite when she determinedly ignored her regular dog food. She had her choice of cottage cheese, scrambled eggs, ground sirloin, cheddar chunks, ice cream, buttered rice and morea virtual buffet for ants.

After I set each dish out, she would go over to look and sniff admiringly, even wag her tail, but then rather reluctantly return to her favorite resting place, a small rug at the top of the stairs to the front door.

She would only drink a lot of water, bowl after bowl, in which she did also get her medicine, mashed and melted. Late on that last afternoon, however she stopped the drinking, too. I couldn't get her to sip even when I brought the water dish to her or offered the ice cubes she once loved to lick. In her own way, she was saying No.

Lately I have been reflecting again on the experience as a result of having heard some discussion about the death of a woman with whom I once shared friendly commuter chitchat as we trained together into the Loop.

Following a stroke, she had been unconscious, vegetative, tragically for almost as long as I had enjoyed the eight years of Bamboo's delightful companionship. Her husband, I learned, had ultimately gone to court and had been granted permission to remove the feeding tube and let nature take its course. A counteraction to prevent this was filed by some well‐intentioned people; but what I believe as good human and legal sense prevailed. So without the tube feeding, this nice long‐suffering woman finally slipped away to God.

People who oppose the dying being released this way argue that they are being starved to death without the feeding tubes. But I don't buy that, especially after having watched Bamboo decide by some deep natural instinct that it was time for her, first, to stop eating even the treats she loved and, finally, to stop drinking while she waited patiently for what was to come, what was inevitable.

There used to be an advertising slogan: It's not nice to fool Mother Nature. If you believe in God and the promise of eternity, perhaps it is equally not nice to fool dying human bodies into a semblance of living when nature is poised to move them beyond the rim of this life. Nature or God, I mean, and absolutely never, of course, a manipulative Dr. Death.

I don't think my puppy was starving those last few days so much as simply stopping. Simply letting herself be folded into an immutable process. At least this is something to ponder in terms of the will of God overwhelming the hopes of man. I am awed and rather apprehensive and yet somehow comfortable with this conclusion.

A couple of months tops with the tubes and no other reasonable hope, I think I'll tell my kids.

Mary Margaret's words struck a cord with both her sons. Her wishes, neatly laid out in a dusty newspaper, were respected. Mary Margaret entered hospice and died peacefully 2 weeks later.

(Tough Questions on Life, Death and a Dog Named Bamboo originally appeared in the The Catholic New World on July 16, 1993. The article was reprinted with their permission.)

Postscript: The author of the essay (my mother) passed away after a week in hospice care and 7 weeks in hospitals following a stroke. She was a published writer for more than 60 years. For her 61st birthday, my brother and I decided to buy her a wrinkly little puppy to keep her company and bark at anyone who came to her house. It ended up being a terrific watchdog as well as my mom's best friend. The last days with her puppy were translated into the essay, which also helped guide me during my mother's final days. My hope is that she and Bamboo are enjoying the promise of eternity in each other's company.

Patrick Carberry

Her name was Mrs. Carberry, but her readers knew her as Mary Margaret. Two months earlier, she suffered a debilitating stroke that took away her vibrant life. Previously a prolific writer of advice columns and opinion pieces, the blockage of blood to her brain dammed the steady flow of wisdom to her innumerable fans. They never again would benefit from the words of this intelligent, feisty, and self‐proclaimed Cranky Catholic. Unfortunately, I would not know Mary Margaret for her words, but only her numbers: her vital signs, her urine output, her tube feed residuals.

Not able to communicate with us, we wondered did Mrs. Carberry want this tracheostomy that was placed? Did she want this peg tube that fed her continuously? And even if she would have initially agreed to them, would she still want them now? Especially given she was not improving and had little hope for a meaningful recovery.

We posed these difficult questions to her two sons. One son believed that his mother would want an end to these aggressive measures. The other son disagreed; he said his mother would want to make every effort to stay alive.

In the end, Mary Margaret's voice found its way to us and provided us with the answer. She did not tell us in the conventional manner via a lawyer or a living will. Her friends did not come forth and let us know about serious conversations during their afternoon lunches. Instead, Mary Margaret penned it to her audience of devoted readers in a newspaper column written 14 years earlier. Mary Margaret's poignant words were revealed to her doctors by her son who understood its undeniable significance.

Mary Margaret was an essayist in Chicago whose pieces filled many major newspapers and magazines. She had strong opinions on matters large and small, writing articles addressing topics ranging from her Catholic beliefs to gender‐based inequities in the workplace. One article in particular addressed sickness and death and provided her sons the answer they sought. Having witnessed illness strike two loved ones, it was only natural for Mary Margaret to write about it. Her very personal essay was entitled Tough Questions on Life, Death and a Dog Named Bamboo. The words, resurfacing years later, and now having direct meaning to her own life and death, may have been some of the most profound and prophetic words of her career:

Tough Questions on Life, Death and a Dog Named Bamboo

I sat with her that evening while she was dyingrubbing her back, smoothing her head, whispering that I loved her, trying to be of some small comfort as she snuggled closer, looking up with her mysteriously accepting, somehow understanding brown eyes.

Adjusting herself once more, she half rose, then toppled sideways and simply stopped breathing. She died as a lady ought to be able to diequietly, as easily as possible, in her own bed. In my bed actually. She was Bamboo, my Shar‐pei, and it is difficult to write this even several months later without tears starting to roll.

It was not just that last day, of course. For a bit more than a week, Bamboo had been giving signs of a serious problema heavy doggie cough indicating severe congestion and a firm, stubborn decision not to eat. The kitchen offered a parade of small bowls of her favorite people foods with which I hoped to restore her appetite when she determinedly ignored her regular dog food. She had her choice of cottage cheese, scrambled eggs, ground sirloin, cheddar chunks, ice cream, buttered rice and morea virtual buffet for ants.

After I set each dish out, she would go over to look and sniff admiringly, even wag her tail, but then rather reluctantly return to her favorite resting place, a small rug at the top of the stairs to the front door.

She would only drink a lot of water, bowl after bowl, in which she did also get her medicine, mashed and melted. Late on that last afternoon, however she stopped the drinking, too. I couldn't get her to sip even when I brought the water dish to her or offered the ice cubes she once loved to lick. In her own way, she was saying No.

Lately I have been reflecting again on the experience as a result of having heard some discussion about the death of a woman with whom I once shared friendly commuter chitchat as we trained together into the Loop.

Following a stroke, she had been unconscious, vegetative, tragically for almost as long as I had enjoyed the eight years of Bamboo's delightful companionship. Her husband, I learned, had ultimately gone to court and had been granted permission to remove the feeding tube and let nature take its course. A counteraction to prevent this was filed by some well‐intentioned people; but what I believe as good human and legal sense prevailed. So without the tube feeding, this nice long‐suffering woman finally slipped away to God.

People who oppose the dying being released this way argue that they are being starved to death without the feeding tubes. But I don't buy that, especially after having watched Bamboo decide by some deep natural instinct that it was time for her, first, to stop eating even the treats she loved and, finally, to stop drinking while she waited patiently for what was to come, what was inevitable.

There used to be an advertising slogan: It's not nice to fool Mother Nature. If you believe in God and the promise of eternity, perhaps it is equally not nice to fool dying human bodies into a semblance of living when nature is poised to move them beyond the rim of this life. Nature or God, I mean, and absolutely never, of course, a manipulative Dr. Death.

I don't think my puppy was starving those last few days so much as simply stopping. Simply letting herself be folded into an immutable process. At least this is something to ponder in terms of the will of God overwhelming the hopes of man. I am awed and rather apprehensive and yet somehow comfortable with this conclusion.

A couple of months tops with the tubes and no other reasonable hope, I think I'll tell my kids.

Mary Margaret's words struck a cord with both her sons. Her wishes, neatly laid out in a dusty newspaper, were respected. Mary Margaret entered hospice and died peacefully 2 weeks later.

(Tough Questions on Life, Death and a Dog Named Bamboo originally appeared in the The Catholic New World on July 16, 1993. The article was reprinted with their permission.)

Postscript: The author of the essay (my mother) passed away after a week in hospice care and 7 weeks in hospitals following a stroke. She was a published writer for more than 60 years. For her 61st birthday, my brother and I decided to buy her a wrinkly little puppy to keep her company and bark at anyone who came to her house. It ended up being a terrific watchdog as well as my mom's best friend. The last days with her puppy were translated into the essay, which also helped guide me during my mother's final days. My hope is that she and Bamboo are enjoying the promise of eternity in each other's company.

Patrick Carberry

More than 53,000 children 19 years of age or younger died in 2004,1 and more than 40% of these children died while hospitalized.25 Recently, pediatric end‐of‐life (EOL) issues have gained clinical and research attention, primarily focused on children with chronic conditions, ethical dilemmas surrounding childhood death and dying, and the need for interdisciplinary palliative care efforts for dying children and their families.2, 3, 69

Much remains unknown about patterns of EOL hospital care at the national level for all children, both with and without complex chronic conditions. Because a large proportion of childhood mortality occurs during hospitalization, the inpatient setting is a crucial arena for patients and families facing EOL issues. However, little is known about how insurance status and interhospital transfer are associated with patterns of hospitalization and mortality for children while hospitalized, or about hospital charges and lengths of stay for children who die as inpatients versus those who survive to discharge. In addition, although spending on EOL health care in the United States has attracted considerable attention in recent years, the published literature focuses almost exclusively on adult populations.1012

Illuminating the patterns of childhood mortality in hospital settings may inform expanding institutional efforts to address death and dying for children and their families. We conducted an analysis of national patterns of hospitalization over a span of a decade (19922002), in order to characterize sociodemographic and health care factors associated with inpatient mortality, and to examine patterns of hospital resource use related to EOL care. We hypothesized that resource use would be higher for children who died versus those who survived, and would be higher for uninsured versus insured children.13 We also hypothesized that children admitted upon transfer from another hospital would have higher risk of mortality.14

METHODS

Our data source was the National Inpatient Sample (NIS), which is a component of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality. The HCUP is a set of databases developed through partnership among health care institutions and federal and state governments.15 The NIS is the largest publicly available all‐payer inpatient database in the United States, and contains de‐identified, patient‐level clinical data included in a typical discharge abstract. For each year, these data reflect hospital stays from between 800 and 1000 institutions sampled to approximate a 20% stratified sample of nonfederal community hospitals, including public hospitals, children's hospitals, and academic medical centers but excluding long‐term hospitals, psychiatric hospitals, and chemical dependency treatment facilities.

We chose the NIS for this analysis because we were interested in the most common diagnoses for hospitalized children. An alternative database, such as the KID (Kids Inpatient Database), is optimal for less commonly seen discharge diagnoses and did not permit a full decade of retrospective analysis.

In order to characterize changes in mortality and health resource utilization related to our research questions, we conducted a comparative cross‐sectional analysis of 3 years of the NIS over the years 1992, 1997, and 2002. For each year of NIS data, discharge‐level weights were provided to permit calculation of national estimates of hospitalization rates standardized to the concurrent national population.15 All inpatient hospital stays of children aged 17 years and younger were selected.

Discharge data were analyzed based on age, sex, payer status, and transfer status on admission. Although transfer status is not often considered in studies of mortality, we expected that it would be associated with mortality, as a potential indicator of disease severity.14 We included only interhospital transfers, and excluded patients transferred from other locations such as long‐term care facilities. We categorized discharges into 5 age groups: newborns, whose hospitalization began at birth; infants up to 1 year of age who were not born during hospitalization; 15 years; 610 years; and 1117 years. This stratification allowed us to separate infants who were admitted from home or from another hospital versus those who were born during hospitalization. Payer groups included Medicaid, private insurance, and uninsured. Medicare and other payers were analyzed, but were present in very small numbers and are not reported.

Outcomes included weighted inpatient mortality rate, weighted mean of length of stay (in days), and weighted mean total hospital charges. For nationally weighted data, lengths of stay and hospital charges are typically reported as means because weighted medians cannot be estimated.16 We compared mortality patterns for patients who were transferred between hospitals versus those who were not, using multivariable logistic regression to identify factors associated with in‐hospital mortality. Of note, transfer status was evaluated from the standpoint of the receiving hospital as children who were admitted upon transfer from another hospital. Thus, our estimates likely underestimate the effects attributed to interhospital transfer, because this evaluation is unilateral and does not include the transferring hospital. The 5 most common principal Diagnosis‐Related Groups (DRGs) upon discharge were compiled for each of the study years for both survivors and decedents. In order to interpret the analyses of discharge‐related hospital charges in constant dollars, we standardized all hospital charges to 2002 US dollars using the Consumer Price Index.17

Statistical analyses included bivariate comparisons of sociodemographic characteristics and the study outcomes, for each of the study years. We also conducted multivariable regression analyses of mortality, comparing effects of sociodemographic variables and transfer status. We conducted all analyses using Stata, version 8 (Stata Corp., College Station, TX), with which we incorporated sample weights to account for the complex stratified sampling of hospitals that comprise the NIS, and to generate variance estimates with which we derived 95% confidence intervals (95% CI). NIS samples included weighted data for 6.2 million discharges in 1992, 7.1 million discharges in 1997, and 7.9 million discharges in 2002. All results are presented using weighted values. The study was funded internally and all analyses were conducted by the authors. The authors had no financial interest in the outcome. The study was exempt from human subjects review as an analysis of de‐identified secondary data.

RESULTS

DISCUSSION

CONCLUSION

This national study of inpatient mortality patterns among US children over the span of a decade presents a new framework of challenges to clinicians and investigators regarding EOL care for children. As health care providers and institutions expand their efforts to meet the needs of severely ill children and their families, such efforts must be cognizant of the high burden of mortality among the youngest children, as well as those who are transferred between hospitals, and children without insurance coverage. These children and their families may require expanded EOL care and support services, beyond those typically available in most hospitals and communities.

More than 53,000 children 19 years of age or younger died in 2004,1 and more than 40% of these children died while hospitalized.25 Recently, pediatric end‐of‐life (EOL) issues have gained clinical and research attention, primarily focused on children with chronic conditions, ethical dilemmas surrounding childhood death and dying, and the need for interdisciplinary palliative care efforts for dying children and their families.2, 3, 69

Much remains unknown about patterns of EOL hospital care at the national level for all children, both with and without complex chronic conditions. Because a large proportion of childhood mortality occurs during hospitalization, the inpatient setting is a crucial arena for patients and families facing EOL issues. However, little is known about how insurance status and interhospital transfer are associated with patterns of hospitalization and mortality for children while hospitalized, or about hospital charges and lengths of stay for children who die as inpatients versus those who survive to discharge. In addition, although spending on EOL health care in the United States has attracted considerable attention in recent years, the published literature focuses almost exclusively on adult populations.1012

Illuminating the patterns of childhood mortality in hospital settings may inform expanding institutional efforts to address death and dying for children and their families. We conducted an analysis of national patterns of hospitalization over a span of a decade (19922002), in order to characterize sociodemographic and health care factors associated with inpatient mortality, and to examine patterns of hospital resource use related to EOL care. We hypothesized that resource use would be higher for children who died versus those who survived, and would be higher for uninsured versus insured children.13 We also hypothesized that children admitted upon transfer from another hospital would have higher risk of mortality.14

METHODS

Our data source was the National Inpatient Sample (NIS), which is a component of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality. The HCUP is a set of databases developed through partnership among health care institutions and federal and state governments.15 The NIS is the largest publicly available all‐payer inpatient database in the United States, and contains de‐identified, patient‐level clinical data included in a typical discharge abstract. For each year, these data reflect hospital stays from between 800 and 1000 institutions sampled to approximate a 20% stratified sample of nonfederal community hospitals, including public hospitals, children's hospitals, and academic medical centers but excluding long‐term hospitals, psychiatric hospitals, and chemical dependency treatment facilities.

We chose the NIS for this analysis because we were interested in the most common diagnoses for hospitalized children. An alternative database, such as the KID (Kids Inpatient Database), is optimal for less commonly seen discharge diagnoses and did not permit a full decade of retrospective analysis.

In order to characterize changes in mortality and health resource utilization related to our research questions, we conducted a comparative cross‐sectional analysis of 3 years of the NIS over the years 1992, 1997, and 2002. For each year of NIS data, discharge‐level weights were provided to permit calculation of national estimates of hospitalization rates standardized to the concurrent national population.15 All inpatient hospital stays of children aged 17 years and younger were selected.

Discharge data were analyzed based on age, sex, payer status, and transfer status on admission. Although transfer status is not often considered in studies of mortality, we expected that it would be associated with mortality, as a potential indicator of disease severity.14 We included only interhospital transfers, and excluded patients transferred from other locations such as long‐term care facilities. We categorized discharges into 5 age groups: newborns, whose hospitalization began at birth; infants up to 1 year of age who were not born during hospitalization; 15 years; 610 years; and 1117 years. This stratification allowed us to separate infants who were admitted from home or from another hospital versus those who were born during hospitalization. Payer groups included Medicaid, private insurance, and uninsured. Medicare and other payers were analyzed, but were present in very small numbers and are not reported.

Outcomes included weighted inpatient mortality rate, weighted mean of length of stay (in days), and weighted mean total hospital charges. For nationally weighted data, lengths of stay and hospital charges are typically reported as means because weighted medians cannot be estimated.16 We compared mortality patterns for patients who were transferred between hospitals versus those who were not, using multivariable logistic regression to identify factors associated with in‐hospital mortality. Of note, transfer status was evaluated from the standpoint of the receiving hospital as children who were admitted upon transfer from another hospital. Thus, our estimates likely underestimate the effects attributed to interhospital transfer, because this evaluation is unilateral and does not include the transferring hospital. The 5 most common principal Diagnosis‐Related Groups (DRGs) upon discharge were compiled for each of the study years for both survivors and decedents. In order to interpret the analyses of discharge‐related hospital charges in constant dollars, we standardized all hospital charges to 2002 US dollars using the Consumer Price Index.17

Statistical analyses included bivariate comparisons of sociodemographic characteristics and the study outcomes, for each of the study years. We also conducted multivariable regression analyses of mortality, comparing effects of sociodemographic variables and transfer status. We conducted all analyses using Stata, version 8 (Stata Corp., College Station, TX), with which we incorporated sample weights to account for the complex stratified sampling of hospitals that comprise the NIS, and to generate variance estimates with which we derived 95% confidence intervals (95% CI). NIS samples included weighted data for 6.2 million discharges in 1992, 7.1 million discharges in 1997, and 7.9 million discharges in 2002. All results are presented using weighted values. The study was funded internally and all analyses were conducted by the authors. The authors had no financial interest in the outcome. The study was exempt from human subjects review as an analysis of de‐identified secondary data.

RESULTS

DISCUSSION

CONCLUSION

This national study of inpatient mortality patterns among US children over the span of a decade presents a new framework of challenges to clinicians and investigators regarding EOL care for children. As health care providers and institutions expand their efforts to meet the needs of severely ill children and their families, such efforts must be cognizant of the high burden of mortality among the youngest children, as well as those who are transferred between hospitals, and children without insurance coverage. These children and their families may require expanded EOL care and support services, beyond those typically available in most hospitals and communities.

More than 53,000 children 19 years of age or younger died in 2004,1 and more than 40% of these children died while hospitalized.25 Recently, pediatric end‐of‐life (EOL) issues have gained clinical and research attention, primarily focused on children with chronic conditions, ethical dilemmas surrounding childhood death and dying, and the need for interdisciplinary palliative care efforts for dying children and their families.2, 3, 69

Much remains unknown about patterns of EOL hospital care at the national level for all children, both with and without complex chronic conditions. Because a large proportion of childhood mortality occurs during hospitalization, the inpatient setting is a crucial arena for patients and families facing EOL issues. However, little is known about how insurance status and interhospital transfer are associated with patterns of hospitalization and mortality for children while hospitalized, or about hospital charges and lengths of stay for children who die as inpatients versus those who survive to discharge. In addition, although spending on EOL health care in the United States has attracted considerable attention in recent years, the published literature focuses almost exclusively on adult populations.1012

Illuminating the patterns of childhood mortality in hospital settings may inform expanding institutional efforts to address death and dying for children and their families. We conducted an analysis of national patterns of hospitalization over a span of a decade (19922002), in order to characterize sociodemographic and health care factors associated with inpatient mortality, and to examine patterns of hospital resource use related to EOL care. We hypothesized that resource use would be higher for children who died versus those who survived, and would be higher for uninsured versus insured children.13 We also hypothesized that children admitted upon transfer from another hospital would have higher risk of mortality.14

METHODS

Our data source was the National Inpatient Sample (NIS), which is a component of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality. The HCUP is a set of databases developed through partnership among health care institutions and federal and state governments.15 The NIS is the largest publicly available all‐payer inpatient database in the United States, and contains de‐identified, patient‐level clinical data included in a typical discharge abstract. For each year, these data reflect hospital stays from between 800 and 1000 institutions sampled to approximate a 20% stratified sample of nonfederal community hospitals, including public hospitals, children's hospitals, and academic medical centers but excluding long‐term hospitals, psychiatric hospitals, and chemical dependency treatment facilities.

We chose the NIS for this analysis because we were interested in the most common diagnoses for hospitalized children. An alternative database, such as the KID (Kids Inpatient Database), is optimal for less commonly seen discharge diagnoses and did not permit a full decade of retrospective analysis.

In order to characterize changes in mortality and health resource utilization related to our research questions, we conducted a comparative cross‐sectional analysis of 3 years of the NIS over the years 1992, 1997, and 2002. For each year of NIS data, discharge‐level weights were provided to permit calculation of national estimates of hospitalization rates standardized to the concurrent national population.15 All inpatient hospital stays of children aged 17 years and younger were selected.

Discharge data were analyzed based on age, sex, payer status, and transfer status on admission. Although transfer status is not often considered in studies of mortality, we expected that it would be associated with mortality, as a potential indicator of disease severity.14 We included only interhospital transfers, and excluded patients transferred from other locations such as long‐term care facilities. We categorized discharges into 5 age groups: newborns, whose hospitalization began at birth; infants up to 1 year of age who were not born during hospitalization; 15 years; 610 years; and 1117 years. This stratification allowed us to separate infants who were admitted from home or from another hospital versus those who were born during hospitalization. Payer groups included Medicaid, private insurance, and uninsured. Medicare and other payers were analyzed, but were present in very small numbers and are not reported.

Outcomes included weighted inpatient mortality rate, weighted mean of length of stay (in days), and weighted mean total hospital charges. For nationally weighted data, lengths of stay and hospital charges are typically reported as means because weighted medians cannot be estimated.16 We compared mortality patterns for patients who were transferred between hospitals versus those who were not, using multivariable logistic regression to identify factors associated with in‐hospital mortality. Of note, transfer status was evaluated from the standpoint of the receiving hospital as children who were admitted upon transfer from another hospital. Thus, our estimates likely underestimate the effects attributed to interhospital transfer, because this evaluation is unilateral and does not include the transferring hospital. The 5 most common principal Diagnosis‐Related Groups (DRGs) upon discharge were compiled for each of the study years for both survivors and decedents. In order to interpret the analyses of discharge‐related hospital charges in constant dollars, we standardized all hospital charges to 2002 US dollars using the Consumer Price Index.17

Statistical analyses included bivariate comparisons of sociodemographic characteristics and the study outcomes, for each of the study years. We also conducted multivariable regression analyses of mortality, comparing effects of sociodemographic variables and transfer status. We conducted all analyses using Stata, version 8 (Stata Corp., College Station, TX), with which we incorporated sample weights to account for the complex stratified sampling of hospitals that comprise the NIS, and to generate variance estimates with which we derived 95% confidence intervals (95% CI). NIS samples included weighted data for 6.2 million discharges in 1992, 7.1 million discharges in 1997, and 7.9 million discharges in 2002. All results are presented using weighted values. The study was funded internally and all analyses were conducted by the authors. The authors had no financial interest in the outcome. The study was exempt from human subjects review as an analysis of de‐identified secondary data.

RESULTS

DISCUSSION

CONCLUSION

This national study of inpatient mortality patterns among US children over the span of a decade presents a new framework of challenges to clinicians and investigators regarding EOL care for children. As health care providers and institutions expand their efforts to meet the needs of severely ill children and their families, such efforts must be cognizant of the high burden of mortality among the youngest children, as well as those who are transferred between hospitals, and children without insurance coverage. These children and their families may require expanded EOL care and support services, beyond those typically available in most hospitals and communities.