Hospital Medicine

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient’s case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. The bolded text represents the patient’s case. Each paragraph that follows represents the discussant’s thoughts.
 

A 42-year-old Malaysian construction worker with subjective fevers of 4 days’ duration presented to an emergency department in Singapore. He reported nonproductive cough, chills without rigors, sore throat, and body aches. He denied sick contacts. Past medical history included chronic hepatitis B virus (HBV) infection. The patient was not taking any medications.

For this patient presenting acutely with subjective fevers, nonproductive cough, chills, aches, and lethargy, initial considerations include infection with a common virus (influenza virus, adenovirus, Epstein-Barr virus [EBV]), acute human immunodeficiency virus (HIV) infection, emerging infection (severe acute respiratory syndrome [SARS], Middle Eastern respiratory syndrome coronavirus [MERS-CoV] infection, avian influenza), and tropical infection (dengue, chikungunya). Also possible are bacterial infections (eg, with Salmonella typhi or Rickettsia or Mycoplasma species), parasitic infections (eg, malaria), and noninfectious illnesses (eg, autoimmune diseases, thyroiditis, acute leukemia, environmental exposures).

The patient’s temperature was 38.5°C; blood pressure, 133/73 mm Hg; heart rate, 95 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 100% on ambient air. On physical examination, he appeared comfortable, and heart, lung, abdomen, skin, and extremities were normal. Laboratory test results included white blood cell (WBC) count, 4400/μL (with normal differential); hemoglobin, 16.1 g/dL; and platelet count, 207,000/μL. Serum chemistries were normal. C-reactive protein (CRP) level was 44.6 mg/L (reference range, 0.2-9.1 mg/L), and procalcitonin level was 0.13 ng/mL (reference range, <0.50 ng/mL). Chest radiograph was normal. Dengue antibodies (immunoglobulin M, immunoglobulin G [IgG]) and dengue NS1 antigen were negative. The patient was discharged with a presumptive diagnosis of viral upper respiratory tract infection.

There is no left shift characteristic of bacterial infection or lymphopenia characteristic of rickettsial disease or acute HIV infection. The serologic testing and the patient’s overall appearance make dengue unlikely. The low procalcitonin supports a nonbacterial cause of illness. CRP elevation may indicate an inflammatory process and is relatively nonspecific.

Myalgias, pharyngitis, and cough improved over several days, but fevers persisted, and a rash developed over the lower abdomen. The patient returned to the emergency department and was admitted. He denied weight loss and night sweats. He had multiple female sexual partners, including commercial sex workers, within the previous 6 months. Temperature was 38.5°C. The posterior oropharynx was slightly erythematous. There was no lymphadenopathy. Firm, mildly erythematous macules were present on the anterior abdominal wall (Figure 1). The rest of the physical examination was normal.

Laboratory testing revealed WBC count, 5800/μL (75% neutrophils, 19% lymphocytes, 3% monocytes, 2% atypical mononuclear cells); hemoglobin, 16.3 g/dL; platelet count, 185,000/μL; sodium, 131 mmol/L; potassium, 3.4 mmol/L; creatinine, 0.9 mg/dL; albumin, 3.2 g/dL; alanine aminotransferase (ALT), 99 U/L; aspartate aminotransferase (AST), 137 U/L; alkaline phosphatase (ALP), 63 U/L; and total bilirubin, 1.9 mg/dL. Prothrombin time was 11.1 seconds; partial thromboplastin time, 36.1 seconds; erythrocyte sedimentation rate, 14 mm/h; and CRP, 62.2 mg/L.

EBV, acute HIV, and cytomegalovirus infections often present with adenopathy, which is absent here. Disseminated gonococcal infection can manifest with fever, body aches, and rash, but his rash and the absence of penile discharge, migratory arthritis, and enthesitis are not characteristic. Mycoplasma infection can present with macules, urticaria, or erythema multiforme. Rickettsia illnesses typically cause vasculitis with progression to petechiae or purpura resulting from endothelial damage. Patients with secondary syphilis may have widespread macular lesions, and the accompanying syphilitic hepatitis often manifests with elevations in ALP instead of ALT and AST. The mild elevation in ALT and AST can occur with many systemic viral infections. Sweet syndrome may manifest with febrile illness and rash, but the acuity of this patient’s illness and the rapid evolution favor infection.

The patient’s fevers (35°-40°C) continued without pattern over the next 3 days. Blood and urine cultures were negative. Polymerase chain reaction (PCR) test of the nasal mucosa was negative for respiratory viruses. PCR blood tests for EBV, HIV-1, and cytomegalovirus were also negative. Antistreptolysin O (ASO) titer was 400 IU/mm (reference range, <200 IU/mm). Antinuclear antibodies were negative, and rheumatoid factor was 12.4 U/mL (reference range, <10.3 U/mL). Computed tomography (CT) of the thorax, abdomen, and pelvis was normal. Results of a biopsy of an anterior abdominal wall skin lesion showed perivascular and periadnexal lymphocytic inflammation. Amoxicillin was started for the treatment of possible group A streptococcal infection.

PCR for HIV would be positive at a high level in acute HIV. The skin biopsy is not characteristic of Sweet syndrome, which typically shows neutrophilic infiltrate without leukocytoclastic vasculitis, or of syphilis, which typically shows a plasma cell infiltrate.

The patient’s erythematous oropharynx may indicate recent streptococcal pharyngitis. The fevers, elevated ASO titer, and CRP level are consistent with acute rheumatic fever, but arthritis, carditis, and neurologic manifestations are lacking. Erythema marginatum manifests on the trunk and limbs as macules or papules with central clearing as the lesions spread outward—and differs from the patient’s rash, which is firm and restricted to the abdominal wall.

Fevers persisted through hospital day 7. The WBC count was 1100/μL (75.7% neutrophils, 22.5% lymphocytes), hemoglobin was 10.3 g/dL, and platelet count was 52,000/μL. Additional laboratory test results included ALP, 234 U/L; ALT, 250 U/L; AST, 459 U/L; lactate dehydrogenase, 2303 U/L (reference range, 222-454 U/L); and ferritin, 14,964 ng/mL (reference range, 47-452 ng/mL).

The duration of illness and negative diagnostic tests for infections increases suspicion for a noninfectious illness. Conditions commonly associated with marked hyperferritinemia include adult-onset Still disease (AOSD) and hemophagocytic lymphohistiocytosis (HLH). Of the 9 AOSD diagnostic (Yamaguchi) criteria, 5 are met in this case: fever, rash, sore throat, abnormal liver function tests, and negative rheumatologic tests. However, the patient lacks arthritis, leukocytosis, lymphadenopathy, and hepatosplenomegaly. Except for the elevated ferritin, the AOSD criteria overlap substantially with the criteria for acute rheumatic fever, and still require that infections be adequately excluded. HLH, a state of abnormal immune activation with resultant organ dysfunction, can be a primary disorder, but in adults more often is secondary to underlying infectious, autoimmune, or malignant (often lymphoma) conditions. Elevated ferritin, cytopenias, elevated ALT and AST, elevated CRP and erythrocyte sedimentation rate, and elevated lactate dehydrogenase are consistent with HLH. The HLH diagnosis can be more firmly established with the more specific findings of hypertriglyceridemia, hypofibrinogenemia, and elevated soluble CD25 level. The histopathologic finding of hemophagocytosis in the bone marrow, lymph nodes, or liver may further support the diagnosis of HLH.

Rash and fevers persisted. Hepatitis A, hepatitis C, Rickettsia IgG, Burkholderia pseudomallei (the causative organism of melioidosis), and Leptospira serologies, as well as PCR for herpes simplex virus and parvovirus, were all negative. Hepatitis B viral load was 962 IU/mL (2.98 log), hepatitis B envelope antigen was negative, and hepatitis B envelope antibody was positive. Orientia tsutsugamushi (organism responsible for scrub typhus) IgG titer was elevated at 1:128. Antiliver kidney microsomal antibodies and antineutrophil cytoplasmic antibodies were negative. Fibrinogen level was 0.69 g/L (reference range, 1.8-4.8 g/L), and beta-2 microglobulin level was 5078 ng/mL (reference range, 878-2000 ng/mL). Bone marrow biopsy results showed hypocellular marrow with suppressed myelopoiesis, few atypical lymphoid cells, and few hemophagocytes. Flow cytometry was negative for clonal B lymphocytes and aberrant expression of T lymphocytes. Bone marrow myobacterial PCR and fungal cultures were negative.

The patient’s chronic HBV infection is unlikely to be related to his presentation given his low viral load and absence of signs of hepatic dysfunction. Excluding rickettsial disease requires paired acute and convalescent serologies. O tsutsugamushi, the causative agent of the rickettsial disease scrub typhus, is endemic in Malaysia; thus, his positive O tsutsugamushi IgG may indicate past exposure. His fevers, myalgias, truncal rash, and hepatitis are consistent with scrub typhus, but he lacks the characteristic severe headache and generalized lymphadenopathy. Although eschar formation with evolution of a papular rash is common in scrub typhus, it is often absent in the variant found in Southeast Asia. Although elevated β₂ microglobulin level is used as a prognostic marker in multiple myeloma and Waldenström macroglobulinemia, it can be elevated in many immune-active states. The patient likely has HLH, which is supported by the hemophagocytosis seen on bone marrow biopsy, and the hypofibrinogenemia. Potential HLH triggers include O tsutsugamushi infection or recent streptococcal pharyngitis.

A deep-punch skin biopsy of the anterior abdominal wall skin lesion was performed because of the absence of subcutaneous fat in the first biopsy specimen. The latest biopsy results showed irregular interstitial expansion of medium-size lymphocytes in a lobular panniculated pattern. The lymphocytes contained enlarged, irregularly contoured nucleoli and were positive for T-cell markers CD2 and CD3 with reduction in CD5 expression. The lymphomatous cells were of CD8+ with uniform expression of activated cytotoxic granule protein granzyme B and were positive for T-cell hemireceptor β.

Positron emission tomography (PET) CT, obtained for staging purposes, showed multiple hypermetabolic subcutaneous and cutaneous lesions over the torso and upper and lower limbs—compatible with lymphomatous infiltrates (Figure 2). Examination, pathology, and imaging findings suggested a rare neoplasm: subcutaneous panniculitis-like T-cell lymphoma (SPTCL). SPTCL was confirmed by T-cell receptor gene rearrangements studies.

When residents or visitors to tropical or sub-tropical regions, those located near or between the Tropics of Cancer and Capricorn, present with fever, physicians usually first think of infectious diseases. This patient’s case is a reminder that these important first considerations should not be the last.

Generating a differential diagnosis for tropical illnesses begins with the patient’s history. Factors to be considered include location (regional disease prevalence), exposures (food/water ingestion, outdoor work/recreation, sexual contact, animal contact), and timing (temporal relationship of symptom development to possible exposure). Common tropical infections are malaria, dengue, typhoid, and emerging infections such as chikungunya, avian influenza, and Zika virus infection.¹This case underscores the need to analyze diagnostic tests critically. Interpreting tests as simply positive or negative, irrespective of disease features, epidemiology, and test characteristics, can contribute to diagnostic error. For example, the patient’s positive ASO titer requires an understanding of disease features and a nuanced interpretation based on the clinical presentation. The erythematous posterior oropharynx prompted concern for postinfectious sequelae of streptococcal pharyngitis, but his illness was more severe and more prolonged than is typical of that condition. The isolated elevated O tsutsugamushi IgG titer provides an example of the role of epidemiology in test interpretation. Although a single positive value might indicate a new exposure for a visitor to an endemic region, IgG seropositivity in Singapore, where scrub typhus is endemic, likely reflects prior exposure to the organism. Diagnosing an acute scrub typhus infection in a patient in an endemic region requires PCR testing. The skin biopsy results highlight the importance of understanding test characteristics. A skin biopsy specimen must be adequate in order to draw valid and accurate conclusions. In this case, the initial skin biopsy was superficial, and the specimen inadequate, but the test was not “negative.” In the diagnostic skin biopsy, deeper tissue was sampled, and panniculitis (inflammation of subcutaneous fat), which arises in inflammatory, infectious, traumatic, enzymatic, and malignant conditions, was identified. An adequate biopsy specimen that contains subcutaneous fat is essential in making this diagnosis.²This patient eventually manifested several elements of hemophagocytic lymphohistiocytosis (HLH), a syndrome of excessive inflammation and resultant organ injury relating to abnormal immune activation and excessive inflammation. HLH results from deficient down-regulation of activated macrophages and lymphocytes.³ It was initially described in pediatric patients but is now recognized in adults, and associated with mortality as high as 50%.³ A high ferritin level (>2000 ng/mL) has 70% sensitivity and 68% specificity for pediatric HLH and should trigger consideration of HLH in any age group.⁴ The diagnostic criteria for HLH initially proposed in 2004 by the Histiocyte Society to identify patients for recruitment into a clinical trial included molecular testing consistent with HLH and/or 5 of 8 clinical, laboratory, or histopathologic features (Table 1).⁵ HScore is a more recent validated scoring system that predicts the probability of HLH (Table 2). A score above 169 signifies diagnostic sensitivity of 93% and specificity of 86%.⁶

• A febrile illness acquired in the tropics is not always attributable to a tropical infection.
• To avoid diagnostic error, weigh positive or negative test results against disease features, patient epidemiology, and test characteristics.
• HLH is characterized by fevers, cytopenias, hepatosplenomegaly, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. In tissue specimens, hemophagocytosis may help differentiate HLH from competing conditions.
• After HLH is diagnosed, try to determine its underlying cause, which may be an infection, autoimmunity, or a malignancy (commonly, a lymphoma).

Disclosure

Nothing to report.

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient’s case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. The bolded text represents the patient’s case. Each paragraph that follows represents the discussant’s thoughts.
 

A 42-year-old Malaysian construction worker with subjective fevers of 4 days’ duration presented to an emergency department in Singapore. He reported nonproductive cough, chills without rigors, sore throat, and body aches. He denied sick contacts. Past medical history included chronic hepatitis B virus (HBV) infection. The patient was not taking any medications.

For this patient presenting acutely with subjective fevers, nonproductive cough, chills, aches, and lethargy, initial considerations include infection with a common virus (influenza virus, adenovirus, Epstein-Barr virus [EBV]), acute human immunodeficiency virus (HIV) infection, emerging infection (severe acute respiratory syndrome [SARS], Middle Eastern respiratory syndrome coronavirus [MERS-CoV] infection, avian influenza), and tropical infection (dengue, chikungunya). Also possible are bacterial infections (eg, with Salmonella typhi or Rickettsia or Mycoplasma species), parasitic infections (eg, malaria), and noninfectious illnesses (eg, autoimmune diseases, thyroiditis, acute leukemia, environmental exposures).

The patient’s temperature was 38.5°C; blood pressure, 133/73 mm Hg; heart rate, 95 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 100% on ambient air. On physical examination, he appeared comfortable, and heart, lung, abdomen, skin, and extremities were normal. Laboratory test results included white blood cell (WBC) count, 4400/μL (with normal differential); hemoglobin, 16.1 g/dL; and platelet count, 207,000/μL. Serum chemistries were normal. C-reactive protein (CRP) level was 44.6 mg/L (reference range, 0.2-9.1 mg/L), and procalcitonin level was 0.13 ng/mL (reference range, <0.50 ng/mL). Chest radiograph was normal. Dengue antibodies (immunoglobulin M, immunoglobulin G [IgG]) and dengue NS1 antigen were negative. The patient was discharged with a presumptive diagnosis of viral upper respiratory tract infection.

There is no left shift characteristic of bacterial infection or lymphopenia characteristic of rickettsial disease or acute HIV infection. The serologic testing and the patient’s overall appearance make dengue unlikely. The low procalcitonin supports a nonbacterial cause of illness. CRP elevation may indicate an inflammatory process and is relatively nonspecific.

Myalgias, pharyngitis, and cough improved over several days, but fevers persisted, and a rash developed over the lower abdomen. The patient returned to the emergency department and was admitted. He denied weight loss and night sweats. He had multiple female sexual partners, including commercial sex workers, within the previous 6 months. Temperature was 38.5°C. The posterior oropharynx was slightly erythematous. There was no lymphadenopathy. Firm, mildly erythematous macules were present on the anterior abdominal wall (Figure 1). The rest of the physical examination was normal.

Laboratory testing revealed WBC count, 5800/μL (75% neutrophils, 19% lymphocytes, 3% monocytes, 2% atypical mononuclear cells); hemoglobin, 16.3 g/dL; platelet count, 185,000/μL; sodium, 131 mmol/L; potassium, 3.4 mmol/L; creatinine, 0.9 mg/dL; albumin, 3.2 g/dL; alanine aminotransferase (ALT), 99 U/L; aspartate aminotransferase (AST), 137 U/L; alkaline phosphatase (ALP), 63 U/L; and total bilirubin, 1.9 mg/dL. Prothrombin time was 11.1 seconds; partial thromboplastin time, 36.1 seconds; erythrocyte sedimentation rate, 14 mm/h; and CRP, 62.2 mg/L.

EBV, acute HIV, and cytomegalovirus infections often present with adenopathy, which is absent here. Disseminated gonococcal infection can manifest with fever, body aches, and rash, but his rash and the absence of penile discharge, migratory arthritis, and enthesitis are not characteristic. Mycoplasma infection can present with macules, urticaria, or erythema multiforme. Rickettsia illnesses typically cause vasculitis with progression to petechiae or purpura resulting from endothelial damage. Patients with secondary syphilis may have widespread macular lesions, and the accompanying syphilitic hepatitis often manifests with elevations in ALP instead of ALT and AST. The mild elevation in ALT and AST can occur with many systemic viral infections. Sweet syndrome may manifest with febrile illness and rash, but the acuity of this patient’s illness and the rapid evolution favor infection.

The patient’s fevers (35°-40°C) continued without pattern over the next 3 days. Blood and urine cultures were negative. Polymerase chain reaction (PCR) test of the nasal mucosa was negative for respiratory viruses. PCR blood tests for EBV, HIV-1, and cytomegalovirus were also negative. Antistreptolysin O (ASO) titer was 400 IU/mm (reference range, <200 IU/mm). Antinuclear antibodies were negative, and rheumatoid factor was 12.4 U/mL (reference range, <10.3 U/mL). Computed tomography (CT) of the thorax, abdomen, and pelvis was normal. Results of a biopsy of an anterior abdominal wall skin lesion showed perivascular and periadnexal lymphocytic inflammation. Amoxicillin was started for the treatment of possible group A streptococcal infection.

PCR for HIV would be positive at a high level in acute HIV. The skin biopsy is not characteristic of Sweet syndrome, which typically shows neutrophilic infiltrate without leukocytoclastic vasculitis, or of syphilis, which typically shows a plasma cell infiltrate.

The patient’s erythematous oropharynx may indicate recent streptococcal pharyngitis. The fevers, elevated ASO titer, and CRP level are consistent with acute rheumatic fever, but arthritis, carditis, and neurologic manifestations are lacking. Erythema marginatum manifests on the trunk and limbs as macules or papules with central clearing as the lesions spread outward—and differs from the patient’s rash, which is firm and restricted to the abdominal wall.

Fevers persisted through hospital day 7. The WBC count was 1100/μL (75.7% neutrophils, 22.5% lymphocytes), hemoglobin was 10.3 g/dL, and platelet count was 52,000/μL. Additional laboratory test results included ALP, 234 U/L; ALT, 250 U/L; AST, 459 U/L; lactate dehydrogenase, 2303 U/L (reference range, 222-454 U/L); and ferritin, 14,964 ng/mL (reference range, 47-452 ng/mL).

The duration of illness and negative diagnostic tests for infections increases suspicion for a noninfectious illness. Conditions commonly associated with marked hyperferritinemia include adult-onset Still disease (AOSD) and hemophagocytic lymphohistiocytosis (HLH). Of the 9 AOSD diagnostic (Yamaguchi) criteria, 5 are met in this case: fever, rash, sore throat, abnormal liver function tests, and negative rheumatologic tests. However, the patient lacks arthritis, leukocytosis, lymphadenopathy, and hepatosplenomegaly. Except for the elevated ferritin, the AOSD criteria overlap substantially with the criteria for acute rheumatic fever, and still require that infections be adequately excluded. HLH, a state of abnormal immune activation with resultant organ dysfunction, can be a primary disorder, but in adults more often is secondary to underlying infectious, autoimmune, or malignant (often lymphoma) conditions. Elevated ferritin, cytopenias, elevated ALT and AST, elevated CRP and erythrocyte sedimentation rate, and elevated lactate dehydrogenase are consistent with HLH. The HLH diagnosis can be more firmly established with the more specific findings of hypertriglyceridemia, hypofibrinogenemia, and elevated soluble CD25 level. The histopathologic finding of hemophagocytosis in the bone marrow, lymph nodes, or liver may further support the diagnosis of HLH.

Rash and fevers persisted. Hepatitis A, hepatitis C, Rickettsia IgG, Burkholderia pseudomallei (the causative organism of melioidosis), and Leptospira serologies, as well as PCR for herpes simplex virus and parvovirus, were all negative. Hepatitis B viral load was 962 IU/mL (2.98 log), hepatitis B envelope antigen was negative, and hepatitis B envelope antibody was positive. Orientia tsutsugamushi (organism responsible for scrub typhus) IgG titer was elevated at 1:128. Antiliver kidney microsomal antibodies and antineutrophil cytoplasmic antibodies were negative. Fibrinogen level was 0.69 g/L (reference range, 1.8-4.8 g/L), and beta-2 microglobulin level was 5078 ng/mL (reference range, 878-2000 ng/mL). Bone marrow biopsy results showed hypocellular marrow with suppressed myelopoiesis, few atypical lymphoid cells, and few hemophagocytes. Flow cytometry was negative for clonal B lymphocytes and aberrant expression of T lymphocytes. Bone marrow myobacterial PCR and fungal cultures were negative.

The patient’s chronic HBV infection is unlikely to be related to his presentation given his low viral load and absence of signs of hepatic dysfunction. Excluding rickettsial disease requires paired acute and convalescent serologies. O tsutsugamushi, the causative agent of the rickettsial disease scrub typhus, is endemic in Malaysia; thus, his positive O tsutsugamushi IgG may indicate past exposure. His fevers, myalgias, truncal rash, and hepatitis are consistent with scrub typhus, but he lacks the characteristic severe headache and generalized lymphadenopathy. Although eschar formation with evolution of a papular rash is common in scrub typhus, it is often absent in the variant found in Southeast Asia. Although elevated β₂ microglobulin level is used as a prognostic marker in multiple myeloma and Waldenström macroglobulinemia, it can be elevated in many immune-active states. The patient likely has HLH, which is supported by the hemophagocytosis seen on bone marrow biopsy, and the hypofibrinogenemia. Potential HLH triggers include O tsutsugamushi infection or recent streptococcal pharyngitis.

A deep-punch skin biopsy of the anterior abdominal wall skin lesion was performed because of the absence of subcutaneous fat in the first biopsy specimen. The latest biopsy results showed irregular interstitial expansion of medium-size lymphocytes in a lobular panniculated pattern. The lymphocytes contained enlarged, irregularly contoured nucleoli and were positive for T-cell markers CD2 and CD3 with reduction in CD5 expression. The lymphomatous cells were of CD8+ with uniform expression of activated cytotoxic granule protein granzyme B and were positive for T-cell hemireceptor β.

Positron emission tomography (PET) CT, obtained for staging purposes, showed multiple hypermetabolic subcutaneous and cutaneous lesions over the torso and upper and lower limbs—compatible with lymphomatous infiltrates (Figure 2). Examination, pathology, and imaging findings suggested a rare neoplasm: subcutaneous panniculitis-like T-cell lymphoma (SPTCL). SPTCL was confirmed by T-cell receptor gene rearrangements studies.

When residents or visitors to tropical or sub-tropical regions, those located near or between the Tropics of Cancer and Capricorn, present with fever, physicians usually first think of infectious diseases. This patient’s case is a reminder that these important first considerations should not be the last.

Generating a differential diagnosis for tropical illnesses begins with the patient’s history. Factors to be considered include location (regional disease prevalence), exposures (food/water ingestion, outdoor work/recreation, sexual contact, animal contact), and timing (temporal relationship of symptom development to possible exposure). Common tropical infections are malaria, dengue, typhoid, and emerging infections such as chikungunya, avian influenza, and Zika virus infection.¹This case underscores the need to analyze diagnostic tests critically. Interpreting tests as simply positive or negative, irrespective of disease features, epidemiology, and test characteristics, can contribute to diagnostic error. For example, the patient’s positive ASO titer requires an understanding of disease features and a nuanced interpretation based on the clinical presentation. The erythematous posterior oropharynx prompted concern for postinfectious sequelae of streptococcal pharyngitis, but his illness was more severe and more prolonged than is typical of that condition. The isolated elevated O tsutsugamushi IgG titer provides an example of the role of epidemiology in test interpretation. Although a single positive value might indicate a new exposure for a visitor to an endemic region, IgG seropositivity in Singapore, where scrub typhus is endemic, likely reflects prior exposure to the organism. Diagnosing an acute scrub typhus infection in a patient in an endemic region requires PCR testing. The skin biopsy results highlight the importance of understanding test characteristics. A skin biopsy specimen must be adequate in order to draw valid and accurate conclusions. In this case, the initial skin biopsy was superficial, and the specimen inadequate, but the test was not “negative.” In the diagnostic skin biopsy, deeper tissue was sampled, and panniculitis (inflammation of subcutaneous fat), which arises in inflammatory, infectious, traumatic, enzymatic, and malignant conditions, was identified. An adequate biopsy specimen that contains subcutaneous fat is essential in making this diagnosis.²This patient eventually manifested several elements of hemophagocytic lymphohistiocytosis (HLH), a syndrome of excessive inflammation and resultant organ injury relating to abnormal immune activation and excessive inflammation. HLH results from deficient down-regulation of activated macrophages and lymphocytes.³ It was initially described in pediatric patients but is now recognized in adults, and associated with mortality as high as 50%.³ A high ferritin level (>2000 ng/mL) has 70% sensitivity and 68% specificity for pediatric HLH and should trigger consideration of HLH in any age group.⁴ The diagnostic criteria for HLH initially proposed in 2004 by the Histiocyte Society to identify patients for recruitment into a clinical trial included molecular testing consistent with HLH and/or 5 of 8 clinical, laboratory, or histopathologic features (Table 1).⁵ HScore is a more recent validated scoring system that predicts the probability of HLH (Table 2). A score above 169 signifies diagnostic sensitivity of 93% and specificity of 86%.⁶

• A febrile illness acquired in the tropics is not always attributable to a tropical infection.
• To avoid diagnostic error, weigh positive or negative test results against disease features, patient epidemiology, and test characteristics.
• HLH is characterized by fevers, cytopenias, hepatosplenomegaly, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. In tissue specimens, hemophagocytosis may help differentiate HLH from competing conditions.
• After HLH is diagnosed, try to determine its underlying cause, which may be an infection, autoimmunity, or a malignancy (commonly, a lymphoma).

Disclosure

Nothing to report.

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient’s case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. The bolded text represents the patient’s case. Each paragraph that follows represents the discussant’s thoughts.
 

A 42-year-old Malaysian construction worker with subjective fevers of 4 days’ duration presented to an emergency department in Singapore. He reported nonproductive cough, chills without rigors, sore throat, and body aches. He denied sick contacts. Past medical history included chronic hepatitis B virus (HBV) infection. The patient was not taking any medications.

For this patient presenting acutely with subjective fevers, nonproductive cough, chills, aches, and lethargy, initial considerations include infection with a common virus (influenza virus, adenovirus, Epstein-Barr virus [EBV]), acute human immunodeficiency virus (HIV) infection, emerging infection (severe acute respiratory syndrome [SARS], Middle Eastern respiratory syndrome coronavirus [MERS-CoV] infection, avian influenza), and tropical infection (dengue, chikungunya). Also possible are bacterial infections (eg, with Salmonella typhi or Rickettsia or Mycoplasma species), parasitic infections (eg, malaria), and noninfectious illnesses (eg, autoimmune diseases, thyroiditis, acute leukemia, environmental exposures).

The patient’s temperature was 38.5°C; blood pressure, 133/73 mm Hg; heart rate, 95 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 100% on ambient air. On physical examination, he appeared comfortable, and heart, lung, abdomen, skin, and extremities were normal. Laboratory test results included white blood cell (WBC) count, 4400/μL (with normal differential); hemoglobin, 16.1 g/dL; and platelet count, 207,000/μL. Serum chemistries were normal. C-reactive protein (CRP) level was 44.6 mg/L (reference range, 0.2-9.1 mg/L), and procalcitonin level was 0.13 ng/mL (reference range, <0.50 ng/mL). Chest radiograph was normal. Dengue antibodies (immunoglobulin M, immunoglobulin G [IgG]) and dengue NS1 antigen were negative. The patient was discharged with a presumptive diagnosis of viral upper respiratory tract infection.

There is no left shift characteristic of bacterial infection or lymphopenia characteristic of rickettsial disease or acute HIV infection. The serologic testing and the patient’s overall appearance make dengue unlikely. The low procalcitonin supports a nonbacterial cause of illness. CRP elevation may indicate an inflammatory process and is relatively nonspecific.

Myalgias, pharyngitis, and cough improved over several days, but fevers persisted, and a rash developed over the lower abdomen. The patient returned to the emergency department and was admitted. He denied weight loss and night sweats. He had multiple female sexual partners, including commercial sex workers, within the previous 6 months. Temperature was 38.5°C. The posterior oropharynx was slightly erythematous. There was no lymphadenopathy. Firm, mildly erythematous macules were present on the anterior abdominal wall (Figure 1). The rest of the physical examination was normal.

Laboratory testing revealed WBC count, 5800/μL (75% neutrophils, 19% lymphocytes, 3% monocytes, 2% atypical mononuclear cells); hemoglobin, 16.3 g/dL; platelet count, 185,000/μL; sodium, 131 mmol/L; potassium, 3.4 mmol/L; creatinine, 0.9 mg/dL; albumin, 3.2 g/dL; alanine aminotransferase (ALT), 99 U/L; aspartate aminotransferase (AST), 137 U/L; alkaline phosphatase (ALP), 63 U/L; and total bilirubin, 1.9 mg/dL. Prothrombin time was 11.1 seconds; partial thromboplastin time, 36.1 seconds; erythrocyte sedimentation rate, 14 mm/h; and CRP, 62.2 mg/L.

EBV, acute HIV, and cytomegalovirus infections often present with adenopathy, which is absent here. Disseminated gonococcal infection can manifest with fever, body aches, and rash, but his rash and the absence of penile discharge, migratory arthritis, and enthesitis are not characteristic. Mycoplasma infection can present with macules, urticaria, or erythema multiforme. Rickettsia illnesses typically cause vasculitis with progression to petechiae or purpura resulting from endothelial damage. Patients with secondary syphilis may have widespread macular lesions, and the accompanying syphilitic hepatitis often manifests with elevations in ALP instead of ALT and AST. The mild elevation in ALT and AST can occur with many systemic viral infections. Sweet syndrome may manifest with febrile illness and rash, but the acuity of this patient’s illness and the rapid evolution favor infection.

The patient’s fevers (35°-40°C) continued without pattern over the next 3 days. Blood and urine cultures were negative. Polymerase chain reaction (PCR) test of the nasal mucosa was negative for respiratory viruses. PCR blood tests for EBV, HIV-1, and cytomegalovirus were also negative. Antistreptolysin O (ASO) titer was 400 IU/mm (reference range, <200 IU/mm). Antinuclear antibodies were negative, and rheumatoid factor was 12.4 U/mL (reference range, <10.3 U/mL). Computed tomography (CT) of the thorax, abdomen, and pelvis was normal. Results of a biopsy of an anterior abdominal wall skin lesion showed perivascular and periadnexal lymphocytic inflammation. Amoxicillin was started for the treatment of possible group A streptococcal infection.

PCR for HIV would be positive at a high level in acute HIV. The skin biopsy is not characteristic of Sweet syndrome, which typically shows neutrophilic infiltrate without leukocytoclastic vasculitis, or of syphilis, which typically shows a plasma cell infiltrate.

The patient’s erythematous oropharynx may indicate recent streptococcal pharyngitis. The fevers, elevated ASO titer, and CRP level are consistent with acute rheumatic fever, but arthritis, carditis, and neurologic manifestations are lacking. Erythema marginatum manifests on the trunk and limbs as macules or papules with central clearing as the lesions spread outward—and differs from the patient’s rash, which is firm and restricted to the abdominal wall.

Fevers persisted through hospital day 7. The WBC count was 1100/μL (75.7% neutrophils, 22.5% lymphocytes), hemoglobin was 10.3 g/dL, and platelet count was 52,000/μL. Additional laboratory test results included ALP, 234 U/L; ALT, 250 U/L; AST, 459 U/L; lactate dehydrogenase, 2303 U/L (reference range, 222-454 U/L); and ferritin, 14,964 ng/mL (reference range, 47-452 ng/mL).

The duration of illness and negative diagnostic tests for infections increases suspicion for a noninfectious illness. Conditions commonly associated with marked hyperferritinemia include adult-onset Still disease (AOSD) and hemophagocytic lymphohistiocytosis (HLH). Of the 9 AOSD diagnostic (Yamaguchi) criteria, 5 are met in this case: fever, rash, sore throat, abnormal liver function tests, and negative rheumatologic tests. However, the patient lacks arthritis, leukocytosis, lymphadenopathy, and hepatosplenomegaly. Except for the elevated ferritin, the AOSD criteria overlap substantially with the criteria for acute rheumatic fever, and still require that infections be adequately excluded. HLH, a state of abnormal immune activation with resultant organ dysfunction, can be a primary disorder, but in adults more often is secondary to underlying infectious, autoimmune, or malignant (often lymphoma) conditions. Elevated ferritin, cytopenias, elevated ALT and AST, elevated CRP and erythrocyte sedimentation rate, and elevated lactate dehydrogenase are consistent with HLH. The HLH diagnosis can be more firmly established with the more specific findings of hypertriglyceridemia, hypofibrinogenemia, and elevated soluble CD25 level. The histopathologic finding of hemophagocytosis in the bone marrow, lymph nodes, or liver may further support the diagnosis of HLH.

Rash and fevers persisted. Hepatitis A, hepatitis C, Rickettsia IgG, Burkholderia pseudomallei (the causative organism of melioidosis), and Leptospira serologies, as well as PCR for herpes simplex virus and parvovirus, were all negative. Hepatitis B viral load was 962 IU/mL (2.98 log), hepatitis B envelope antigen was negative, and hepatitis B envelope antibody was positive. Orientia tsutsugamushi (organism responsible for scrub typhus) IgG titer was elevated at 1:128. Antiliver kidney microsomal antibodies and antineutrophil cytoplasmic antibodies were negative. Fibrinogen level was 0.69 g/L (reference range, 1.8-4.8 g/L), and beta-2 microglobulin level was 5078 ng/mL (reference range, 878-2000 ng/mL). Bone marrow biopsy results showed hypocellular marrow with suppressed myelopoiesis, few atypical lymphoid cells, and few hemophagocytes. Flow cytometry was negative for clonal B lymphocytes and aberrant expression of T lymphocytes. Bone marrow myobacterial PCR and fungal cultures were negative.

The patient’s chronic HBV infection is unlikely to be related to his presentation given his low viral load and absence of signs of hepatic dysfunction. Excluding rickettsial disease requires paired acute and convalescent serologies. O tsutsugamushi, the causative agent of the rickettsial disease scrub typhus, is endemic in Malaysia; thus, his positive O tsutsugamushi IgG may indicate past exposure. His fevers, myalgias, truncal rash, and hepatitis are consistent with scrub typhus, but he lacks the characteristic severe headache and generalized lymphadenopathy. Although eschar formation with evolution of a papular rash is common in scrub typhus, it is often absent in the variant found in Southeast Asia. Although elevated β₂ microglobulin level is used as a prognostic marker in multiple myeloma and Waldenström macroglobulinemia, it can be elevated in many immune-active states. The patient likely has HLH, which is supported by the hemophagocytosis seen on bone marrow biopsy, and the hypofibrinogenemia. Potential HLH triggers include O tsutsugamushi infection or recent streptococcal pharyngitis.

A deep-punch skin biopsy of the anterior abdominal wall skin lesion was performed because of the absence of subcutaneous fat in the first biopsy specimen. The latest biopsy results showed irregular interstitial expansion of medium-size lymphocytes in a lobular panniculated pattern. The lymphocytes contained enlarged, irregularly contoured nucleoli and were positive for T-cell markers CD2 and CD3 with reduction in CD5 expression. The lymphomatous cells were of CD8+ with uniform expression of activated cytotoxic granule protein granzyme B and were positive for T-cell hemireceptor β.

Positron emission tomography (PET) CT, obtained for staging purposes, showed multiple hypermetabolic subcutaneous and cutaneous lesions over the torso and upper and lower limbs—compatible with lymphomatous infiltrates (Figure 2). Examination, pathology, and imaging findings suggested a rare neoplasm: subcutaneous panniculitis-like T-cell lymphoma (SPTCL). SPTCL was confirmed by T-cell receptor gene rearrangements studies.

When residents or visitors to tropical or sub-tropical regions, those located near or between the Tropics of Cancer and Capricorn, present with fever, physicians usually first think of infectious diseases. This patient’s case is a reminder that these important first considerations should not be the last.

Generating a differential diagnosis for tropical illnesses begins with the patient’s history. Factors to be considered include location (regional disease prevalence), exposures (food/water ingestion, outdoor work/recreation, sexual contact, animal contact), and timing (temporal relationship of symptom development to possible exposure). Common tropical infections are malaria, dengue, typhoid, and emerging infections such as chikungunya, avian influenza, and Zika virus infection.¹This case underscores the need to analyze diagnostic tests critically. Interpreting tests as simply positive or negative, irrespective of disease features, epidemiology, and test characteristics, can contribute to diagnostic error. For example, the patient’s positive ASO titer requires an understanding of disease features and a nuanced interpretation based on the clinical presentation. The erythematous posterior oropharynx prompted concern for postinfectious sequelae of streptococcal pharyngitis, but his illness was more severe and more prolonged than is typical of that condition. The isolated elevated O tsutsugamushi IgG titer provides an example of the role of epidemiology in test interpretation. Although a single positive value might indicate a new exposure for a visitor to an endemic region, IgG seropositivity in Singapore, where scrub typhus is endemic, likely reflects prior exposure to the organism. Diagnosing an acute scrub typhus infection in a patient in an endemic region requires PCR testing. The skin biopsy results highlight the importance of understanding test characteristics. A skin biopsy specimen must be adequate in order to draw valid and accurate conclusions. In this case, the initial skin biopsy was superficial, and the specimen inadequate, but the test was not “negative.” In the diagnostic skin biopsy, deeper tissue was sampled, and panniculitis (inflammation of subcutaneous fat), which arises in inflammatory, infectious, traumatic, enzymatic, and malignant conditions, was identified. An adequate biopsy specimen that contains subcutaneous fat is essential in making this diagnosis.²This patient eventually manifested several elements of hemophagocytic lymphohistiocytosis (HLH), a syndrome of excessive inflammation and resultant organ injury relating to abnormal immune activation and excessive inflammation. HLH results from deficient down-regulation of activated macrophages and lymphocytes.³ It was initially described in pediatric patients but is now recognized in adults, and associated with mortality as high as 50%.³ A high ferritin level (>2000 ng/mL) has 70% sensitivity and 68% specificity for pediatric HLH and should trigger consideration of HLH in any age group.⁴ The diagnostic criteria for HLH initially proposed in 2004 by the Histiocyte Society to identify patients for recruitment into a clinical trial included molecular testing consistent with HLH and/or 5 of 8 clinical, laboratory, or histopathologic features (Table 1).⁵ HScore is a more recent validated scoring system that predicts the probability of HLH (Table 2). A score above 169 signifies diagnostic sensitivity of 93% and specificity of 86%.⁶

• A febrile illness acquired in the tropics is not always attributable to a tropical infection.
• To avoid diagnostic error, weigh positive or negative test results against disease features, patient epidemiology, and test characteristics.
• HLH is characterized by fevers, cytopenias, hepatosplenomegaly, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. In tissue specimens, hemophagocytosis may help differentiate HLH from competing conditions.
• After HLH is diagnosed, try to determine its underlying cause, which may be an infection, autoimmunity, or a malignancy (commonly, a lymphoma).

Disclosure

Nothing to report.

Readmission prevention is paramount for hospitals and, by extension, hospitalist programs. Hospitalists see early and reliable outpatient follow-up as a safe landing for their most complicated patient cases. The option of a postdischarge clinic arises from the challenge to arrange adequate postdischarge care for patients who lack easy access because of insurance or provider availability. Guaranteeing postdischarge access by opening a dedicated, hospitalist-led postdischarge clinic appears to be an easy solution, but it is a solution that requires significant investment (including investment in physician and staff training and administrative support) and careful navigation of existing primary care relationships. In addition, a clinic staffed only with physicians may not be well equipped to address the complex social factors in healthcare utilization and readmission. Better understanding of the evidence supporting post discharge physician visits, several models of clinics, and the key operational questions are essential to address before crossing the inpatient-outpatient divide.

A postdischarge outpatient provider visit is often seen as a key factor in reducing readmissions. In 2013, Medicare added strength to this association by establishing transitional care management codes, which provide enhanced reimbursement to providers for a visit within 7 or 14 days of discharge, with focused attention on transitional issues.¹ However, whether a postdischarge visit reduces readmissions remains unclear. Given evidence that higher primary care density is associated with lower healthcare utilization,² CMS’s financial investment in incentivizing post discharge physician visits may be a good bet. On the other hand, simply having a primary care physician (PCP) may be a risk factor for readmission. This association suggests that postdischarge vigilance leads to identification of medical problems that lead to rehospitalization.³ This uncertainty is not resolved in systematic reviews of readmission reduction initiatives, which were not focused solely on the impact of a physician visit.^4,5

The earliest study of postdischarge visits in a general medical population found an association between intensive outpatient follow-up by new providers in a Veterans Affairs population and an increase in hospital readmissions.⁶ This model is similar to some hospitalist models for postdischarge clinics, as the visit was with a noncontinuity provider. The largest recent study, of patients hospitalized with acute myocardial infarction, community-acquired pneumonia, or congestive heart failure (CHF) between 2009 and 2012, found increased frequency of postdischarge follow-up but no concomitant reduction in readmissions.⁷ Although small observational studies⁸ have found a postdischarge primary care visit may reduce the risk for readmission in general medical patients, the bulk of the recent data is negative.

In high-risk patients, however, there may be a clear benefit to postdischarge follow-up. In a North Carolina Medicaid population, a physician visit after discharge was associated with fewer readmissions among high-risk patients, but not among lower risk patients, whose readmission rates were low to start.⁹ The results of that study support the idea that risk stratification may identify patients who can benefit from more intensive outpatient follow-up. In general medical populations, existing studies may suffer from an absence of adequate risk assessment.

The evidence in specific disease states may show a clearer association between a postdischarge physician visit and reduced risk for readmission. One quarter of patients with CHF are rehospitalized within 30 days of discharge.¹⁰ In this disease with frequent exacerbations, a clinic visit to monitor volume status, weight, and medication adherence might reduce the frequency of readmissions or prolong the interval between rehospitalizations. A large observational study observed that earlier post discharge follow up by a cardiologist or a PCP was associated with lower risk of readmission, but only in the quintile with the closest follow-up. In addition, fewer than 40% of patients in this group had a visit within 7 days.¹¹ In another heart failure population, follow-up with either a PCP or cardiologist within 7 days of discharge was again associated with lower risk for readmission.¹² Thus, data suggest a protective effect of postdischarge visits in CHF patients, in contrast to a general medical population. Patients with end-stage renal disease may also fit in this group protected by a postdischarge physician visit, as 1 additional visit within the month after discharge was estimated to reduce rehospitalizations and produce significant cost savings.¹³

With other specific discharge diagnoses, results are varied. Two small observational studies in chronic obstructive pulmonary disease had conflicting results—one found a modest reduction in readmission and emergency department (ED) visits for patients seen by a PCP or pulmonologist within 30 days of discharge,¹⁴ and the other found no effect on readmissions but an associated reduction in mortality.¹⁵ More data are needed to clarify further the interaction of postdischarge visits with mortality, but the association between postdischarge physician visits and readmission reduction is controversial for patients with chronic obstructive pulmonary disease.

Finally, the evidence for dedicated postdischarge clinics is even more limited. A study of a hospitalist-led postdischarge clinic in a Veterans Affairs hospital found reduced length of stay and earlier postdischarge follow-up in a postdischarge clinic, but no effect on readmissions.¹⁶ Other studies have found earlier postdischarge follow-up with dedicated discharge clinics but have not evaluated readmission rates specifically.¹⁷In summary, the effect of postdischarge visits on risk for readmission is an area of active research, but remains unclear. The data reviewed suggest a benefit for the highest risk patients, specifically those with severe chronic illness, or those deemed high-risk with a readmission tool.⁹ At present, because physicians cannot accurately predict which patients will be readmitted,¹⁸ discharging physicians often take a broad approach and schedule outpatient visits for all patients. As readmission tools are further refined, the group of patients who will benefit from postdischarge care will be easier to identify, and a benefit to postdischarge visits may be seen

It is also important to note that this review emphasizes the physician visit and its potential impact on readmissions. Socioeconomic causes are increasingly being recognized as driving readmissions and other utilization.¹⁹ Whether an isolated physician visit is sufficient to prevent readmissions for patients with nonmedical drivers of healthcare utilization is unclear. For those patients, a discharge visit likely is a necessary component of a readmission reduction strategy for high-risk patients, but may be insufficient for patients who require not just an isolated visit but rather a more integrated and comprehensive care program.^8,20,21

Despite the unclear relationship between postdischarge physician care and readmissions, dedicated postdischarge clinics, some staffed by hospitalists, have been adopted over the past 10 years. The three primary types of clinics arise in safety net environments, in academic medical centers, and as comprehensive high-risk patient solutions. Reviewing several types of clinics further clarifies the nature of this structural innovation.

Safety Net Hospital Models

Safety net hospitals and their hospitalists struggle with securing adequate postdischarge access for their population, which has inadequate insurance and poor access to primary care. Patient characteristics also play a role in the complex postdischarge care for this population, given its high rate of ED use (owing to perceived convenience and capabilities) for ambulatory-sensitive conditions.²² In addition, immigrants, particularly those with low English-language proficiency, underuse and have poor access to primary care.^23,24 Postdischarge clinics in this environment focus first on providing a reliable postdischarge plan and then on linking to primary care. Examples of two clinics are at Harborview Medical Center in Seattle, Washington²⁵ and Texas Health in Fort Worth.

Harborview is a 400-bed hospital affiliated with the University of Washington. More than 50% of its patients are considered indigent. The clinic was established in 2007 to provide a postdischarge option for uninsured patients, and a link to primary care in federally qualified health centers. The clinic was staffed 5 days a week with one or two hospitalists or advanced practice nurses. Visit duration was 20 minutes, 270 visits occurred per month, and the no-show rate was 30%. A small subgroup of the hospitalist group staffed the clinic. Particular clinical foci included CHF patients, patients with wound-care needs, and homeless, immigrant, and recently incarcerated patients. A key goal was connecting to longitudinal primary care, and the clinic successfully connected more than 70% of patients to primary care in community health centers. This clinic ultimately transitioned from a hospitalist practice to a primary care practice with a primary focus on post-ED follow-up for unaffiliated patients.²⁶

In 2010, Texas Health faced a similar challenge with unaffiliated patients, and established a nurse practitioner–based clinic with hospitalist oversight to provide care primarily for patients without insurance or without an existing primary care relationship.

Academic Medical Center Models

Another clinical model is designed for patients who receive primary care at practices affiliated with academic medical centers. Although many of these patients have insurance and a PCP, there is often no availability with their continuity provider, because of the resident’s inpatient schedule or the faculty member’s conflicting priorities.^27,28 Academic medical centers, including the University of California at San Francisco, the University of New Mexico, and the Beth Israel Deaconess Medical Center, have established discharge clinics within their faculty primary care practices. A model of this type of clinic was set up at Beth Israel Deaconess in 2010. Staffed by four hospitalists and using 40-minute appointments, this clinic was physically based in the primary care practice. As such, it took advantage of the existing clinic’s administrative and clinical functions, including triage, billing, and scheduling. A visit was scheduled in that clinic by the discharging physician team if a primary care appointment was not available with the patient’s continuity provider. Visits were standardized and focused on outstanding issues at discharge, medication reconciliation, and symptom trajectory. The hospitalists used the clinic’s clinical resources, including nurses, social workers, and pharmacists, but had no other dedicated staff. That there were only four hospitalists meant they were able to gain sufficient exposure to the outpatient setting, provide consistent high-quality care, and gain credibility with the PCPs. As the patients who were seen had PCPs of their own, during the visit significant attention was focused first on the postdischarge concerns, and then on promptly returning the patients to routine primary care. Significant patient outreach was used to address the clinic’s no-show rate, which was almost 50% in the early months. Within a year, the rate was down, closer to 20%. This clinic closed in 2015 after the primary care practice, in which it was based, transitioned to a patient-centered medical home. Since that time, this type of initiative has spread further, with neurohospitalist discharge clinics established, and postdischarge neurology follow-up becoming faster and more reliable.²⁹

Academic medical centers and safety net hospitals substitute for routine primary care to address the basic challenge of primary care access, often without significant enhancements or additional resources, such as dedicated care management and pharmacy, social work, and nursing support. Commonalities of these clinics include dedicated physician staff, appointments generally longer than average outpatient appointments, and visit content concentrated on the key issues at transition (medication reconciliation, outstanding tests, symptom trajectory). As possible, clinics adopted a multidisciplinary approach, with social workers, community health workers, and nurses, to respond to the breadth of patients’ postdischarge needs, which often extend beyond pure medical need. The most frequent barriers encountered included the knowledge gap for hospitalist providers in the outpatient setting (a gap mitigated by using dedicated providers) and the patients’ high no-show rate (not surprising given that the providers are generally new to them). Few clinics have attempted to create continuity across inpatient and outpatient providers, though continuity might reduce no-shows as well as eliminate at least 1 transition.

Comprehensive High-Risk Patient Solutions

At the other end of the clinic spectrum are more integrated postdischarge approaches, which also evolved from the hospitalist model with hospitalist staffing. However, these approaches were introduced in response to the clinical needs of the highest risk patients (who are most vulnerable to frequent provider transitions), not to a systemic inability to provide routine postdischarge care.³⁰

The most long-standing model for this type of clinic is represented by CareMore Health System, a subsidiary of Anthem.^30-32 The extensivist, an expanded-scope hospitalist, acts as primary care coordinator, coordinating a multidisciplinary team for a panel of about 100 patients, representing the sickest 5% of the Medicare Advantage–insured population. Unlike the traditional hospitalist, the extensivist follows patients across all care sites, including hospital, rehabilitation sites, and outpatient clinic. For the most part, this relationship is not designed to evolve into a longitudinal relationship, but rather is an intervention only for the several-months period of acute need. Internal data have shown effects on hospital readmissions as well as length of stay.³⁰

Another integrated clinic was established in 2013, at the University of Chicago. This was an effort to redesign care for patients at highest risk for hospitalization.³³ Similar to the CareMore process, a high-risk population is identified by prior hospitalization and expected high Medicare costs. A comprehensive care physician cares for these patients across care settings. The clinic takes a team-based approach to patient care, with team members selected on the basis of patient need. Physicians have panels limited to only 200 patients, and generally spend part of the day in clinic, and part in seeing their hospitalized patients. Although reminiscent of a traditional primary care setting, this clinic is designed specifically for a high-risk, frequently hospitalized population, and therefore requires physicians with both a skill set akin to that of hospitalists, and an approach of palliative care and holistic patient care. Outcomes from this trial clinic are expected in 2017 or 2018.

Considering some key operational questions (Table) can help guide hospitals, hospitalists, and healthcare systems as they venture into the postdischarge clinic space. Return on investment and sustainability are two key questions for postdischarge clinics.

Return on investment varies by payment structure. In capitated environments with a strong emphasis on readmissions and total medical expenditure, a successful postdischarge clinic would recoup the investment through readmission reduction. However, maintaining adequate patient volume against high no-show rates may strain the group financially. In addition, although a hospitalist group may reap few measurable benefits from this clinical exposure, the unique view of the outpatient world afforded to hospitalists working in this environment could enrich the group as a whole by providing a more well-rounded vantage point.

Another key question surrounds sustainability. The clinic at the Beth Israel Deaconess Medical Center in Boston temporarily closed due to high inpatient volume and corresponding need for those hospitalists in the inpatient setting, early in its inception. It subsequently closed due to evolution in the clinic where it was based, rendering it unnecessary. Clinics that are contingent on other clinics will be vulnerable to external forces. Finally, staffing these clinics may be a stretch for a hospitalist group, as a partly different skill set is required for patient care in the outpatient setting. Hospitalists interested in care transitions are well suited for this role. In addition, hospitalists interested in more clinical variety, or in more schedule variety than that provided in a traditional hospitalist schedule, often enjoy the work. A vast majority of hospitalists think PCPs are responsible for postdischarge problems, and would not be interested in working in the postdischarge world.³⁴ A poor fit for providers may lead to clinic failure.

As evident from this review, gaps in understanding the benefits of postdischarge care have persisted for 10 years. Discharge clinics have been scantly described in the literature. The primary unanswered question remains the effect on readmissions, but this has been the sole research focus to date. Other key research areas are the impact on other patient-centered clinical and system outcomes (eg, patient satisfaction, particularly for patients seeing new providers), postdischarge mortality, the effect on other adverse events, and total medical expenditure.

The healthcare system is evolving in the context of a focus on readmissions, primary care access challenges, and high-risk patients’ specific needs. These forces are spurring innovation in the realm of postdischarge physician clinics, as even the basic need for an appointment may not be met by the existing outpatient primary care system. In this context, multiple new outpatient care structures have arisen, many staffed by hospitalists. Some, such as clinics based in safety net hospitals and academic medical centers, address the simple requirement that patients who lack easy access, because of insurance status or provider availability, can see a doctor after discharge. This type of clinic may be an essential step in alleviating a strained system but may not represent a sustainable long-term solution. More comprehensive solutions for improving patient care and clinical outcomes may be offered by integrated systems, such as CareMore, which also emerged from the hospitalist model. A lasting question is whether these clinics, both the narrowly focused and the comprehensive, will have longevity in the evolving healthcare market. Inevitably, though, hospitalist directors will continue to raise such questions, and should stand to benefit from the experiences of others described in this review.

Disclosure

Nothing to report.

Readmission prevention is paramount for hospitals and, by extension, hospitalist programs. Hospitalists see early and reliable outpatient follow-up as a safe landing for their most complicated patient cases. The option of a postdischarge clinic arises from the challenge to arrange adequate postdischarge care for patients who lack easy access because of insurance or provider availability. Guaranteeing postdischarge access by opening a dedicated, hospitalist-led postdischarge clinic appears to be an easy solution, but it is a solution that requires significant investment (including investment in physician and staff training and administrative support) and careful navigation of existing primary care relationships. In addition, a clinic staffed only with physicians may not be well equipped to address the complex social factors in healthcare utilization and readmission. Better understanding of the evidence supporting post discharge physician visits, several models of clinics, and the key operational questions are essential to address before crossing the inpatient-outpatient divide.

A postdischarge outpatient provider visit is often seen as a key factor in reducing readmissions. In 2013, Medicare added strength to this association by establishing transitional care management codes, which provide enhanced reimbursement to providers for a visit within 7 or 14 days of discharge, with focused attention on transitional issues.¹ However, whether a postdischarge visit reduces readmissions remains unclear. Given evidence that higher primary care density is associated with lower healthcare utilization,² CMS’s financial investment in incentivizing post discharge physician visits may be a good bet. On the other hand, simply having a primary care physician (PCP) may be a risk factor for readmission. This association suggests that postdischarge vigilance leads to identification of medical problems that lead to rehospitalization.³ This uncertainty is not resolved in systematic reviews of readmission reduction initiatives, which were not focused solely on the impact of a physician visit.^4,5

The earliest study of postdischarge visits in a general medical population found an association between intensive outpatient follow-up by new providers in a Veterans Affairs population and an increase in hospital readmissions.⁶ This model is similar to some hospitalist models for postdischarge clinics, as the visit was with a noncontinuity provider. The largest recent study, of patients hospitalized with acute myocardial infarction, community-acquired pneumonia, or congestive heart failure (CHF) between 2009 and 2012, found increased frequency of postdischarge follow-up but no concomitant reduction in readmissions.⁷ Although small observational studies⁸ have found a postdischarge primary care visit may reduce the risk for readmission in general medical patients, the bulk of the recent data is negative.

In high-risk patients, however, there may be a clear benefit to postdischarge follow-up. In a North Carolina Medicaid population, a physician visit after discharge was associated with fewer readmissions among high-risk patients, but not among lower risk patients, whose readmission rates were low to start.⁹ The results of that study support the idea that risk stratification may identify patients who can benefit from more intensive outpatient follow-up. In general medical populations, existing studies may suffer from an absence of adequate risk assessment.

The evidence in specific disease states may show a clearer association between a postdischarge physician visit and reduced risk for readmission. One quarter of patients with CHF are rehospitalized within 30 days of discharge.¹⁰ In this disease with frequent exacerbations, a clinic visit to monitor volume status, weight, and medication adherence might reduce the frequency of readmissions or prolong the interval between rehospitalizations. A large observational study observed that earlier post discharge follow up by a cardiologist or a PCP was associated with lower risk of readmission, but only in the quintile with the closest follow-up. In addition, fewer than 40% of patients in this group had a visit within 7 days.¹¹ In another heart failure population, follow-up with either a PCP or cardiologist within 7 days of discharge was again associated with lower risk for readmission.¹² Thus, data suggest a protective effect of postdischarge visits in CHF patients, in contrast to a general medical population. Patients with end-stage renal disease may also fit in this group protected by a postdischarge physician visit, as 1 additional visit within the month after discharge was estimated to reduce rehospitalizations and produce significant cost savings.¹³

With other specific discharge diagnoses, results are varied. Two small observational studies in chronic obstructive pulmonary disease had conflicting results—one found a modest reduction in readmission and emergency department (ED) visits for patients seen by a PCP or pulmonologist within 30 days of discharge,¹⁴ and the other found no effect on readmissions but an associated reduction in mortality.¹⁵ More data are needed to clarify further the interaction of postdischarge visits with mortality, but the association between postdischarge physician visits and readmission reduction is controversial for patients with chronic obstructive pulmonary disease.

Finally, the evidence for dedicated postdischarge clinics is even more limited. A study of a hospitalist-led postdischarge clinic in a Veterans Affairs hospital found reduced length of stay and earlier postdischarge follow-up in a postdischarge clinic, but no effect on readmissions.¹⁶ Other studies have found earlier postdischarge follow-up with dedicated discharge clinics but have not evaluated readmission rates specifically.¹⁷In summary, the effect of postdischarge visits on risk for readmission is an area of active research, but remains unclear. The data reviewed suggest a benefit for the highest risk patients, specifically those with severe chronic illness, or those deemed high-risk with a readmission tool.⁹ At present, because physicians cannot accurately predict which patients will be readmitted,¹⁸ discharging physicians often take a broad approach and schedule outpatient visits for all patients. As readmission tools are further refined, the group of patients who will benefit from postdischarge care will be easier to identify, and a benefit to postdischarge visits may be seen

It is also important to note that this review emphasizes the physician visit and its potential impact on readmissions. Socioeconomic causes are increasingly being recognized as driving readmissions and other utilization.¹⁹ Whether an isolated physician visit is sufficient to prevent readmissions for patients with nonmedical drivers of healthcare utilization is unclear. For those patients, a discharge visit likely is a necessary component of a readmission reduction strategy for high-risk patients, but may be insufficient for patients who require not just an isolated visit but rather a more integrated and comprehensive care program.^8,20,21

Despite the unclear relationship between postdischarge physician care and readmissions, dedicated postdischarge clinics, some staffed by hospitalists, have been adopted over the past 10 years. The three primary types of clinics arise in safety net environments, in academic medical centers, and as comprehensive high-risk patient solutions. Reviewing several types of clinics further clarifies the nature of this structural innovation.

Safety Net Hospital Models

Safety net hospitals and their hospitalists struggle with securing adequate postdischarge access for their population, which has inadequate insurance and poor access to primary care. Patient characteristics also play a role in the complex postdischarge care for this population, given its high rate of ED use (owing to perceived convenience and capabilities) for ambulatory-sensitive conditions.²² In addition, immigrants, particularly those with low English-language proficiency, underuse and have poor access to primary care.^23,24 Postdischarge clinics in this environment focus first on providing a reliable postdischarge plan and then on linking to primary care. Examples of two clinics are at Harborview Medical Center in Seattle, Washington²⁵ and Texas Health in Fort Worth.

Harborview is a 400-bed hospital affiliated with the University of Washington. More than 50% of its patients are considered indigent. The clinic was established in 2007 to provide a postdischarge option for uninsured patients, and a link to primary care in federally qualified health centers. The clinic was staffed 5 days a week with one or two hospitalists or advanced practice nurses. Visit duration was 20 minutes, 270 visits occurred per month, and the no-show rate was 30%. A small subgroup of the hospitalist group staffed the clinic. Particular clinical foci included CHF patients, patients with wound-care needs, and homeless, immigrant, and recently incarcerated patients. A key goal was connecting to longitudinal primary care, and the clinic successfully connected more than 70% of patients to primary care in community health centers. This clinic ultimately transitioned from a hospitalist practice to a primary care practice with a primary focus on post-ED follow-up for unaffiliated patients.²⁶

In 2010, Texas Health faced a similar challenge with unaffiliated patients, and established a nurse practitioner–based clinic with hospitalist oversight to provide care primarily for patients without insurance or without an existing primary care relationship.

Academic Medical Center Models

Another clinical model is designed for patients who receive primary care at practices affiliated with academic medical centers. Although many of these patients have insurance and a PCP, there is often no availability with their continuity provider, because of the resident’s inpatient schedule or the faculty member’s conflicting priorities.^27,28 Academic medical centers, including the University of California at San Francisco, the University of New Mexico, and the Beth Israel Deaconess Medical Center, have established discharge clinics within their faculty primary care practices. A model of this type of clinic was set up at Beth Israel Deaconess in 2010. Staffed by four hospitalists and using 40-minute appointments, this clinic was physically based in the primary care practice. As such, it took advantage of the existing clinic’s administrative and clinical functions, including triage, billing, and scheduling. A visit was scheduled in that clinic by the discharging physician team if a primary care appointment was not available with the patient’s continuity provider. Visits were standardized and focused on outstanding issues at discharge, medication reconciliation, and symptom trajectory. The hospitalists used the clinic’s clinical resources, including nurses, social workers, and pharmacists, but had no other dedicated staff. That there were only four hospitalists meant they were able to gain sufficient exposure to the outpatient setting, provide consistent high-quality care, and gain credibility with the PCPs. As the patients who were seen had PCPs of their own, during the visit significant attention was focused first on the postdischarge concerns, and then on promptly returning the patients to routine primary care. Significant patient outreach was used to address the clinic’s no-show rate, which was almost 50% in the early months. Within a year, the rate was down, closer to 20%. This clinic closed in 2015 after the primary care practice, in which it was based, transitioned to a patient-centered medical home. Since that time, this type of initiative has spread further, with neurohospitalist discharge clinics established, and postdischarge neurology follow-up becoming faster and more reliable.²⁹

Academic medical centers and safety net hospitals substitute for routine primary care to address the basic challenge of primary care access, often without significant enhancements or additional resources, such as dedicated care management and pharmacy, social work, and nursing support. Commonalities of these clinics include dedicated physician staff, appointments generally longer than average outpatient appointments, and visit content concentrated on the key issues at transition (medication reconciliation, outstanding tests, symptom trajectory). As possible, clinics adopted a multidisciplinary approach, with social workers, community health workers, and nurses, to respond to the breadth of patients’ postdischarge needs, which often extend beyond pure medical need. The most frequent barriers encountered included the knowledge gap for hospitalist providers in the outpatient setting (a gap mitigated by using dedicated providers) and the patients’ high no-show rate (not surprising given that the providers are generally new to them). Few clinics have attempted to create continuity across inpatient and outpatient providers, though continuity might reduce no-shows as well as eliminate at least 1 transition.

Comprehensive High-Risk Patient Solutions

At the other end of the clinic spectrum are more integrated postdischarge approaches, which also evolved from the hospitalist model with hospitalist staffing. However, these approaches were introduced in response to the clinical needs of the highest risk patients (who are most vulnerable to frequent provider transitions), not to a systemic inability to provide routine postdischarge care.³⁰

The most long-standing model for this type of clinic is represented by CareMore Health System, a subsidiary of Anthem.^30-32 The extensivist, an expanded-scope hospitalist, acts as primary care coordinator, coordinating a multidisciplinary team for a panel of about 100 patients, representing the sickest 5% of the Medicare Advantage–insured population. Unlike the traditional hospitalist, the extensivist follows patients across all care sites, including hospital, rehabilitation sites, and outpatient clinic. For the most part, this relationship is not designed to evolve into a longitudinal relationship, but rather is an intervention only for the several-months period of acute need. Internal data have shown effects on hospital readmissions as well as length of stay.³⁰

Another integrated clinic was established in 2013, at the University of Chicago. This was an effort to redesign care for patients at highest risk for hospitalization.³³ Similar to the CareMore process, a high-risk population is identified by prior hospitalization and expected high Medicare costs. A comprehensive care physician cares for these patients across care settings. The clinic takes a team-based approach to patient care, with team members selected on the basis of patient need. Physicians have panels limited to only 200 patients, and generally spend part of the day in clinic, and part in seeing their hospitalized patients. Although reminiscent of a traditional primary care setting, this clinic is designed specifically for a high-risk, frequently hospitalized population, and therefore requires physicians with both a skill set akin to that of hospitalists, and an approach of palliative care and holistic patient care. Outcomes from this trial clinic are expected in 2017 or 2018.

Considering some key operational questions (Table) can help guide hospitals, hospitalists, and healthcare systems as they venture into the postdischarge clinic space. Return on investment and sustainability are two key questions for postdischarge clinics.

Return on investment varies by payment structure. In capitated environments with a strong emphasis on readmissions and total medical expenditure, a successful postdischarge clinic would recoup the investment through readmission reduction. However, maintaining adequate patient volume against high no-show rates may strain the group financially. In addition, although a hospitalist group may reap few measurable benefits from this clinical exposure, the unique view of the outpatient world afforded to hospitalists working in this environment could enrich the group as a whole by providing a more well-rounded vantage point.

Another key question surrounds sustainability. The clinic at the Beth Israel Deaconess Medical Center in Boston temporarily closed due to high inpatient volume and corresponding need for those hospitalists in the inpatient setting, early in its inception. It subsequently closed due to evolution in the clinic where it was based, rendering it unnecessary. Clinics that are contingent on other clinics will be vulnerable to external forces. Finally, staffing these clinics may be a stretch for a hospitalist group, as a partly different skill set is required for patient care in the outpatient setting. Hospitalists interested in care transitions are well suited for this role. In addition, hospitalists interested in more clinical variety, or in more schedule variety than that provided in a traditional hospitalist schedule, often enjoy the work. A vast majority of hospitalists think PCPs are responsible for postdischarge problems, and would not be interested in working in the postdischarge world.³⁴ A poor fit for providers may lead to clinic failure.

As evident from this review, gaps in understanding the benefits of postdischarge care have persisted for 10 years. Discharge clinics have been scantly described in the literature. The primary unanswered question remains the effect on readmissions, but this has been the sole research focus to date. Other key research areas are the impact on other patient-centered clinical and system outcomes (eg, patient satisfaction, particularly for patients seeing new providers), postdischarge mortality, the effect on other adverse events, and total medical expenditure.

The healthcare system is evolving in the context of a focus on readmissions, primary care access challenges, and high-risk patients’ specific needs. These forces are spurring innovation in the realm of postdischarge physician clinics, as even the basic need for an appointment may not be met by the existing outpatient primary care system. In this context, multiple new outpatient care structures have arisen, many staffed by hospitalists. Some, such as clinics based in safety net hospitals and academic medical centers, address the simple requirement that patients who lack easy access, because of insurance status or provider availability, can see a doctor after discharge. This type of clinic may be an essential step in alleviating a strained system but may not represent a sustainable long-term solution. More comprehensive solutions for improving patient care and clinical outcomes may be offered by integrated systems, such as CareMore, which also emerged from the hospitalist model. A lasting question is whether these clinics, both the narrowly focused and the comprehensive, will have longevity in the evolving healthcare market. Inevitably, though, hospitalist directors will continue to raise such questions, and should stand to benefit from the experiences of others described in this review.

Disclosure

Nothing to report.

Readmission prevention is paramount for hospitals and, by extension, hospitalist programs. Hospitalists see early and reliable outpatient follow-up as a safe landing for their most complicated patient cases. The option of a postdischarge clinic arises from the challenge to arrange adequate postdischarge care for patients who lack easy access because of insurance or provider availability. Guaranteeing postdischarge access by opening a dedicated, hospitalist-led postdischarge clinic appears to be an easy solution, but it is a solution that requires significant investment (including investment in physician and staff training and administrative support) and careful navigation of existing primary care relationships. In addition, a clinic staffed only with physicians may not be well equipped to address the complex social factors in healthcare utilization and readmission. Better understanding of the evidence supporting post discharge physician visits, several models of clinics, and the key operational questions are essential to address before crossing the inpatient-outpatient divide.

A postdischarge outpatient provider visit is often seen as a key factor in reducing readmissions. In 2013, Medicare added strength to this association by establishing transitional care management codes, which provide enhanced reimbursement to providers for a visit within 7 or 14 days of discharge, with focused attention on transitional issues.¹ However, whether a postdischarge visit reduces readmissions remains unclear. Given evidence that higher primary care density is associated with lower healthcare utilization,² CMS’s financial investment in incentivizing post discharge physician visits may be a good bet. On the other hand, simply having a primary care physician (PCP) may be a risk factor for readmission. This association suggests that postdischarge vigilance leads to identification of medical problems that lead to rehospitalization.³ This uncertainty is not resolved in systematic reviews of readmission reduction initiatives, which were not focused solely on the impact of a physician visit.^4,5

The earliest study of postdischarge visits in a general medical population found an association between intensive outpatient follow-up by new providers in a Veterans Affairs population and an increase in hospital readmissions.⁶ This model is similar to some hospitalist models for postdischarge clinics, as the visit was with a noncontinuity provider. The largest recent study, of patients hospitalized with acute myocardial infarction, community-acquired pneumonia, or congestive heart failure (CHF) between 2009 and 2012, found increased frequency of postdischarge follow-up but no concomitant reduction in readmissions.⁷ Although small observational studies⁸ have found a postdischarge primary care visit may reduce the risk for readmission in general medical patients, the bulk of the recent data is negative.

In high-risk patients, however, there may be a clear benefit to postdischarge follow-up. In a North Carolina Medicaid population, a physician visit after discharge was associated with fewer readmissions among high-risk patients, but not among lower risk patients, whose readmission rates were low to start.⁹ The results of that study support the idea that risk stratification may identify patients who can benefit from more intensive outpatient follow-up. In general medical populations, existing studies may suffer from an absence of adequate risk assessment.

The evidence in specific disease states may show a clearer association between a postdischarge physician visit and reduced risk for readmission. One quarter of patients with CHF are rehospitalized within 30 days of discharge.¹⁰ In this disease with frequent exacerbations, a clinic visit to monitor volume status, weight, and medication adherence might reduce the frequency of readmissions or prolong the interval between rehospitalizations. A large observational study observed that earlier post discharge follow up by a cardiologist or a PCP was associated with lower risk of readmission, but only in the quintile with the closest follow-up. In addition, fewer than 40% of patients in this group had a visit within 7 days.¹¹ In another heart failure population, follow-up with either a PCP or cardiologist within 7 days of discharge was again associated with lower risk for readmission.¹² Thus, data suggest a protective effect of postdischarge visits in CHF patients, in contrast to a general medical population. Patients with end-stage renal disease may also fit in this group protected by a postdischarge physician visit, as 1 additional visit within the month after discharge was estimated to reduce rehospitalizations and produce significant cost savings.¹³

With other specific discharge diagnoses, results are varied. Two small observational studies in chronic obstructive pulmonary disease had conflicting results—one found a modest reduction in readmission and emergency department (ED) visits for patients seen by a PCP or pulmonologist within 30 days of discharge,¹⁴ and the other found no effect on readmissions but an associated reduction in mortality.¹⁵ More data are needed to clarify further the interaction of postdischarge visits with mortality, but the association between postdischarge physician visits and readmission reduction is controversial for patients with chronic obstructive pulmonary disease.

Finally, the evidence for dedicated postdischarge clinics is even more limited. A study of a hospitalist-led postdischarge clinic in a Veterans Affairs hospital found reduced length of stay and earlier postdischarge follow-up in a postdischarge clinic, but no effect on readmissions.¹⁶ Other studies have found earlier postdischarge follow-up with dedicated discharge clinics but have not evaluated readmission rates specifically.¹⁷In summary, the effect of postdischarge visits on risk for readmission is an area of active research, but remains unclear. The data reviewed suggest a benefit for the highest risk patients, specifically those with severe chronic illness, or those deemed high-risk with a readmission tool.⁹ At present, because physicians cannot accurately predict which patients will be readmitted,¹⁸ discharging physicians often take a broad approach and schedule outpatient visits for all patients. As readmission tools are further refined, the group of patients who will benefit from postdischarge care will be easier to identify, and a benefit to postdischarge visits may be seen

It is also important to note that this review emphasizes the physician visit and its potential impact on readmissions. Socioeconomic causes are increasingly being recognized as driving readmissions and other utilization.¹⁹ Whether an isolated physician visit is sufficient to prevent readmissions for patients with nonmedical drivers of healthcare utilization is unclear. For those patients, a discharge visit likely is a necessary component of a readmission reduction strategy for high-risk patients, but may be insufficient for patients who require not just an isolated visit but rather a more integrated and comprehensive care program.^8,20,21

Despite the unclear relationship between postdischarge physician care and readmissions, dedicated postdischarge clinics, some staffed by hospitalists, have been adopted over the past 10 years. The three primary types of clinics arise in safety net environments, in academic medical centers, and as comprehensive high-risk patient solutions. Reviewing several types of clinics further clarifies the nature of this structural innovation.

Safety Net Hospital Models

Safety net hospitals and their hospitalists struggle with securing adequate postdischarge access for their population, which has inadequate insurance and poor access to primary care. Patient characteristics also play a role in the complex postdischarge care for this population, given its high rate of ED use (owing to perceived convenience and capabilities) for ambulatory-sensitive conditions.²² In addition, immigrants, particularly those with low English-language proficiency, underuse and have poor access to primary care.^23,24 Postdischarge clinics in this environment focus first on providing a reliable postdischarge plan and then on linking to primary care. Examples of two clinics are at Harborview Medical Center in Seattle, Washington²⁵ and Texas Health in Fort Worth.

Harborview is a 400-bed hospital affiliated with the University of Washington. More than 50% of its patients are considered indigent. The clinic was established in 2007 to provide a postdischarge option for uninsured patients, and a link to primary care in federally qualified health centers. The clinic was staffed 5 days a week with one or two hospitalists or advanced practice nurses. Visit duration was 20 minutes, 270 visits occurred per month, and the no-show rate was 30%. A small subgroup of the hospitalist group staffed the clinic. Particular clinical foci included CHF patients, patients with wound-care needs, and homeless, immigrant, and recently incarcerated patients. A key goal was connecting to longitudinal primary care, and the clinic successfully connected more than 70% of patients to primary care in community health centers. This clinic ultimately transitioned from a hospitalist practice to a primary care practice with a primary focus on post-ED follow-up for unaffiliated patients.²⁶

In 2010, Texas Health faced a similar challenge with unaffiliated patients, and established a nurse practitioner–based clinic with hospitalist oversight to provide care primarily for patients without insurance or without an existing primary care relationship.

Academic Medical Center Models

Another clinical model is designed for patients who receive primary care at practices affiliated with academic medical centers. Although many of these patients have insurance and a PCP, there is often no availability with their continuity provider, because of the resident’s inpatient schedule or the faculty member’s conflicting priorities.^27,28 Academic medical centers, including the University of California at San Francisco, the University of New Mexico, and the Beth Israel Deaconess Medical Center, have established discharge clinics within their faculty primary care practices. A model of this type of clinic was set up at Beth Israel Deaconess in 2010. Staffed by four hospitalists and using 40-minute appointments, this clinic was physically based in the primary care practice. As such, it took advantage of the existing clinic’s administrative and clinical functions, including triage, billing, and scheduling. A visit was scheduled in that clinic by the discharging physician team if a primary care appointment was not available with the patient’s continuity provider. Visits were standardized and focused on outstanding issues at discharge, medication reconciliation, and symptom trajectory. The hospitalists used the clinic’s clinical resources, including nurses, social workers, and pharmacists, but had no other dedicated staff. That there were only four hospitalists meant they were able to gain sufficient exposure to the outpatient setting, provide consistent high-quality care, and gain credibility with the PCPs. As the patients who were seen had PCPs of their own, during the visit significant attention was focused first on the postdischarge concerns, and then on promptly returning the patients to routine primary care. Significant patient outreach was used to address the clinic’s no-show rate, which was almost 50% in the early months. Within a year, the rate was down, closer to 20%. This clinic closed in 2015 after the primary care practice, in which it was based, transitioned to a patient-centered medical home. Since that time, this type of initiative has spread further, with neurohospitalist discharge clinics established, and postdischarge neurology follow-up becoming faster and more reliable.²⁹

Academic medical centers and safety net hospitals substitute for routine primary care to address the basic challenge of primary care access, often without significant enhancements or additional resources, such as dedicated care management and pharmacy, social work, and nursing support. Commonalities of these clinics include dedicated physician staff, appointments generally longer than average outpatient appointments, and visit content concentrated on the key issues at transition (medication reconciliation, outstanding tests, symptom trajectory). As possible, clinics adopted a multidisciplinary approach, with social workers, community health workers, and nurses, to respond to the breadth of patients’ postdischarge needs, which often extend beyond pure medical need. The most frequent barriers encountered included the knowledge gap for hospitalist providers in the outpatient setting (a gap mitigated by using dedicated providers) and the patients’ high no-show rate (not surprising given that the providers are generally new to them). Few clinics have attempted to create continuity across inpatient and outpatient providers, though continuity might reduce no-shows as well as eliminate at least 1 transition.

Comprehensive High-Risk Patient Solutions

At the other end of the clinic spectrum are more integrated postdischarge approaches, which also evolved from the hospitalist model with hospitalist staffing. However, these approaches were introduced in response to the clinical needs of the highest risk patients (who are most vulnerable to frequent provider transitions), not to a systemic inability to provide routine postdischarge care.³⁰

The most long-standing model for this type of clinic is represented by CareMore Health System, a subsidiary of Anthem.^30-32 The extensivist, an expanded-scope hospitalist, acts as primary care coordinator, coordinating a multidisciplinary team for a panel of about 100 patients, representing the sickest 5% of the Medicare Advantage–insured population. Unlike the traditional hospitalist, the extensivist follows patients across all care sites, including hospital, rehabilitation sites, and outpatient clinic. For the most part, this relationship is not designed to evolve into a longitudinal relationship, but rather is an intervention only for the several-months period of acute need. Internal data have shown effects on hospital readmissions as well as length of stay.³⁰

Another integrated clinic was established in 2013, at the University of Chicago. This was an effort to redesign care for patients at highest risk for hospitalization.³³ Similar to the CareMore process, a high-risk population is identified by prior hospitalization and expected high Medicare costs. A comprehensive care physician cares for these patients across care settings. The clinic takes a team-based approach to patient care, with team members selected on the basis of patient need. Physicians have panels limited to only 200 patients, and generally spend part of the day in clinic, and part in seeing their hospitalized patients. Although reminiscent of a traditional primary care setting, this clinic is designed specifically for a high-risk, frequently hospitalized population, and therefore requires physicians with both a skill set akin to that of hospitalists, and an approach of palliative care and holistic patient care. Outcomes from this trial clinic are expected in 2017 or 2018.

Considering some key operational questions (Table) can help guide hospitals, hospitalists, and healthcare systems as they venture into the postdischarge clinic space. Return on investment and sustainability are two key questions for postdischarge clinics.

Return on investment varies by payment structure. In capitated environments with a strong emphasis on readmissions and total medical expenditure, a successful postdischarge clinic would recoup the investment through readmission reduction. However, maintaining adequate patient volume against high no-show rates may strain the group financially. In addition, although a hospitalist group may reap few measurable benefits from this clinical exposure, the unique view of the outpatient world afforded to hospitalists working in this environment could enrich the group as a whole by providing a more well-rounded vantage point.

Another key question surrounds sustainability. The clinic at the Beth Israel Deaconess Medical Center in Boston temporarily closed due to high inpatient volume and corresponding need for those hospitalists in the inpatient setting, early in its inception. It subsequently closed due to evolution in the clinic where it was based, rendering it unnecessary. Clinics that are contingent on other clinics will be vulnerable to external forces. Finally, staffing these clinics may be a stretch for a hospitalist group, as a partly different skill set is required for patient care in the outpatient setting. Hospitalists interested in care transitions are well suited for this role. In addition, hospitalists interested in more clinical variety, or in more schedule variety than that provided in a traditional hospitalist schedule, often enjoy the work. A vast majority of hospitalists think PCPs are responsible for postdischarge problems, and would not be interested in working in the postdischarge world.³⁴ A poor fit for providers may lead to clinic failure.

As evident from this review, gaps in understanding the benefits of postdischarge care have persisted for 10 years. Discharge clinics have been scantly described in the literature. The primary unanswered question remains the effect on readmissions, but this has been the sole research focus to date. Other key research areas are the impact on other patient-centered clinical and system outcomes (eg, patient satisfaction, particularly for patients seeing new providers), postdischarge mortality, the effect on other adverse events, and total medical expenditure.

The healthcare system is evolving in the context of a focus on readmissions, primary care access challenges, and high-risk patients’ specific needs. These forces are spurring innovation in the realm of postdischarge physician clinics, as even the basic need for an appointment may not be met by the existing outpatient primary care system. In this context, multiple new outpatient care structures have arisen, many staffed by hospitalists. Some, such as clinics based in safety net hospitals and academic medical centers, address the simple requirement that patients who lack easy access, because of insurance status or provider availability, can see a doctor after discharge. This type of clinic may be an essential step in alleviating a strained system but may not represent a sustainable long-term solution. More comprehensive solutions for improving patient care and clinical outcomes may be offered by integrated systems, such as CareMore, which also emerged from the hospitalist model. A lasting question is whether these clinics, both the narrowly focused and the comprehensive, will have longevity in the evolving healthcare market. Inevitably, though, hospitalist directors will continue to raise such questions, and should stand to benefit from the experiences of others described in this review.

Disclosure

Nothing to report.

Measles is a highly contagious acute respiratory illness that includes a characteristic rash. After exposure, up to 90% of susceptible persons develop measles.¹ Even though it is considered a childhood illness, measles can affect people of all age groups. Measles continues to be major health problem around the world, despite the availability of a safe and effective vaccine, and it remains one of the leading causes of childhood mortality, with nearly 115,000 deaths reported by the World Health Organization² in 2014. In 2000, measles was declared eliminated from the United States, but outbreaks still occasionally occur.^3-6

The disease is self-limited, but some patients develop complications that may require hospitalization for treatment. People at highest risk for complications are children younger than 5 years, adults older than 20 years, pregnant women, and immunocompromised individuals.⁷

During the licensure of live measles vaccine in 1963, an average of 549,000 measles cases and 495 measles deaths, as well as 48,000 hospitalizations and 4000 encephalitis cases, were reported annually in the United States. Almost all Americans were affected by measles by adolescence.

Implementation of the 1-dose vaccine program substantially reduced reported incidence in the United States by 1988, and led to a dramatic decline in measles-related hospitalizations and deaths.^3-6 The 2-dose MMR (measles, mumps, rubella) vaccination was introduced in 1989, and measles was declared eliminated in the United States in 2000.^3-6

National–level one-dose MMR coverage among children 19-35 months has remained above 90% during the last two decades.⁸ NIS-Teen vaccination coverage data for 13- to 17-year-olds since 2008 has been near or above 90%,⁹ and 94% of children enrolled in kindergarten had evidence of 2 MMR doses in the 2014-2015 school year.¹⁰

A large multistate measles outbreak was reported in the United States in 2014-2015.^4,11 One hundred fifty-nine cases were reported in the United States between January 4 and April 5, 2015. The majority of patients either were unvaccinated (45%) or had an unknown vaccination status (38%). Age ranged from 6 weeks to 70 years, and 22 patients (14%) were hospitalized.⁴

Measles is caused by an RNA-containing paramyxovirus that is spread by the respiratory route. Average incubation period from exposure to rash onset is 14 days (range, 7-21 days).^12,13 Peak infectivity occurs during the prodromal phase, before rash onset (Figure 1), but patients are infectious from 4 days before rash onset through 4 days after rash onset.^7,12,13

The disease prodrome consists of a high fever (39°C-40.5°C), coryza, cough, and conjunctivitis followed by Koplik spots (Figure 2A). Koplik spots are pathognomonic for measles but rarely discovered. They appear before the skin rash alongside second molars on the buccal surface of the cheeks. The spots usually disappear when the characteristic maculopapular, nonpruritic rash erupts initially at the hairline and behind the ears, and within four days progresses toward the trunk and limbs, including the palms and soles (Figures 2B, 2C).

The presenting symptoms of primary measles infection are nonspecific, particularly if Koplik spots are not identified. The differential diagnosis for a patient who presents with high fever and rash include Kawasaki disease, dengue, parvovirus B19, serum sickness, syphilis, systemic lupus erythematous, toxic shock syndrome, enterovirus infection, human herpes virus 6 (roseola), viral hemorrhagic fever, drug eruption, infectious mononucleosis, Rocky Mountain spotted fever, rubella, scarlet fever, chikungunya, and Zika virus infection.

Measles complications can affect nearly every organ system (Table). Rates of complications from measles infection depend on age and underlying condition. Coexisting vitamin A deficiency increases complication rates.²⁰

Bacterial infections in the setting of measles infection are more common in adults than in children, and are more severe among people who are malnourished or have an immunodeficiency disorder. The most common infectious complications, which involve the respiratory tract, include pneumonia, laryngotracheitis (“measles croup”), bronchitis, otitis media (most common complication among children in the United States), and sinusitis.^7,13,21

Indications for hospitalizing children include respiratory distress, laryngeal obstruction, dehydration that requires intravenous fluids, diarrhea with more than 10 stools a day or bloody stool, severe anemia, altered mental status, convulsion, severe rash with developing hemorrhagic areas, extensive mouth ulcers, corneal clouding or ulcers, visual disturbance, and mastoiditis.²²

Pneumonia is a common indication for hospitalizing adults.^23,24 Measles-associated interstitial giant cell (Hecht) pneumonia is most often recognized among immunocompromised and malnourished patients.¹³ Primary pneumonia is caused by the measles virus, but bacterial superinfection can occur. The most common bacterial pathogens include Streptococcus, Pneumococcus, and Staphylococcus,^13,24 and less commonly isolated organisms include gram-negative bacteria, such as Haemophilus influenzae, Pseudomonas aeruginosa, Neisseria meningitides, and Enterobacter cloacae.²³

Uncommon complications of measles are myocarditis, glomerulonephritis, acute renal failure, and thrombocytopenic purpura.^25,26

Neurologic complications in measles are an important concern. Measles-associated central nervous system complications are considered a result of an immune-mediated reaction to myelin protein and not from direct viral insult.^26-28 Immunocompromised patients are at risk for developing fatal encephalitis, and those who survive often experience cognitive decline or seizures.

Measles is associated with four different encephalitic diseases: primary measles encephalitis, acute post-measles encephalomyelitis, measles inclusion body encephalitis, and subacute sclerosing panencephalitis.

Primary measles encephalitis is characterized by fever, headache, stiff neck, and meningeal signs. Onset occurs between 1 and 15 days after rash onset, and the disease affects 1/1000 patients. Seizure, altered mental status, and coma can also develop. Viral RNA detection in the cerebrospinal fluid (CSF) confirms the diagnosis.²⁹Acute post-measles encephalomyelitis is more common in adults than in children.¹² It typically develops after the rash fades and the other symptoms subside. Patients suddenly experience a recurrence of fevers or seizures. Deafness, intellectual decline, epilepsy, postencephalitic hyperkinesia, hemiplegia, and/or paraplegia also can develop.^27-29

Measles inclusion body encephalitis is described only in immunocompromised patients, and onset occurs within 1 year of infection. Seizures are an initial and common symptom, and some patients also experience hemiplegia, stupor, hypertonia, and dysarthria.²⁹ Diagnostic findings include seroconversion during the disease course, improvement after withholding of the immunosuppressive regimen, and normal CSF. Brain biopsy confirms the diagnosis.

Subacute sclerosing panencephalitis (SSPE) is a slowly progressing and untreatable degenerative neurologic disorder characterized by demyelination of multiple brain areas. SSPE develops 7 to 10 years after natural measles infection, and usually affects children or adolescents. Clinical presentation includes intellectual decline, frequent rhythmic myoclonic jerks, seizure, and dementia. As the disease progresses, coma, quadriplegia, vegetative state, and autonomic instability develop. Death usually occurs within 2 years of onset.^30,31 In children, the risk for SSPE after measles infection is estimated to be 4 to 11 per 100,000 infections. After the 1989-1991 resurgence of measles in the United States, however, the risk for SSPE was estimated to be 22 per 100,000 infections.^30-32 The pathogenesis of SSPE is not fully understood but is thought to result from persistent aberrant measles virus infection.³²

The SSPE diagnosis is based on clinical presentation, presence of anti-measles antibodies in CSF, typical electroencephalography pattern (periodic paroxysmal bursts) with accompanying myoclonus, tissue analysis, and magnetic resonance imaging.³⁰

Suspicion for measles should prompt immediate consultation with local or state public health officials. Laboratory testing can be carefully considered after consultation, and care is needed in interpreting serologic studies.

The mainstays of measles infection diagnosis are detection of viral RNA by reverse transcriptase–polymerase chain reaction, or isolation of the virus in the clinical specimen, and detection of measles-specific IgM (immunoglobulin M) antibodies. A detailed protocol for collecting specimens for viral isolation appears on the Centers for Disease Control and Prevention website (http://www.cdc.gov/measles/lab-tools/rt-pcr.html).

IgM antibodies are detectable over the 15 weeks after rash onset, but the recommendation is to collect serum between 72 hours and 4 weeks after rash onset.³³ Clinicians should be aware that false-positive IgM results may occur with rheumatologic diseases, parvovirus B19 infection, rubella, and infectious mononucleosis.

IgG (immunoglobulin G) antibodies are usually detectable a week after rash onset. The laboratory can confirm measles by detecting more than a 4-fold increase in IgG titers between the acute phase and the convalescent phase. After measles infection, most adults develop lifelong immunity with positive IgG serology.³⁴

Additional tests, such as IgG avidity and plaque reduction neutralization assay, can be used to confirm suspected cases in previously vaccinated individuals.³⁴

General Principles

Uncomplicated measles treatment is supportive and includes oral fluids and antipyretics.^7,22 Severe bacterial infections, encephalitis, or dehydration may require hospitalization, and in these cases infectious disease consultation is recommended. Patients with pneumonia, purulent otitis media, or tonsillitis should be treated with antibiotics.³⁵ Observational data suggest antibiotics may reduce the occurrence of bacterial infection in children, but there are no usage guidelines.³⁵ Vitamin A supplementation has been associated with a 50% decrease in morbidity and mortality and with blindness prevention.²² This supplementation should be considered in severe measles cases (all hospitalized patients), especially for children, regardless of country of residence, and for adult patients who exhibit clinical signs of vitamin A deficiency.^22,24

Antiviral Treatment

No specific treatment is available.³⁶ Ribavirin demonstrates in vitro activity against the virus, but the Food and Drug Administration has not approved the drug for treatment of measles. Ribavirin has been used for cases of severe measles, and for patients with SSPE along with intrathecal interferon alpha. This antiviral treatment is considered experimental.³⁷

All patients hospitalized with measles infection should be cautioned about the potential downstream complications of the disease and should follow up with their primary care physician for surveillance after discharge.³⁸

If measles symptoms develop, patients should self-quarantine and contact their primary care physician or public health department as soon as possible. Regardless of immune status, family members and other exposed persons should be educated about the measles symptoms that may occur during the 21 days after exposure.³⁸

Both suspected and confirmed cases of measles should be reported immediately to local public health authorities.

Infection Control and Prophylaxis

Current guidelines recommend 2 doses of measles-containing vaccine to all adults at higher risk for contracting measles: international travelers, healthcare personnel, and high school and college students. Infants 6 or 11 months old should receive 1 MMR dose before international travel.^1,38

Strict airborne isolation—use of N95 respirator or respirator with similar effectiveness in preventing airborne transmission—is mandatory from 3 to 5 days before rash onset to 4 days after rash onset (immunocompetent patients) or for the duration of the disease (immunocompromised patients).³⁸

Healthcare workers should have documented presumptive evidence of immunity to measles.³⁹ Healthcare providers without evidence of immunity should be excused from work from day 5 to day 21 of exposure, even if they have received postexposure vaccine or intramuscular immunoglobulin. They should be offered the first MMR dose within 72 hours of measles exposure to prevent or modify the disease. Susceptible family members or visitors should not be allowed in the patient’s room.¹

Postexposure Prophylaxis

Standard MMR vaccination within 72 hours after exposure may protect against disease in people without a contraindication to measles vaccine. The public health department usually identifies these individuals and provides postexposure prophylaxis recommendations.^38,39

People with HIV, patients receiving immunosuppressive therapy, and pregnant women and infants who have been exposed to measles and who are at risk for developing morbid disease can be treated with immunoglobulin (IG). If administered within 6 days of exposure, IG can prevent or modify disease in people who are unvaccinated or severely immunocompromised (ie, not immune). The recommended dose of IG administered intramuscularly is 0.5 mL/kg of body weight (maximum, 15 mL), and the recommended dose of IG given intravenously is 400 mg/kg. Anyone heavier than 30 kg would require intravenous IG to achieve adequate antibody levels.

Physicians should not vaccinate pregnant women, patients with severe immunosuppression from disease or therapy, patients with moderate or severe illness, and people with a history of severe allergic reaction to the vaccine.^1,40 The measles vaccine should be deferred for 6 months after IG administration.³⁶ More details are available in the recommendations made by the Advisory Committee on Immunization Practices.¹

Although rare in the United States, measles remains a common and potentially devastating infection among patients who have not been vaccinated. Diagnosis requires clinical suspicion, engagement of public health authorities, and judicious use of laboratory testing. Hospitalists may encounter infectious and neurologic complications of measles long after the initial infection and should be aware of these associations.

Disclosure

Nothing to report.

Measles is a highly contagious acute respiratory illness that includes a characteristic rash. After exposure, up to 90% of susceptible persons develop measles.¹ Even though it is considered a childhood illness, measles can affect people of all age groups. Measles continues to be major health problem around the world, despite the availability of a safe and effective vaccine, and it remains one of the leading causes of childhood mortality, with nearly 115,000 deaths reported by the World Health Organization² in 2014. In 2000, measles was declared eliminated from the United States, but outbreaks still occasionally occur.^3-6

The disease is self-limited, but some patients develop complications that may require hospitalization for treatment. People at highest risk for complications are children younger than 5 years, adults older than 20 years, pregnant women, and immunocompromised individuals.⁷

During the licensure of live measles vaccine in 1963, an average of 549,000 measles cases and 495 measles deaths, as well as 48,000 hospitalizations and 4000 encephalitis cases, were reported annually in the United States. Almost all Americans were affected by measles by adolescence.

Implementation of the 1-dose vaccine program substantially reduced reported incidence in the United States by 1988, and led to a dramatic decline in measles-related hospitalizations and deaths.^3-6 The 2-dose MMR (measles, mumps, rubella) vaccination was introduced in 1989, and measles was declared eliminated in the United States in 2000.^3-6

National–level one-dose MMR coverage among children 19-35 months has remained above 90% during the last two decades.⁸ NIS-Teen vaccination coverage data for 13- to 17-year-olds since 2008 has been near or above 90%,⁹ and 94% of children enrolled in kindergarten had evidence of 2 MMR doses in the 2014-2015 school year.¹⁰

A large multistate measles outbreak was reported in the United States in 2014-2015.^4,11 One hundred fifty-nine cases were reported in the United States between January 4 and April 5, 2015. The majority of patients either were unvaccinated (45%) or had an unknown vaccination status (38%). Age ranged from 6 weeks to 70 years, and 22 patients (14%) were hospitalized.⁴

Measles is caused by an RNA-containing paramyxovirus that is spread by the respiratory route. Average incubation period from exposure to rash onset is 14 days (range, 7-21 days).^12,13 Peak infectivity occurs during the prodromal phase, before rash onset (Figure 1), but patients are infectious from 4 days before rash onset through 4 days after rash onset.^7,12,13

The disease prodrome consists of a high fever (39°C-40.5°C), coryza, cough, and conjunctivitis followed by Koplik spots (Figure 2A). Koplik spots are pathognomonic for measles but rarely discovered. They appear before the skin rash alongside second molars on the buccal surface of the cheeks. The spots usually disappear when the characteristic maculopapular, nonpruritic rash erupts initially at the hairline and behind the ears, and within four days progresses toward the trunk and limbs, including the palms and soles (Figures 2B, 2C).

The presenting symptoms of primary measles infection are nonspecific, particularly if Koplik spots are not identified. The differential diagnosis for a patient who presents with high fever and rash include Kawasaki disease, dengue, parvovirus B19, serum sickness, syphilis, systemic lupus erythematous, toxic shock syndrome, enterovirus infection, human herpes virus 6 (roseola), viral hemorrhagic fever, drug eruption, infectious mononucleosis, Rocky Mountain spotted fever, rubella, scarlet fever, chikungunya, and Zika virus infection.

Measles complications can affect nearly every organ system (Table). Rates of complications from measles infection depend on age and underlying condition. Coexisting vitamin A deficiency increases complication rates.²⁰

Bacterial infections in the setting of measles infection are more common in adults than in children, and are more severe among people who are malnourished or have an immunodeficiency disorder. The most common infectious complications, which involve the respiratory tract, include pneumonia, laryngotracheitis (“measles croup”), bronchitis, otitis media (most common complication among children in the United States), and sinusitis.^7,13,21

Indications for hospitalizing children include respiratory distress, laryngeal obstruction, dehydration that requires intravenous fluids, diarrhea with more than 10 stools a day or bloody stool, severe anemia, altered mental status, convulsion, severe rash with developing hemorrhagic areas, extensive mouth ulcers, corneal clouding or ulcers, visual disturbance, and mastoiditis.²²

Pneumonia is a common indication for hospitalizing adults.^23,24 Measles-associated interstitial giant cell (Hecht) pneumonia is most often recognized among immunocompromised and malnourished patients.¹³ Primary pneumonia is caused by the measles virus, but bacterial superinfection can occur. The most common bacterial pathogens include Streptococcus, Pneumococcus, and Staphylococcus,^13,24 and less commonly isolated organisms include gram-negative bacteria, such as Haemophilus influenzae, Pseudomonas aeruginosa, Neisseria meningitides, and Enterobacter cloacae.²³

Uncommon complications of measles are myocarditis, glomerulonephritis, acute renal failure, and thrombocytopenic purpura.^25,26

Neurologic complications in measles are an important concern. Measles-associated central nervous system complications are considered a result of an immune-mediated reaction to myelin protein and not from direct viral insult.^26-28 Immunocompromised patients are at risk for developing fatal encephalitis, and those who survive often experience cognitive decline or seizures.

Measles is associated with four different encephalitic diseases: primary measles encephalitis, acute post-measles encephalomyelitis, measles inclusion body encephalitis, and subacute sclerosing panencephalitis.

Primary measles encephalitis is characterized by fever, headache, stiff neck, and meningeal signs. Onset occurs between 1 and 15 days after rash onset, and the disease affects 1/1000 patients. Seizure, altered mental status, and coma can also develop. Viral RNA detection in the cerebrospinal fluid (CSF) confirms the diagnosis.²⁹Acute post-measles encephalomyelitis is more common in adults than in children.¹² It typically develops after the rash fades and the other symptoms subside. Patients suddenly experience a recurrence of fevers or seizures. Deafness, intellectual decline, epilepsy, postencephalitic hyperkinesia, hemiplegia, and/or paraplegia also can develop.^27-29

Measles inclusion body encephalitis is described only in immunocompromised patients, and onset occurs within 1 year of infection. Seizures are an initial and common symptom, and some patients also experience hemiplegia, stupor, hypertonia, and dysarthria.²⁹ Diagnostic findings include seroconversion during the disease course, improvement after withholding of the immunosuppressive regimen, and normal CSF. Brain biopsy confirms the diagnosis.

Subacute sclerosing panencephalitis (SSPE) is a slowly progressing and untreatable degenerative neurologic disorder characterized by demyelination of multiple brain areas. SSPE develops 7 to 10 years after natural measles infection, and usually affects children or adolescents. Clinical presentation includes intellectual decline, frequent rhythmic myoclonic jerks, seizure, and dementia. As the disease progresses, coma, quadriplegia, vegetative state, and autonomic instability develop. Death usually occurs within 2 years of onset.^30,31 In children, the risk for SSPE after measles infection is estimated to be 4 to 11 per 100,000 infections. After the 1989-1991 resurgence of measles in the United States, however, the risk for SSPE was estimated to be 22 per 100,000 infections.^30-32 The pathogenesis of SSPE is not fully understood but is thought to result from persistent aberrant measles virus infection.³²

The SSPE diagnosis is based on clinical presentation, presence of anti-measles antibodies in CSF, typical electroencephalography pattern (periodic paroxysmal bursts) with accompanying myoclonus, tissue analysis, and magnetic resonance imaging.³⁰

Suspicion for measles should prompt immediate consultation with local or state public health officials. Laboratory testing can be carefully considered after consultation, and care is needed in interpreting serologic studies.

The mainstays of measles infection diagnosis are detection of viral RNA by reverse transcriptase–polymerase chain reaction, or isolation of the virus in the clinical specimen, and detection of measles-specific IgM (immunoglobulin M) antibodies. A detailed protocol for collecting specimens for viral isolation appears on the Centers for Disease Control and Prevention website (http://www.cdc.gov/measles/lab-tools/rt-pcr.html).

IgM antibodies are detectable over the 15 weeks after rash onset, but the recommendation is to collect serum between 72 hours and 4 weeks after rash onset.³³ Clinicians should be aware that false-positive IgM results may occur with rheumatologic diseases, parvovirus B19 infection, rubella, and infectious mononucleosis.

IgG (immunoglobulin G) antibodies are usually detectable a week after rash onset. The laboratory can confirm measles by detecting more than a 4-fold increase in IgG titers between the acute phase and the convalescent phase. After measles infection, most adults develop lifelong immunity with positive IgG serology.³⁴

Additional tests, such as IgG avidity and plaque reduction neutralization assay, can be used to confirm suspected cases in previously vaccinated individuals.³⁴

General Principles

Uncomplicated measles treatment is supportive and includes oral fluids and antipyretics.^7,22 Severe bacterial infections, encephalitis, or dehydration may require hospitalization, and in these cases infectious disease consultation is recommended. Patients with pneumonia, purulent otitis media, or tonsillitis should be treated with antibiotics.³⁵ Observational data suggest antibiotics may reduce the occurrence of bacterial infection in children, but there are no usage guidelines.³⁵ Vitamin A supplementation has been associated with a 50% decrease in morbidity and mortality and with blindness prevention.²² This supplementation should be considered in severe measles cases (all hospitalized patients), especially for children, regardless of country of residence, and for adult patients who exhibit clinical signs of vitamin A deficiency.^22,24

Antiviral Treatment

No specific treatment is available.³⁶ Ribavirin demonstrates in vitro activity against the virus, but the Food and Drug Administration has not approved the drug for treatment of measles. Ribavirin has been used for cases of severe measles, and for patients with SSPE along with intrathecal interferon alpha. This antiviral treatment is considered experimental.³⁷

All patients hospitalized with measles infection should be cautioned about the potential downstream complications of the disease and should follow up with their primary care physician for surveillance after discharge.³⁸

If measles symptoms develop, patients should self-quarantine and contact their primary care physician or public health department as soon as possible. Regardless of immune status, family members and other exposed persons should be educated about the measles symptoms that may occur during the 21 days after exposure.³⁸

Both suspected and confirmed cases of measles should be reported immediately to local public health authorities.

Infection Control and Prophylaxis

Current guidelines recommend 2 doses of measles-containing vaccine to all adults at higher risk for contracting measles: international travelers, healthcare personnel, and high school and college students. Infants 6 or 11 months old should receive 1 MMR dose before international travel.^1,38

Strict airborne isolation—use of N95 respirator or respirator with similar effectiveness in preventing airborne transmission—is mandatory from 3 to 5 days before rash onset to 4 days after rash onset (immunocompetent patients) or for the duration of the disease (immunocompromised patients).³⁸

Healthcare workers should have documented presumptive evidence of immunity to measles.³⁹ Healthcare providers without evidence of immunity should be excused from work from day 5 to day 21 of exposure, even if they have received postexposure vaccine or intramuscular immunoglobulin. They should be offered the first MMR dose within 72 hours of measles exposure to prevent or modify the disease. Susceptible family members or visitors should not be allowed in the patient’s room.¹

Postexposure Prophylaxis

Standard MMR vaccination within 72 hours after exposure may protect against disease in people without a contraindication to measles vaccine. The public health department usually identifies these individuals and provides postexposure prophylaxis recommendations.^38,39

People with HIV, patients receiving immunosuppressive therapy, and pregnant women and infants who have been exposed to measles and who are at risk for developing morbid disease can be treated with immunoglobulin (IG). If administered within 6 days of exposure, IG can prevent or modify disease in people who are unvaccinated or severely immunocompromised (ie, not immune). The recommended dose of IG administered intramuscularly is 0.5 mL/kg of body weight (maximum, 15 mL), and the recommended dose of IG given intravenously is 400 mg/kg. Anyone heavier than 30 kg would require intravenous IG to achieve adequate antibody levels.

Physicians should not vaccinate pregnant women, patients with severe immunosuppression from disease or therapy, patients with moderate or severe illness, and people with a history of severe allergic reaction to the vaccine.^1,40 The measles vaccine should be deferred for 6 months after IG administration.³⁶ More details are available in the recommendations made by the Advisory Committee on Immunization Practices.¹

Although rare in the United States, measles remains a common and potentially devastating infection among patients who have not been vaccinated. Diagnosis requires clinical suspicion, engagement of public health authorities, and judicious use of laboratory testing. Hospitalists may encounter infectious and neurologic complications of measles long after the initial infection and should be aware of these associations.

Disclosure

Nothing to report.

Measles is a highly contagious acute respiratory illness that includes a characteristic rash. After exposure, up to 90% of susceptible persons develop measles.¹ Even though it is considered a childhood illness, measles can affect people of all age groups. Measles continues to be major health problem around the world, despite the availability of a safe and effective vaccine, and it remains one of the leading causes of childhood mortality, with nearly 115,000 deaths reported by the World Health Organization² in 2014. In 2000, measles was declared eliminated from the United States, but outbreaks still occasionally occur.^3-6

The disease is self-limited, but some patients develop complications that may require hospitalization for treatment. People at highest risk for complications are children younger than 5 years, adults older than 20 years, pregnant women, and immunocompromised individuals.⁷

During the licensure of live measles vaccine in 1963, an average of 549,000 measles cases and 495 measles deaths, as well as 48,000 hospitalizations and 4000 encephalitis cases, were reported annually in the United States. Almost all Americans were affected by measles by adolescence.

Implementation of the 1-dose vaccine program substantially reduced reported incidence in the United States by 1988, and led to a dramatic decline in measles-related hospitalizations and deaths.^3-6 The 2-dose MMR (measles, mumps, rubella) vaccination was introduced in 1989, and measles was declared eliminated in the United States in 2000.^3-6

National–level one-dose MMR coverage among children 19-35 months has remained above 90% during the last two decades.⁸ NIS-Teen vaccination coverage data for 13- to 17-year-olds since 2008 has been near or above 90%,⁹ and 94% of children enrolled in kindergarten had evidence of 2 MMR doses in the 2014-2015 school year.¹⁰

A large multistate measles outbreak was reported in the United States in 2014-2015.^4,11 One hundred fifty-nine cases were reported in the United States between January 4 and April 5, 2015. The majority of patients either were unvaccinated (45%) or had an unknown vaccination status (38%). Age ranged from 6 weeks to 70 years, and 22 patients (14%) were hospitalized.⁴

Measles is caused by an RNA-containing paramyxovirus that is spread by the respiratory route. Average incubation period from exposure to rash onset is 14 days (range, 7-21 days).^12,13 Peak infectivity occurs during the prodromal phase, before rash onset (Figure 1), but patients are infectious from 4 days before rash onset through 4 days after rash onset.^7,12,13

The disease prodrome consists of a high fever (39°C-40.5°C), coryza, cough, and conjunctivitis followed by Koplik spots (Figure 2A). Koplik spots are pathognomonic for measles but rarely discovered. They appear before the skin rash alongside second molars on the buccal surface of the cheeks. The spots usually disappear when the characteristic maculopapular, nonpruritic rash erupts initially at the hairline and behind the ears, and within four days progresses toward the trunk and limbs, including the palms and soles (Figures 2B, 2C).

The presenting symptoms of primary measles infection are nonspecific, particularly if Koplik spots are not identified. The differential diagnosis for a patient who presents with high fever and rash include Kawasaki disease, dengue, parvovirus B19, serum sickness, syphilis, systemic lupus erythematous, toxic shock syndrome, enterovirus infection, human herpes virus 6 (roseola), viral hemorrhagic fever, drug eruption, infectious mononucleosis, Rocky Mountain spotted fever, rubella, scarlet fever, chikungunya, and Zika virus infection.

Measles complications can affect nearly every organ system (Table). Rates of complications from measles infection depend on age and underlying condition. Coexisting vitamin A deficiency increases complication rates.²⁰

Bacterial infections in the setting of measles infection are more common in adults than in children, and are more severe among people who are malnourished or have an immunodeficiency disorder. The most common infectious complications, which involve the respiratory tract, include pneumonia, laryngotracheitis (“measles croup”), bronchitis, otitis media (most common complication among children in the United States), and sinusitis.^7,13,21

Indications for hospitalizing children include respiratory distress, laryngeal obstruction, dehydration that requires intravenous fluids, diarrhea with more than 10 stools a day or bloody stool, severe anemia, altered mental status, convulsion, severe rash with developing hemorrhagic areas, extensive mouth ulcers, corneal clouding or ulcers, visual disturbance, and mastoiditis.²²

Pneumonia is a common indication for hospitalizing adults.^23,24 Measles-associated interstitial giant cell (Hecht) pneumonia is most often recognized among immunocompromised and malnourished patients.¹³ Primary pneumonia is caused by the measles virus, but bacterial superinfection can occur. The most common bacterial pathogens include Streptococcus, Pneumococcus, and Staphylococcus,^13,24 and less commonly isolated organisms include gram-negative bacteria, such as Haemophilus influenzae, Pseudomonas aeruginosa, Neisseria meningitides, and Enterobacter cloacae.²³

Uncommon complications of measles are myocarditis, glomerulonephritis, acute renal failure, and thrombocytopenic purpura.^25,26

Neurologic complications in measles are an important concern. Measles-associated central nervous system complications are considered a result of an immune-mediated reaction to myelin protein and not from direct viral insult.^26-28 Immunocompromised patients are at risk for developing fatal encephalitis, and those who survive often experience cognitive decline or seizures.

Measles is associated with four different encephalitic diseases: primary measles encephalitis, acute post-measles encephalomyelitis, measles inclusion body encephalitis, and subacute sclerosing panencephalitis.

Primary measles encephalitis is characterized by fever, headache, stiff neck, and meningeal signs. Onset occurs between 1 and 15 days after rash onset, and the disease affects 1/1000 patients. Seizure, altered mental status, and coma can also develop. Viral RNA detection in the cerebrospinal fluid (CSF) confirms the diagnosis.²⁹Acute post-measles encephalomyelitis is more common in adults than in children.¹² It typically develops after the rash fades and the other symptoms subside. Patients suddenly experience a recurrence of fevers or seizures. Deafness, intellectual decline, epilepsy, postencephalitic hyperkinesia, hemiplegia, and/or paraplegia also can develop.^27-29

Measles inclusion body encephalitis is described only in immunocompromised patients, and onset occurs within 1 year of infection. Seizures are an initial and common symptom, and some patients also experience hemiplegia, stupor, hypertonia, and dysarthria.²⁹ Diagnostic findings include seroconversion during the disease course, improvement after withholding of the immunosuppressive regimen, and normal CSF. Brain biopsy confirms the diagnosis.

Subacute sclerosing panencephalitis (SSPE) is a slowly progressing and untreatable degenerative neurologic disorder characterized by demyelination of multiple brain areas. SSPE develops 7 to 10 years after natural measles infection, and usually affects children or adolescents. Clinical presentation includes intellectual decline, frequent rhythmic myoclonic jerks, seizure, and dementia. As the disease progresses, coma, quadriplegia, vegetative state, and autonomic instability develop. Death usually occurs within 2 years of onset.^30,31 In children, the risk for SSPE after measles infection is estimated to be 4 to 11 per 100,000 infections. After the 1989-1991 resurgence of measles in the United States, however, the risk for SSPE was estimated to be 22 per 100,000 infections.^30-32 The pathogenesis of SSPE is not fully understood but is thought to result from persistent aberrant measles virus infection.³²

The SSPE diagnosis is based on clinical presentation, presence of anti-measles antibodies in CSF, typical electroencephalography pattern (periodic paroxysmal bursts) with accompanying myoclonus, tissue analysis, and magnetic resonance imaging.³⁰

Suspicion for measles should prompt immediate consultation with local or state public health officials. Laboratory testing can be carefully considered after consultation, and care is needed in interpreting serologic studies.

The mainstays of measles infection diagnosis are detection of viral RNA by reverse transcriptase–polymerase chain reaction, or isolation of the virus in the clinical specimen, and detection of measles-specific IgM (immunoglobulin M) antibodies. A detailed protocol for collecting specimens for viral isolation appears on the Centers for Disease Control and Prevention website (http://www.cdc.gov/measles/lab-tools/rt-pcr.html).

IgM antibodies are detectable over the 15 weeks after rash onset, but the recommendation is to collect serum between 72 hours and 4 weeks after rash onset.³³ Clinicians should be aware that false-positive IgM results may occur with rheumatologic diseases, parvovirus B19 infection, rubella, and infectious mononucleosis.

IgG (immunoglobulin G) antibodies are usually detectable a week after rash onset. The laboratory can confirm measles by detecting more than a 4-fold increase in IgG titers between the acute phase and the convalescent phase. After measles infection, most adults develop lifelong immunity with positive IgG serology.³⁴

Additional tests, such as IgG avidity and plaque reduction neutralization assay, can be used to confirm suspected cases in previously vaccinated individuals.³⁴

General Principles

Uncomplicated measles treatment is supportive and includes oral fluids and antipyretics.^7,22 Severe bacterial infections, encephalitis, or dehydration may require hospitalization, and in these cases infectious disease consultation is recommended. Patients with pneumonia, purulent otitis media, or tonsillitis should be treated with antibiotics.³⁵ Observational data suggest antibiotics may reduce the occurrence of bacterial infection in children, but there are no usage guidelines.³⁵ Vitamin A supplementation has been associated with a 50% decrease in morbidity and mortality and with blindness prevention.²² This supplementation should be considered in severe measles cases (all hospitalized patients), especially for children, regardless of country of residence, and for adult patients who exhibit clinical signs of vitamin A deficiency.^22,24

Antiviral Treatment

No specific treatment is available.³⁶ Ribavirin demonstrates in vitro activity against the virus, but the Food and Drug Administration has not approved the drug for treatment of measles. Ribavirin has been used for cases of severe measles, and for patients with SSPE along with intrathecal interferon alpha. This antiviral treatment is considered experimental.³⁷

All patients hospitalized with measles infection should be cautioned about the potential downstream complications of the disease and should follow up with their primary care physician for surveillance after discharge.³⁸

If measles symptoms develop, patients should self-quarantine and contact their primary care physician or public health department as soon as possible. Regardless of immune status, family members and other exposed persons should be educated about the measles symptoms that may occur during the 21 days after exposure.³⁸

Both suspected and confirmed cases of measles should be reported immediately to local public health authorities.

Infection Control and Prophylaxis

Current guidelines recommend 2 doses of measles-containing vaccine to all adults at higher risk for contracting measles: international travelers, healthcare personnel, and high school and college students. Infants 6 or 11 months old should receive 1 MMR dose before international travel.^1,38

Strict airborne isolation—use of N95 respirator or respirator with similar effectiveness in preventing airborne transmission—is mandatory from 3 to 5 days before rash onset to 4 days after rash onset (immunocompetent patients) or for the duration of the disease (immunocompromised patients).³⁸

Healthcare workers should have documented presumptive evidence of immunity to measles.³⁹ Healthcare providers without evidence of immunity should be excused from work from day 5 to day 21 of exposure, even if they have received postexposure vaccine or intramuscular immunoglobulin. They should be offered the first MMR dose within 72 hours of measles exposure to prevent or modify the disease. Susceptible family members or visitors should not be allowed in the patient’s room.¹

Postexposure Prophylaxis

Standard MMR vaccination within 72 hours after exposure may protect against disease in people without a contraindication to measles vaccine. The public health department usually identifies these individuals and provides postexposure prophylaxis recommendations.^38,39

People with HIV, patients receiving immunosuppressive therapy, and pregnant women and infants who have been exposed to measles and who are at risk for developing morbid disease can be treated with immunoglobulin (IG). If administered within 6 days of exposure, IG can prevent or modify disease in people who are unvaccinated or severely immunocompromised (ie, not immune). The recommended dose of IG administered intramuscularly is 0.5 mL/kg of body weight (maximum, 15 mL), and the recommended dose of IG given intravenously is 400 mg/kg. Anyone heavier than 30 kg would require intravenous IG to achieve adequate antibody levels.

Physicians should not vaccinate pregnant women, patients with severe immunosuppression from disease or therapy, patients with moderate or severe illness, and people with a history of severe allergic reaction to the vaccine.^1,40 The measles vaccine should be deferred for 6 months after IG administration.³⁶ More details are available in the recommendations made by the Advisory Committee on Immunization Practices.¹

Although rare in the United States, measles remains a common and potentially devastating infection among patients who have not been vaccinated. Diagnosis requires clinical suspicion, engagement of public health authorities, and judicious use of laboratory testing. Hospitalists may encounter infectious and neurologic complications of measles long after the initial infection and should be aware of these associations.

Disclosure

Nothing to report.

Mobility impairment (reduced ability to change body position or ambulate) is common among older adults during hospitalization¹ and is correlated with higher rates of readmission,² long-term care placement,³ and even death.⁴ Although some may perceive mobility impairment during hospitalization as a temporary inconvenience, recent research suggests disruptions of basic activities of daily life such as mobility may be “traumatic” ⁵ or “toxic”⁶ to older adults with long-term post-hospital effects.⁷ While these studies highlight the underestimated effects of low mobility during hospitalization, they are based on data collected for research purposes using mobility measurement tools not typically utilized in routine hospital care.

The absence of a standardized mobility measurement tool used as part of routine hospital care poses a barrier to estimating the effects of low hospital mobility and programs seeking to improve mobility levels in hospitalized patients. In this issue of the Journal of Hospital Medicine, Valiani et al.⁸ found a novel approach to measure mobility using a universally disseminated clinical scale (Braden). Using the activity subscale of the Braden scale, the authors found that mobility level changes during hospitalization can have a striking impact on post-discharge mortality. Their results indicate that older adults who develop mobility impairment during hospitalization had higher odds of death, specifically 1.23 times greater risk, within 6 months after discharge (23% decreased chance of survival). Most of the risk applies in the first 30 days and remains to a lesser extent for up to 5 years post-hospitalization. An equally interesting finding was that those who enter the hospital with low mobility but improve have a 46% higher survival rate. Again, most of the benefit is seen during hospitalization or immediately afterward, but the benefit persists for up to 5 years. A schematic of the results are presented in the Figure. Notably, Valiani et al.⁸ did not find regression to the mean Braden score of 3.

Disclosure

Nothing to report.

Mobility impairment (reduced ability to change body position or ambulate) is common among older adults during hospitalization¹ and is correlated with higher rates of readmission,² long-term care placement,³ and even death.⁴ Although some may perceive mobility impairment during hospitalization as a temporary inconvenience, recent research suggests disruptions of basic activities of daily life such as mobility may be “traumatic” ⁵ or “toxic”⁶ to older adults with long-term post-hospital effects.⁷ While these studies highlight the underestimated effects of low mobility during hospitalization, they are based on data collected for research purposes using mobility measurement tools not typically utilized in routine hospital care.

The absence of a standardized mobility measurement tool used as part of routine hospital care poses a barrier to estimating the effects of low hospital mobility and programs seeking to improve mobility levels in hospitalized patients. In this issue of the Journal of Hospital Medicine, Valiani et al.⁸ found a novel approach to measure mobility using a universally disseminated clinical scale (Braden). Using the activity subscale of the Braden scale, the authors found that mobility level changes during hospitalization can have a striking impact on post-discharge mortality. Their results indicate that older adults who develop mobility impairment during hospitalization had higher odds of death, specifically 1.23 times greater risk, within 6 months after discharge (23% decreased chance of survival). Most of the risk applies in the first 30 days and remains to a lesser extent for up to 5 years post-hospitalization. An equally interesting finding was that those who enter the hospital with low mobility but improve have a 46% higher survival rate. Again, most of the benefit is seen during hospitalization or immediately afterward, but the benefit persists for up to 5 years. A schematic of the results are presented in the Figure. Notably, Valiani et al.⁸ did not find regression to the mean Braden score of 3.

Disclosure

Nothing to report.

Mobility impairment (reduced ability to change body position or ambulate) is common among older adults during hospitalization¹ and is correlated with higher rates of readmission,² long-term care placement,³ and even death.⁴ Although some may perceive mobility impairment during hospitalization as a temporary inconvenience, recent research suggests disruptions of basic activities of daily life such as mobility may be “traumatic” ⁵ or “toxic”⁶ to older adults with long-term post-hospital effects.⁷ While these studies highlight the underestimated effects of low mobility during hospitalization, they are based on data collected for research purposes using mobility measurement tools not typically utilized in routine hospital care.

The absence of a standardized mobility measurement tool used as part of routine hospital care poses a barrier to estimating the effects of low hospital mobility and programs seeking to improve mobility levels in hospitalized patients. In this issue of the Journal of Hospital Medicine, Valiani et al.⁸ found a novel approach to measure mobility using a universally disseminated clinical scale (Braden). Using the activity subscale of the Braden scale, the authors found that mobility level changes during hospitalization can have a striking impact on post-discharge mortality. Their results indicate that older adults who develop mobility impairment during hospitalization had higher odds of death, specifically 1.23 times greater risk, within 6 months after discharge (23% decreased chance of survival). Most of the risk applies in the first 30 days and remains to a lesser extent for up to 5 years post-hospitalization. An equally interesting finding was that those who enter the hospital with low mobility but improve have a 46% higher survival rate. Again, most of the benefit is seen during hospitalization or immediately afterward, but the benefit persists for up to 5 years. A schematic of the results are presented in the Figure. Notably, Valiani et al.⁸ did not find regression to the mean Braden score of 3.

Disclosure

Nothing to report.

After patients have experienced an illness requiring a hospital stay, they are increasingly finding that despite having received treatment in a hospital bed, they were never actually admitted—at least not from the perspective of their insurers. Instead, these patients were kept under observation, an outpatient designation that allows a hospital to bill for observation services without formally admitting a patient.

Recent studies have recorded significant increases in hospitals’ use of observation stays among the Medicare population,^1-3 raising concerns about the financial ramifications for patients. Under observation, patients are potentially responsible for a greater share of the cost and bear the financial consequences of inappropriate observation stays. Currently, around 6% of Medicare patients hospitalized as outpatients spend more than 48 hours (or two midnights) in observation, sometimes much longer, exposing them to significant out-of-pocket costs.³ In addition, liberal use of observation can lead to increased hospital stays, for example among lower-severity emergency department (ED) patients who could have been safely discharged but were instead kept for a costly observation stay.⁴ At the same time, hospitals do not necessarily benefit from this cost shifting; in fact, hospital margin is worse for patients under Medicare observation care.⁵ Yet hospitals are obligated to be compliant with CMS observation regulations and may try to avoid the consequences (eg, audits, non-payment) for inpatient stays that are deemed inappropriate by CMS.

While the nuances of how CMS finances observation stays have made the practice controversial, the use of observation care in other payer groups that may not have the same reimbursement policies, and its impact on patients, have not been well studied. In this issue of the Journal of Hospital Medicine, Nuckols et al.⁶ begins to address this gap by carefully exploring trends in observation stays in a multipayer data set.

The authors use data for four states (Georgia, Nebraska, South Carolina, and Tennessee) from the Healthcare Cost and Utilization Project (Agency for Healthcare Quality and Research) and the American Community Survey (US Census Bureau) to calculate population based rates of ED visits, observation stays, and inpatient admissions. To date, this is the first study to examine and compare the use of observation stays in an all-payer data set. Similar to prior work that examined the Medicare population, the authors find increased rates of treat-and-release ED visits and observation stays over time with a corresponding decline in inpatient admissions. As this study clearly shows, observation stays are comprising a greater fraction of the total hospital care delivered to patients with acute illnesses.

In many ways, the findings of Nuckols et al.⁶ raise more questions than they answer. For example, does the rise in observation stays represent a fundamental shift in how hospitals deliver care, an alternative to costly inpatient admissions? Are changing payer incentives driving hospitals to be more prudent in their inpatient admission practices, or are similar services simply being delivered under a new billing designation? And, most important, does this shift have any repercussions for the quality and safety of patient care?

Ultimately, the answer to these questions is, “It depends.” As the authors mention, most US hospitals admit observation patients to general medical wards, where they receive care at the admitting provider’s discretion instead of utilizing specific care pathways or observation protocols.⁷ In some of these hospitals, there may be little to no difference in how the observation patient is treated compared with a similar patient who is hospitalized as an inpatient.

However, a minority of hospitals has been more strategic in their delivery of observation care and have developed observation units. While observation units vary in design, common features include a dedicated location in the hospital with dedicated staff, reliance on clear inclusion-exclusion criteria for admission to the unit, and the use of rapid diagnostic or treatment protocols for a limited number of conditions. About half of these observation units are ED-based, reducing transitions of care between services. Protocol-driven observation units have the potential to prevent unnecessary inpatient admissions, standardize evidence-based practice, and reduce practice variation and resource use, apparently without increasing adverse events.⁸ In addition, they may also lead to better experiences of care for many patients compared with inpatient admissions.

Medicare’s own policy on observation hospital care succinctly describes ED observation units: “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment in order to make a decision concerning their admission or discharge…usually in less than 24 hours.” Due to regulatory changes and auditing pressure, observation care has expanded beyond this definition in length of stay, scope, and practice such that much of observation care now occurs on general hospital wards. Ideally, observation policy must be realigned with its original intent and investment made in ED observation units.

The shifting landscape of hospital-based care as described by Nuckols et al.⁶ highlights the need for a more strategic approach to the delivery of acute care. Unfortunately, to date, there has been a lack of attention among policymakers towards promoting a system of emergent and urgent care that is coordinated and efficient. Observation stays are one major area for which innovations in the acute care delivery system may result in meaningful improvement in patient outcomes and greater value for the healthcare system. Incentivizing a system of high-value observation care, such as promoting the use of observation units that employ evidence-based practices, should be a key priority when considering approaches to reducing the cost of hospital-based and other acute care.

One strategy is to better define and possibly expand the cohort of patients likely to benefit from care in an observation unit. Hospitals with significant experience using observation units treat not only common observation conditions like chest pain, asthma, or cellulitis, but also higher-risk inpatient conditions like syncope and diabetic ketoacidosis using rapid diagnostic and treatment protocols.

Identifying high-value observation care also will require developing patient outcome measures specific for observation stays. Observation-specific quality measures will allow a comparison of hospitals that use different care pathways for observation patients or treat certain populations of patients in observation units. This necessitates looking beyond resource use (costs and length of stay), which most studies on observation units have focused on, and examining a broader range of patient outcomes like time to symptomatic resolution, quality of life, or return to productivity after an acute illness.

Finally, observation care is also a good target for payment redesign. For example, incentive payments could be provided to hospitals that choose to develop observation units, employ observation units that utilize best known practices for observation care (such as protocols and clearly defined patient cohorts), or deliver particularly good acute care outcomes for patients with observation-amenable conditions. On the consumer side, value-based contracting could be used to shunt patients with acute conditions that require evaluation in an urgent care center or ED to hospitals that use observation units.

While the declines in inpatient admission and increases in treat-and-release ED patients have been well-documented over time, perhaps the biggest contribution of this study from Nuckols et al.⁶ lies in its identification of the changes in observation care, which have been increasing in all payer groups. Our opportunity now is to shape whether these shifts toward observation care deliver greater value for patients.

Acknowledgment

The authors thank Joanna Guo, BA, for her editorial and technical assistance.

Disclosure

Nothing to report.

After patients have experienced an illness requiring a hospital stay, they are increasingly finding that despite having received treatment in a hospital bed, they were never actually admitted—at least not from the perspective of their insurers. Instead, these patients were kept under observation, an outpatient designation that allows a hospital to bill for observation services without formally admitting a patient.

Recent studies have recorded significant increases in hospitals’ use of observation stays among the Medicare population,^1-3 raising concerns about the financial ramifications for patients. Under observation, patients are potentially responsible for a greater share of the cost and bear the financial consequences of inappropriate observation stays. Currently, around 6% of Medicare patients hospitalized as outpatients spend more than 48 hours (or two midnights) in observation, sometimes much longer, exposing them to significant out-of-pocket costs.³ In addition, liberal use of observation can lead to increased hospital stays, for example among lower-severity emergency department (ED) patients who could have been safely discharged but were instead kept for a costly observation stay.⁴ At the same time, hospitals do not necessarily benefit from this cost shifting; in fact, hospital margin is worse for patients under Medicare observation care.⁵ Yet hospitals are obligated to be compliant with CMS observation regulations and may try to avoid the consequences (eg, audits, non-payment) for inpatient stays that are deemed inappropriate by CMS.

While the nuances of how CMS finances observation stays have made the practice controversial, the use of observation care in other payer groups that may not have the same reimbursement policies, and its impact on patients, have not been well studied. In this issue of the Journal of Hospital Medicine, Nuckols et al.⁶ begins to address this gap by carefully exploring trends in observation stays in a multipayer data set.

The authors use data for four states (Georgia, Nebraska, South Carolina, and Tennessee) from the Healthcare Cost and Utilization Project (Agency for Healthcare Quality and Research) and the American Community Survey (US Census Bureau) to calculate population based rates of ED visits, observation stays, and inpatient admissions. To date, this is the first study to examine and compare the use of observation stays in an all-payer data set. Similar to prior work that examined the Medicare population, the authors find increased rates of treat-and-release ED visits and observation stays over time with a corresponding decline in inpatient admissions. As this study clearly shows, observation stays are comprising a greater fraction of the total hospital care delivered to patients with acute illnesses.

In many ways, the findings of Nuckols et al.⁶ raise more questions than they answer. For example, does the rise in observation stays represent a fundamental shift in how hospitals deliver care, an alternative to costly inpatient admissions? Are changing payer incentives driving hospitals to be more prudent in their inpatient admission practices, or are similar services simply being delivered under a new billing designation? And, most important, does this shift have any repercussions for the quality and safety of patient care?

Ultimately, the answer to these questions is, “It depends.” As the authors mention, most US hospitals admit observation patients to general medical wards, where they receive care at the admitting provider’s discretion instead of utilizing specific care pathways or observation protocols.⁷ In some of these hospitals, there may be little to no difference in how the observation patient is treated compared with a similar patient who is hospitalized as an inpatient.

However, a minority of hospitals has been more strategic in their delivery of observation care and have developed observation units. While observation units vary in design, common features include a dedicated location in the hospital with dedicated staff, reliance on clear inclusion-exclusion criteria for admission to the unit, and the use of rapid diagnostic or treatment protocols for a limited number of conditions. About half of these observation units are ED-based, reducing transitions of care between services. Protocol-driven observation units have the potential to prevent unnecessary inpatient admissions, standardize evidence-based practice, and reduce practice variation and resource use, apparently without increasing adverse events.⁸ In addition, they may also lead to better experiences of care for many patients compared with inpatient admissions.

Medicare’s own policy on observation hospital care succinctly describes ED observation units: “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment in order to make a decision concerning their admission or discharge…usually in less than 24 hours.” Due to regulatory changes and auditing pressure, observation care has expanded beyond this definition in length of stay, scope, and practice such that much of observation care now occurs on general hospital wards. Ideally, observation policy must be realigned with its original intent and investment made in ED observation units.

The shifting landscape of hospital-based care as described by Nuckols et al.⁶ highlights the need for a more strategic approach to the delivery of acute care. Unfortunately, to date, there has been a lack of attention among policymakers towards promoting a system of emergent and urgent care that is coordinated and efficient. Observation stays are one major area for which innovations in the acute care delivery system may result in meaningful improvement in patient outcomes and greater value for the healthcare system. Incentivizing a system of high-value observation care, such as promoting the use of observation units that employ evidence-based practices, should be a key priority when considering approaches to reducing the cost of hospital-based and other acute care.

One strategy is to better define and possibly expand the cohort of patients likely to benefit from care in an observation unit. Hospitals with significant experience using observation units treat not only common observation conditions like chest pain, asthma, or cellulitis, but also higher-risk inpatient conditions like syncope and diabetic ketoacidosis using rapid diagnostic and treatment protocols.

Identifying high-value observation care also will require developing patient outcome measures specific for observation stays. Observation-specific quality measures will allow a comparison of hospitals that use different care pathways for observation patients or treat certain populations of patients in observation units. This necessitates looking beyond resource use (costs and length of stay), which most studies on observation units have focused on, and examining a broader range of patient outcomes like time to symptomatic resolution, quality of life, or return to productivity after an acute illness.

Finally, observation care is also a good target for payment redesign. For example, incentive payments could be provided to hospitals that choose to develop observation units, employ observation units that utilize best known practices for observation care (such as protocols and clearly defined patient cohorts), or deliver particularly good acute care outcomes for patients with observation-amenable conditions. On the consumer side, value-based contracting could be used to shunt patients with acute conditions that require evaluation in an urgent care center or ED to hospitals that use observation units.

While the declines in inpatient admission and increases in treat-and-release ED patients have been well-documented over time, perhaps the biggest contribution of this study from Nuckols et al.⁶ lies in its identification of the changes in observation care, which have been increasing in all payer groups. Our opportunity now is to shape whether these shifts toward observation care deliver greater value for patients.

Acknowledgment

The authors thank Joanna Guo, BA, for her editorial and technical assistance.

Disclosure

Nothing to report.

After patients have experienced an illness requiring a hospital stay, they are increasingly finding that despite having received treatment in a hospital bed, they were never actually admitted—at least not from the perspective of their insurers. Instead, these patients were kept under observation, an outpatient designation that allows a hospital to bill for observation services without formally admitting a patient.

Recent studies have recorded significant increases in hospitals’ use of observation stays among the Medicare population,^1-3 raising concerns about the financial ramifications for patients. Under observation, patients are potentially responsible for a greater share of the cost and bear the financial consequences of inappropriate observation stays. Currently, around 6% of Medicare patients hospitalized as outpatients spend more than 48 hours (or two midnights) in observation, sometimes much longer, exposing them to significant out-of-pocket costs.³ In addition, liberal use of observation can lead to increased hospital stays, for example among lower-severity emergency department (ED) patients who could have been safely discharged but were instead kept for a costly observation stay.⁴ At the same time, hospitals do not necessarily benefit from this cost shifting; in fact, hospital margin is worse for patients under Medicare observation care.⁵ Yet hospitals are obligated to be compliant with CMS observation regulations and may try to avoid the consequences (eg, audits, non-payment) for inpatient stays that are deemed inappropriate by CMS.

While the nuances of how CMS finances observation stays have made the practice controversial, the use of observation care in other payer groups that may not have the same reimbursement policies, and its impact on patients, have not been well studied. In this issue of the Journal of Hospital Medicine, Nuckols et al.⁶ begins to address this gap by carefully exploring trends in observation stays in a multipayer data set.

The authors use data for four states (Georgia, Nebraska, South Carolina, and Tennessee) from the Healthcare Cost and Utilization Project (Agency for Healthcare Quality and Research) and the American Community Survey (US Census Bureau) to calculate population based rates of ED visits, observation stays, and inpatient admissions. To date, this is the first study to examine and compare the use of observation stays in an all-payer data set. Similar to prior work that examined the Medicare population, the authors find increased rates of treat-and-release ED visits and observation stays over time with a corresponding decline in inpatient admissions. As this study clearly shows, observation stays are comprising a greater fraction of the total hospital care delivered to patients with acute illnesses.

In many ways, the findings of Nuckols et al.⁶ raise more questions than they answer. For example, does the rise in observation stays represent a fundamental shift in how hospitals deliver care, an alternative to costly inpatient admissions? Are changing payer incentives driving hospitals to be more prudent in their inpatient admission practices, or are similar services simply being delivered under a new billing designation? And, most important, does this shift have any repercussions for the quality and safety of patient care?

Ultimately, the answer to these questions is, “It depends.” As the authors mention, most US hospitals admit observation patients to general medical wards, where they receive care at the admitting provider’s discretion instead of utilizing specific care pathways or observation protocols.⁷ In some of these hospitals, there may be little to no difference in how the observation patient is treated compared with a similar patient who is hospitalized as an inpatient.

However, a minority of hospitals has been more strategic in their delivery of observation care and have developed observation units. While observation units vary in design, common features include a dedicated location in the hospital with dedicated staff, reliance on clear inclusion-exclusion criteria for admission to the unit, and the use of rapid diagnostic or treatment protocols for a limited number of conditions. About half of these observation units are ED-based, reducing transitions of care between services. Protocol-driven observation units have the potential to prevent unnecessary inpatient admissions, standardize evidence-based practice, and reduce practice variation and resource use, apparently without increasing adverse events.⁸ In addition, they may also lead to better experiences of care for many patients compared with inpatient admissions.

Medicare’s own policy on observation hospital care succinctly describes ED observation units: “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment in order to make a decision concerning their admission or discharge…usually in less than 24 hours.” Due to regulatory changes and auditing pressure, observation care has expanded beyond this definition in length of stay, scope, and practice such that much of observation care now occurs on general hospital wards. Ideally, observation policy must be realigned with its original intent and investment made in ED observation units.

The shifting landscape of hospital-based care as described by Nuckols et al.⁶ highlights the need for a more strategic approach to the delivery of acute care. Unfortunately, to date, there has been a lack of attention among policymakers towards promoting a system of emergent and urgent care that is coordinated and efficient. Observation stays are one major area for which innovations in the acute care delivery system may result in meaningful improvement in patient outcomes and greater value for the healthcare system. Incentivizing a system of high-value observation care, such as promoting the use of observation units that employ evidence-based practices, should be a key priority when considering approaches to reducing the cost of hospital-based and other acute care.

One strategy is to better define and possibly expand the cohort of patients likely to benefit from care in an observation unit. Hospitals with significant experience using observation units treat not only common observation conditions like chest pain, asthma, or cellulitis, but also higher-risk inpatient conditions like syncope and diabetic ketoacidosis using rapid diagnostic and treatment protocols.

Identifying high-value observation care also will require developing patient outcome measures specific for observation stays. Observation-specific quality measures will allow a comparison of hospitals that use different care pathways for observation patients or treat certain populations of patients in observation units. This necessitates looking beyond resource use (costs and length of stay), which most studies on observation units have focused on, and examining a broader range of patient outcomes like time to symptomatic resolution, quality of life, or return to productivity after an acute illness.

Finally, observation care is also a good target for payment redesign. For example, incentive payments could be provided to hospitals that choose to develop observation units, employ observation units that utilize best known practices for observation care (such as protocols and clearly defined patient cohorts), or deliver particularly good acute care outcomes for patients with observation-amenable conditions. On the consumer side, value-based contracting could be used to shunt patients with acute conditions that require evaluation in an urgent care center or ED to hospitals that use observation units.

While the declines in inpatient admission and increases in treat-and-release ED patients have been well-documented over time, perhaps the biggest contribution of this study from Nuckols et al.⁶ lies in its identification of the changes in observation care, which have been increasing in all payer groups. Our opportunity now is to shape whether these shifts toward observation care deliver greater value for patients.

Acknowledgment

The authors thank Joanna Guo, BA, for her editorial and technical assistance.

Disclosure

Nothing to report.

Monitor watcher personnel are frequently used to assist nurses with identifying meaningful events on telemetry monitors. Although effectiveness of monitor watchers on patient outcomes has not been demonstrated conclusively,¹ as many as 60% of United States hospitals may be using monitor watchers in some capacity.² Presumed benefits of monitor watchers include prompt recognition of changes in patients’ conditions and the potential to reduce alarm fatigue among hospital staff. Alarm fatigue is desensitization resulting from overexposure to alarm signals that are either invalid or clinically irrelevant. Alarm fatigue has resulted in missed patient events and preventable deaths.³ In this issue of the Journal of Hospital Medicine, Palchaudhuri et al.⁴ report findings from their observational study of telemetry monitor alarms intercepted by monitor watchers as a mechanism for reducing both nurses’ exposure to alarm signals and subsequent alarm fatigue.

To our knowledge, the study by Palchaudhuri et al.⁴ is the first to report the effect of monitor watchers on nurses’ exposure to alarm signals. In this study, over a 2-month period monitor watchers intercepted 87% of alarms before they were sent to the nurse’s telephone. Monitor watchers intercepted over 90% of bradycardia and tachycardia alarms, indicating that they believed these alarms to be clinically irrelevant. Monitor watchers also intercepted about 75% of alarms for lethal arrhythmias, indicating that they believed these alarms to be invalid.

In this study, decisions about alarm validity and relevance were made through close communication between monitor watchers and nursing staff. If an alarm was sounding and the monitor watcher had already spoken with the nurse about it and established that the nurse was addressing the problem, the monitor watcher would intercept subsequent alarms for that issue or event (according to personal communication with S. Palchaudhuri). The results of the study not only indicate that monitor watchers can reduce the number of alarms to which a nurse is exposed, but also support previous findings that few alarms are valid or clinically relevant.^5-7 The results of this study also suggest that “nuisance” alarms should include not only clinically irrelevant alarms, but also relevant alarms for which the nurse is actively seeking a solution. Monitor watchers may have an important role in addressing these alarms.

The study raises important considerations regarding monitor watcher practice and alarm fatigue. If monitor watchers are to be effective in reducing nurses’ exposure to alarms, they must use good judgment to determine when to intercept an alarm, call the nurse, or both. In the absence of proper judgment, monitor watchers may inadvertently increase nurses’ fatigue through redundant calls or inappropriately suppress valid relevant alarms. In free-text responses to our national monitor watcher survey, nurses expressed frustration over redundant calls from monitor watchers for invalid and irrelevant alarms.² Research suggests that monitor watchers may not identify potentially dangerous alarms with complete accuracy. In a recent study reported in The Journal of the American Medical Society (JAMA), monitor watchers missed about 18% of patients with detectable rhythm or rate changes on telemetry in the hour before an emergency response team was activated.⁸

Several factors and conditions may affect monitor watchers’ judgment: 1) education and training, 2) location and access to contextual patient information, and 3) fatigue. First, across the US, the level of education required for monitor watcher positions ranges from a high school diploma to licensure as a registered nurse. The content and frequency of in-service training required also varies.² These differing requirements may influence monitor watchers’ ability to interpret alarms.

Second, most monitor watchers are located off the patient care unit,² which influences their access to information. Even in remote locations, monitor watchers can assess alarm validity by reviewing parameter waveforms for artifact. However, determining the relevance of an alarm to a particular patient is a more complex task requiring contextual information about the patient.⁹ Monitor watchers must work closely with clinicians at the bedside to determine the relevance of alarms, and repeated contact between monitor watchers and nurses over alarm conditions may itself increase nurses’ alarm fatigue.

Finally, fatigue may affect monitor watchers themselves and reduce their effectiveness. This issue was raised by Palchaudhuri et al. Both the number of monitors watched and the length of the monitor watcher’s shift likely influence alertness and effectiveness. In a simulation study, Segall et al.¹⁰ found that monitor watchers’ recognition of serious arrhythmias was significantly delayed when they were responsible for more than 40 patient monitors. Monitor watchers often work 12-hour shifts,² and although no research has been reported on their shift-related alertness, this is a long time to remain attentive.

Given these potential challenges, future research should specifically address adverse patient outcomes and missed clinically relevant alarms. Only two of the seven patients who arrested during the study by Palchaudhuri et al.⁴ were on telemetry, and neither arrested due to lethal arrhythmias. While this is an important indication that no alarms for lethal arrhythmias were inadvertently suppressed, it is difficult to achieve adequate statistical power to assess rare outcomes like cardiac arrests. In a future study, alarms intercepted by monitor watchers could be assessed for accuracy and relevance to patient care to determine whether important alarms were inadvertently suppressed.

In summary, the study by Palchaudhuri et al.⁴ represents a preliminary step in considering the potential utility of monitor watchers for reducing invalid and clinically irrelevant alarms as well as subsequent alarm fatigue. As the authors note, dedicated monitor watchers can screen alarms much more quickly than nurses who may be engaged in other activities when an alarm signals. The study raises interesting questions about how monitor watchers should be incorporated into workflow. Should their only responsibility be to call regarding potentially critical events, or should they be able to prevent alarms from reaching the nurse? Could monitor watchers provide guidance to reduce alarm fatigue, such as suggesting parameter changes when they see trends in irrelevant alarms? Future research is warranted to understand how monitor watchers can be used most effectively to reduce alarm fatigue, and which characteristics of monitor watchers and their practice result in the best patient outcomes.

Disclosure

Nothing to report.

Monitor watcher personnel are frequently used to assist nurses with identifying meaningful events on telemetry monitors. Although effectiveness of monitor watchers on patient outcomes has not been demonstrated conclusively,¹ as many as 60% of United States hospitals may be using monitor watchers in some capacity.² Presumed benefits of monitor watchers include prompt recognition of changes in patients’ conditions and the potential to reduce alarm fatigue among hospital staff. Alarm fatigue is desensitization resulting from overexposure to alarm signals that are either invalid or clinically irrelevant. Alarm fatigue has resulted in missed patient events and preventable deaths.³ In this issue of the Journal of Hospital Medicine, Palchaudhuri et al.⁴ report findings from their observational study of telemetry monitor alarms intercepted by monitor watchers as a mechanism for reducing both nurses’ exposure to alarm signals and subsequent alarm fatigue.

To our knowledge, the study by Palchaudhuri et al.⁴ is the first to report the effect of monitor watchers on nurses’ exposure to alarm signals. In this study, over a 2-month period monitor watchers intercepted 87% of alarms before they were sent to the nurse’s telephone. Monitor watchers intercepted over 90% of bradycardia and tachycardia alarms, indicating that they believed these alarms to be clinically irrelevant. Monitor watchers also intercepted about 75% of alarms for lethal arrhythmias, indicating that they believed these alarms to be invalid.

In this study, decisions about alarm validity and relevance were made through close communication between monitor watchers and nursing staff. If an alarm was sounding and the monitor watcher had already spoken with the nurse about it and established that the nurse was addressing the problem, the monitor watcher would intercept subsequent alarms for that issue or event (according to personal communication with S. Palchaudhuri). The results of the study not only indicate that monitor watchers can reduce the number of alarms to which a nurse is exposed, but also support previous findings that few alarms are valid or clinically relevant.^5-7 The results of this study also suggest that “nuisance” alarms should include not only clinically irrelevant alarms, but also relevant alarms for which the nurse is actively seeking a solution. Monitor watchers may have an important role in addressing these alarms.

The study raises important considerations regarding monitor watcher practice and alarm fatigue. If monitor watchers are to be effective in reducing nurses’ exposure to alarms, they must use good judgment to determine when to intercept an alarm, call the nurse, or both. In the absence of proper judgment, monitor watchers may inadvertently increase nurses’ fatigue through redundant calls or inappropriately suppress valid relevant alarms. In free-text responses to our national monitor watcher survey, nurses expressed frustration over redundant calls from monitor watchers for invalid and irrelevant alarms.² Research suggests that monitor watchers may not identify potentially dangerous alarms with complete accuracy. In a recent study reported in The Journal of the American Medical Society (JAMA), monitor watchers missed about 18% of patients with detectable rhythm or rate changes on telemetry in the hour before an emergency response team was activated.⁸

Several factors and conditions may affect monitor watchers’ judgment: 1) education and training, 2) location and access to contextual patient information, and 3) fatigue. First, across the US, the level of education required for monitor watcher positions ranges from a high school diploma to licensure as a registered nurse. The content and frequency of in-service training required also varies.² These differing requirements may influence monitor watchers’ ability to interpret alarms.

Second, most monitor watchers are located off the patient care unit,² which influences their access to information. Even in remote locations, monitor watchers can assess alarm validity by reviewing parameter waveforms for artifact. However, determining the relevance of an alarm to a particular patient is a more complex task requiring contextual information about the patient.⁹ Monitor watchers must work closely with clinicians at the bedside to determine the relevance of alarms, and repeated contact between monitor watchers and nurses over alarm conditions may itself increase nurses’ alarm fatigue.

Finally, fatigue may affect monitor watchers themselves and reduce their effectiveness. This issue was raised by Palchaudhuri et al. Both the number of monitors watched and the length of the monitor watcher’s shift likely influence alertness and effectiveness. In a simulation study, Segall et al.¹⁰ found that monitor watchers’ recognition of serious arrhythmias was significantly delayed when they were responsible for more than 40 patient monitors. Monitor watchers often work 12-hour shifts,² and although no research has been reported on their shift-related alertness, this is a long time to remain attentive.

Given these potential challenges, future research should specifically address adverse patient outcomes and missed clinically relevant alarms. Only two of the seven patients who arrested during the study by Palchaudhuri et al.⁴ were on telemetry, and neither arrested due to lethal arrhythmias. While this is an important indication that no alarms for lethal arrhythmias were inadvertently suppressed, it is difficult to achieve adequate statistical power to assess rare outcomes like cardiac arrests. In a future study, alarms intercepted by monitor watchers could be assessed for accuracy and relevance to patient care to determine whether important alarms were inadvertently suppressed.

In summary, the study by Palchaudhuri et al.⁴ represents a preliminary step in considering the potential utility of monitor watchers for reducing invalid and clinically irrelevant alarms as well as subsequent alarm fatigue. As the authors note, dedicated monitor watchers can screen alarms much more quickly than nurses who may be engaged in other activities when an alarm signals. The study raises interesting questions about how monitor watchers should be incorporated into workflow. Should their only responsibility be to call regarding potentially critical events, or should they be able to prevent alarms from reaching the nurse? Could monitor watchers provide guidance to reduce alarm fatigue, such as suggesting parameter changes when they see trends in irrelevant alarms? Future research is warranted to understand how monitor watchers can be used most effectively to reduce alarm fatigue, and which characteristics of monitor watchers and their practice result in the best patient outcomes.

Disclosure

Nothing to report.

Monitor watcher personnel are frequently used to assist nurses with identifying meaningful events on telemetry monitors. Although effectiveness of monitor watchers on patient outcomes has not been demonstrated conclusively,¹ as many as 60% of United States hospitals may be using monitor watchers in some capacity.² Presumed benefits of monitor watchers include prompt recognition of changes in patients’ conditions and the potential to reduce alarm fatigue among hospital staff. Alarm fatigue is desensitization resulting from overexposure to alarm signals that are either invalid or clinically irrelevant. Alarm fatigue has resulted in missed patient events and preventable deaths.³ In this issue of the Journal of Hospital Medicine, Palchaudhuri et al.⁴ report findings from their observational study of telemetry monitor alarms intercepted by monitor watchers as a mechanism for reducing both nurses’ exposure to alarm signals and subsequent alarm fatigue.

To our knowledge, the study by Palchaudhuri et al.⁴ is the first to report the effect of monitor watchers on nurses’ exposure to alarm signals. In this study, over a 2-month period monitor watchers intercepted 87% of alarms before they were sent to the nurse’s telephone. Monitor watchers intercepted over 90% of bradycardia and tachycardia alarms, indicating that they believed these alarms to be clinically irrelevant. Monitor watchers also intercepted about 75% of alarms for lethal arrhythmias, indicating that they believed these alarms to be invalid.

In this study, decisions about alarm validity and relevance were made through close communication between monitor watchers and nursing staff. If an alarm was sounding and the monitor watcher had already spoken with the nurse about it and established that the nurse was addressing the problem, the monitor watcher would intercept subsequent alarms for that issue or event (according to personal communication with S. Palchaudhuri). The results of the study not only indicate that monitor watchers can reduce the number of alarms to which a nurse is exposed, but also support previous findings that few alarms are valid or clinically relevant.^5-7 The results of this study also suggest that “nuisance” alarms should include not only clinically irrelevant alarms, but also relevant alarms for which the nurse is actively seeking a solution. Monitor watchers may have an important role in addressing these alarms.

The study raises important considerations regarding monitor watcher practice and alarm fatigue. If monitor watchers are to be effective in reducing nurses’ exposure to alarms, they must use good judgment to determine when to intercept an alarm, call the nurse, or both. In the absence of proper judgment, monitor watchers may inadvertently increase nurses’ fatigue through redundant calls or inappropriately suppress valid relevant alarms. In free-text responses to our national monitor watcher survey, nurses expressed frustration over redundant calls from monitor watchers for invalid and irrelevant alarms.² Research suggests that monitor watchers may not identify potentially dangerous alarms with complete accuracy. In a recent study reported in The Journal of the American Medical Society (JAMA), monitor watchers missed about 18% of patients with detectable rhythm or rate changes on telemetry in the hour before an emergency response team was activated.⁸

Several factors and conditions may affect monitor watchers’ judgment: 1) education and training, 2) location and access to contextual patient information, and 3) fatigue. First, across the US, the level of education required for monitor watcher positions ranges from a high school diploma to licensure as a registered nurse. The content and frequency of in-service training required also varies.² These differing requirements may influence monitor watchers’ ability to interpret alarms.

Second, most monitor watchers are located off the patient care unit,² which influences their access to information. Even in remote locations, monitor watchers can assess alarm validity by reviewing parameter waveforms for artifact. However, determining the relevance of an alarm to a particular patient is a more complex task requiring contextual information about the patient.⁹ Monitor watchers must work closely with clinicians at the bedside to determine the relevance of alarms, and repeated contact between monitor watchers and nurses over alarm conditions may itself increase nurses’ alarm fatigue.

Finally, fatigue may affect monitor watchers themselves and reduce their effectiveness. This issue was raised by Palchaudhuri et al. Both the number of monitors watched and the length of the monitor watcher’s shift likely influence alertness and effectiveness. In a simulation study, Segall et al.¹⁰ found that monitor watchers’ recognition of serious arrhythmias was significantly delayed when they were responsible for more than 40 patient monitors. Monitor watchers often work 12-hour shifts,² and although no research has been reported on their shift-related alertness, this is a long time to remain attentive.

Given these potential challenges, future research should specifically address adverse patient outcomes and missed clinically relevant alarms. Only two of the seven patients who arrested during the study by Palchaudhuri et al.⁴ were on telemetry, and neither arrested due to lethal arrhythmias. While this is an important indication that no alarms for lethal arrhythmias were inadvertently suppressed, it is difficult to achieve adequate statistical power to assess rare outcomes like cardiac arrests. In a future study, alarms intercepted by monitor watchers could be assessed for accuracy and relevance to patient care to determine whether important alarms were inadvertently suppressed.

In summary, the study by Palchaudhuri et al.⁴ represents a preliminary step in considering the potential utility of monitor watchers for reducing invalid and clinically irrelevant alarms as well as subsequent alarm fatigue. As the authors note, dedicated monitor watchers can screen alarms much more quickly than nurses who may be engaged in other activities when an alarm signals. The study raises interesting questions about how monitor watchers should be incorporated into workflow. Should their only responsibility be to call regarding potentially critical events, or should they be able to prevent alarms from reaching the nurse? Could monitor watchers provide guidance to reduce alarm fatigue, such as suggesting parameter changes when they see trends in irrelevant alarms? Future research is warranted to understand how monitor watchers can be used most effectively to reduce alarm fatigue, and which characteristics of monitor watchers and their practice result in the best patient outcomes.

Disclosure

Nothing to report.

Click here to access the June 2017 Digital Edition.

Table of Contents

• A Pathway to Full Practice Authority for Physician Assistants in the VA
• Outcomes Associated With a Multidisciplinary Pain Oversight Committee to Facilitate Management of Chronic Opioid Therapy
• Quality of Chronic Obstructive Pulmonary Disease-Related Health Care in Rural and Urban Clinics
• Three Anomalies and a Complication: Ruptured Noncoronary Sinus of Valsalva Aneurysm, Atrial Septal Aneurysm, and Patent Foramen Ovale
• Orthorexia Nervosa: An Obsession With Healthy Eating
• Interprofessional Education in PACT Primary Care-Mental Health Integration

Click here to access the June 2017 Digital Edition.

Table of Contents

• A Pathway to Full Practice Authority for Physician Assistants in the VA
• Outcomes Associated With a Multidisciplinary Pain Oversight Committee to Facilitate Management of Chronic Opioid Therapy
• Quality of Chronic Obstructive Pulmonary Disease-Related Health Care in Rural and Urban Clinics
• Three Anomalies and a Complication: Ruptured Noncoronary Sinus of Valsalva Aneurysm, Atrial Septal Aneurysm, and Patent Foramen Ovale
• Orthorexia Nervosa: An Obsession With Healthy Eating
• Interprofessional Education in PACT Primary Care-Mental Health Integration

Click here to access the June 2017 Digital Edition.

Table of Contents

• A Pathway to Full Practice Authority for Physician Assistants in the VA
• Outcomes Associated With a Multidisciplinary Pain Oversight Committee to Facilitate Management of Chronic Opioid Therapy
• Quality of Chronic Obstructive Pulmonary Disease-Related Health Care in Rural and Urban Clinics
• Three Anomalies and a Complication: Ruptured Noncoronary Sinus of Valsalva Aneurysm, Atrial Septal Aneurysm, and Patent Foramen Ovale
• Orthorexia Nervosa: An Obsession With Healthy Eating
• Interprofessional Education in PACT Primary Care-Mental Health Integration

Ashley L. Adams, PharmD. What are the key leadership attributes of pharmacy leaders?

Julie A. Groppi, PharmD. As a pharmacy leader, you have to be confident in what you do as a pharmacist and not only look at what you are doing now but what you can do in the future. You always have to look for that next apple to pick, because you have to be willing to accept change and help influence change, even though many people do not like change. As a supervisor, I ran a large and growing clinical pharmacy program. I remember many colleagues saying, “You mean, I have to do this now?” I would always try to bring the conversation around with staff to ensure that the benefit of the change or ‘what is in it for you’ was included in the approach. If you are a leader, communicating with physicians, pharmacists, or VA leadership, you just need to sell it to show why it is important and how the change will improve the process. If you don’t, then you won’t be able facilitate or sustain the momentum needed for change.

One important aspect of being a change leader is to make sure you listen (and talk) to those working in the area on a daily basis when you are going through your processes and trying to create change on what is going happen. It is important to make sure your stakeholders are involved and heard while you think about all of your potential obstacles; this is something that I always have tried to do. Also, reflecting on where you have been and what you have done will help you to think differently and is something you should do both professionally and personally. I may not need to know every aspect of the process, but I need to know the obstacles to figure out ways to prevent or break down those walls and solve those underlying issues.

Dr. Adams. What are some of the challenges and opportunities you have found in pharmacy leadership

Dr. Groppi. I think the challenges [are related to] the sheer volume of work that is out there. Having the ability to be able to separate and think about where you want your team to go is the challenge of any leader. When you are right in the middle of it, you tend to focus on the task at hand to get the work done. One week, it is pain management, and then the next week it is hepatitis C, and then it’s assessing acute care services, then gaps or problems somewhere else. There are always different obstacles and different initiatives (pressures) coming at you. You have to not lose your sense of where you want to go. Often, many people cannot stop and look at the whole picture.

I joined the Clinical Pharmacy Practice office in 2011, and one of the first things we were challenged with when the office started was to write guidelines, create policies, and develop tools that would help guide the practice. However, when we started sending out resources to the field, many people were too busy with what was going on at their local facility to focus on what we had developed, so we had to step back. We brainstormed some ideas and looked at our peers in other offices who had demonstrated success. When we started discussing pharmacist scope of practice agreements, I looked at nursing service and their movement related to scope of practice and how it had impacted change in the profession over the past several years.

Nursing has great infrastructure and support for its program. They created many different types of clinical practice councils within nursing, and they were able to institute a lot of changes and spread their initiatives. We thought, “Why don’t we do this for clinical pharmacy?” So we started doing more outreach to the different sites and had discussions with our advisory board, which resulted in the development of the National Clinical Pharmacy Practice Council (NCPPC). We promoted facility and VISN councils to start talking about practice issues and regularly discussing our initiatives as a part of teleconferences, so we could gain support and keep the momentum. Now the NCPPC has grown and everyone is excited about what is happening. It is having a multipronged effect to impact clinical practice.

Dr. Adams. When you are starting on a new project, how do you and your fellow coworkers decide which one is the best to pursue?

Dr. Groppi. We just do them all—I’m joking... sometimes it feels that way. It’s really hard. There are a lot of different things happening at once and many competing priorities, so we try to do as many things as possible. We will assist with requests that come through the Central Office or questions coming from other program offices related to clinical pharmacy practice and we try to get involved and help support and share the success stories of our pharmacist roles as much as possible. For example, the National Nephrology Office contacted us, about the anticoagulation directive. They wanted to do something similar for nephrology since so many pharmacists were effectively and safely managing erythropoietin stimulating agents. This started a conversation.

Often, the priorities come from patient demand such as in primary care. When VA was implementing patient aligned care teams (PACTs), PBM had to ensure that we had conversations ready to describe clinical pharmacy practice in this area. The same thing occurred with hepatitis C. There were new drugs approved and roles for pharmacists, and often there were not enough providers to care for patients. It became an opportunity.

Frequently, choices are based on what we think will be the largest yield and the biggest gaps in care. Other times, it is based on national priorities. We look at the strategic plan for VA and develop our initiatives accordingly. What’s a new priority or component of the strategic plan for this year? What’s the plan for next year or moving forward? Telepharmacy a few years ago or telehealth is an example. We were making sure to describe our practice in the area and then set goals that are going to sustain the profession.

We focused on PACTs during the first few years as we had hundreds of pharmacists practicing. The next big area was specialty and acute care. We started leading workgroups and focused on policies and guidance to share strong practices. The past several years the focus has been on pain management because everyone is struggling with the number of veterans on opioids. When there is a big crisis, you have to hit it full force and look for opportunities that exist. Antimicrobial stewardship was another great example where we were able to provide help and describe the important role of pharmacists based on the strong practices we have across VA. Many times prioritization is on demand, but always keeping in mind what is happening around you and how it supports our VHA strategic plan.

Dr. Adams. What would be your main advice for future pharmacy leaders? Just taking those opportunities and going with them?

Dr. Groppi. Yes. Look for the spot where you might be able to make a positive impact on patient care for the better and improve outcomes with medications. There are data saying that about 80% of treatment is postdiagnosis, and we are quibbling over roles for clinical pharmacy specialists in the team. There is plenty of work that can be done, more than we as a profession or any single profession can often take on. Why don’t we just look for the opportunities to help? There are enough pieces of pie to go around, so let’s just say the pharmacist’s role is to provide management of medications, this is where we can really help. Look for any of these gaps and go for it. Don’t be afraid.

Ashley L. Adams, PharmD. What are the key leadership attributes of pharmacy leaders?

Julie A. Groppi, PharmD. As a pharmacy leader, you have to be confident in what you do as a pharmacist and not only look at what you are doing now but what you can do in the future. You always have to look for that next apple to pick, because you have to be willing to accept change and help influence change, even though many people do not like change. As a supervisor, I ran a large and growing clinical pharmacy program. I remember many colleagues saying, “You mean, I have to do this now?” I would always try to bring the conversation around with staff to ensure that the benefit of the change or ‘what is in it for you’ was included in the approach. If you are a leader, communicating with physicians, pharmacists, or VA leadership, you just need to sell it to show why it is important and how the change will improve the process. If you don’t, then you won’t be able facilitate or sustain the momentum needed for change.

One important aspect of being a change leader is to make sure you listen (and talk) to those working in the area on a daily basis when you are going through your processes and trying to create change on what is going happen. It is important to make sure your stakeholders are involved and heard while you think about all of your potential obstacles; this is something that I always have tried to do. Also, reflecting on where you have been and what you have done will help you to think differently and is something you should do both professionally and personally. I may not need to know every aspect of the process, but I need to know the obstacles to figure out ways to prevent or break down those walls and solve those underlying issues.

Dr. Adams. What are some of the challenges and opportunities you have found in pharmacy leadership

Dr. Groppi. I think the challenges [are related to] the sheer volume of work that is out there. Having the ability to be able to separate and think about where you want your team to go is the challenge of any leader. When you are right in the middle of it, you tend to focus on the task at hand to get the work done. One week, it is pain management, and then the next week it is hepatitis C, and then it’s assessing acute care services, then gaps or problems somewhere else. There are always different obstacles and different initiatives (pressures) coming at you. You have to not lose your sense of where you want to go. Often, many people cannot stop and look at the whole picture.

I joined the Clinical Pharmacy Practice office in 2011, and one of the first things we were challenged with when the office started was to write guidelines, create policies, and develop tools that would help guide the practice. However, when we started sending out resources to the field, many people were too busy with what was going on at their local facility to focus on what we had developed, so we had to step back. We brainstormed some ideas and looked at our peers in other offices who had demonstrated success. When we started discussing pharmacist scope of practice agreements, I looked at nursing service and their movement related to scope of practice and how it had impacted change in the profession over the past several years.

Nursing has great infrastructure and support for its program. They created many different types of clinical practice councils within nursing, and they were able to institute a lot of changes and spread their initiatives. We thought, “Why don’t we do this for clinical pharmacy?” So we started doing more outreach to the different sites and had discussions with our advisory board, which resulted in the development of the National Clinical Pharmacy Practice Council (NCPPC). We promoted facility and VISN councils to start talking about practice issues and regularly discussing our initiatives as a part of teleconferences, so we could gain support and keep the momentum. Now the NCPPC has grown and everyone is excited about what is happening. It is having a multipronged effect to impact clinical practice.

Dr. Adams. When you are starting on a new project, how do you and your fellow coworkers decide which one is the best to pursue?

Dr. Groppi. We just do them all—I’m joking... sometimes it feels that way. It’s really hard. There are a lot of different things happening at once and many competing priorities, so we try to do as many things as possible. We will assist with requests that come through the Central Office or questions coming from other program offices related to clinical pharmacy practice and we try to get involved and help support and share the success stories of our pharmacist roles as much as possible. For example, the National Nephrology Office contacted us, about the anticoagulation directive. They wanted to do something similar for nephrology since so many pharmacists were effectively and safely managing erythropoietin stimulating agents. This started a conversation.

Often, the priorities come from patient demand such as in primary care. When VA was implementing patient aligned care teams (PACTs), PBM had to ensure that we had conversations ready to describe clinical pharmacy practice in this area. The same thing occurred with hepatitis C. There were new drugs approved and roles for pharmacists, and often there were not enough providers to care for patients. It became an opportunity.

Frequently, choices are based on what we think will be the largest yield and the biggest gaps in care. Other times, it is based on national priorities. We look at the strategic plan for VA and develop our initiatives accordingly. What’s a new priority or component of the strategic plan for this year? What’s the plan for next year or moving forward? Telepharmacy a few years ago or telehealth is an example. We were making sure to describe our practice in the area and then set goals that are going to sustain the profession.

We focused on PACTs during the first few years as we had hundreds of pharmacists practicing. The next big area was specialty and acute care. We started leading workgroups and focused on policies and guidance to share strong practices. The past several years the focus has been on pain management because everyone is struggling with the number of veterans on opioids. When there is a big crisis, you have to hit it full force and look for opportunities that exist. Antimicrobial stewardship was another great example where we were able to provide help and describe the important role of pharmacists based on the strong practices we have across VA. Many times prioritization is on demand, but always keeping in mind what is happening around you and how it supports our VHA strategic plan.

Dr. Adams. What would be your main advice for future pharmacy leaders? Just taking those opportunities and going with them?

Dr. Groppi. Yes. Look for the spot where you might be able to make a positive impact on patient care for the better and improve outcomes with medications. There are data saying that about 80% of treatment is postdiagnosis, and we are quibbling over roles for clinical pharmacy specialists in the team. There is plenty of work that can be done, more than we as a profession or any single profession can often take on. Why don’t we just look for the opportunities to help? There are enough pieces of pie to go around, so let’s just say the pharmacist’s role is to provide management of medications, this is where we can really help. Look for any of these gaps and go for it. Don’t be afraid.

Ashley L. Adams, PharmD. What are the key leadership attributes of pharmacy leaders?

Julie A. Groppi, PharmD. As a pharmacy leader, you have to be confident in what you do as a pharmacist and not only look at what you are doing now but what you can do in the future. You always have to look for that next apple to pick, because you have to be willing to accept change and help influence change, even though many people do not like change. As a supervisor, I ran a large and growing clinical pharmacy program. I remember many colleagues saying, “You mean, I have to do this now?” I would always try to bring the conversation around with staff to ensure that the benefit of the change or ‘what is in it for you’ was included in the approach. If you are a leader, communicating with physicians, pharmacists, or VA leadership, you just need to sell it to show why it is important and how the change will improve the process. If you don’t, then you won’t be able facilitate or sustain the momentum needed for change.

One important aspect of being a change leader is to make sure you listen (and talk) to those working in the area on a daily basis when you are going through your processes and trying to create change on what is going happen. It is important to make sure your stakeholders are involved and heard while you think about all of your potential obstacles; this is something that I always have tried to do. Also, reflecting on where you have been and what you have done will help you to think differently and is something you should do both professionally and personally. I may not need to know every aspect of the process, but I need to know the obstacles to figure out ways to prevent or break down those walls and solve those underlying issues.

Dr. Adams. What are some of the challenges and opportunities you have found in pharmacy leadership

Dr. Groppi. I think the challenges [are related to] the sheer volume of work that is out there. Having the ability to be able to separate and think about where you want your team to go is the challenge of any leader. When you are right in the middle of it, you tend to focus on the task at hand to get the work done. One week, it is pain management, and then the next week it is hepatitis C, and then it’s assessing acute care services, then gaps or problems somewhere else. There are always different obstacles and different initiatives (pressures) coming at you. You have to not lose your sense of where you want to go. Often, many people cannot stop and look at the whole picture.

I joined the Clinical Pharmacy Practice office in 2011, and one of the first things we were challenged with when the office started was to write guidelines, create policies, and develop tools that would help guide the practice. However, when we started sending out resources to the field, many people were too busy with what was going on at their local facility to focus on what we had developed, so we had to step back. We brainstormed some ideas and looked at our peers in other offices who had demonstrated success. When we started discussing pharmacist scope of practice agreements, I looked at nursing service and their movement related to scope of practice and how it had impacted change in the profession over the past several years.

Nursing has great infrastructure and support for its program. They created many different types of clinical practice councils within nursing, and they were able to institute a lot of changes and spread their initiatives. We thought, “Why don’t we do this for clinical pharmacy?” So we started doing more outreach to the different sites and had discussions with our advisory board, which resulted in the development of the National Clinical Pharmacy Practice Council (NCPPC). We promoted facility and VISN councils to start talking about practice issues and regularly discussing our initiatives as a part of teleconferences, so we could gain support and keep the momentum. Now the NCPPC has grown and everyone is excited about what is happening. It is having a multipronged effect to impact clinical practice.

Dr. Adams. When you are starting on a new project, how do you and your fellow coworkers decide which one is the best to pursue?

Dr. Groppi. We just do them all—I’m joking... sometimes it feels that way. It’s really hard. There are a lot of different things happening at once and many competing priorities, so we try to do as many things as possible. We will assist with requests that come through the Central Office or questions coming from other program offices related to clinical pharmacy practice and we try to get involved and help support and share the success stories of our pharmacist roles as much as possible. For example, the National Nephrology Office contacted us, about the anticoagulation directive. They wanted to do something similar for nephrology since so many pharmacists were effectively and safely managing erythropoietin stimulating agents. This started a conversation.

Often, the priorities come from patient demand such as in primary care. When VA was implementing patient aligned care teams (PACTs), PBM had to ensure that we had conversations ready to describe clinical pharmacy practice in this area. The same thing occurred with hepatitis C. There were new drugs approved and roles for pharmacists, and often there were not enough providers to care for patients. It became an opportunity.

Frequently, choices are based on what we think will be the largest yield and the biggest gaps in care. Other times, it is based on national priorities. We look at the strategic plan for VA and develop our initiatives accordingly. What’s a new priority or component of the strategic plan for this year? What’s the plan for next year or moving forward? Telepharmacy a few years ago or telehealth is an example. We were making sure to describe our practice in the area and then set goals that are going to sustain the profession.

We focused on PACTs during the first few years as we had hundreds of pharmacists practicing. The next big area was specialty and acute care. We started leading workgroups and focused on policies and guidance to share strong practices. The past several years the focus has been on pain management because everyone is struggling with the number of veterans on opioids. When there is a big crisis, you have to hit it full force and look for opportunities that exist. Antimicrobial stewardship was another great example where we were able to provide help and describe the important role of pharmacists based on the strong practices we have across VA. Many times prioritization is on demand, but always keeping in mind what is happening around you and how it supports our VHA strategic plan.

Dr. Adams. What would be your main advice for future pharmacy leaders? Just taking those opportunities and going with them?

Dr. Groppi. Yes. Look for the spot where you might be able to make a positive impact on patient care for the better and improve outcomes with medications. There are data saying that about 80% of treatment is postdiagnosis, and we are quibbling over roles for clinical pharmacy specialists in the team. There is plenty of work that can be done, more than we as a profession or any single profession can often take on. Why don’t we just look for the opportunities to help? There are enough pieces of pie to go around, so let’s just say the pharmacist’s role is to provide management of medications, this is where we can really help. Look for any of these gaps and go for it. Don’t be afraid.

“Unprecedented detail” was observed about how a patient’s clinical condition changes in response to Ebola virus disease and treatment. That’s what NIH researchers who analyzed daily gene activation found in a 26-day study of 1 patient.

The patient, who was admitted to the NIH Clinical Center on day 7 of illness, received intensive supportive care, including fluids and electrolytes, but did not receive any experimental Ebola drugs. The researchers took blood samples daily to measure the rise and decline of virus replication and to track the timing, intensity, and duration of expression of numerous immune system genes. They correlated changes in gene expression with subsequent alterations in the patient’s clinical condition, such as development and resolution of blood-clotting dysfunction.

The researchers pinpointed “key transition points” in the response to infection, NIH says. For example, they observed a marked decline in antiviral responses that correlated with clearance of virus from white blood cells. The researchers also found that most host responses shifted rapidly from activating genes involved in cell damage and inflammation toward those linked to promotion of cellular and organ repair—a “pivot” that came before the patient began showing signs of clinical improvement.

Although the study centered on only 1 patient, the researchers say it may help inform the development of treatments designed to boost or accelerate host factors that counter the virus and promote healing.

“Unprecedented detail” was observed about how a patient’s clinical condition changes in response to Ebola virus disease and treatment. That’s what NIH researchers who analyzed daily gene activation found in a 26-day study of 1 patient.

The patient, who was admitted to the NIH Clinical Center on day 7 of illness, received intensive supportive care, including fluids and electrolytes, but did not receive any experimental Ebola drugs. The researchers took blood samples daily to measure the rise and decline of virus replication and to track the timing, intensity, and duration of expression of numerous immune system genes. They correlated changes in gene expression with subsequent alterations in the patient’s clinical condition, such as development and resolution of blood-clotting dysfunction.

The researchers pinpointed “key transition points” in the response to infection, NIH says. For example, they observed a marked decline in antiviral responses that correlated with clearance of virus from white blood cells. The researchers also found that most host responses shifted rapidly from activating genes involved in cell damage and inflammation toward those linked to promotion of cellular and organ repair—a “pivot” that came before the patient began showing signs of clinical improvement.

Although the study centered on only 1 patient, the researchers say it may help inform the development of treatments designed to boost or accelerate host factors that counter the virus and promote healing.

“Unprecedented detail” was observed about how a patient’s clinical condition changes in response to Ebola virus disease and treatment. That’s what NIH researchers who analyzed daily gene activation found in a 26-day study of 1 patient.

The patient, who was admitted to the NIH Clinical Center on day 7 of illness, received intensive supportive care, including fluids and electrolytes, but did not receive any experimental Ebola drugs. The researchers took blood samples daily to measure the rise and decline of virus replication and to track the timing, intensity, and duration of expression of numerous immune system genes. They correlated changes in gene expression with subsequent alterations in the patient’s clinical condition, such as development and resolution of blood-clotting dysfunction.

The researchers pinpointed “key transition points” in the response to infection, NIH says. For example, they observed a marked decline in antiviral responses that correlated with clearance of virus from white blood cells. The researchers also found that most host responses shifted rapidly from activating genes involved in cell damage and inflammation toward those linked to promotion of cellular and organ repair—a “pivot” that came before the patient began showing signs of clinical improvement.

Although the study centered on only 1 patient, the researchers say it may help inform the development of treatments designed to boost or accelerate host factors that counter the virus and promote healing.

Interhospital transfer (IHT) is defined as the transfer of hospitalized patients between acute care hospitals. Although cited reasons for transfer include providing patients access to unique specialty services,¹ patterns and practices of IHT remain largely unstudied. Interhospital transfer is known to be common in certain patient populations, including selected patients presenting to the intensive care unit² and those with acute myocardial infarction (AMI),^3-5 but no recent studies have looked at frequency of IHT among a broader group of hospitalized patients nationally. Little is known about which patients are selected for transfer and why.⁶ Limited evidence suggests poor concordance between cited reason for transfer among patients, transferring physicians, and receiving physicians,⁷ indicating ambiguity in this care process.

Interhospital transfer exposes patients to the potential risks associated with discontinuity of care. Communication is particularly vulnerable to error during times of transition.^8-10 Patients transferred between acute care hospitals are especially vulnerable, given the severity of illness in this patient population,¹¹ and the absence of other factors to fill in gaps in communication, such as common electronic health records. Limited existing literature suggests transferred patients use more resources ^12-13 and experience worse outcomes compared to nontransferred patients,¹¹ although these data involved limited patient populations, and adjustment for illness severity and other factors was variably addressed.^14-16

To improve the quality and safety of IHT, therefore, it is necessary to understand which patients benefit from IHT and identify best practices in the IHT process.¹⁷ A fundamental first step is to study patterns and practices of IHT, in particular with an eye towards identifying unwarranted variation.¹⁸ This is important to understand the prevalence of the issue, provide possible evidence of lack of standardization, and natural experiments with which to identify best practices.

To address this, we conducted a foundational study examining a national sample of Medicare patients to determine the nationwide frequency of IHT among elderly patients, patient and hospital-level predictors of transfer, and hospital variability in IHT practices.

We performed a cross-sectional analysis using 2 nationally representative datasets: (1) Center for Medicare and Medicaid Services (CMS) 2013 100% Master Beneficiary Summary and Inpatient claims files, which contains data on all fee-for-service program Medicare enrollees’ demographic information, date of death, and hospitalization claims, including ICD-9 codes for diagnoses, diagnosis-related group (DRG), and dates of service; merged with (2) 2013 American Hospital Association (AHA) data,¹⁹ which contains hospital-level characteristics for all acute care hospitals in the U.S. Our study protocol was approved by the Partners Healthcare Human Subjects Review Committee.

Beneficiaries were eligible for inclusion if they were 65 years or older, continuously enrolled in Medicare A and B, with an acute care hospitalization claim in 2013, excluding Medicare managed care and end-stage renal disease (ESRD) beneficiaries. We additionally excluded beneficiaries hospitalized at federal or nonacute care hospitals, or critical access hospitals given their mission to stabilize and transfer patients to referral hospitals.²⁰

Transferred patients were defined as: (1) beneficiaries with a “transfer out” claim and a corresponding “transfer in” claim at a different hospital; as well as (2) beneficiaries with a “transfer out” claim and a corresponding date of admission to another hospital within 1 day following the date of claim; and (3) beneficiaries with a “transfer in” claim and a corresponding date of discharge from another hospital within 1 day preceding the date of claim. Beneficiaries transferred to the same hospital, or cared for at hospitals with “outlier” transfer in rates equal to 100% or transfer out rates greater than 35%, were excluded from analysis given the suggestion of nonstandard claims practices. Beneficiaries with greater than 1 transfer within the same hospitalization were additionally excluded.

Patient Characteristics

Patient characteristics were obtained from the CMS data files and included: demographics (age, sex, race); DRG-weight, categorized into quartiles; primary diagnosis for the index hospitalization using ICD-9 codes; patient comorbidity using ICD-9 codes compiled into a CMS-Hierarchical Condition Category (HCC) risk score;²¹ presence of Medicaid co-insurance; number of hospitalizations in the past 12 months, categorized into 0, 1, 2-3, and 4 or more; season, defined as calendar quarters; and median income per household by census tract. These characteristics were chosen a priori given expert opinion in combination with prior research demonstrating association with IHT.^11,22

Hospital Characteristics

Hospital characteristics were obtained from AHA data files and included hospitals’ size, categorized into small, medium, and large (less than 100, 100 to 399, 400 or more beds); geographic location; ownership; teaching status; setting (urban vs. rural); case mix index (CMI) for all patients cared for at the hospital; and presence of selected specialty services, including certified trauma center, medical intensive care unit, cardiac intensive care unit, cardiac surgery services, adult interventional cardiac catheterization, adult cardiac electrophysiology, and composite score of presence of 55 other specialty services (complete list in Appendix A). All characteristics were chosen a priori given expert opinion or relationship of characteristics with IHT, and prior research utilizing AHA data.^23-24

Analysis

Descriptive statistics were used to evaluate the frequency of IHT, characteristics of transferred patients, and number of days to transfer. Patient and hospital characteristics of transferred vs. nontransferred patients were compared using chi-square analyses.

To analyze the effects of each patient and hospital characteristic on the odds of transfer, we used logistic regression models incorporating all patient and hospital characteristics, accounting for fixed effects for diagnosis, and utilizing generalized estimating equations (the GENMOD procedure in SAS statistical software, v 9.4; SAS Institute Inc., Cary, North Carolina) to account for the clustering of patients within hospitals.²⁵ Indicator variables were created for missing covariate data and included in analyses when missing data accounted for greater than 10% of the total cohort.

To measure the variability in transfer rates between hospitals, we used a sequence of random effects logistic regression models. We first ran a model with no covariates, representing the unadjusted differences in transfer rates between hospitals. We then added patient characteristics to see if the unadjusted differences in IHT rates were explained by differences in patient characteristics between hospitals. Lastly, we added hospital characteristics to determine if these explained the remaining differences in transfer rates. Each of the 3 models provided a measure of between-hospital variability, reflecting the degree to which IHT rates differed between hospitals. Additionally, we used the intercept from the unadjusted model and the measure of between-hospital variability from each model to calculate the 95% confidence intervals, illustrating the range of IHT rates spanning 95% of all hospitals. We used those same numbers to calculate the 25^th and 75^th percentiles, illustrating the range of IHT rates for the middle half of hospitals.

Among 28 million eligible beneficiaries, 6.6 million had an acute care hospitalization to nonfederal, noncritical access hospitals, and 107,741 met our defined criteria for IHT. An additional 3790 beneficiaries were excluded for being transferred to the same facility, 416 beneficiaries (115 transferred, 301 nontransferred) were excluded as they were cared for at 1 of the 11 hospitals with “outlier” transfer in/out rates, and 2329 were excluded because they had more than 1 transfer during hospitalization. Thus, the final cohort consisted of 101,507 transferred (1.5%) and 6,625,474 nontransferred beneficiaries (Figure 1). Of the 101,507 transferred beneficiaries, 2799 (2.8%) were included more than once (ie, experienced more than 1 IHT on separate hospitalizations throughout the study period; the vast majority of these had 2 separate hospitalizations resulting in IHT). Characteristics of transferred and nontransferred beneficiaries are shown (Table 1).

Among transferred patients, the top 5 primary diagnoses at time of transfer included AMI (12.2%), congestive heart failure (CHF) (7.2%), sepsis (6.6%), arrhythmia (6.6%), and pneumonia (3.4%). Comorbid conditions most commonly present in transferred patients included CHF (52.6%), renal failure (51.8%), arrhythmia (49.8%), and chronic obstructive pulmonary disease (COPD; 37.0%). The most common day of transfer was day after admission (hospital day 2, 24.7%), with 75% of transferred patients transferred before hospital day 6 (Appendix B).

After adjusting for all other patient and hospital characteristics and clustering by hospital, the following variables were associated with greater odds of transfer: older age, male sex, nonblack race, non-Medicaid co-insurance, higher comorbidity (HCC score), lower DRG-weight, and fewer hospitalizations in the prior 12 months. Beneficiaries also had greater odds of transfer if initially hospitalized at smaller hospitals, nonteaching hospitals, public hospitals, at hospitals in the Northeast, those with fewer specialty services, and those with a low CMI (Table 2).

In this nationally representative study of 6.6 million Medicare beneficiaries, we found that 1.5% of patients were transferred between acute care facilities and were most often transferred prior to hospital day 6. Older age, male sex, nonblack race, higher medical comorbidity, lower DRG weight, and fewer recent hospitalizations were associated with greater odds of transfer. Initial hospitalization at smaller, nonteaching, public hospitals, with fewer specialty services were associated with greater odds of transfer, while higher CMI was associated with a lower odds of transfer. The most common comorbid conditions among transferred patients included CHF, renal failure, arrhythmia, and COPD; particularly notable was the very high prevalence of these conditions among transferred as compared with nontransferred patients. Importantly, we found significant variation in IHT by region and a large variation in transfer practices by hospital, with significant variability in transfer rates even after accounting for known patient and hospital characteristics.

Among our examined population, we found that a sizable number of patients undergo IHT—more than 100,000 per year. Primary diagnoses at time of transfer consist of common inpatient conditions, including AMI, CHF, sepsis, arrhythmia, and pneumonia. Limited prior data support our findings, with up to 50% of AMI patients reportedly undergoing IHT,^3-5 and severe sepsis and respiratory illness reported as common diagnoses at transfer.¹¹ Although knowledge of these primary diagnoses does not directly confer an understanding of reason for transfer, one can speculate based on our findings. For example, research demonstrates the majority of AMI patients who undergo IHT had further intervention, including stress testing, cardiac catheterization, and/or coronary artery bypass graft surgery.^5,26 Thus, it is reasonable to presume that many of the beneficiaries

In this national study of IHT, we found that a sizable number of patients admitted to the hospital undergo transfer to another acute care facility. Patients are transferred with common medical conditions, including those requiring specialized care such as AMI, and a high rate of comorbid clinical conditions, and certain patient and hospital characteristics are associated with greater odds of transfer. Although many of the observed associations between characteristics and odds of transfer were expected based on limited existing literature, we found several unexpected findings, eg, suggesting the possibility of a threshold beyond which sicker patients are not transferred. Additionally, we found that black and Medicaid patients had lower odds of transfer, which warrants further investigation for potential health care disparity. Importantly, we found much variability in the practice of IHT, as evidenced by the inexplicable differences in transfer by hospital region, and by residual unexplained variability in hospital transfer rates after accounting for patient and hospital characteristics, which may be due to lack of standard guidelines to direct IHT practices. In conclusion, this study of hospitalized Medicare patients provides important foundational information regarding rates and predictors of IHT nationally, as well as unexplained variability that exists within this complex care transition. Further investigation will be essential to understand reasons for, processes related to, and outcomes of transferred patients, to help guide standardization in best practices in care.

Disclosure

Nothing to report.

Interhospital transfer (IHT) is defined as the transfer of hospitalized patients between acute care hospitals. Although cited reasons for transfer include providing patients access to unique specialty services,¹ patterns and practices of IHT remain largely unstudied. Interhospital transfer is known to be common in certain patient populations, including selected patients presenting to the intensive care unit² and those with acute myocardial infarction (AMI),^3-5 but no recent studies have looked at frequency of IHT among a broader group of hospitalized patients nationally. Little is known about which patients are selected for transfer and why.⁶ Limited evidence suggests poor concordance between cited reason for transfer among patients, transferring physicians, and receiving physicians,⁷ indicating ambiguity in this care process.

Interhospital transfer exposes patients to the potential risks associated with discontinuity of care. Communication is particularly vulnerable to error during times of transition.^8-10 Patients transferred between acute care hospitals are especially vulnerable, given the severity of illness in this patient population,¹¹ and the absence of other factors to fill in gaps in communication, such as common electronic health records. Limited existing literature suggests transferred patients use more resources ^12-13 and experience worse outcomes compared to nontransferred patients,¹¹ although these data involved limited patient populations, and adjustment for illness severity and other factors was variably addressed.^14-16

To improve the quality and safety of IHT, therefore, it is necessary to understand which patients benefit from IHT and identify best practices in the IHT process.¹⁷ A fundamental first step is to study patterns and practices of IHT, in particular with an eye towards identifying unwarranted variation.¹⁸ This is important to understand the prevalence of the issue, provide possible evidence of lack of standardization, and natural experiments with which to identify best practices.

To address this, we conducted a foundational study examining a national sample of Medicare patients to determine the nationwide frequency of IHT among elderly patients, patient and hospital-level predictors of transfer, and hospital variability in IHT practices.

We performed a cross-sectional analysis using 2 nationally representative datasets: (1) Center for Medicare and Medicaid Services (CMS) 2013 100% Master Beneficiary Summary and Inpatient claims files, which contains data on all fee-for-service program Medicare enrollees’ demographic information, date of death, and hospitalization claims, including ICD-9 codes for diagnoses, diagnosis-related group (DRG), and dates of service; merged with (2) 2013 American Hospital Association (AHA) data,¹⁹ which contains hospital-level characteristics for all acute care hospitals in the U.S. Our study protocol was approved by the Partners Healthcare Human Subjects Review Committee.

Beneficiaries were eligible for inclusion if they were 65 years or older, continuously enrolled in Medicare A and B, with an acute care hospitalization claim in 2013, excluding Medicare managed care and end-stage renal disease (ESRD) beneficiaries. We additionally excluded beneficiaries hospitalized at federal or nonacute care hospitals, or critical access hospitals given their mission to stabilize and transfer patients to referral hospitals.²⁰

Transferred patients were defined as: (1) beneficiaries with a “transfer out” claim and a corresponding “transfer in” claim at a different hospital; as well as (2) beneficiaries with a “transfer out” claim and a corresponding date of admission to another hospital within 1 day following the date of claim; and (3) beneficiaries with a “transfer in” claim and a corresponding date of discharge from another hospital within 1 day preceding the date of claim. Beneficiaries transferred to the same hospital, or cared for at hospitals with “outlier” transfer in rates equal to 100% or transfer out rates greater than 35%, were excluded from analysis given the suggestion of nonstandard claims practices. Beneficiaries with greater than 1 transfer within the same hospitalization were additionally excluded.

Patient Characteristics

Patient characteristics were obtained from the CMS data files and included: demographics (age, sex, race); DRG-weight, categorized into quartiles; primary diagnosis for the index hospitalization using ICD-9 codes; patient comorbidity using ICD-9 codes compiled into a CMS-Hierarchical Condition Category (HCC) risk score;²¹ presence of Medicaid co-insurance; number of hospitalizations in the past 12 months, categorized into 0, 1, 2-3, and 4 or more; season, defined as calendar quarters; and median income per household by census tract. These characteristics were chosen a priori given expert opinion in combination with prior research demonstrating association with IHT.^11,22

Hospital Characteristics

Hospital characteristics were obtained from AHA data files and included hospitals’ size, categorized into small, medium, and large (less than 100, 100 to 399, 400 or more beds); geographic location; ownership; teaching status; setting (urban vs. rural); case mix index (CMI) for all patients cared for at the hospital; and presence of selected specialty services, including certified trauma center, medical intensive care unit, cardiac intensive care unit, cardiac surgery services, adult interventional cardiac catheterization, adult cardiac electrophysiology, and composite score of presence of 55 other specialty services (complete list in Appendix A). All characteristics were chosen a priori given expert opinion or relationship of characteristics with IHT, and prior research utilizing AHA data.^23-24

Analysis

Descriptive statistics were used to evaluate the frequency of IHT, characteristics of transferred patients, and number of days to transfer. Patient and hospital characteristics of transferred vs. nontransferred patients were compared using chi-square analyses.

To analyze the effects of each patient and hospital characteristic on the odds of transfer, we used logistic regression models incorporating all patient and hospital characteristics, accounting for fixed effects for diagnosis, and utilizing generalized estimating equations (the GENMOD procedure in SAS statistical software, v 9.4; SAS Institute Inc., Cary, North Carolina) to account for the clustering of patients within hospitals.²⁵ Indicator variables were created for missing covariate data and included in analyses when missing data accounted for greater than 10% of the total cohort.

To measure the variability in transfer rates between hospitals, we used a sequence of random effects logistic regression models. We first ran a model with no covariates, representing the unadjusted differences in transfer rates between hospitals. We then added patient characteristics to see if the unadjusted differences in IHT rates were explained by differences in patient characteristics between hospitals. Lastly, we added hospital characteristics to determine if these explained the remaining differences in transfer rates. Each of the 3 models provided a measure of between-hospital variability, reflecting the degree to which IHT rates differed between hospitals. Additionally, we used the intercept from the unadjusted model and the measure of between-hospital variability from each model to calculate the 95% confidence intervals, illustrating the range of IHT rates spanning 95% of all hospitals. We used those same numbers to calculate the 25^th and 75^th percentiles, illustrating the range of IHT rates for the middle half of hospitals.

Among 28 million eligible beneficiaries, 6.6 million had an acute care hospitalization to nonfederal, noncritical access hospitals, and 107,741 met our defined criteria for IHT. An additional 3790 beneficiaries were excluded for being transferred to the same facility, 416 beneficiaries (115 transferred, 301 nontransferred) were excluded as they were cared for at 1 of the 11 hospitals with “outlier” transfer in/out rates, and 2329 were excluded because they had more than 1 transfer during hospitalization. Thus, the final cohort consisted of 101,507 transferred (1.5%) and 6,625,474 nontransferred beneficiaries (Figure 1). Of the 101,507 transferred beneficiaries, 2799 (2.8%) were included more than once (ie, experienced more than 1 IHT on separate hospitalizations throughout the study period; the vast majority of these had 2 separate hospitalizations resulting in IHT). Characteristics of transferred and nontransferred beneficiaries are shown (Table 1).

Among transferred patients, the top 5 primary diagnoses at time of transfer included AMI (12.2%), congestive heart failure (CHF) (7.2%), sepsis (6.6%), arrhythmia (6.6%), and pneumonia (3.4%). Comorbid conditions most commonly present in transferred patients included CHF (52.6%), renal failure (51.8%), arrhythmia (49.8%), and chronic obstructive pulmonary disease (COPD; 37.0%). The most common day of transfer was day after admission (hospital day 2, 24.7%), with 75% of transferred patients transferred before hospital day 6 (Appendix B).

After adjusting for all other patient and hospital characteristics and clustering by hospital, the following variables were associated with greater odds of transfer: older age, male sex, nonblack race, non-Medicaid co-insurance, higher comorbidity (HCC score), lower DRG-weight, and fewer hospitalizations in the prior 12 months. Beneficiaries also had greater odds of transfer if initially hospitalized at smaller hospitals, nonteaching hospitals, public hospitals, at hospitals in the Northeast, those with fewer specialty services, and those with a low CMI (Table 2).

In this nationally representative study of 6.6 million Medicare beneficiaries, we found that 1.5% of patients were transferred between acute care facilities and were most often transferred prior to hospital day 6. Older age, male sex, nonblack race, higher medical comorbidity, lower DRG weight, and fewer recent hospitalizations were associated with greater odds of transfer. Initial hospitalization at smaller, nonteaching, public hospitals, with fewer specialty services were associated with greater odds of transfer, while higher CMI was associated with a lower odds of transfer. The most common comorbid conditions among transferred patients included CHF, renal failure, arrhythmia, and COPD; particularly notable was the very high prevalence of these conditions among transferred as compared with nontransferred patients. Importantly, we found significant variation in IHT by region and a large variation in transfer practices by hospital, with significant variability in transfer rates even after accounting for known patient and hospital characteristics.

Among our examined population, we found that a sizable number of patients undergo IHT—more than 100,000 per year. Primary diagnoses at time of transfer consist of common inpatient conditions, including AMI, CHF, sepsis, arrhythmia, and pneumonia. Limited prior data support our findings, with up to 50% of AMI patients reportedly undergoing IHT,^3-5 and severe sepsis and respiratory illness reported as common diagnoses at transfer.¹¹ Although knowledge of these primary diagnoses does not directly confer an understanding of reason for transfer, one can speculate based on our findings. For example, research demonstrates the majority of AMI patients who undergo IHT had further intervention, including stress testing, cardiac catheterization, and/or coronary artery bypass graft surgery.^5,26 Thus, it is reasonable to presume that many of the beneficiaries

In this national study of IHT, we found that a sizable number of patients admitted to the hospital undergo transfer to another acute care facility. Patients are transferred with common medical conditions, including those requiring specialized care such as AMI, and a high rate of comorbid clinical conditions, and certain patient and hospital characteristics are associated with greater odds of transfer. Although many of the observed associations between characteristics and odds of transfer were expected based on limited existing literature, we found several unexpected findings, eg, suggesting the possibility of a threshold beyond which sicker patients are not transferred. Additionally, we found that black and Medicaid patients had lower odds of transfer, which warrants further investigation for potential health care disparity. Importantly, we found much variability in the practice of IHT, as evidenced by the inexplicable differences in transfer by hospital region, and by residual unexplained variability in hospital transfer rates after accounting for patient and hospital characteristics, which may be due to lack of standard guidelines to direct IHT practices. In conclusion, this study of hospitalized Medicare patients provides important foundational information regarding rates and predictors of IHT nationally, as well as unexplained variability that exists within this complex care transition. Further investigation will be essential to understand reasons for, processes related to, and outcomes of transferred patients, to help guide standardization in best practices in care.

Disclosure

Nothing to report.

Interhospital transfer (IHT) is defined as the transfer of hospitalized patients between acute care hospitals. Although cited reasons for transfer include providing patients access to unique specialty services,¹ patterns and practices of IHT remain largely unstudied. Interhospital transfer is known to be common in certain patient populations, including selected patients presenting to the intensive care unit² and those with acute myocardial infarction (AMI),^3-5 but no recent studies have looked at frequency of IHT among a broader group of hospitalized patients nationally. Little is known about which patients are selected for transfer and why.⁶ Limited evidence suggests poor concordance between cited reason for transfer among patients, transferring physicians, and receiving physicians,⁷ indicating ambiguity in this care process.

Interhospital transfer exposes patients to the potential risks associated with discontinuity of care. Communication is particularly vulnerable to error during times of transition.^8-10 Patients transferred between acute care hospitals are especially vulnerable, given the severity of illness in this patient population,¹¹ and the absence of other factors to fill in gaps in communication, such as common electronic health records. Limited existing literature suggests transferred patients use more resources ^12-13 and experience worse outcomes compared to nontransferred patients,¹¹ although these data involved limited patient populations, and adjustment for illness severity and other factors was variably addressed.^14-16

To improve the quality and safety of IHT, therefore, it is necessary to understand which patients benefit from IHT and identify best practices in the IHT process.¹⁷ A fundamental first step is to study patterns and practices of IHT, in particular with an eye towards identifying unwarranted variation.¹⁸ This is important to understand the prevalence of the issue, provide possible evidence of lack of standardization, and natural experiments with which to identify best practices.

To address this, we conducted a foundational study examining a national sample of Medicare patients to determine the nationwide frequency of IHT among elderly patients, patient and hospital-level predictors of transfer, and hospital variability in IHT practices.

We performed a cross-sectional analysis using 2 nationally representative datasets: (1) Center for Medicare and Medicaid Services (CMS) 2013 100% Master Beneficiary Summary and Inpatient claims files, which contains data on all fee-for-service program Medicare enrollees’ demographic information, date of death, and hospitalization claims, including ICD-9 codes for diagnoses, diagnosis-related group (DRG), and dates of service; merged with (2) 2013 American Hospital Association (AHA) data,¹⁹ which contains hospital-level characteristics for all acute care hospitals in the U.S. Our study protocol was approved by the Partners Healthcare Human Subjects Review Committee.

Beneficiaries were eligible for inclusion if they were 65 years or older, continuously enrolled in Medicare A and B, with an acute care hospitalization claim in 2013, excluding Medicare managed care and end-stage renal disease (ESRD) beneficiaries. We additionally excluded beneficiaries hospitalized at federal or nonacute care hospitals, or critical access hospitals given their mission to stabilize and transfer patients to referral hospitals.²⁰

Transferred patients were defined as: (1) beneficiaries with a “transfer out” claim and a corresponding “transfer in” claim at a different hospital; as well as (2) beneficiaries with a “transfer out” claim and a corresponding date of admission to another hospital within 1 day following the date of claim; and (3) beneficiaries with a “transfer in” claim and a corresponding date of discharge from another hospital within 1 day preceding the date of claim. Beneficiaries transferred to the same hospital, or cared for at hospitals with “outlier” transfer in rates equal to 100% or transfer out rates greater than 35%, were excluded from analysis given the suggestion of nonstandard claims practices. Beneficiaries with greater than 1 transfer within the same hospitalization were additionally excluded.

Patient Characteristics

Patient characteristics were obtained from the CMS data files and included: demographics (age, sex, race); DRG-weight, categorized into quartiles; primary diagnosis for the index hospitalization using ICD-9 codes; patient comorbidity using ICD-9 codes compiled into a CMS-Hierarchical Condition Category (HCC) risk score;²¹ presence of Medicaid co-insurance; number of hospitalizations in the past 12 months, categorized into 0, 1, 2-3, and 4 or more; season, defined as calendar quarters; and median income per household by census tract. These characteristics were chosen a priori given expert opinion in combination with prior research demonstrating association with IHT.^11,22

Hospital Characteristics

Hospital characteristics were obtained from AHA data files and included hospitals’ size, categorized into small, medium, and large (less than 100, 100 to 399, 400 or more beds); geographic location; ownership; teaching status; setting (urban vs. rural); case mix index (CMI) for all patients cared for at the hospital; and presence of selected specialty services, including certified trauma center, medical intensive care unit, cardiac intensive care unit, cardiac surgery services, adult interventional cardiac catheterization, adult cardiac electrophysiology, and composite score of presence of 55 other specialty services (complete list in Appendix A). All characteristics were chosen a priori given expert opinion or relationship of characteristics with IHT, and prior research utilizing AHA data.^23-24

Analysis

Descriptive statistics were used to evaluate the frequency of IHT, characteristics of transferred patients, and number of days to transfer. Patient and hospital characteristics of transferred vs. nontransferred patients were compared using chi-square analyses.

To analyze the effects of each patient and hospital characteristic on the odds of transfer, we used logistic regression models incorporating all patient and hospital characteristics, accounting for fixed effects for diagnosis, and utilizing generalized estimating equations (the GENMOD procedure in SAS statistical software, v 9.4; SAS Institute Inc., Cary, North Carolina) to account for the clustering of patients within hospitals.²⁵ Indicator variables were created for missing covariate data and included in analyses when missing data accounted for greater than 10% of the total cohort.

To measure the variability in transfer rates between hospitals, we used a sequence of random effects logistic regression models. We first ran a model with no covariates, representing the unadjusted differences in transfer rates between hospitals. We then added patient characteristics to see if the unadjusted differences in IHT rates were explained by differences in patient characteristics between hospitals. Lastly, we added hospital characteristics to determine if these explained the remaining differences in transfer rates. Each of the 3 models provided a measure of between-hospital variability, reflecting the degree to which IHT rates differed between hospitals. Additionally, we used the intercept from the unadjusted model and the measure of between-hospital variability from each model to calculate the 95% confidence intervals, illustrating the range of IHT rates spanning 95% of all hospitals. We used those same numbers to calculate the 25^th and 75^th percentiles, illustrating the range of IHT rates for the middle half of hospitals.

Among 28 million eligible beneficiaries, 6.6 million had an acute care hospitalization to nonfederal, noncritical access hospitals, and 107,741 met our defined criteria for IHT. An additional 3790 beneficiaries were excluded for being transferred to the same facility, 416 beneficiaries (115 transferred, 301 nontransferred) were excluded as they were cared for at 1 of the 11 hospitals with “outlier” transfer in/out rates, and 2329 were excluded because they had more than 1 transfer during hospitalization. Thus, the final cohort consisted of 101,507 transferred (1.5%) and 6,625,474 nontransferred beneficiaries (Figure 1). Of the 101,507 transferred beneficiaries, 2799 (2.8%) were included more than once (ie, experienced more than 1 IHT on separate hospitalizations throughout the study period; the vast majority of these had 2 separate hospitalizations resulting in IHT). Characteristics of transferred and nontransferred beneficiaries are shown (Table 1).

Among transferred patients, the top 5 primary diagnoses at time of transfer included AMI (12.2%), congestive heart failure (CHF) (7.2%), sepsis (6.6%), arrhythmia (6.6%), and pneumonia (3.4%). Comorbid conditions most commonly present in transferred patients included CHF (52.6%), renal failure (51.8%), arrhythmia (49.8%), and chronic obstructive pulmonary disease (COPD; 37.0%). The most common day of transfer was day after admission (hospital day 2, 24.7%), with 75% of transferred patients transferred before hospital day 6 (Appendix B).

After adjusting for all other patient and hospital characteristics and clustering by hospital, the following variables were associated with greater odds of transfer: older age, male sex, nonblack race, non-Medicaid co-insurance, higher comorbidity (HCC score), lower DRG-weight, and fewer hospitalizations in the prior 12 months. Beneficiaries also had greater odds of transfer if initially hospitalized at smaller hospitals, nonteaching hospitals, public hospitals, at hospitals in the Northeast, those with fewer specialty services, and those with a low CMI (Table 2).

In this nationally representative study of 6.6 million Medicare beneficiaries, we found that 1.5% of patients were transferred between acute care facilities and were most often transferred prior to hospital day 6. Older age, male sex, nonblack race, higher medical comorbidity, lower DRG weight, and fewer recent hospitalizations were associated with greater odds of transfer. Initial hospitalization at smaller, nonteaching, public hospitals, with fewer specialty services were associated with greater odds of transfer, while higher CMI was associated with a lower odds of transfer. The most common comorbid conditions among transferred patients included CHF, renal failure, arrhythmia, and COPD; particularly notable was the very high prevalence of these conditions among transferred as compared with nontransferred patients. Importantly, we found significant variation in IHT by region and a large variation in transfer practices by hospital, with significant variability in transfer rates even after accounting for known patient and hospital characteristics.

Among our examined population, we found that a sizable number of patients undergo IHT—more than 100,000 per year. Primary diagnoses at time of transfer consist of common inpatient conditions, including AMI, CHF, sepsis, arrhythmia, and pneumonia. Limited prior data support our findings, with up to 50% of AMI patients reportedly undergoing IHT,^3-5 and severe sepsis and respiratory illness reported as common diagnoses at transfer.¹¹ Although knowledge of these primary diagnoses does not directly confer an understanding of reason for transfer, one can speculate based on our findings. For example, research demonstrates the majority of AMI patients who undergo IHT had further intervention, including stress testing, cardiac catheterization, and/or coronary artery bypass graft surgery.^5,26 Thus, it is reasonable to presume that many of the beneficiaries

In this national study of IHT, we found that a sizable number of patients admitted to the hospital undergo transfer to another acute care facility. Patients are transferred with common medical conditions, including those requiring specialized care such as AMI, and a high rate of comorbid clinical conditions, and certain patient and hospital characteristics are associated with greater odds of transfer. Although many of the observed associations between characteristics and odds of transfer were expected based on limited existing literature, we found several unexpected findings, eg, suggesting the possibility of a threshold beyond which sicker patients are not transferred. Additionally, we found that black and Medicaid patients had lower odds of transfer, which warrants further investigation for potential health care disparity. Importantly, we found much variability in the practice of IHT, as evidenced by the inexplicable differences in transfer by hospital region, and by residual unexplained variability in hospital transfer rates after accounting for patient and hospital characteristics, which may be due to lack of standard guidelines to direct IHT practices. In conclusion, this study of hospitalized Medicare patients provides important foundational information regarding rates and predictors of IHT nationally, as well as unexplained variability that exists within this complex care transition. Further investigation will be essential to understand reasons for, processes related to, and outcomes of transferred patients, to help guide standardization in best practices in care.

Disclosure

Nothing to report.