Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

My father was a god; my grandfather was a god. My aunt killed my mother, and my grandfather plans on killing me. I guess you might call us a dysfunctional family. Some people also say I am a god, but I don’t see it that way. There’s no accounting for what people believe in. The ancient Greeks and Romans liked to make up stories about me; sometimes even I am not sure what is truth and what is fiction. I thought I’d take this chance to tell you about myself. If you are a modern-day proponent of the healing arts, perhaps you will find this of interest.

Dear Old Dad

My father was Apollo, son of Jupiter. He wasn’t a great dad; he was more interested in his godly duties and romantic liaisons than in my upbringing. My mother was a nymph named Coronis. I never met her. She was obviously beautiful and alluring; it’s a nymph thing. She met Apollo, and they spent many happy days in the olive groves. I was conceived on a beautiful hillside above the Aegean Sea.

Apollo soon lost interest in Coronis; he was busy with the family business: causing plagues, driving the chariot of fire across the sky, and so on. Coronis discovered she was pregnant and met a heroic mortal, Ischys; together, they tried to start a new life. There was no way Apollo was going to go along with this. No one leaves a god; it’s supposed to be the other way around. Apollo killed the mortal Ischys and had his sister Diana shoot an arrow into Coronis’ heart. As my mother’s body burned on a funeral pyre, Apollo had a fit of remorse and cut me from my mother’s womb—the first of what would eventually be called cesarean sections. Welcome to my life.

The Early Years

My home was on Mount Pelion. Chiron, a centaur, was my nanny and mentor. He was an expert hunter and was well versed in medicine and music. He was always horsing around. His daughter, Ocyrhoe, prophesied that I would become a great healer; with my heritage, it seemed a safe bet. When Chiron died, years later, Jupiter placed him in the sky; you might recognize him as Sagittarius. One day, millennia later, a company would take his name and would have trouble making influenza vaccine. I grew up under his tutelage and, in time, became an adequate healer myself.

The Wife and Kids

When I grew older, it was time to take a wife. I found a woman with an interest in botanicals. Her name was Epione. We had many children together, but things eroded in our relationship after that. It might have been a postpartum thing, or maybe I spent too much time at work. I’ll never know. She became more interested in soporifics—mandrake especially. She started spending a lot of time in her cave. She and Bacchus were always sitting around our home partying and listening to Pluto’s underworld band, The Dead, and enjoying their favorite song, “The Deadly Nightshade.”

I did pretty well with my children; they all went into the family healing business. My first daughter was named Hygeia. She was always by my side and a great help in my practice. She specialized in preventing disease. My second daughter was Panacea. She was pretty good with a cure and was always in high demand. She started hanging around with some chick named Placebo. Her name in Latin means “I will please,” and she always did. Two of my sons, Machaon and Podalirius, became naval surgeons; one was wounded at Troy but survived. My third son, Telosophorus, was born a dwarf and specialized in rehabilitation.

 

Things Take a Turn for the Worse

Life was going pretty well until I was lured into the shadowy realms of life and death. I had always believed that if the gods decided a patient was to get better, then I must use my skill to aid in this endeavor. If the Fates had decreed a patient was to die, there was little I could do against the will of the gods. Then events occurred that would enable me to take things to a whole new level, and—once again—it was because of sex.

Theseus was the king of Athens. He became king when his father committed suicide, thinking wrongly that Theseus was dead. This was not an auspicious start for a ruler. When Theseus’ first wife died, he married the princess Phaedra, daughter of the Cretan King Minos—a truly freaky chick. Theseus had a grown son, Hippolytus, who had rugged good looks and a bright future, a real stud. Phaedra decided Hippolytus would be a better husband for her than his father, but Hippolytus spurned her advances. Phaedra, in her wrath, turned Theseus against his son. Theseus used his own godly contacts and convinced Neptune to deal with Hippolytus. While Hippolytus was driving a chariot along a coastal road, Neptune set a sea monster to rise up from the ocean, scaring Theseus’ horse, which led to a fatal crash.

The goddess Diana, my aunt, came to me and taught me the secret to reviving the dead. Don’t expect me to share it with you. No “see one, do one, teach one” from me. I’ll just say it involves very small thunderbolts. I would have been better off without the knowledge. Using the new technique, I revived Hippolytus, who spent the rest of his days in Italy with a water nymph named Egeria. Not a bad afterlife. My trouble, on the other hand, had just begun. Pluto, god of the underworld, was furious. He thought no man should remove the dead from his realm. It was a classic turf battle, and I lost. Jupiter, my grandfather, was forced to put me to death with a thunderbolt.

Life after Death

My name lived on. The earliest places of healing were temples of Aesculapius; the Iatros, who worked there, were the earliest physicians. Yes, they did make me a god, but it’s not like I could stop them. On the island of Kós, my thousandth grandson was named Hippocrates—you may have heard of him. Another of my descendants, Galen, trained at my temple in Pergamon.

It’s been a few thousand years since all of this happened. Don’t ask how you can be reading my words—it’s a mythology thing. Things did not go well for Apollo after I died. When he heard I had been killed, my father lost his temper and took out his wrath on the cyclops who had made Jupiter’s thunderbolts on Mount Aetna. His punishment for that temper tantrum was to serve a mortal, Admetus, for a year. Admetus fell ill; near death, he convinced Apollo to appeal to the Fates. They agreed that someone would take his place. Nobody in the kingdom volunteered for this duty, not even his elderly parents. Finally his wife Alcestis volunteered, and her fate was set. When Death came for her, Hercules, who was passing through, seized Death and would not let him go until she was spared.

 

Lessons from the Past

You, the modern hospitalist, may read this tale and wonder what it has to do with modern-day medicine and why it is in this publication. Perhaps the Fates have had their way with the medical editor—hence this topic in this publication. Some parts of the tale are of etymological interest: Panacea, Hygeia, Iatros, Aesculapius, Chiron, and Aetna, to name a few. The bigger issue is the question of how your medical forefathers looked at life and death. Perhaps a patient might be healed, but if not, it was the gods’ will. Death was not easily cheated. Ademetus was saved by his wife’s sacrifice; she was willing to donate her life for his. There is something in this tale about futile resuscitation as well. And of course, the most important message: It never pays to get involved in sex or politics. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

My father was a god; my grandfather was a god. My aunt killed my mother, and my grandfather plans on killing me. I guess you might call us a dysfunctional family. Some people also say I am a god, but I don’t see it that way. There’s no accounting for what people believe in. The ancient Greeks and Romans liked to make up stories about me; sometimes even I am not sure what is truth and what is fiction. I thought I’d take this chance to tell you about myself. If you are a modern-day proponent of the healing arts, perhaps you will find this of interest.

Dear Old Dad

My father was Apollo, son of Jupiter. He wasn’t a great dad; he was more interested in his godly duties and romantic liaisons than in my upbringing. My mother was a nymph named Coronis. I never met her. She was obviously beautiful and alluring; it’s a nymph thing. She met Apollo, and they spent many happy days in the olive groves. I was conceived on a beautiful hillside above the Aegean Sea.

Apollo soon lost interest in Coronis; he was busy with the family business: causing plagues, driving the chariot of fire across the sky, and so on. Coronis discovered she was pregnant and met a heroic mortal, Ischys; together, they tried to start a new life. There was no way Apollo was going to go along with this. No one leaves a god; it’s supposed to be the other way around. Apollo killed the mortal Ischys and had his sister Diana shoot an arrow into Coronis’ heart. As my mother’s body burned on a funeral pyre, Apollo had a fit of remorse and cut me from my mother’s womb—the first of what would eventually be called cesarean sections. Welcome to my life.

The Early Years

My home was on Mount Pelion. Chiron, a centaur, was my nanny and mentor. He was an expert hunter and was well versed in medicine and music. He was always horsing around. His daughter, Ocyrhoe, prophesied that I would become a great healer; with my heritage, it seemed a safe bet. When Chiron died, years later, Jupiter placed him in the sky; you might recognize him as Sagittarius. One day, millennia later, a company would take his name and would have trouble making influenza vaccine. I grew up under his tutelage and, in time, became an adequate healer myself.

The Wife and Kids

When I grew older, it was time to take a wife. I found a woman with an interest in botanicals. Her name was Epione. We had many children together, but things eroded in our relationship after that. It might have been a postpartum thing, or maybe I spent too much time at work. I’ll never know. She became more interested in soporifics—mandrake especially. She started spending a lot of time in her cave. She and Bacchus were always sitting around our home partying and listening to Pluto’s underworld band, The Dead, and enjoying their favorite song, “The Deadly Nightshade.”

I did pretty well with my children; they all went into the family healing business. My first daughter was named Hygeia. She was always by my side and a great help in my practice. She specialized in preventing disease. My second daughter was Panacea. She was pretty good with a cure and was always in high demand. She started hanging around with some chick named Placebo. Her name in Latin means “I will please,” and she always did. Two of my sons, Machaon and Podalirius, became naval surgeons; one was wounded at Troy but survived. My third son, Telosophorus, was born a dwarf and specialized in rehabilitation.

 

Things Take a Turn for the Worse

Life was going pretty well until I was lured into the shadowy realms of life and death. I had always believed that if the gods decided a patient was to get better, then I must use my skill to aid in this endeavor. If the Fates had decreed a patient was to die, there was little I could do against the will of the gods. Then events occurred that would enable me to take things to a whole new level, and—once again—it was because of sex.

Theseus was the king of Athens. He became king when his father committed suicide, thinking wrongly that Theseus was dead. This was not an auspicious start for a ruler. When Theseus’ first wife died, he married the princess Phaedra, daughter of the Cretan King Minos—a truly freaky chick. Theseus had a grown son, Hippolytus, who had rugged good looks and a bright future, a real stud. Phaedra decided Hippolytus would be a better husband for her than his father, but Hippolytus spurned her advances. Phaedra, in her wrath, turned Theseus against his son. Theseus used his own godly contacts and convinced Neptune to deal with Hippolytus. While Hippolytus was driving a chariot along a coastal road, Neptune set a sea monster to rise up from the ocean, scaring Theseus’ horse, which led to a fatal crash.

The goddess Diana, my aunt, came to me and taught me the secret to reviving the dead. Don’t expect me to share it with you. No “see one, do one, teach one” from me. I’ll just say it involves very small thunderbolts. I would have been better off without the knowledge. Using the new technique, I revived Hippolytus, who spent the rest of his days in Italy with a water nymph named Egeria. Not a bad afterlife. My trouble, on the other hand, had just begun. Pluto, god of the underworld, was furious. He thought no man should remove the dead from his realm. It was a classic turf battle, and I lost. Jupiter, my grandfather, was forced to put me to death with a thunderbolt.

Life after Death

My name lived on. The earliest places of healing were temples of Aesculapius; the Iatros, who worked there, were the earliest physicians. Yes, they did make me a god, but it’s not like I could stop them. On the island of Kós, my thousandth grandson was named Hippocrates—you may have heard of him. Another of my descendants, Galen, trained at my temple in Pergamon.

It’s been a few thousand years since all of this happened. Don’t ask how you can be reading my words—it’s a mythology thing. Things did not go well for Apollo after I died. When he heard I had been killed, my father lost his temper and took out his wrath on the cyclops who had made Jupiter’s thunderbolts on Mount Aetna. His punishment for that temper tantrum was to serve a mortal, Admetus, for a year. Admetus fell ill; near death, he convinced Apollo to appeal to the Fates. They agreed that someone would take his place. Nobody in the kingdom volunteered for this duty, not even his elderly parents. Finally his wife Alcestis volunteered, and her fate was set. When Death came for her, Hercules, who was passing through, seized Death and would not let him go until she was spared.

 

Lessons from the Past

You, the modern hospitalist, may read this tale and wonder what it has to do with modern-day medicine and why it is in this publication. Perhaps the Fates have had their way with the medical editor—hence this topic in this publication. Some parts of the tale are of etymological interest: Panacea, Hygeia, Iatros, Aesculapius, Chiron, and Aetna, to name a few. The bigger issue is the question of how your medical forefathers looked at life and death. Perhaps a patient might be healed, but if not, it was the gods’ will. Death was not easily cheated. Ademetus was saved by his wife’s sacrifice; she was willing to donate her life for his. There is something in this tale about futile resuscitation as well. And of course, the most important message: It never pays to get involved in sex or politics. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

My father was a god; my grandfather was a god. My aunt killed my mother, and my grandfather plans on killing me. I guess you might call us a dysfunctional family. Some people also say I am a god, but I don’t see it that way. There’s no accounting for what people believe in. The ancient Greeks and Romans liked to make up stories about me; sometimes even I am not sure what is truth and what is fiction. I thought I’d take this chance to tell you about myself. If you are a modern-day proponent of the healing arts, perhaps you will find this of interest.

Dear Old Dad

My father was Apollo, son of Jupiter. He wasn’t a great dad; he was more interested in his godly duties and romantic liaisons than in my upbringing. My mother was a nymph named Coronis. I never met her. She was obviously beautiful and alluring; it’s a nymph thing. She met Apollo, and they spent many happy days in the olive groves. I was conceived on a beautiful hillside above the Aegean Sea.

Apollo soon lost interest in Coronis; he was busy with the family business: causing plagues, driving the chariot of fire across the sky, and so on. Coronis discovered she was pregnant and met a heroic mortal, Ischys; together, they tried to start a new life. There was no way Apollo was going to go along with this. No one leaves a god; it’s supposed to be the other way around. Apollo killed the mortal Ischys and had his sister Diana shoot an arrow into Coronis’ heart. As my mother’s body burned on a funeral pyre, Apollo had a fit of remorse and cut me from my mother’s womb—the first of what would eventually be called cesarean sections. Welcome to my life.

The Early Years

My home was on Mount Pelion. Chiron, a centaur, was my nanny and mentor. He was an expert hunter and was well versed in medicine and music. He was always horsing around. His daughter, Ocyrhoe, prophesied that I would become a great healer; with my heritage, it seemed a safe bet. When Chiron died, years later, Jupiter placed him in the sky; you might recognize him as Sagittarius. One day, millennia later, a company would take his name and would have trouble making influenza vaccine. I grew up under his tutelage and, in time, became an adequate healer myself.

The Wife and Kids

When I grew older, it was time to take a wife. I found a woman with an interest in botanicals. Her name was Epione. We had many children together, but things eroded in our relationship after that. It might have been a postpartum thing, or maybe I spent too much time at work. I’ll never know. She became more interested in soporifics—mandrake especially. She started spending a lot of time in her cave. She and Bacchus were always sitting around our home partying and listening to Pluto’s underworld band, The Dead, and enjoying their favorite song, “The Deadly Nightshade.”

I did pretty well with my children; they all went into the family healing business. My first daughter was named Hygeia. She was always by my side and a great help in my practice. She specialized in preventing disease. My second daughter was Panacea. She was pretty good with a cure and was always in high demand. She started hanging around with some chick named Placebo. Her name in Latin means “I will please,” and she always did. Two of my sons, Machaon and Podalirius, became naval surgeons; one was wounded at Troy but survived. My third son, Telosophorus, was born a dwarf and specialized in rehabilitation.

 

Things Take a Turn for the Worse

Life was going pretty well until I was lured into the shadowy realms of life and death. I had always believed that if the gods decided a patient was to get better, then I must use my skill to aid in this endeavor. If the Fates had decreed a patient was to die, there was little I could do against the will of the gods. Then events occurred that would enable me to take things to a whole new level, and—once again—it was because of sex.

Theseus was the king of Athens. He became king when his father committed suicide, thinking wrongly that Theseus was dead. This was not an auspicious start for a ruler. When Theseus’ first wife died, he married the princess Phaedra, daughter of the Cretan King Minos—a truly freaky chick. Theseus had a grown son, Hippolytus, who had rugged good looks and a bright future, a real stud. Phaedra decided Hippolytus would be a better husband for her than his father, but Hippolytus spurned her advances. Phaedra, in her wrath, turned Theseus against his son. Theseus used his own godly contacts and convinced Neptune to deal with Hippolytus. While Hippolytus was driving a chariot along a coastal road, Neptune set a sea monster to rise up from the ocean, scaring Theseus’ horse, which led to a fatal crash.

The goddess Diana, my aunt, came to me and taught me the secret to reviving the dead. Don’t expect me to share it with you. No “see one, do one, teach one” from me. I’ll just say it involves very small thunderbolts. I would have been better off without the knowledge. Using the new technique, I revived Hippolytus, who spent the rest of his days in Italy with a water nymph named Egeria. Not a bad afterlife. My trouble, on the other hand, had just begun. Pluto, god of the underworld, was furious. He thought no man should remove the dead from his realm. It was a classic turf battle, and I lost. Jupiter, my grandfather, was forced to put me to death with a thunderbolt.

Life after Death

My name lived on. The earliest places of healing were temples of Aesculapius; the Iatros, who worked there, were the earliest physicians. Yes, they did make me a god, but it’s not like I could stop them. On the island of Kós, my thousandth grandson was named Hippocrates—you may have heard of him. Another of my descendants, Galen, trained at my temple in Pergamon.

It’s been a few thousand years since all of this happened. Don’t ask how you can be reading my words—it’s a mythology thing. Things did not go well for Apollo after I died. When he heard I had been killed, my father lost his temper and took out his wrath on the cyclops who had made Jupiter’s thunderbolts on Mount Aetna. His punishment for that temper tantrum was to serve a mortal, Admetus, for a year. Admetus fell ill; near death, he convinced Apollo to appeal to the Fates. They agreed that someone would take his place. Nobody in the kingdom volunteered for this duty, not even his elderly parents. Finally his wife Alcestis volunteered, and her fate was set. When Death came for her, Hercules, who was passing through, seized Death and would not let him go until she was spared.

 

Lessons from the Past

You, the modern hospitalist, may read this tale and wonder what it has to do with modern-day medicine and why it is in this publication. Perhaps the Fates have had their way with the medical editor—hence this topic in this publication. Some parts of the tale are of etymological interest: Panacea, Hygeia, Iatros, Aesculapius, Chiron, and Aetna, to name a few. The bigger issue is the question of how your medical forefathers looked at life and death. Perhaps a patient might be healed, but if not, it was the gods’ will. Death was not easily cheated. Ademetus was saved by his wife’s sacrifice; she was willing to donate her life for his. There is something in this tale about futile resuscitation as well. And of course, the most important message: It never pays to get involved in sex or politics. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

The vacation conundrum most people face has to do with things like whether to drive or fly, or whether to sleep on the ground or in a hotel. But some hospitalists encounter tricky problems when figuring out how to operationalize their contractual provision for vacation time.

What is the Vacation Conundrum?

I’m a big believer in hospitalists having liberal amounts of time off, but I think most practices should avoid contractually specifying vacation time. This may sound contradictory and terribly unfair to the doctor. But avoiding a contractual guarantee of vacation time doesn’t mean the hospitalist gets any less time off. And the way hospitalist contracts address vacation time has gotten a lot of organizations in trouble. Let me explain.

Contracts often stipulate that a hospitalist will have a specified number of weeks of vacation time annually, and this language has usually been taken from the organization’s existing contracts with other physicians. But confusion often arises some time after the hospitalist practice is up and running. One big problem is deciding who will cover for the hospitalist on vacation. If all doctors work extra shifts to cover for a member of the practice who is on vacation, they will all take turns working extra—a practice that negates the effect of the promised holiday. Another problem is that most hospitalists follow non-traditional work schedules, making it difficult to determine which of the days not worked are vacation days and which are days the doctor just wasn’t scheduled to work.

To better understand this issue, it is worth thinking about how most hospitalist schedules differ from that of a typical office-based doctor or businessperson. Someone in business is usually expected to work every Monday through Friday of the year—except government holidays. Those weekdays that the business person doesn’t work are usually regarded as vacation days. (Note that I’m intentionally ignoring sick time in this discussion.) Weekend days are almost never regarded as vacation days in the business world.

But things are far more complicated for hospitalists because of the non-traditional—not always Monday through Friday—schedule they work. If a hospitalist has Tuesday and Wednesday off this week, should that be counted as vacation time or simply weekend days displaced into the middle of the week because the doctor worked the prior weekend? It is often impossible to answer this question unambiguously.

Another issue to be considered is that decisions about vacation time and the normal—non-vacation—schedule the hospitalists use are often made independently. For example, many groups use a seven days on-seven days off schedule, with 12-hour shifts on each worked day. This might lead to an agreement that every seven worked days will count as two weeks of work that has been compressed into one week on the calendar. If that’s the case, debate can arise when trying to figure out what one week of vacation really means.

One could reasonably argue that it means the doctor is relieved of five days of work, because in most jobs a week off means being off Monday through Friday. Or, because every seven worked days counts as two weeks of work, a week off could mean being relieved of half of those days—or 3.5 days off. Lastly, a hospitalist could reasonably argue that a week off means being relieved of all seven days of one of the worked weeks. This last approach is the most common way the issue is handled. Specifying vacation in numbers of days or hours, rather than in numbers of weeks, helps but does not eliminate this confusion.

 

Things can get really tricky when hospitalists start adjusting their standard work schedule. They might shorten or lengthen certain existing shifts or add new shifts (e.g., an evening admitting shift) all of which complicates figuring out what a day or week of vacation really means. Think about a group that has a standard schedule of 10-hour day shifts, 14-hour night shifts, and a six-hour evening admitting shift (e.g., 5 p.m. to 11 p.m.). What will a day or week of vacation mean for them? Maybe they could specify a certain number of hours of vacation rather than days or weeks. That would be useful only for practices that contract for doctors to work a specified number of hours annually, which is probably not the best way to organize a hospitalist’s work. And hours of vacation time can get pretty complicated because doctors usually don’t regard an hour of a day shift as equivalent to an hour of the night or evening shift.

I have a great relationship with a hospital executive who works a Monday-through-Friday schedule. For years, when she noticed that I had been off for a few days, she would always ask if I had just gotten back from “vacation.” I wouldn’t bother to explain to her that it usually wasn’t vacation; it was just days I wasn’t scheduled to work to make up for working 12 to 20 consecutive days. But after about a year of her asking me about my vacation every two or three weeks, she mentioned how much she envied that I had so much vacation time, when in fact I had worked more days that year—had less time off and less vacation time—than she had. I could have taken the time to respond to each of her inquiries about my vacations by explaining which were just days I wasn’t scheduled to work and which really were vacation days. But the distinction is really arbitrary. As long as I’m getting enough time off—a lot—how each of those days is labeled doesn’t really matter.

Solutions to the Vacation Conundrum

I think it’s best to use one of the following two approaches to avoid confusion about vacation time:

1. Specify how many shifts—or other work periods—the hospitalist is expected to work monthly or annually; or
2. Agree—perhaps in a contract—that each hospitalist will work the same number of days (shifts) annually unless doctors mutually decide to do otherwise.

All of the other days can be thought of as days not scheduled to work—weekends, if you will, even if the days off occur during the week instead of Saturday and Sunday—vacation days, or even CME days. That way there is no need to keep track of how the days not worked are labeled or classified.

Full-time hospitalists in the group I am part of work 210 days annually. After I explain our schedule to a prospective new member of the group, I’m often asked how much vacation a new hire will get. I explain that we just specify how much work is expected of a doctor, and the non-worked days can be classified any way they would like. Understandably, some people really want a provision for vacation in the contract, so I will sometimes ask them to tell me how many vacation days they would like annually. If they say they’d like 21 days of vacation, I tell them that will be fine. We will write the contract to reflect the 231 days they are expected to work annually, but they will have 21 days of vacation. So they’re back to working the same 210 days a year that the rest of us work.

 

Summary

If your current contract specifies numbers of days—or weeks or hours—of vacation time and that works well, without any confusion about what constitutes a vacation day, then there is no reason to change anything right now. But you should think about what a day of vacation might mean if you change your current schedule a great deal—if you changed the duration of shifts, for example. If that might cast uncertainty on what a day of vacation means, then consider developing a contract that is silent on vacation and just specifies how much work is expected of the doctor.

I want to emphasize again that a hospitalist will have exactly the same amount of time off for vacation or any other purpose in a contract that just specifies the number of shifts/days worked and is silent on vacation time. This does not take anything away from the doctor. It is simply a different way to address the issue in the contract, while eliminating a lot of potential confusion and frustration.

If you want to know if this is really a reasonable and workable approach to vacation time, you should talk with the emergency department (ED) doctors at your hospital. If you ask them how much vacation they get, they’re likely to look puzzled and say something like, “I don’t know how much vacation time I get. All I know is that I work 14 shifts a month.” Years ago, the non-traditional working schedule used by ED doctors led many or most groups to adopt the approach to vacation I’m suggesting for hospitalists. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

The vacation conundrum most people face has to do with things like whether to drive or fly, or whether to sleep on the ground or in a hotel. But some hospitalists encounter tricky problems when figuring out how to operationalize their contractual provision for vacation time.

What is the Vacation Conundrum?

I’m a big believer in hospitalists having liberal amounts of time off, but I think most practices should avoid contractually specifying vacation time. This may sound contradictory and terribly unfair to the doctor. But avoiding a contractual guarantee of vacation time doesn’t mean the hospitalist gets any less time off. And the way hospitalist contracts address vacation time has gotten a lot of organizations in trouble. Let me explain.

Contracts often stipulate that a hospitalist will have a specified number of weeks of vacation time annually, and this language has usually been taken from the organization’s existing contracts with other physicians. But confusion often arises some time after the hospitalist practice is up and running. One big problem is deciding who will cover for the hospitalist on vacation. If all doctors work extra shifts to cover for a member of the practice who is on vacation, they will all take turns working extra—a practice that negates the effect of the promised holiday. Another problem is that most hospitalists follow non-traditional work schedules, making it difficult to determine which of the days not worked are vacation days and which are days the doctor just wasn’t scheduled to work.

To better understand this issue, it is worth thinking about how most hospitalist schedules differ from that of a typical office-based doctor or businessperson. Someone in business is usually expected to work every Monday through Friday of the year—except government holidays. Those weekdays that the business person doesn’t work are usually regarded as vacation days. (Note that I’m intentionally ignoring sick time in this discussion.) Weekend days are almost never regarded as vacation days in the business world.

But things are far more complicated for hospitalists because of the non-traditional—not always Monday through Friday—schedule they work. If a hospitalist has Tuesday and Wednesday off this week, should that be counted as vacation time or simply weekend days displaced into the middle of the week because the doctor worked the prior weekend? It is often impossible to answer this question unambiguously.

Another issue to be considered is that decisions about vacation time and the normal—non-vacation—schedule the hospitalists use are often made independently. For example, many groups use a seven days on-seven days off schedule, with 12-hour shifts on each worked day. This might lead to an agreement that every seven worked days will count as two weeks of work that has been compressed into one week on the calendar. If that’s the case, debate can arise when trying to figure out what one week of vacation really means.

One could reasonably argue that it means the doctor is relieved of five days of work, because in most jobs a week off means being off Monday through Friday. Or, because every seven worked days counts as two weeks of work, a week off could mean being relieved of half of those days—or 3.5 days off. Lastly, a hospitalist could reasonably argue that a week off means being relieved of all seven days of one of the worked weeks. This last approach is the most common way the issue is handled. Specifying vacation in numbers of days or hours, rather than in numbers of weeks, helps but does not eliminate this confusion.

 

Things can get really tricky when hospitalists start adjusting their standard work schedule. They might shorten or lengthen certain existing shifts or add new shifts (e.g., an evening admitting shift) all of which complicates figuring out what a day or week of vacation really means. Think about a group that has a standard schedule of 10-hour day shifts, 14-hour night shifts, and a six-hour evening admitting shift (e.g., 5 p.m. to 11 p.m.). What will a day or week of vacation mean for them? Maybe they could specify a certain number of hours of vacation rather than days or weeks. That would be useful only for practices that contract for doctors to work a specified number of hours annually, which is probably not the best way to organize a hospitalist’s work. And hours of vacation time can get pretty complicated because doctors usually don’t regard an hour of a day shift as equivalent to an hour of the night or evening shift.

I have a great relationship with a hospital executive who works a Monday-through-Friday schedule. For years, when she noticed that I had been off for a few days, she would always ask if I had just gotten back from “vacation.” I wouldn’t bother to explain to her that it usually wasn’t vacation; it was just days I wasn’t scheduled to work to make up for working 12 to 20 consecutive days. But after about a year of her asking me about my vacation every two or three weeks, she mentioned how much she envied that I had so much vacation time, when in fact I had worked more days that year—had less time off and less vacation time—than she had. I could have taken the time to respond to each of her inquiries about my vacations by explaining which were just days I wasn’t scheduled to work and which really were vacation days. But the distinction is really arbitrary. As long as I’m getting enough time off—a lot—how each of those days is labeled doesn’t really matter.

Solutions to the Vacation Conundrum

I think it’s best to use one of the following two approaches to avoid confusion about vacation time:

1. Specify how many shifts—or other work periods—the hospitalist is expected to work monthly or annually; or
2. Agree—perhaps in a contract—that each hospitalist will work the same number of days (shifts) annually unless doctors mutually decide to do otherwise.

All of the other days can be thought of as days not scheduled to work—weekends, if you will, even if the days off occur during the week instead of Saturday and Sunday—vacation days, or even CME days. That way there is no need to keep track of how the days not worked are labeled or classified.

Full-time hospitalists in the group I am part of work 210 days annually. After I explain our schedule to a prospective new member of the group, I’m often asked how much vacation a new hire will get. I explain that we just specify how much work is expected of a doctor, and the non-worked days can be classified any way they would like. Understandably, some people really want a provision for vacation in the contract, so I will sometimes ask them to tell me how many vacation days they would like annually. If they say they’d like 21 days of vacation, I tell them that will be fine. We will write the contract to reflect the 231 days they are expected to work annually, but they will have 21 days of vacation. So they’re back to working the same 210 days a year that the rest of us work.

 

Summary

If your current contract specifies numbers of days—or weeks or hours—of vacation time and that works well, without any confusion about what constitutes a vacation day, then there is no reason to change anything right now. But you should think about what a day of vacation might mean if you change your current schedule a great deal—if you changed the duration of shifts, for example. If that might cast uncertainty on what a day of vacation means, then consider developing a contract that is silent on vacation and just specifies how much work is expected of the doctor.

I want to emphasize again that a hospitalist will have exactly the same amount of time off for vacation or any other purpose in a contract that just specifies the number of shifts/days worked and is silent on vacation time. This does not take anything away from the doctor. It is simply a different way to address the issue in the contract, while eliminating a lot of potential confusion and frustration.

If you want to know if this is really a reasonable and workable approach to vacation time, you should talk with the emergency department (ED) doctors at your hospital. If you ask them how much vacation they get, they’re likely to look puzzled and say something like, “I don’t know how much vacation time I get. All I know is that I work 14 shifts a month.” Years ago, the non-traditional working schedule used by ED doctors led many or most groups to adopt the approach to vacation I’m suggesting for hospitalists. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

The vacation conundrum most people face has to do with things like whether to drive or fly, or whether to sleep on the ground or in a hotel. But some hospitalists encounter tricky problems when figuring out how to operationalize their contractual provision for vacation time.

What is the Vacation Conundrum?

I’m a big believer in hospitalists having liberal amounts of time off, but I think most practices should avoid contractually specifying vacation time. This may sound contradictory and terribly unfair to the doctor. But avoiding a contractual guarantee of vacation time doesn’t mean the hospitalist gets any less time off. And the way hospitalist contracts address vacation time has gotten a lot of organizations in trouble. Let me explain.

Contracts often stipulate that a hospitalist will have a specified number of weeks of vacation time annually, and this language has usually been taken from the organization’s existing contracts with other physicians. But confusion often arises some time after the hospitalist practice is up and running. One big problem is deciding who will cover for the hospitalist on vacation. If all doctors work extra shifts to cover for a member of the practice who is on vacation, they will all take turns working extra—a practice that negates the effect of the promised holiday. Another problem is that most hospitalists follow non-traditional work schedules, making it difficult to determine which of the days not worked are vacation days and which are days the doctor just wasn’t scheduled to work.

To better understand this issue, it is worth thinking about how most hospitalist schedules differ from that of a typical office-based doctor or businessperson. Someone in business is usually expected to work every Monday through Friday of the year—except government holidays. Those weekdays that the business person doesn’t work are usually regarded as vacation days. (Note that I’m intentionally ignoring sick time in this discussion.) Weekend days are almost never regarded as vacation days in the business world.

But things are far more complicated for hospitalists because of the non-traditional—not always Monday through Friday—schedule they work. If a hospitalist has Tuesday and Wednesday off this week, should that be counted as vacation time or simply weekend days displaced into the middle of the week because the doctor worked the prior weekend? It is often impossible to answer this question unambiguously.

Another issue to be considered is that decisions about vacation time and the normal—non-vacation—schedule the hospitalists use are often made independently. For example, many groups use a seven days on-seven days off schedule, with 12-hour shifts on each worked day. This might lead to an agreement that every seven worked days will count as two weeks of work that has been compressed into one week on the calendar. If that’s the case, debate can arise when trying to figure out what one week of vacation really means.

One could reasonably argue that it means the doctor is relieved of five days of work, because in most jobs a week off means being off Monday through Friday. Or, because every seven worked days counts as two weeks of work, a week off could mean being relieved of half of those days—or 3.5 days off. Lastly, a hospitalist could reasonably argue that a week off means being relieved of all seven days of one of the worked weeks. This last approach is the most common way the issue is handled. Specifying vacation in numbers of days or hours, rather than in numbers of weeks, helps but does not eliminate this confusion.

 

Things can get really tricky when hospitalists start adjusting their standard work schedule. They might shorten or lengthen certain existing shifts or add new shifts (e.g., an evening admitting shift) all of which complicates figuring out what a day or week of vacation really means. Think about a group that has a standard schedule of 10-hour day shifts, 14-hour night shifts, and a six-hour evening admitting shift (e.g., 5 p.m. to 11 p.m.). What will a day or week of vacation mean for them? Maybe they could specify a certain number of hours of vacation rather than days or weeks. That would be useful only for practices that contract for doctors to work a specified number of hours annually, which is probably not the best way to organize a hospitalist’s work. And hours of vacation time can get pretty complicated because doctors usually don’t regard an hour of a day shift as equivalent to an hour of the night or evening shift.

I have a great relationship with a hospital executive who works a Monday-through-Friday schedule. For years, when she noticed that I had been off for a few days, she would always ask if I had just gotten back from “vacation.” I wouldn’t bother to explain to her that it usually wasn’t vacation; it was just days I wasn’t scheduled to work to make up for working 12 to 20 consecutive days. But after about a year of her asking me about my vacation every two or three weeks, she mentioned how much she envied that I had so much vacation time, when in fact I had worked more days that year—had less time off and less vacation time—than she had. I could have taken the time to respond to each of her inquiries about my vacations by explaining which were just days I wasn’t scheduled to work and which really were vacation days. But the distinction is really arbitrary. As long as I’m getting enough time off—a lot—how each of those days is labeled doesn’t really matter.

Solutions to the Vacation Conundrum

I think it’s best to use one of the following two approaches to avoid confusion about vacation time:

1. Specify how many shifts—or other work periods—the hospitalist is expected to work monthly or annually; or
2. Agree—perhaps in a contract—that each hospitalist will work the same number of days (shifts) annually unless doctors mutually decide to do otherwise.

All of the other days can be thought of as days not scheduled to work—weekends, if you will, even if the days off occur during the week instead of Saturday and Sunday—vacation days, or even CME days. That way there is no need to keep track of how the days not worked are labeled or classified.

Full-time hospitalists in the group I am part of work 210 days annually. After I explain our schedule to a prospective new member of the group, I’m often asked how much vacation a new hire will get. I explain that we just specify how much work is expected of a doctor, and the non-worked days can be classified any way they would like. Understandably, some people really want a provision for vacation in the contract, so I will sometimes ask them to tell me how many vacation days they would like annually. If they say they’d like 21 days of vacation, I tell them that will be fine. We will write the contract to reflect the 231 days they are expected to work annually, but they will have 21 days of vacation. So they’re back to working the same 210 days a year that the rest of us work.

 

Summary

If your current contract specifies numbers of days—or weeks or hours—of vacation time and that works well, without any confusion about what constitutes a vacation day, then there is no reason to change anything right now. But you should think about what a day of vacation might mean if you change your current schedule a great deal—if you changed the duration of shifts, for example. If that might cast uncertainty on what a day of vacation means, then consider developing a contract that is silent on vacation and just specifies how much work is expected of the doctor.

I want to emphasize again that a hospitalist will have exactly the same amount of time off for vacation or any other purpose in a contract that just specifies the number of shifts/days worked and is silent on vacation time. This does not take anything away from the doctor. It is simply a different way to address the issue in the contract, while eliminating a lot of potential confusion and frustration.

If you want to know if this is really a reasonable and workable approach to vacation time, you should talk with the emergency department (ED) doctors at your hospital. If you ask them how much vacation they get, they’re likely to look puzzled and say something like, “I don’t know how much vacation time I get. All I know is that I work 14 shifts a month.” Years ago, the non-traditional working schedule used by ED doctors led many or most groups to adopt the approach to vacation I’m suggesting for hospitalists. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Reduce CR-BSI

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-2732.

For practicing clinicians, quality improvement (QI) is a difficult and important task. There can be requirements for extra steps, additional forms, or new safety procedures when caring for patients; there is also the promise of improved clinical outcomes. This tradeoff can be justified when solid, evidence-based techniques are implemented, but—unfortunately—definitive evidence is not always available. Public reporting of a variety of quality indicators, now mandated by the Centers for Medicare and Medicaid Services (CMS), is likely to boost calls for changes in clinical medicine, and the pressure to adopt new safety practices is likely to increase.

Fortunately, this article by Pronovost and colleagues provides a test of state-of-the-art QI theory applied to an important QI target, catheter-related bloodstream infections (CR-BSI). Annually there are 80,000 CR-BSI in the United States, causing about 28,000 deaths in ICU patients; the medical costs to treat these infections is estimated at $2.3 billion. There have been numerous published and unpublished trials of QI methods that have reduced the incidence of such infections, but none have been as large as this one, a state-wide ICU trial conducted in Michigan and funded by the Agency for Healthcare Research and Quality (AHRQ).

One-hundred-three ICUs, representing 85% of ICU beds in the state, participated in the study. In addition to the intervention to reduce CR-BSI, a comprehensive program aimed at instilling a culture of safety was implemented, including the creation of a QI team with a physician and nurse as team leaders, use of a daily goals sheet to enhance clinician-clinician communication, an intervention to reduce ventilator-associated pneumonia, and a comprehensive safety program designed to improve the culture of safety.

The study intervention was designed to improve clinicians’ use of five evidence-based procedures recommended by the Centers for Disease Control and Prevention (CDC):

1. Handwashing;
2. Use of full barrier precautions;
3. Use of chlorhexidine antiseptic;
4. Avoidance of femoral line placement; and
5. Removal of unnecessary catheters.

The strategies used to encourage these practices were technologically simple and easy to implement. They included the use of a central line kit with a procedure checklist, the termination of any procedure for failure to follow protocol, and daily discussions of line removal on rounds. Additionally, at regular meetings, all clinicians received feedback regarding numbers and rates of CR-BSI.

The results were impressive: The overall rate of CR-BSI decreased from a baseline median of 2.7 (mean, 7.7) infections per 1,000 catheter-days to 0 (mean, 2.3) during the first three-month period after implementation of the intervention (P<0.002). During the 18 months of follow-up, this reduction was sustained at 0 (mean, 1.4). The results applied in both academic and non-teaching hospitals, regardless of size.

Even with such simple methods, managing a statewide implementation of a comprehensive QI program is a feat of organization, as anyone who has implemented even small-scale projects knows. An accompanying editorial praised the effort, noting the magnitude of the accomplishment and recommending widespread adoption of these simple yet effective techniques. Given the push toward the adoption of similar methods, this demonstration is welcome and makes the wholesale acceptance of such measures not only easier but also imperative.

Quality Performance Measures across the Nation

Landon BE, Normand SL, Lessler A, et al. Quality of care for the treatment of acute medical conditions in US hospitals. Arch Intern Med. 2006 Dec 11;166(22):2511-2517.

 

Background

Current efforts have focused on examining and reporting indicators in order to increase the quality of care provided to patients in the United States. In January 2004 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began collecting monthly data from its accredited hospitals on performance measures across three of five select disease conditions. Similarly, since 2004, CMS has provided data from Hospital Quality Alliance members on 10 performance measures in the areas of congestive heart failure, acute myocardial infarction, and pneumonia. This study collected data from these reports to expand on previous work examining the quality of care in the United States on a national level. It also analyzed the characteristics of hospitals that have met these quality measures.

Methods

Overall, 4,856 different hospitals were included in the analysis. Data was obtained for all relevant discharges between January 1 and June 2004 from both CMS and JCAHO, with preference given to the JCAHO data. Discrepancies in reporting data between the two data sets were less than 1%. The 2003 Annual Survey of Hospitals from the American Hospital Association (AHA) was used to define the population of hospitals operating in the United States in terms of:

• Number of beds;
• Ownership (for-profit, not-for-profit, government, or military);
• Region;
• Metropolitan statistical area type (rural, small, medium, or large);
• Teaching status (major—member of the Council of Teaching Hospitals, minor—any other medical school affiliation or residency program, or non-teaching);
• Availability of advanced technology (MRI and PET scanning);
• Nurse staffing patterns; and
• Number of Medicaid and Medicare discharges.

These data sets were linked. Composite scales were created for each disease. Bivariate associations using two-tailed T-tests for continuous variables and chi-squared tests for categorical variables were made. For each individual and composite measure, the mean performance and the 25th and 75th percentiles were calculated. The top performing quintiles for each of the three diseases were taken and cross-tabulated across the three specific disease composites. A random-effects logistic regression model was estimated for each composite using a binary logistic model with SAS statistical software and the grouped hospital data that modeled the number of opportunities met in each hospital out of the total number of opportunities at the hospital.

Results

Hospitalized patients with congestive heart failure, acute myocardial infarction, and pneumonia received 75.9% of the recommended processes of care as a whole. Performance varied considerably, from a mean of 0.36 (0.00-0.67) for thrombolytic therapy administered within 30 minutes of arrival for an MI to a mean of 0.98 (0.98-1.00) for assessment of oxygen for patients with pneumonia. Mean composite scores were 0.85 (0.81-0.95) for acute myocardial infarction, 0.64 (0.52-0.78) for congestive heart failure, and 0.88 (0.80-0.97) for pneumonia.

When comparing hospitals in quintiles of performance, 10.5% were in the top quintile for two out of three diseases, but only 3.8% were in the top quintile for all three diseases. “Treatment and diagnosis” as well as “counseling and prevention” were correlated among all three conditions after factor analysis.

Multivariate analysis demonstrated for-profit hospitals as consistently performing worse than not-for-profit hospitals in meeting performance measures. Federal and military hospitals had the highest success in meeting the measures for the three diseases analyzed. Major teaching hospitals met more quality indicators for patients with acute MI and “treatment and diagnosis” but not for CHF, pneumonia, or “counseling and prevention” when compared with non-teaching hospitals. Performance decreased as the share of Medicaid patients increased. More technology and a registered nursing staff with more education were factors associated with higher success in meeting quality indicators.

 

Conclusions

This ambitious study evaluated the quality of hospital care across the nation using information collected from both JCAHO and CMS. It demonstrated room for improvement, with hospitals as a whole providing 76% of the recommended measures for acute MI, CHF, and pneumonia. The study suggests that ownership characteristics, teaching status, JCAHO accreditation, technology investments, and nursing staff with degrees strongly correlates to success in meeting performance measures.

The authors conclude that the findings have implications for public policy and patient choice. They hypothesize that regions of the country and rural locations more often associated with low performance could use additional resources aimed at bolstering performance. Patients living in rural areas have little choice without traveling great distances. The authors also state that the characteristics of hospitals that influence performance, such as ownership, teaching status, JCAHO accreditation, technology investments, and nursing status, are remediable.

It is important to bear in mind, however, given the cross-sectional nature of the data, that the associations reported are not proof of causality. Quality performance measures were not highly correlated among hospitals for the three conditions studied, with only 3.8% in the top quintile for all three diseases; this result demonstrates the difficulty inherent in generically rating hospitals. Additionally, this study makes no attempt to examine how meeting performance measures affects clinical outcomes, an important part of this ongoing national debate.

Treat DVT

Kearon C, Ginsberg JS, Julian JA, et al. Comparison of fixed-dose weight-adjusted unfractionated heparin and low-molecular-weight heparin for acute treatment of venous thromboembolism. JAMA. 2006 Aug 23;296(8):935-942.

Background

The current practice of treating DVT involves starting the patient on LMW (low molecular weight) heparin administered subcutaneously or initiating an IV drip of unfractionated heparin. The latter prevents the patient from being discharged as soon as treatment is initiated and requires repeat checking of aPTTs and drip adjustments, which may lead to over-shoot and/or sub-therapeutic dosage. On the other hand, treatment with LMW heparin is costly and can be tricky for patients with varying degrees of renal failure. Using fixed-dose subcutaneous injections of unfractionated heparin is a novel idea and could be the solution to the above-mentioned issues.

Methods

Eight hospitals in Canada and New Zealand with a total of 708 eligible and willing participants were involved in the study. The study design was a randomized, controlled, non-inferiority trial; the adjudication and monitoring committees were blinded. Patients older than 18 with a new diagnosis of DVT and/or pulmonary embolism were considered eligible. Patients with any of the usual contraindications for anticoagulation, including recent major bleeding events, were excluded, as were patients with renal failure and pregnancy.

Computerized randomization was done at a central location, and patients were started on either twice daily weight-based dosing of LMW heparin (100 IU/kg) or twice daily dosing of weight-based unfractionated heparin (first dose of 333 U/kg, subsequent doses of 250 U/kg). No coagulation testing was done to modify these doses. The patients were treated for at least five days, until the International Normalized Ratio (INR) was in the therapeutic range for two consecutive days. Patients were concomitantly started on warfarin. Recurrent venous thromboses, bleeding episodes—described as drop of hemoglobin >2.0—and death were primary endpoints.

Results

The assumption of non-inferiority was supported by the analysis of recurrent VTEs, which were 12 (3.4%) in the LMW heparin group and 13 (3.8%) in the unfractionated heparin group—clinically, a non-significant difference. Bleeding rates at 10 days or at three months were not significantly different for the two groups. Number of deaths was 18 in the unfractionated heparin group and 22 in the LMW heparin group. No patients were reported to have developed heparin-induced thrombocytopenia, a serious and often life-threatening complication of unfractionated heparin use.

 

Conclusions

This interesting study demonstrates that the use of fixed dose, unmonitored, subcutaneous unfractionated heparin in twice daily dosing is non-inferior to treatment with different kinds of LMW heparin. The authors have also analyzed the cost difference, which, at existing U.S. pricing, would be in the vicinity of $675 for the six-day treatment of an 80-kg patient. Though more data is needed on patients with special considerations such as renal failure, the results, which support non-inferiority and cite a major cost advantage, merit further studies to validate these conclusions and to further evaluate this approach in patient populations with special considerations.

Non-Invasive Testing Prior to Vascular Surgery

Poldermans D, Bax JJ, Schouten O, et al. Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol. 2006 Sep 5;48(5):964-969.

Background

Current guidelines from the AHA and the American College of Cardiology (ACC) recommend non-invasive testing for patients scheduled for major vascular surgery as part of the pre-operative work-up if they have clinical factors suggestive of increased cardiac risk. The study was performed to show that no testing combined with aggressive beta blockade is not inferior in comparison to non-invasive testing for patients in the intermediate risk group who are preparing to undergo major vascular surgery. Testing often results in delays that can result in poor outcomes; additionally, invasive intervention based upon non-invasive test results has not been clearly shown to add any benefit to the eventual outcome of the patient.

Methods

The study was conducted at five clinical centers in Europe and Brazil, where 1,476 patients undergoing elective open abdominal aortic or infrainguinal arterial reconstruction were enrolled. The design was a randomized, controlled, non-inferiority trial with the outcome assessors blinded. Inclusion criteria consisted of age older than 70, angina pectoris, prior myocardial infarction (MI), compensated or history of congestive heart failure, diabetes mellitus, renal dysfunction and prior stroke, or transient ischemic attack. Patients with one or two risk factors were labeled intermediate risk and were randomized to receive either just beta-blocker therapy or non-invasive testing with dobutamine echocardiography or dobutamine or dipyridamole perfusion scintigraphy.

Patients with limited or no ischemia were referred for surgery with beta-blocker therapy. In patients with extensive ischemia—five ischemic segments or more—coronary angiography and revascularization were performed if the main surgery could be delayed. Beta-blocker therapy was instituted in all patients, with a goal heart rate of 60-65. The beta-blocker therapy was continued postoperatively. IV metoprolol was used in the ICU if a patient could not take drugs orally. Primary endpoints were a combination of cardiac death and nonfatal MI at 30 days and two years.

Results

Of the 770 patients classified as intermediate risk, 386 received cardiac testing and 384 patients were not tested. There were no significant differences in the presence of ischemic heart disease in the two subsets. The time gap between screening to vascular surgery was 34 days (seven to 88 days) in the no testing group, compared with 53 days (1,3­21 days) in the testing group (P<0.001). There was no difference in the composite endpoints—either at 30 days or at two years—for the two groups.

Conclusions

This excellent study shows that the approach of no screening in patients with intermediate cardiac risk factors before vascular surgery is non-inferior. An interesting point elucidated by the authors in their discussion details why studies designed to achieve a goal heart rate, rather than those based on fixed dose beta-blockers, are ideal to show the benefits of beta blockade in this population subset. The benefit of coronary revascularization for intermediate risk patients with extensive ischemia could not be defined, however; the number was too small to show any significance.

 

Reduce CR-BSI

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-2732.

For practicing clinicians, quality improvement (QI) is a difficult and important task. There can be requirements for extra steps, additional forms, or new safety procedures when caring for patients; there is also the promise of improved clinical outcomes. This tradeoff can be justified when solid, evidence-based techniques are implemented, but—unfortunately—definitive evidence is not always available. Public reporting of a variety of quality indicators, now mandated by the Centers for Medicare and Medicaid Services (CMS), is likely to boost calls for changes in clinical medicine, and the pressure to adopt new safety practices is likely to increase.

Fortunately, this article by Pronovost and colleagues provides a test of state-of-the-art QI theory applied to an important QI target, catheter-related bloodstream infections (CR-BSI). Annually there are 80,000 CR-BSI in the United States, causing about 28,000 deaths in ICU patients; the medical costs to treat these infections is estimated at $2.3 billion. There have been numerous published and unpublished trials of QI methods that have reduced the incidence of such infections, but none have been as large as this one, a state-wide ICU trial conducted in Michigan and funded by the Agency for Healthcare Research and Quality (AHRQ).

One-hundred-three ICUs, representing 85% of ICU beds in the state, participated in the study. In addition to the intervention to reduce CR-BSI, a comprehensive program aimed at instilling a culture of safety was implemented, including the creation of a QI team with a physician and nurse as team leaders, use of a daily goals sheet to enhance clinician-clinician communication, an intervention to reduce ventilator-associated pneumonia, and a comprehensive safety program designed to improve the culture of safety.

The study intervention was designed to improve clinicians’ use of five evidence-based procedures recommended by the Centers for Disease Control and Prevention (CDC):

1. Handwashing;
2. Use of full barrier precautions;
3. Use of chlorhexidine antiseptic;
4. Avoidance of femoral line placement; and
5. Removal of unnecessary catheters.

The strategies used to encourage these practices were technologically simple and easy to implement. They included the use of a central line kit with a procedure checklist, the termination of any procedure for failure to follow protocol, and daily discussions of line removal on rounds. Additionally, at regular meetings, all clinicians received feedback regarding numbers and rates of CR-BSI.

The results were impressive: The overall rate of CR-BSI decreased from a baseline median of 2.7 (mean, 7.7) infections per 1,000 catheter-days to 0 (mean, 2.3) during the first three-month period after implementation of the intervention (P<0.002). During the 18 months of follow-up, this reduction was sustained at 0 (mean, 1.4). The results applied in both academic and non-teaching hospitals, regardless of size.

Even with such simple methods, managing a statewide implementation of a comprehensive QI program is a feat of organization, as anyone who has implemented even small-scale projects knows. An accompanying editorial praised the effort, noting the magnitude of the accomplishment and recommending widespread adoption of these simple yet effective techniques. Given the push toward the adoption of similar methods, this demonstration is welcome and makes the wholesale acceptance of such measures not only easier but also imperative.

Quality Performance Measures across the Nation

Landon BE, Normand SL, Lessler A, et al. Quality of care for the treatment of acute medical conditions in US hospitals. Arch Intern Med. 2006 Dec 11;166(22):2511-2517.

 

Background

Current efforts have focused on examining and reporting indicators in order to increase the quality of care provided to patients in the United States. In January 2004 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began collecting monthly data from its accredited hospitals on performance measures across three of five select disease conditions. Similarly, since 2004, CMS has provided data from Hospital Quality Alliance members on 10 performance measures in the areas of congestive heart failure, acute myocardial infarction, and pneumonia. This study collected data from these reports to expand on previous work examining the quality of care in the United States on a national level. It also analyzed the characteristics of hospitals that have met these quality measures.

Methods

Overall, 4,856 different hospitals were included in the analysis. Data was obtained for all relevant discharges between January 1 and June 2004 from both CMS and JCAHO, with preference given to the JCAHO data. Discrepancies in reporting data between the two data sets were less than 1%. The 2003 Annual Survey of Hospitals from the American Hospital Association (AHA) was used to define the population of hospitals operating in the United States in terms of:

• Number of beds;
• Ownership (for-profit, not-for-profit, government, or military);
• Region;
• Metropolitan statistical area type (rural, small, medium, or large);
• Teaching status (major—member of the Council of Teaching Hospitals, minor—any other medical school affiliation or residency program, or non-teaching);
• Availability of advanced technology (MRI and PET scanning);
• Nurse staffing patterns; and
• Number of Medicaid and Medicare discharges.

These data sets were linked. Composite scales were created for each disease. Bivariate associations using two-tailed T-tests for continuous variables and chi-squared tests for categorical variables were made. For each individual and composite measure, the mean performance and the 25th and 75th percentiles were calculated. The top performing quintiles for each of the three diseases were taken and cross-tabulated across the three specific disease composites. A random-effects logistic regression model was estimated for each composite using a binary logistic model with SAS statistical software and the grouped hospital data that modeled the number of opportunities met in each hospital out of the total number of opportunities at the hospital.

Results

Hospitalized patients with congestive heart failure, acute myocardial infarction, and pneumonia received 75.9% of the recommended processes of care as a whole. Performance varied considerably, from a mean of 0.36 (0.00-0.67) for thrombolytic therapy administered within 30 minutes of arrival for an MI to a mean of 0.98 (0.98-1.00) for assessment of oxygen for patients with pneumonia. Mean composite scores were 0.85 (0.81-0.95) for acute myocardial infarction, 0.64 (0.52-0.78) for congestive heart failure, and 0.88 (0.80-0.97) for pneumonia.

When comparing hospitals in quintiles of performance, 10.5% were in the top quintile for two out of three diseases, but only 3.8% were in the top quintile for all three diseases. “Treatment and diagnosis” as well as “counseling and prevention” were correlated among all three conditions after factor analysis.

Multivariate analysis demonstrated for-profit hospitals as consistently performing worse than not-for-profit hospitals in meeting performance measures. Federal and military hospitals had the highest success in meeting the measures for the three diseases analyzed. Major teaching hospitals met more quality indicators for patients with acute MI and “treatment and diagnosis” but not for CHF, pneumonia, or “counseling and prevention” when compared with non-teaching hospitals. Performance decreased as the share of Medicaid patients increased. More technology and a registered nursing staff with more education were factors associated with higher success in meeting quality indicators.

 

Conclusions

This ambitious study evaluated the quality of hospital care across the nation using information collected from both JCAHO and CMS. It demonstrated room for improvement, with hospitals as a whole providing 76% of the recommended measures for acute MI, CHF, and pneumonia. The study suggests that ownership characteristics, teaching status, JCAHO accreditation, technology investments, and nursing staff with degrees strongly correlates to success in meeting performance measures.

The authors conclude that the findings have implications for public policy and patient choice. They hypothesize that regions of the country and rural locations more often associated with low performance could use additional resources aimed at bolstering performance. Patients living in rural areas have little choice without traveling great distances. The authors also state that the characteristics of hospitals that influence performance, such as ownership, teaching status, JCAHO accreditation, technology investments, and nursing status, are remediable.

It is important to bear in mind, however, given the cross-sectional nature of the data, that the associations reported are not proof of causality. Quality performance measures were not highly correlated among hospitals for the three conditions studied, with only 3.8% in the top quintile for all three diseases; this result demonstrates the difficulty inherent in generically rating hospitals. Additionally, this study makes no attempt to examine how meeting performance measures affects clinical outcomes, an important part of this ongoing national debate.

Treat DVT

Kearon C, Ginsberg JS, Julian JA, et al. Comparison of fixed-dose weight-adjusted unfractionated heparin and low-molecular-weight heparin for acute treatment of venous thromboembolism. JAMA. 2006 Aug 23;296(8):935-942.

Background

The current practice of treating DVT involves starting the patient on LMW (low molecular weight) heparin administered subcutaneously or initiating an IV drip of unfractionated heparin. The latter prevents the patient from being discharged as soon as treatment is initiated and requires repeat checking of aPTTs and drip adjustments, which may lead to over-shoot and/or sub-therapeutic dosage. On the other hand, treatment with LMW heparin is costly and can be tricky for patients with varying degrees of renal failure. Using fixed-dose subcutaneous injections of unfractionated heparin is a novel idea and could be the solution to the above-mentioned issues.

Methods

Eight hospitals in Canada and New Zealand with a total of 708 eligible and willing participants were involved in the study. The study design was a randomized, controlled, non-inferiority trial; the adjudication and monitoring committees were blinded. Patients older than 18 with a new diagnosis of DVT and/or pulmonary embolism were considered eligible. Patients with any of the usual contraindications for anticoagulation, including recent major bleeding events, were excluded, as were patients with renal failure and pregnancy.

Computerized randomization was done at a central location, and patients were started on either twice daily weight-based dosing of LMW heparin (100 IU/kg) or twice daily dosing of weight-based unfractionated heparin (first dose of 333 U/kg, subsequent doses of 250 U/kg). No coagulation testing was done to modify these doses. The patients were treated for at least five days, until the International Normalized Ratio (INR) was in the therapeutic range for two consecutive days. Patients were concomitantly started on warfarin. Recurrent venous thromboses, bleeding episodes—described as drop of hemoglobin >2.0—and death were primary endpoints.

Results

The assumption of non-inferiority was supported by the analysis of recurrent VTEs, which were 12 (3.4%) in the LMW heparin group and 13 (3.8%) in the unfractionated heparin group—clinically, a non-significant difference. Bleeding rates at 10 days or at three months were not significantly different for the two groups. Number of deaths was 18 in the unfractionated heparin group and 22 in the LMW heparin group. No patients were reported to have developed heparin-induced thrombocytopenia, a serious and often life-threatening complication of unfractionated heparin use.

 

Conclusions

This interesting study demonstrates that the use of fixed dose, unmonitored, subcutaneous unfractionated heparin in twice daily dosing is non-inferior to treatment with different kinds of LMW heparin. The authors have also analyzed the cost difference, which, at existing U.S. pricing, would be in the vicinity of $675 for the six-day treatment of an 80-kg patient. Though more data is needed on patients with special considerations such as renal failure, the results, which support non-inferiority and cite a major cost advantage, merit further studies to validate these conclusions and to further evaluate this approach in patient populations with special considerations.

Non-Invasive Testing Prior to Vascular Surgery

Poldermans D, Bax JJ, Schouten O, et al. Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol. 2006 Sep 5;48(5):964-969.

Background

Current guidelines from the AHA and the American College of Cardiology (ACC) recommend non-invasive testing for patients scheduled for major vascular surgery as part of the pre-operative work-up if they have clinical factors suggestive of increased cardiac risk. The study was performed to show that no testing combined with aggressive beta blockade is not inferior in comparison to non-invasive testing for patients in the intermediate risk group who are preparing to undergo major vascular surgery. Testing often results in delays that can result in poor outcomes; additionally, invasive intervention based upon non-invasive test results has not been clearly shown to add any benefit to the eventual outcome of the patient.

Methods

The study was conducted at five clinical centers in Europe and Brazil, where 1,476 patients undergoing elective open abdominal aortic or infrainguinal arterial reconstruction were enrolled. The design was a randomized, controlled, non-inferiority trial with the outcome assessors blinded. Inclusion criteria consisted of age older than 70, angina pectoris, prior myocardial infarction (MI), compensated or history of congestive heart failure, diabetes mellitus, renal dysfunction and prior stroke, or transient ischemic attack. Patients with one or two risk factors were labeled intermediate risk and were randomized to receive either just beta-blocker therapy or non-invasive testing with dobutamine echocardiography or dobutamine or dipyridamole perfusion scintigraphy.

Patients with limited or no ischemia were referred for surgery with beta-blocker therapy. In patients with extensive ischemia—five ischemic segments or more—coronary angiography and revascularization were performed if the main surgery could be delayed. Beta-blocker therapy was instituted in all patients, with a goal heart rate of 60-65. The beta-blocker therapy was continued postoperatively. IV metoprolol was used in the ICU if a patient could not take drugs orally. Primary endpoints were a combination of cardiac death and nonfatal MI at 30 days and two years.

Results

Of the 770 patients classified as intermediate risk, 386 received cardiac testing and 384 patients were not tested. There were no significant differences in the presence of ischemic heart disease in the two subsets. The time gap between screening to vascular surgery was 34 days (seven to 88 days) in the no testing group, compared with 53 days (1,3­21 days) in the testing group (P<0.001). There was no difference in the composite endpoints—either at 30 days or at two years—for the two groups.

Conclusions

This excellent study shows that the approach of no screening in patients with intermediate cardiac risk factors before vascular surgery is non-inferior. An interesting point elucidated by the authors in their discussion details why studies designed to achieve a goal heart rate, rather than those based on fixed dose beta-blockers, are ideal to show the benefits of beta blockade in this population subset. The benefit of coronary revascularization for intermediate risk patients with extensive ischemia could not be defined, however; the number was too small to show any significance.

 

Reduce CR-BSI

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-2732.

For practicing clinicians, quality improvement (QI) is a difficult and important task. There can be requirements for extra steps, additional forms, or new safety procedures when caring for patients; there is also the promise of improved clinical outcomes. This tradeoff can be justified when solid, evidence-based techniques are implemented, but—unfortunately—definitive evidence is not always available. Public reporting of a variety of quality indicators, now mandated by the Centers for Medicare and Medicaid Services (CMS), is likely to boost calls for changes in clinical medicine, and the pressure to adopt new safety practices is likely to increase.

Fortunately, this article by Pronovost and colleagues provides a test of state-of-the-art QI theory applied to an important QI target, catheter-related bloodstream infections (CR-BSI). Annually there are 80,000 CR-BSI in the United States, causing about 28,000 deaths in ICU patients; the medical costs to treat these infections is estimated at $2.3 billion. There have been numerous published and unpublished trials of QI methods that have reduced the incidence of such infections, but none have been as large as this one, a state-wide ICU trial conducted in Michigan and funded by the Agency for Healthcare Research and Quality (AHRQ).

One-hundred-three ICUs, representing 85% of ICU beds in the state, participated in the study. In addition to the intervention to reduce CR-BSI, a comprehensive program aimed at instilling a culture of safety was implemented, including the creation of a QI team with a physician and nurse as team leaders, use of a daily goals sheet to enhance clinician-clinician communication, an intervention to reduce ventilator-associated pneumonia, and a comprehensive safety program designed to improve the culture of safety.

The study intervention was designed to improve clinicians’ use of five evidence-based procedures recommended by the Centers for Disease Control and Prevention (CDC):

1. Handwashing;
2. Use of full barrier precautions;
3. Use of chlorhexidine antiseptic;
4. Avoidance of femoral line placement; and
5. Removal of unnecessary catheters.

The strategies used to encourage these practices were technologically simple and easy to implement. They included the use of a central line kit with a procedure checklist, the termination of any procedure for failure to follow protocol, and daily discussions of line removal on rounds. Additionally, at regular meetings, all clinicians received feedback regarding numbers and rates of CR-BSI.

The results were impressive: The overall rate of CR-BSI decreased from a baseline median of 2.7 (mean, 7.7) infections per 1,000 catheter-days to 0 (mean, 2.3) during the first three-month period after implementation of the intervention (P<0.002). During the 18 months of follow-up, this reduction was sustained at 0 (mean, 1.4). The results applied in both academic and non-teaching hospitals, regardless of size.

Even with such simple methods, managing a statewide implementation of a comprehensive QI program is a feat of organization, as anyone who has implemented even small-scale projects knows. An accompanying editorial praised the effort, noting the magnitude of the accomplishment and recommending widespread adoption of these simple yet effective techniques. Given the push toward the adoption of similar methods, this demonstration is welcome and makes the wholesale acceptance of such measures not only easier but also imperative.

Quality Performance Measures across the Nation

Landon BE, Normand SL, Lessler A, et al. Quality of care for the treatment of acute medical conditions in US hospitals. Arch Intern Med. 2006 Dec 11;166(22):2511-2517.

 

Background

Current efforts have focused on examining and reporting indicators in order to increase the quality of care provided to patients in the United States. In January 2004 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began collecting monthly data from its accredited hospitals on performance measures across three of five select disease conditions. Similarly, since 2004, CMS has provided data from Hospital Quality Alliance members on 10 performance measures in the areas of congestive heart failure, acute myocardial infarction, and pneumonia. This study collected data from these reports to expand on previous work examining the quality of care in the United States on a national level. It also analyzed the characteristics of hospitals that have met these quality measures.

Methods

Overall, 4,856 different hospitals were included in the analysis. Data was obtained for all relevant discharges between January 1 and June 2004 from both CMS and JCAHO, with preference given to the JCAHO data. Discrepancies in reporting data between the two data sets were less than 1%. The 2003 Annual Survey of Hospitals from the American Hospital Association (AHA) was used to define the population of hospitals operating in the United States in terms of:

• Number of beds;
• Ownership (for-profit, not-for-profit, government, or military);
• Region;
• Metropolitan statistical area type (rural, small, medium, or large);
• Teaching status (major—member of the Council of Teaching Hospitals, minor—any other medical school affiliation or residency program, or non-teaching);
• Availability of advanced technology (MRI and PET scanning);
• Nurse staffing patterns; and
• Number of Medicaid and Medicare discharges.

These data sets were linked. Composite scales were created for each disease. Bivariate associations using two-tailed T-tests for continuous variables and chi-squared tests for categorical variables were made. For each individual and composite measure, the mean performance and the 25th and 75th percentiles were calculated. The top performing quintiles for each of the three diseases were taken and cross-tabulated across the three specific disease composites. A random-effects logistic regression model was estimated for each composite using a binary logistic model with SAS statistical software and the grouped hospital data that modeled the number of opportunities met in each hospital out of the total number of opportunities at the hospital.

Results

Hospitalized patients with congestive heart failure, acute myocardial infarction, and pneumonia received 75.9% of the recommended processes of care as a whole. Performance varied considerably, from a mean of 0.36 (0.00-0.67) for thrombolytic therapy administered within 30 minutes of arrival for an MI to a mean of 0.98 (0.98-1.00) for assessment of oxygen for patients with pneumonia. Mean composite scores were 0.85 (0.81-0.95) for acute myocardial infarction, 0.64 (0.52-0.78) for congestive heart failure, and 0.88 (0.80-0.97) for pneumonia.

When comparing hospitals in quintiles of performance, 10.5% were in the top quintile for two out of three diseases, but only 3.8% were in the top quintile for all three diseases. “Treatment and diagnosis” as well as “counseling and prevention” were correlated among all three conditions after factor analysis.

Multivariate analysis demonstrated for-profit hospitals as consistently performing worse than not-for-profit hospitals in meeting performance measures. Federal and military hospitals had the highest success in meeting the measures for the three diseases analyzed. Major teaching hospitals met more quality indicators for patients with acute MI and “treatment and diagnosis” but not for CHF, pneumonia, or “counseling and prevention” when compared with non-teaching hospitals. Performance decreased as the share of Medicaid patients increased. More technology and a registered nursing staff with more education were factors associated with higher success in meeting quality indicators.

 

Conclusions

This ambitious study evaluated the quality of hospital care across the nation using information collected from both JCAHO and CMS. It demonstrated room for improvement, with hospitals as a whole providing 76% of the recommended measures for acute MI, CHF, and pneumonia. The study suggests that ownership characteristics, teaching status, JCAHO accreditation, technology investments, and nursing staff with degrees strongly correlates to success in meeting performance measures.

The authors conclude that the findings have implications for public policy and patient choice. They hypothesize that regions of the country and rural locations more often associated with low performance could use additional resources aimed at bolstering performance. Patients living in rural areas have little choice without traveling great distances. The authors also state that the characteristics of hospitals that influence performance, such as ownership, teaching status, JCAHO accreditation, technology investments, and nursing status, are remediable.

It is important to bear in mind, however, given the cross-sectional nature of the data, that the associations reported are not proof of causality. Quality performance measures were not highly correlated among hospitals for the three conditions studied, with only 3.8% in the top quintile for all three diseases; this result demonstrates the difficulty inherent in generically rating hospitals. Additionally, this study makes no attempt to examine how meeting performance measures affects clinical outcomes, an important part of this ongoing national debate.

Treat DVT

Kearon C, Ginsberg JS, Julian JA, et al. Comparison of fixed-dose weight-adjusted unfractionated heparin and low-molecular-weight heparin for acute treatment of venous thromboembolism. JAMA. 2006 Aug 23;296(8):935-942.

Background

The current practice of treating DVT involves starting the patient on LMW (low molecular weight) heparin administered subcutaneously or initiating an IV drip of unfractionated heparin. The latter prevents the patient from being discharged as soon as treatment is initiated and requires repeat checking of aPTTs and drip adjustments, which may lead to over-shoot and/or sub-therapeutic dosage. On the other hand, treatment with LMW heparin is costly and can be tricky for patients with varying degrees of renal failure. Using fixed-dose subcutaneous injections of unfractionated heparin is a novel idea and could be the solution to the above-mentioned issues.

Methods

Eight hospitals in Canada and New Zealand with a total of 708 eligible and willing participants were involved in the study. The study design was a randomized, controlled, non-inferiority trial; the adjudication and monitoring committees were blinded. Patients older than 18 with a new diagnosis of DVT and/or pulmonary embolism were considered eligible. Patients with any of the usual contraindications for anticoagulation, including recent major bleeding events, were excluded, as were patients with renal failure and pregnancy.

Computerized randomization was done at a central location, and patients were started on either twice daily weight-based dosing of LMW heparin (100 IU/kg) or twice daily dosing of weight-based unfractionated heparin (first dose of 333 U/kg, subsequent doses of 250 U/kg). No coagulation testing was done to modify these doses. The patients were treated for at least five days, until the International Normalized Ratio (INR) was in the therapeutic range for two consecutive days. Patients were concomitantly started on warfarin. Recurrent venous thromboses, bleeding episodes—described as drop of hemoglobin >2.0—and death were primary endpoints.

Results

The assumption of non-inferiority was supported by the analysis of recurrent VTEs, which were 12 (3.4%) in the LMW heparin group and 13 (3.8%) in the unfractionated heparin group—clinically, a non-significant difference. Bleeding rates at 10 days or at three months were not significantly different for the two groups. Number of deaths was 18 in the unfractionated heparin group and 22 in the LMW heparin group. No patients were reported to have developed heparin-induced thrombocytopenia, a serious and often life-threatening complication of unfractionated heparin use.

 

Conclusions

This interesting study demonstrates that the use of fixed dose, unmonitored, subcutaneous unfractionated heparin in twice daily dosing is non-inferior to treatment with different kinds of LMW heparin. The authors have also analyzed the cost difference, which, at existing U.S. pricing, would be in the vicinity of $675 for the six-day treatment of an 80-kg patient. Though more data is needed on patients with special considerations such as renal failure, the results, which support non-inferiority and cite a major cost advantage, merit further studies to validate these conclusions and to further evaluate this approach in patient populations with special considerations.

Non-Invasive Testing Prior to Vascular Surgery

Poldermans D, Bax JJ, Schouten O, et al. Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol. 2006 Sep 5;48(5):964-969.

Background

Current guidelines from the AHA and the American College of Cardiology (ACC) recommend non-invasive testing for patients scheduled for major vascular surgery as part of the pre-operative work-up if they have clinical factors suggestive of increased cardiac risk. The study was performed to show that no testing combined with aggressive beta blockade is not inferior in comparison to non-invasive testing for patients in the intermediate risk group who are preparing to undergo major vascular surgery. Testing often results in delays that can result in poor outcomes; additionally, invasive intervention based upon non-invasive test results has not been clearly shown to add any benefit to the eventual outcome of the patient.

Methods

The study was conducted at five clinical centers in Europe and Brazil, where 1,476 patients undergoing elective open abdominal aortic or infrainguinal arterial reconstruction were enrolled. The design was a randomized, controlled, non-inferiority trial with the outcome assessors blinded. Inclusion criteria consisted of age older than 70, angina pectoris, prior myocardial infarction (MI), compensated or history of congestive heart failure, diabetes mellitus, renal dysfunction and prior stroke, or transient ischemic attack. Patients with one or two risk factors were labeled intermediate risk and were randomized to receive either just beta-blocker therapy or non-invasive testing with dobutamine echocardiography or dobutamine or dipyridamole perfusion scintigraphy.

Patients with limited or no ischemia were referred for surgery with beta-blocker therapy. In patients with extensive ischemia—five ischemic segments or more—coronary angiography and revascularization were performed if the main surgery could be delayed. Beta-blocker therapy was instituted in all patients, with a goal heart rate of 60-65. The beta-blocker therapy was continued postoperatively. IV metoprolol was used in the ICU if a patient could not take drugs orally. Primary endpoints were a combination of cardiac death and nonfatal MI at 30 days and two years.

Results

Of the 770 patients classified as intermediate risk, 386 received cardiac testing and 384 patients were not tested. There were no significant differences in the presence of ischemic heart disease in the two subsets. The time gap between screening to vascular surgery was 34 days (seven to 88 days) in the no testing group, compared with 53 days (1,3­21 days) in the testing group (P<0.001). There was no difference in the composite endpoints—either at 30 days or at two years—for the two groups.

Conclusions

This excellent study shows that the approach of no screening in patients with intermediate cardiac risk factors before vascular surgery is non-inferior. An interesting point elucidated by the authors in their discussion details why studies designed to achieve a goal heart rate, rather than those based on fixed dose beta-blockers, are ideal to show the benefits of beta blockade in this population subset. The benefit of coronary revascularization for intermediate risk patients with extensive ischemia could not be defined, however; the number was too small to show any significance.